How do teenagers get addicted to opioids? Many media stories focus on painkillers prescribed after sports injuries. Those narratives have motivated states such as Pennsylvania and New Jersey to pass laws limiting doctors' ability to prescribe opioids for younger patients.
Yet data from the athenahealth network reveals that, in fact, very few teens receive prescriptions for opioids.
In the fourth quarter of 2016, researchers found, only 1.3 percent of approximately 130,000 patients ages 13 to 19 — visiting primary care providers and other specialists — received an opioid prescription. During that time, opioids were prescribed to only 4.8 percent of 10,000 teenagers who visited more than 290 orthopedic surgeons.
And those numbers have been dropping. Across all specialties, athenahealth researchers found, the percentage of teenagers ages 13 to 19 who received an opioid prescription fell by more than a third between the end of 2012 and the end of 2016. The rate of opioid prescribing is falling faster for teens than for all patients nationwide.
The volume of prescriptions is so low, some clinicians say, that focusing on prescribing habits — without boosting other prevention measures — isn't likely to move the needle on the rate of abuse.
Indeed, research shows that social determinants of health, such as poverty and mental illness, are more closely correlated with risk of substance abuse disorder.
Across all age groups, the percent of patients who become addicted to their own prescription is relatively low. According to the American Society of Addiction Medicine, most adolescents who misuse prescription pain relievers buy them off the black market or steal them from a relative's medicine cabinet.
"That external reservoir is absolutely the biggest problem for teens [who are already abusing drugs]," says Sharon Levy, M.D., a pediatrician and director of the adolescent substance abuse program at Boston Children's Hospital.
And teenagers aren't likely to abuse their own prescriptions unless they are already abusing illicit substances, Levy says.
So, it's important for physicians to take more time for conversations around pain management, says Jennifer M. Weiss, M.D., an orthopedic surgeon specializing in pediatric sports medicine at Kaiser Permanente in Los Angeles.
Speaking on behalf of the American Academy of Orthopaedic Surgeons, or AAOS, Weiss says many orthopedic specialists, especially pediatric and trauma physicians, are working to improve patient education about opioids.
AAOS provides education resources about nonaddictive alternatives to pain management, and about how to talk to families about the risks when a narcotic prescription is required.
"I communicate the risk of addiction, but I also don't want to create any sort of fear around administering this medication when the child needs pain relief," Weiss says.
The goal is not only to understand the patient's tolerance of pain, but also the family's expectations, she says. Orthopedic surgeons are also advised to ask about past history and experience using narcotic medication.
Depending on the case, Weiss will suggest the patient and family think of opioids as a backup to a nonaddictive alternative.
And she's finding that parents are often more comfortable with this suggestion.
"There's been such a huge shift in the education on the patient side of this issue," she says. "A few years ago, the conversation was 'I have a right for my child to not be in pain,' whereas today the conversation is structured more around, 'How can we best manage my child's pain?'"
To prevent teens from distributing their prescriptions to others, AAOS suggests that doctors follow up about whether a patient finished the duration of his or her prescription — and if not, provide information around how to dispose of pills safely.
But the most effective interventions, says Levy of Boston Children's Hospital, will likely take place outside of a doctor's office.
"By the time you're in the moment when you're prescribing a teenager an opioid," she says, "that's too late in the game [to prevent addiction]."
Instead, she's focused on educating children and teens, early on, about substance abuse.
"We really have to think about how we prevent people from going down this path," she says. "Every kid that starts taking opioids recreationally starts with marijuana and alcohol. That's really where the prevention work needs to begin."
Chelsea Rice is a staff writer for athenaInsight. Follow her on Twitter @ChelseaRice.