“How many licks does it take to get admitted to the Pediatric Intensive Care Unit: The dangers of accidental exposure of Buprenorphine/Naloxone (suboxone) in children.”

Host: James Broadhurst,  MD

Guests:
Scot Bateman, MD
UMass Memorial Children’s Medical Center

Patricia Vanasse, MSW, LICSW
UMass Memorial Medical Center

—

How Many Licks Does it Take to get into the Pediatric Intensive Care Unit?
The Hazards of Accidental Ingestion of buprenorphine/naloxone (Suboxone) in Children
By Scott T. Bateman, MD

“We have another toddler with a Suboxone ingestion needing the PICU” is a call I receive from our emergency room frequently on service in the Pediatric Intensive Care Unit at UMass Memorial Children’s Medical Center.  Suboxone contains two drugs: 1) the partial mu opioid receptor agonist buprenophine and 2) naloxone, an opioid antagonist. The ratio is 4:1 buprenorphine to naloxone.  It is used for the treatment of opioid dependence and has an excellent success rate and safety profile in adults.   In children who are opioid naive, the buprenorphine activity can lead to significant opioid toxicity. The patients coming to the PICU have various degrees of this toxicity on arrival, and all require close management for respiratory depression. A significant number have been treated with repeated doses of IV naloxone, the antidote. We started noticing this trend back in 2009 and subsequently I co-authored a paper on the incidence and complications of Suboxone ingestions in the PICU. We found that for all ingestions in our toddler age children, Suboxone was the most common, accounting for 33% of all accidental ingestions. We also reported that the drugs were all prescribed to a child’s caregiver in the household. Since that paper was published, our PICU has seen a steady and ongoing influx of patients with Suboxone overdoses. It appears that prescription uses of Suboxone have broadened and thus more of this drug is available. Children are drawn to this little orange pill because it looks and feels like an M&M. It is imprinted with a sword logo on one side.  Because the drug is absorbed sub-lingually (enters the body by being absorbed by the mucous membranes in the mouth), all the child has to do is place the pill in his/her mouth to begin getting the effects of the buprenorphine.  Licking the pill will also provide systemic absorption of the buprenorphine. The smaller the child, the larger the dose per lick for his or her body size. Therefore, it doesn’t take many licks (or time in the mouth) before a child could start showing signs of opioid toxicity with sleepiness and lethargy. Almost all other types of pills require the child to swallow them to get the toxicity.

My understanding from my adult colleagues is that there is a huge epidemic of prescribed opioid abuse in this area and that Suboxone is a big part of preventing further abuse and even death. This drug has had a significantly positive impact on these patients, helping to decrease HIV transmission, opioid overdose, and even criminal activity.²  However, there needs to be greater awareness by both patients and providers regarding the potential dangers of accidental ingestion in order to protect the children. Efforts are underway on a state level to highlight the risks of Suboxone and children. A pamphlet has been prepared: http://massclearinghouse.ehs.state.ma.us/protecting-others-and-protecting-treatment.html. Single dose packaging is available for the medication, but it is unfortunately not covered by Medicaid. New preparations of the drug, a dissolvable film, may be more child-proof, but also may be more dangerous if found by a child.  Discussing the risks to children is part of ongoing physician prescription training for this drug and contracts with patients about safe handling of the drug are required.

The risk of accidental ingestion of Suboxone is known and being addressed in different ways, but unfortunately the incidence of PICU hospitalization of children with Suboxone intoxication has been on the rise over the past 2 years. The families of these children explain, “One pill was left in the car,” or “Grandmother was over with her pills,” or “One must have fallen on the floor,” or “We didn’t realize that it was out,” or  remarkably, “I gave it to my child because I thought it was candy.”  It is frustrating to see how easy it is for children to get their hands on this drug. The kids are quickly attracted to this candy-like medication and this potent drug affects their small bodies very quickly. I am urging all who use or prescribe this drug to make extra efforts to follow up on its safe storage and am also urging ongoing home safety checks and, if possible, single dose packaging. With more awareness and emphasis on the dangers of Suboxone to children, we can make strides in licking this problem.

Scott T. Bateman, MD is Division Chief, Pediatric Critical Care, UMass Memorial Children’s Medical Center, and Associate Professor of Clinical Pediatrics,University of Massachusetts Chan Medical School. He can be reached at scott.bateman@umassmemorial.org.

References:

1. Pedapati EV, Bateman ST. Toddlers requiring pediatric intensive care unit admission following at-home exposure to buprenorphine/naloxone. Pediatr Crit Care Med. 2011 Mar;12(2):e102-7.
2. Yokell MA, Zaller ND, Green TC, and Rich J.  Buprenorphine and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An International Review. Curr Drug Abuse Rev. 2011 March 1; 4(1): 28–41.