From Andreas H. Taenzer, MD, MS Professor of Anesthesiology and Critical Care, Medicine & Pediatrics, The George Washington University School of Medicine and Health Sciences, National Children’s Hospital
We recently investigated if early administration of anti seizure medication (ASM) in traumatic brain injuries (TBI) with ICU admission was associated with a change in outcome in patients over 65 years of age using the MIMIC database.
In a retrospective cohort of 1125 patients, 68% received ASM within 24 hours. While the administration of ASM was not associated with a change in seizures, 7-day, 30-day and 1-year mortality was lower in the early ASM group. Adjusted death hazard ratio at 7 days [HR] = 0.48 [95% confidence interval {CI} 0.28–0.88], P = 0.005), at 30 days (adjusted HR 0.67 [95% CI 0.45–0.99], P = 0.045), and at 1 year (adjusted HR 0.72 [95% CI 0.54–0.97], P = 0.029). This association held true for mild, moderate and severe TBI.
While the extrapolation of these data to children is difficult, there is some biological plausibility for using ASM in TBI in children along with adult data.
Glaser AC, Kanter JH, Martinez-Camblor P, Taenzer A, Anderson MV, Buhl L, Shaefi S, Pannu A, Boone MD. The Effect of Antiseizure Medication Administration on Mortality and Early Posttraumatic Seizures in Critically Ill Older Adults with Traumatic Brain Injury. Neurocritical care. 2022 Oct;37(2):538-46
From Chris Buresh MD, Jeff Foti MD, Meagan Lindsey MSN, RN, Lynn Martin MD, MBA on universal naloxone
.We all were happy to read the publications by McKnight and Holland-Hall1 and Teranella et at2 on universal (Intranasal) naloxone dispensing as well as the AAP guidelines on outpatient opioid prescribing3 recently reviewed in the PAAD. We could not agree more fervently.
I (CB) am a pediatrician and emergency medicine doctor that works both in the emergency department (ED) of Seattle Children’s Hospital (SCH) and our county hospital. In these roles, I respond to opioid overdoses, many of which seem unexpected, in a variety of ways. This experience has made me a believer in widespread naloxone distribution. This last weekend I was helping at a community-based Narcan and CPR training event and was really struck by the number of kids attending. I noticed an adult had to excuse herself from the room, so I decided to check on her and found her emotionally distraught. She was the grandmother to several of the kids whose father had died of an overdose and mother was suffering from chaotic drug use. The children have routinely found her unresponsive so they begged their grandmother to come to the event so that they could learn how to use these tools and be empowered to save their mom, their neighbors, and their friends. Prescribing or distributing naloxone to your patients not only protects them, but it also gives them the agency to be protectors of their communities and loved ones.
While kids are self-reporting less drug use this year, we know that mortality continues to rise. This is thought to be largely due to fentanyl making its way into everything from street ‘Percocet’ to ‘Xanax’ to ‘Adderall’.4 Many of the patients that I (CB) reverse with naloxone had no idea that they were using opioids and many of those dying have no history of opioid use disorder. As previously noted,1,2 most of these children are dying in the presence of others, but this is the least likely age group to be given bystander naloxone.5,6 Also worth noting, children with mental health problems are disproportionately represented amongst the dead.7 Critically, a study from Ontario revealed that 25.4% of adolescents and young adults who died of an overdose had a healthcare encounter in the week prior to their death.8 Physicians clearly have an opportunity (maybe responsibility?) to bend the curve.
At SCH ED we have started screening for kids that we think can benefit from having naloxone. We have identified 12 chief complaints (problems bringing patients into the ED) that may indicate they are at higher risk for drug use. Any child aged 13 or over with one of those chief complaints will have an EMR alert fire to do a more detailed screening and specifically ask whether they would like naloxone. We also screen the same population more intensively for opioid use disorder and offer buprenorphine for its treatment when appropriate. Kids who trigger the EMR alert are 18 times as likely to get naloxone as those who do not. In the 3 years that we have been doing this naloxone prescriptions have increased significantly (see below; note 2024 is year to date). Our inpatient service also saw increases in prescribing. A smaller increase was seen for buprenorphine.
Community-based naloxone distribution is cost effective, saving over $2700 for each dollar spent.9 We know that the more naloxone that is distributed in a community, the lower the rates of death by overdose are. Studies from Massachusetts show a clear dose-response relationship.10 To wit, I (CB) was recently taking my kids out for ice cream. Across the street someone had become unresponsive and was turning blue. We responded, but I didn’t have my naloxone with me. I called 911 on speaker phone and called out to bystanders for naloxone while doing a jaw thrust and sternal rub. Before the 911 dispatcher had finished collecting information, I had 2 doses of intranasal Narcan in hand and a third at my feet that bystanders had given us. Widespread community distribution of naloxone saved that 25 year old woman’s life before EMS arrived.
We are not advocating for more screening or extra work. We want anyone with a history of any kind of substance use, even cigarettes, alcohol, or cannabis to be offered a naloxone prescription, perhaps anyone with a mental health condition as well. Finally, as previously suggested in the PAAD, anyone that is being sent home with an opioid prescription should also be sent home with naloxone. Your healthcare contacts with adolescents present a unique and powerful opportunity to make your communities safer. This opportunity to save lives should not be squandered.
References
1. McKnight E, Holland-Hall C. Pediatricians' Role in Overdose Prevention: A Call for Universal Naloxone Dispensing. Pediatrics 2024;154(4) (In eng). DOI: 10.1542/peds.2024-067258.
2. Terranella A, Guy G, Jr., Mikosz C. Naloxone Dispensing to Youth Ages 10-19: 2017-2022. Pediatrics 2024;154(4) (In eng). DOI: 10.1542/peds.2023-065137.
3. Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics 2024. DOI: 10.1542/peds.2024-068752.
4. Friedman J, Godvin M, Shover CL, et al. Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA. 2022;327(14):1398-1400. doi:10.1001/jama.2022.2847
5. Quinn K, Kumar S, Hunter CT, et al. Naloxone administration among opioid-involved overdose deaths in 38 United States jurisdictions in the State Unintentional Drug Overdose Reporting System, 2019. Drug Alcohol Depend. 2022 Jun 1;235:109467. doi: 10.1016/j.drugalcdep.2022.109467. Epub 2022 Apr 16. PMID: 35461083; PMCID: PMC9106898.
6. Tanz LJ, Dinwiddie AT, Mattson CL, et al. Drug Overdose Deaths Among Persons Ages 10-19 Years – United States, July 2019-December 2021. Morb Mortal Wkly Rep 2022;71:1576-82. DOI: http://dx.doi.org/10.15585.mmwr.mm7150a2.
7. Marshall T, Olson K, Youngson E, et al. Preexisting mental health disorders and risk of opioid use disorder in young people: A case-control study. Early Interv Psychiatry. 2023 Oct;17(10):963-73. doi: 10.1111/eip.13385. Epub 2023 Feb 15.
8. Akbar, S., Iacono, A., Yang, J., et al. Characteristics of Opioid Toxicity Deaths Among Adolescents and Young Adults in Ontario Prior To and During the COVID-19 Pandemic. Journal of Adolescent Health 2024;75(1):35–42. https://doi.org/10.1016/j.jadohealth.2024.02.024
9. Naumann RB, Durrance CP, Ranapurwala SI, et al. Impact of a community-based naloxone distribution program on opioid overdose death rates. Drug and alcohol dependence, 2019; 204, 107536. https://doi-org.offcampus.lib.washington.edu/10.1016/j.drugalcdep.2019.06.038
10. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachuesetts: interrupted time series analysis. BMJ 2013;346:f174. Doi:10.1136/bmj.f174.
From Shelly Stohl
I both applaud and thank you for everything you do on behalf of PAAD and Ron's memory. Like so many others, I appreciate the invaluable updates and insights you share so regularly.
As you are the one who invests the time, effort, and care in maintaining the PAAD forum, it is of course your prerogative to choose what messages to share. At the same time, I'm not sure how your readership will receive the promotion of a contentious political position that doesn't relate directly - and certainly not solely - to pediatrics, to anesthesia, or even to healthcare in general. The issues at stake in the upcoming election are far, far broader than the healthcare factors cited in the Scientific American endorsement.
I worry and pray for the future of America, her people, her cohesiveness, her allies, and more.
From Leonardo Gendzel
I don't think this platform is the place to make a political statement with an opinion/editorial piece. I am disappointed that the PAAD mixed anesthesiology and politics. Moreover, the piece didn't present straightforward objective facts; it presented conclusions based on selected facts in an effort to sway undecided voters. In my opinion, this wasn't the best use of a valuable and wonderful platform.