By Derek Walter
More California newborns are fighting to survive their first few weeks because they were born addicted to opiates. They are the most vulnerable victims of the state’s opioid crisis — a public health epidemic that California doctors and officials are scrambling to address —but older children and teens have also been affected.
“We’re seeing this more frequently and evaluating all types of drug-addicted children,” said Angela J. Vickers, medical director of the Sutter Health Child Abuse and Neglect Program in Sacramento. “This has spiked dramatically over the last five to 10 years.”
About 1,190 newborns were diagnosed with a drug withdrawal syndrome in 2016 — a jump of 50 percent from the prior decade, according to a Sacramento Bee analysis of data from California’s Office of Statewide Health Planning and Development.
Doctors across the state say that in addition to treating more babies who are born with a drug dependency, they’re seeing an increase in children and teens who are addicted to opiates, a class of highly-addictive drugs.
The state Department of Health Care Services announced in late April that it is ramping up efforts to curb opioid-related death and addiction in California. The agency will use a $90 million federal grant to increase access to medications used to treat opioid addiction in parts of the state with the highest overdose rates.
“California’s overall opioid-related death rate is low compared to other states, but there are some areas in the state that have some of the worst prescribing rates and death rates in the country,” the agency’s director, Jennifer Kent, said in a release. California’s rural northern counties — including Lake, Plumas, Lassen, Sierra, Humboldt, Trinity, Del Norte and Shasta counties — have been hardest hit by the epidemic, according to agency statistics.
Although most of the users are adults, the epidemic has affected children too.
Opiates, which are also called opioids, are drugs that relieve pain by acting upon the opioid receptors in nerve cells. According to the National Institute of Drug Abuse, they are available by prescription under names such as oxycodone (OxyContin), hydrocodone (Vicodin), codeine, fentanyl and morphine. They are generally prescribed for pain and, when taken for a short period of time, can offer relief.
But they are also highly addictive and, many California experts believe, often over-prescribed.
According to a study published in February in the Journal for the American Medical Association, the incidence rates for neonatal abstinence syndrome and maternal opioid use have increased almost five-fold nationwide between 2004 and 2013. Neonatal Abstinence Syndrome occurs when a newborn is exposed to opiates while in utero, and can cause the baby to experience vomiting, blotchy skin, fever, diarrhea and sleep problems.
Vickers said children who are born in this condition must be slowly weaned off the medicine with Methadone or increasingly smaller doses of the original drug, a process which can result in a hospital stay of numerous days. Child Protective Services may then need to become involved if the mother was taking the drug illegally or was abusive, she said.
Acute or chronic pain?
The problem extends beyond just babies, according to Dr. David Sine, who is the medical director of hospice and palliative care for Valley Children’s Hospital in Madera and has a practice in Exeter specializing in pediatrics and pain management.
Sine sees the overprescribing of opiates as a “huge problem” in the Central Valley. Children who are not in perpetual, chronic pain should be given lower-strength drugs or alternative treatment in most cases, he said.
“I’ve had patients that go in to a clinic with a severe ear pain and leave with a prescription for codeine,” he said. “I’ve never prescribed codeine for a kid with ear pain. Those are the things that happen all the time. I’ve encountered a 14- or 15-year-old that’s been taking Vicodin for strep throat. Right there you have the potential to create an addict.”
Sine believes that some medical professionals misunderstand how to treat acute pain compared to chronic pain. The former is considered the body’s normal response to some type of wound or injury. Meanwhile, chronic pain persists for weeks, months or even longer. Typically, it’s related to a long-term or terminal illness and may require powerful drugs like opiates.
He believes that many teens in the region have easy access to such drugs because it’s so common to find them in a relatives’ medicine cabinet. Experimenting with just a couple of doses may be enough to become addicted, Sine said.
When parents are addicted, meanwhile, the burden falls especially hard on children. According to the National Institutes of Health, people addicted to opioids are more likely to be violent, engage in risky behavior and have difficulty maintaining employment.
Children with parents who are long-term abusers are at a higher risk of repeating such behavior. Or, if their parents become abusive or neglectful, the children can end up in the state’s foster system.
‘Not an option for them’
Dr. Giovanni Cucchiaro, director of the comfort, pain management and palliative care program at Children’s Hospital Los Angeles, said he’s seen similar issues with overmedication.
Cucchiaro said some patients that come to a clinic complaining of pain may have an underlying mental health issue. Physical pain can often be a symptom of a deeper problem.
“Many actually have significant psychological issues, (such as) depression or more severe forms like bipolar disorder,” he said. “The common complaint is pain, but the pain is a psychological problem and they’re treated with opioids rather than addressing the background psychological problem.”
For those that legitimately require such medication, proper storage is key to avoid children getting a hold of the drugs, Cucchiaro added.
When he prescribes opioids to children, he tells the parents, “You’re in charge of the medication. You do not give it to your kids to self-administer the drug.’
“We get kids who’ve taken the entire bottle.” Parents sometimes fail to monitor medications because they “do not seem to understand the risk involved with these medications,” he said.
There aren’t easy answers. Sine said that some recent regulations designed to curb over-prescription also make it more difficult and cumbersome for doctors to effectively treat their patients. He advocates for more random drug tests at the high-school level, although with a more clinical approach to helping children get off the drugs instead of a solely punitive approach.
California has sought to end the opioid epidemic with a law that went into effect this year. Senate Bill 482 requires doctors consult a database of a patient’s prescription history before prescribing opioids. The law was inspired by two young children who were killed by a driver high on painkillers.
The ongoing challenge, and certainly not one unique to opioids, is finding effective treatment for those who are addicted. The best treatment facilities rarely take Medi-Cal, and in many instances, are cash-only, according to Cucchiaro.
About 70 percent of his patients have Medi-Cal, the state’s low-income health program, so cash-only facilities are “not an option for them,” he said.
The Health Care Services department, which manages Medi-Cal, hopes the federal grant will help expand treatment access.
The agency will use much of the funding to increase the availability of buprenorphine, a medication that can be used to wean people off of opioids. Unlike methadone, buprenorphine is available in primary-care and mental-health offices. It can also be dispensed by community pharmacies and has less abuse potential than methadone, according to the department. It’s safety, however, has not been tested on children younger than 16, so it is not advised for patients younger than that, said DHCS spokesman Norman Williams.
The agency estimates that 21,000 people — both adults and teens 16 and older — will receive treatment through the grant over the next two years.