AUSTIN (KXAN) – A Central Texas mom was standing in the kitchen fixing snacks for her children when her 12-year-old daughter walked over and said she was in pain.
The mom reached into to the medicine cabinet and pulled out some Tylenol when the girl interjected.
“Can’t I have the other one,” said the girl, who had her tonsils and adenoids surgically removed in late October. “It’s stronger.”
The first two or three days after getting home from the hospital, the once energetic gymnast who always practiced through her pain spent several days in bed as her parents alternated between giving her Tylenol and the opioid doctors prescribed her.
She had been up and moving for a few days when she asked her mom for the narcotic pain medication, hydrocodone with acetaminophen.
“If she wasn’t who she was, and I didn’t know she had a pretty high pain threshold, I probably would have given it to her without a second thought,” said the mom, who didn’t want to be identified to maintain her child’s privacy. “I had given her the [Tylenol] earlier in the day and it worked, so I knew that it was effective.”
The parents were concerned their daughter knew the difference between drugstore and a potentially addictive pain medication. They also wondered why the girl’s doctor prescribed two large bottles of an opioid, totaling around three cups. They only ended up giving their daughter one-tenth of the amount prescribed.
'Can't I have the other one, it's stronger.'
Although recent state and federal measures should help prevent opioids from being prescribed or over-prescribed to minors, it’s unclear just how often doctors are prescribing the highly addictive drug to Texas children since regulations tracking and analyzing opioids in children are lax.
Allison Benz, executive director of the Texas State Board of Pharmacy, said children may be prescribed opioids for routine procedures, such as treatment of a torn ACL or wisdom teeth removal. It’s what happens afterwards, when a child possibly becomes addicted, that’s an issue.
She said a child might like the way it feels and then go searching in the parents or grandparents medicine cabinets, or even steal opioids when they’re visiting their friends. Eventually, that could lead to a dangerous life of addiction.
“Nobody is doing very much to look at the number of prescriptions and unfortunately it’s only after there’s a bad outcome that anyone has any understanding that a physician or dentist or a nurse practitioner is misinformed about the safety of opioids and children,” said Dr. Rae Brown, chair of the American Academy of Pediatrics.
Curbing Death and Addiction
Rep. James White, R- Hillister, said he believes it will take lawmakers, doctors, pharmacists and patients working together to solve the opioid epidemic and safeguard the state’s children.
White is a member of the new Texas House Committee on Opioid and Substance Abuse that will examine the issue during the Legislative interim, which ends in January 2019. Texas House Speaker Joe Straus announced the creation of the committee in October, and they’re expected to meet for the first time in March.
“When it comes to kids, they tend to have a lower level of being able to take these drugs,” White said. “They probably have a higher capability of becoming addicted so I do believe that this Committee, and the Legislature in general, does have a compelling role to sit down with the medical community and our patients and look at some strategies that will ensure that our children don’t fall into these dangerous traps.”
In 2016, 9 percent of Texas students in 7th through 12th grades misused codeine cough syrup and 4 percent who misused other opioids, according to the Texas Health and Human Services commission.
Prescription Rate by County
The map below shows the number of retail opioid prescriptions dispensed per 100 persons in Texas in 2016, according to the Centers for Disease Control and Prevention. Information was not available for 36 counties.
The county with the highest prescription rate is: Childress County, with 177.3 opioid prescriptions per 100 persons.
Proper Dosing a Bother
The Central Texas girl’s parents didn’t even know she was prescribed narcotic pain medication until they left the pharmacy and opened up a paper bag with two large bottles of hydrocodone mixed with acetaminophen.
"It's ridiculous. It's actually crazy,” said the girl’s father. “Why would anybody give a 12-year-old that much medicine?”
Brown, an anesthesiologist and pain physician who has been studying the pharmacology of opioids for nearly 20 years, said the drug isn’t typically used to treat children whose tonsils were removed, let alone the amount that was prescribed to that girl.
“It doesn't mean that they wanted the child to have three cups,” Brown said. “That just means that they wrote a prescription for a long period of time hoping that they wouldn’t have to hear from the parent again ever, because that’s a bother.”
When the drug is prescribed to children, Benz said it’s important for doctors and pharmacists to take dosing into consideration. “Children are smaller, their bodies process medications differently. The dose is going to be different and the pharmacist should be aware of that and make sure that the dose is appropriate for a child versus an adult.”
Benz said all pharmacists have access to a patient’s date of birth when filling the prescription. If a pharmacist notices an unusual or unlikely amount of opioids prescribed to a child, they can call the doctor who wrote the prescription to discuss whether or not the prescription should be changed due to the child’s age, weight or other circumstances.
“The pharmacist has a corresponding responsibility to protect prescriptions and to make sure it’s a legitimate need,” Benz said.
Although reporting requirements in Texas are becoming stricter, Brown said no one is actively looking into the prescription of opioids across the nation on a daily basis.
Locally, the Texas Medical Board says it is a complaint-driven agency that will investigate someone’s prescribing history, if they receive a complaint against the physician.
For children, the board says it would be a red flag if a pediatrician was issuing a high number of opioid prescriptions due to the nature of those drugs and their potential side effects on the younger patients they serve.
Last year, the Texas Medical Board issued about 55 disciplinary actions related to controlled substances.
Outcomes of their investigations result in anything from fines and additional monitoring to temporary and permanent license suspensions. In one case, a Texas doctor is serving time in federal prison after he was found guilty of conspiring to distribute opioids.
Dangers for Children
One of the couple’s daughters received an opioid cough medicine when she was around 6 or 7 years old. As of this year, new federal regulations will prevent that drug from being prescribed to children.
The U.S. Food & Drug Administration issued its strongest warning banning hydrocodone and codeine from being used in certain medications for minors since it could cause “dangerously high levels of the opioid in their bodies,” FDA spokeswoman Tara Rabin said in an email.
The caveat is that the drug is only prohibited in cold or coughs in minors, but it doesn’t necessarily prevent doctors from prescribing opioids to children and teens for other reasons.
Those two drugs, along with tramadol, are the three most commonly dispensed opioids in Travis County.
“It’s alarming,” the girl’s mother said. “It’s good news to know they’re actually looking at it.”
In Texas, Promethazine, a cough syrup that contains codeine, was one of the top five commonly abused drugs dispensed by pharmacies in fiscal year 2015, according to the Pharmacy Board’s sunset report.
“We consume about 80 percent of all the opioids that are manufactured in the entire world. We do not have 80 percent of the population. That number, all by itself, suggests that we are prescribing too many opioid compounds," Brown said.
In some instances, Brown said opioid use by children can cause nausea, constipation and respiratory depression, where a child stops breathing.
“There’s all kinds of side effects of opioids and the side effects are worse than the pain and will cause more trouble than the pain,” Brown said.
Enhanced Monitoring Ahead
As a member of the Texas House committee studying treatments and solutions for the opioid epidemic, Rep. Kevin Roberts, R-Houston, said he looks forward to hearing from families, agencies and experts across the state as they look for solutions.
“Anybody can become addicted and it is ruining families,” Roberts said. “We see families breaking apart, we see children then entering the foster care system because of this.”
Roberts said he was prescribed too many opioids himself last year when he underwent sinus surgery in between the regular and special Legislative session last year. His doctor sent him home with enough hydrocodone for 30 days.
He knew that was just one example of over-prescription of opioids because as a 14-year-old in Amarillo, Roberts began delivering prescriptions for an independent pharmacist. He went on to spend more than a decade working in the pharmacy services industry.
“Because of my background, I know you don’t want to stay on 30 days of hydrocodone because of the risk of addiction,” Roberts said. “If we’re sending children home with similar prescriptions for pain, parents don’t know the risk. They’re going by the physician’s order.”
With two teenagers of her own, Travis County Judge Sarah Eckhardt has heard firsthand about children who were prescribed “extreme doses” of opioids and is concerned about the toll overprescribing is taking on the community.
'Anybody can become addicted and it is ruining families.'
"The medical community is doing some soul-searching right now, with regard to the ethics of aggressive marketing to physicians and then the physicians obligation to make sure that the marketing reflects the best science and the best healthcare," Eckhardt said.
Travis County filed a lawsuit against several manufacturers, distributors and marketers of pharmaceutical opioids, claiming their aggressive “marketing scheme” has normalized the use of those drugs and falsely claimed the risk of addiction is low.
The lawsuit, filed Feb. 5, says easy access to prescription opioids have made it the recreational drug of choice among Travis County teenagers.
“Painkillers are very helpful when utilized appropriately,” Eckhardt said, “but if they are unchecked, unmonitored and used without mindfulness, you get addiction.”
Locally, more than 5 percent of the of the state’s prescription opioids that were distributed in 2017 were by Travis County pharmacies, according to an analysis of Pharmacy Board data.
Statewide, a growing number of Texas pharmacists are utilizing the Prescription Monitoring Program, a tool that allows them to identify opioid and other prescription drug abusers.
The program, which is currently optional, tracks every controlled substance that is dispensed statewide. It provides pharmacists with information about a patient’s controlled substance prescription history to see if they are “doctor shopping,” or visiting different physicians to obtain multiple prescriptions of the same highly addictive drug that would otherwise be illegal.
During fiscal year 2015, nearly 38.6 million controlled substance prescriptions were dispensed, but pharmacists only used the program to look up 2.1 percent of them before giving them to customers, according to state data.
The Pharmacy Board took over oversight of the program from the Texas Department of Public Safety in September 2016 and is already seeing an increase in medical professionals using it.
Only 833,654 prescriptions were searched by pharmacists in fiscal year 2015. Over the last calendar year, more than 2 million were searched by pharmacists as well as other professions who have access to it, such as doctors, veterinarians, dentists, medical examiners and state investigators.
A law that goes into effect in fall 2019 will require all pharmacists and prescribing doctors to utilize the Prescription Monitoring Program before dispensing certain highly addictive medications, including opioids, benzodiazepines, barbiturates and carisoprodol.
Texas pharmacists are also now required by law to report any controlled substance that they dispense within 24 hours instead of the previous rule which gave them up to a week to report it. Before that change went into effect in September, Texas was one of only a handful of states that didn’t require certain addictive drugs, such as opioids, to be reported within a day.
The sponsor of those new measures, State Rep. Senfronia Thompson, D-Houston, said lawmakers will track the progress of the Prescription Monitoring Program to see what else they can do to reduce the number of people abusing opioids or even dying from overdoses.
“We always have a few doctors out there, just in any profession, that probably may be overdoing it but with this system in place, we plan to rein a lot of those persons in,” Thompson said.
But, those doctors over-prescribing to children is exactly what some families are worried about. After the 12-year-old girl recovered from her tonsillectomy, her parents locked away the extra medication away and planned to safely dispose of it as soon as possible.
“We want to keep our kids out of pain, we want to protect them and I was just afraid,” the girl’s mom said. “To have access to that quantity, that’s insane. How many people keep that medicine on their shelf?”
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