The Opioid Epidemic and Our Children
When parents get addicted, children suffer.
Posted Jul 15, 2016
It’s no news that a serious epidemic is taking lives and ruining those it leaves behind. The opioid addiction crisis lays waste to families and communities. Inevitably, children become victims, directly through becoming addicted themselves, but even more frequently, indirectly through the devastation on their families. Only recently has research focused on child impacts. What we are beginning to discover has implications for effective treatments and for protecting children.
The scope of the problem. Opioid addiction encompasses not only the illicit drug heroin, but also pain-relief prescription drugs, such as oxycodone, hydrocodone, codeine, morphine and fentanyl, among others. As of 2014, an estimated 1.9 million Americans over 12 years of age were addicted to one or more of these prescription drugs, while 586,000 were addicted to heroin. This addiction is often lethal. Opioid overdose is now the leading cause of accidental death in the U. S., surpassing automobile and gun deaths.
Opioid use is not randomly distributed across the U.S. Those addicted tend to live in communities, some rural, some urban, stressed by low education, low employment and financial strain. When opioid addiction clusters, it can be self-reinforcing, as victims are part of networks of other users. This points toward opioid addiction as a community problem, not just an individual one.
Teens may be especially vulnerable, as their sensation-seeking and risk-taking tendencies collide with a still developing brain. Although alcohol and cigarette abuse is far more prevalent among teens, nearly half a million adolescents (467,000) reported using prescription drugs for non-medical purposes, as of 2014. Such drug use is a gateway to heroin, as four out of five heroin users report starting with opioid prescription drugs, often obtained from friends.
When mothers are addicted. While adolescent opioid addiction is a serious public health issue, it is dwarfed by the indirect impact of growing up where adult caregivers are addicted. One estimate, based on a 2004 national study, is that over seven million children are living with at least one addicted parent. Since the overall opioid overdose death rate has quadrupled from 1999 to 2008, it is likely that today, significantly more children are affected.
Women of childbearing age are disproportionately represented among addicts. For example, in an HIV outbreak in rural Indiana, due to needle-sharing among opioid addicts, half were women, with a median age of 32. In general, as compared with men, women report more chronic pain and are prescribed more addictive pain medications. In the past decade, there has been a 33% increase in non-medical opioid use among pregnant women in the U.S. Hence, hospitals have seen a near tripling of treatment of newborns for prenatal opioid exposure, with stays in the NICU increasing sevenfold over the same period.
Prenatal exposure to opioids. Most infants (55% - 94%) exposed to opioids prenatally are born with NAS (neonatal abstinence syndrome), which has increased fourfold from 2004 to 2013, mostly from prescription drug use, not from illicit opioids such as heroin. NAS is a constellation of behaviors that includes inconsolability, irritability, sneezing, excessive sucking, poor suck quality, and a high-pitched cry. This fits the description of a “difficult” infant, one that challenges caregivers to respond appropriately to soothe the infant. By definition, NAS babies are extremely difficult to soothe, setting them up for less responsive caregiving. Moreover, opioid exposed infants are likely to have central nervous system abnormalities, leaving the babies at risk for apnea and seizures. The CNS effects of opioids have been shown to be more severe than those of prenatal exposure to cocaine, the so-called “crack babies.” Assessment of infants after treatment for NAS finds developmental delays in language and cognition appearing in the first six months. Over the next several years, there is increased risk of attention deficit disorder, anxiety, aggression and maternal rejection.
Risks for children do not stop there. In a national survey of mothers entering 50 different residential treatment programs throughout the U.S. during 1996-2000, most of these women reported multiple traumas. For example, 32% had been homeless in the two years before treatment, 66% had been arrested, 57% had been abused as a child by their own parent, and nearly 30% had tried to commit suicide. Social isolation was the rule. Those who lived with a partner got no support; in fact, 58% reported their partner also used drugs. The mothers had few, if any, non-drug using friends. Moreover, since most residential treatment programs do not allow children, treatment for mothers often involves separation from children.
Given the multiple risks of home environments of mothers with opioid addiction, it is not surprising that their children suffer from a variety of physical, emotional and behavioral problems. Compared to national samples, children of these mothers were twice as likely to have asthma, three times as likely to have hearing problems and seven times more likely to have vision problems. Over 10% of the children had been in a serious fight with a teacher, and almost a quarter of the kids were referred by school officials for behavior problems. Overall, 96% of the children were exposed to more than 4 risk factors, a level of risk double that of the general population and one associated with psychiatric problems and lowered IQ. Thus, opioid addiction by family members is a public health emergency for children as well as the addicts themselves.
Treatment programs. So-called “integrated programs” that allow children to stay with their mothers and provide child care and other services predict longer maternal stays in treatment, increasing the odds of success. Prevention efforts directed at teens can reduce opioid use. Evaluations of Life Skills Training (LST) for 7th graders found that by 12th grade significantly fewer teens were misusing opioids. LST sessions involve role-playing, games and exercises designed to practice refusing drugs, resisting peer pressure, and making good choices. In one study, when LST was combined with family involvement components, 12th grade use of opioids were reduced from 25.9% (among those who had not received the program) to 16.3% among those who had. Nonetheless, even after an intensive intervention, over 16% of the 12th graders studied had exposure to non-medical use of opioids, which are highly addictive.
Efforts to arm teens and adults with tools to resist addictive drugs are laudable. However, we need to look more broadly at the contextual factors that fuel this epidemic – a dramatic rise in prescribing of powerful opioids without exploring other medically effective alternatives, a medication oriented society, in which advertising relentlessly pushes a pill for all ills, a sense of hopelessness that pervades some rural communities. Just as we identify vulnerable teens and adults, at risk for opioid addiction, so too must we identify vulnerable communities. The multi-problem nature of addiction—sometimes including depression, homelessness and violence—means that opioid abuse can be the “canary in the coalmine” that signals much broader distress. Just as the Marshall Plan rebuilt Europe after the devastation of World War II, cannot a new “Marshall Plan” rebuild our own devastated communities?
To read further:
Anand, K. J. S., & Campbell-Yeo, M. (2015). Consequences of prenatal opioid use for newborns. Acta Paediatrica 104, 1066-1069.
Beckwith, A. M. & Burke, S. A. (2015). Identification of early developmental deficits in infants with prenatal heroin, methadone and other opioid exposure. Clinical Pediatrics 54, 328-335.
Crowley, D. M., et al. (2014). Can we build an efficient response to the prescription drug epidemic? Assessing the cost effectiveness of universal prevention in the PROSPER trial. Preventive Medicine 62, 71-77.
Milligan,K., et al. (2011). Length of stay and treatment completion for mothers with substance abuse issues in integrated programs. Drugs: Education, Prevention, and Policy 18, 219-227.