Faculty Bibliography

INTRODUCTION/BACKGROUND:Clozapine is an atypical antipsychotic used to treat refractory schizophrenia; in both therapeutic use and overdose, it can cause significant toxicity. We report two young siblings who developed altered mental status after ingesting clozapine due to a pharmacy dispensing error. CASE REPORT/METHODS:A 5-year-old girl and her 19-month-old sister presented to the emergency department (ED) with altered mental status after they took their first dose of what was believed to be cimetidine, prescribed to treat molluscum contagiosum. Both children were discharged after a brief period of observation in the ED. Two days later, when the older child continued to be symptomatic, their mother used a web-based pill identifier and discovered that the pills dispensed by the pharmacy were 200 mg clozapine tablets, not the cimetidine that had been prescribed. Ingestion was confirmed with an elevated serum clozapine concentration in the older child of 17 mcg/L at 85 hours post-ingestion (adult therapeutic range: 350-600 mcg/L). Both children had complete resolution of their symptoms 4 days following the ingestion with supportive care alone. DISCUSSION/CONCLUSIONS:We report two cases of pediatric clozapine toxicity due to a pharmacy dispensing error. The error was due, in part, to similarly named medications being stored adjacent to each other on a shelf. Dispensing errors are not rare occurrences and their root causes are multi-factorial. This case demonstrates the importance of reducing such errors, particularly for medications with potential for severe toxicity.

Objectives/UNASSIGNED:The aims of the study were to determine the frequency of and factors associated with leftover or expired prescription medication ("leftover medication") presence in homes with children and to assess caregivers' reported behaviors and knowledge regarding disposal of leftover medications in the home. Methods/UNASSIGNED:This study is a planned secondary analysis from a survey of primary caregivers of children aged 1 to 17 years presenting to an emergency department. The survey assessed leftover medications in the home and medication disposal practices, knowledge, and guidance. The survey was developed iteratively and pilot tested. Multivariable logistic regression was used to identify factors associated with leftover medication presence in the home. Results/UNASSIGNED:We enrolled 550 primary caregivers; 97 of the 538 analyzed (18.0%; 95% confidence interval [CI], 14.8-21.5) reported having leftover medications in their home, most commonly antibiotics and opioids. Of respondents, 217/536 (40.5%) reported not knowing how to properly dispose of medications and only 88/535 (16.4%) reported receiving guidance regarding medication disposal. Most caregivers reported throwing leftover medications in the trash (55.7%) or flushing them down the toilet (38.5%). Caregivers with private insurance for their child were more likely to have leftover medications (adjusted odds ratio [aOR], 1.99; CI, 1.15-3.44), whereas Hispanic caregivers (aOR, 0.24; CI, 0.14-0.42) and those who received guidance on leftover medications (aOR, 0.30; CI, 0.11-0.81) were less likely to have leftover medications in the home. Conclusions/UNASSIGNED:Leftover medications are commonly stored in homes with children and most caregivers do not receive guidance on medication disposal. Improved education and targeted interventions are needed to ensure proper medication disposal practices.

OBJECTIVES/OBJECTIVE:Limited literature has investigated caregiver sharing of prescription medications with children. Our primary aim was to determine the frequency of and factors associated with prescription medication sharing within families. Our secondary aim was to determine the source and type of medications shared. METHODS:We conducted a survey of a convenience sample of caregivers of children 1 to 17 years in a pediatric emergency department. The survey was developed through literature review, iterative feedback, and pilot testing on caregivers. We used logistic regression to identify factors associated with any history of medication sharing with a child in the home (primary outcome). RESULTS:We enrolled 550 primary caregivers; 68 of the 535 analyzed (12.7%; 95% confidence interval [CI], 10.0-15.8) reported prescription medication sharing with their child/children. Of those who shared, 50 (73.5%) shared asthma medications and 14 (20.6%) shared antibiotics. Of the caregivers who shared prescription medications, 70.6% shared a medication for one child with another child, whereas 33.8% of caregivers shared their own or another adult's medication with their child. A child in the home with asthma (adjusted odds ratio [aOR], 3.35; CI, 1.82-6.17), a greater number of children in the household (aOR, 1.29; CI, 1.04-1.60), and a caregiver who previously shared medications with other family members and/or friends (aOR, 4.10; CI, 1.84-9.15) were factors independently associated with medication sharing. CONCLUSIONS:Prescription medication sharing within families is common and most often involves asthma medications. We identified several factors associated with prescription medication sharing that could be used to target caregivers for preventative interventions.

Importance/UNASSIGNED:Prescription opioids are involved in more than half of opioid overdoses among younger persons. Understanding opioid prescribing practices is essential for developing appropriate interventions for this population. Objective/UNASSIGNED:To examine temporal trends in opioid prescribing practices in children, adolescents, and younger adults in the US from 2006 to 2018. Design, Setting, and Participants/UNASSIGNED:A population-based, cross-sectional analysis of opioid prescription data was conducted from January 1, 2006, to December 31, 2018. Longitudinal data on retail pharmacy-dispensed opioids for patients younger than 25 years were used in the analysis. Data analysis was performed from December 26, 2019, to July 8, 2020. Main Outcomes and Measures/UNASSIGNED:Opioid dispensing rate, mean amount of opioid dispensed in morphine milligram equivalents (MME) per day (individuals aged 15-24 years) or MME per kilogram per day (age <15 years), duration of prescription (mean, short [≤3 days], and long [≥30 days] duration), high-dosage prescriptions, and extended-release or long-acting (ER/LA) formulation prescriptions. Outcomes were calculated for age groups: 0 to 5, 6 to 9, 10 to 14, 15 to 19, and 20 to 24 years. Joinpoint regression was used to examine opioid prescribing trends. Results/UNASSIGNED:From 2006 to 2018, the opioid dispensing rate for patients younger than 25 years decreased from 14.28 to 6.45, with an annual decrease of 15.15% (95% CI, -17.26% to -12.99%) from 2013 to 2018. The mean amount of opioids dispensed and rates of short-duration and high-dosage prescriptions decreased for all age groups older than 5 years, with the largest decreases in individuals aged 15 to 24 years. Mean duration per prescription increased initially for all ages, but then decreased for individuals aged 10 years or older. The duration remained longer than 5 days across all ages. The rate of long-duration prescriptions increased for all age groups younger than 15 years and initially increased, but then decreased after 2014 for individuals aged 15 to 24 years. For children aged 0 to 5 years dispensed an opioid, annual increases from 2011 to 2014 were noted for the mean amount of opioids dispensed (annual percent change [APC], 10.58%; 95% CI, 1.77% to 20.16%) and rates of long-duration (APC, 30.42%; 95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI, 16.81% to 47.53%), and ER/LA formulation (APC, 27.86%; 95% CI, 12.04% to 45.91%) prescriptions, although the mean amount dispensed and rate of high-dosage prescriptions decreased from 2014 to 2018. Conclusions and Relevance/UNASSIGNED:These findings suggest that opioid dispensing rates decreased for patients younger than 25 years, with decreasing rates of high-dosage and long-duration prescriptions for adolescents and younger adults. However, opioids remain readily dispensed, and possible high-risk prescribing practices appear to be common, especially in younger children.

Research Objective: The opioid epidemic in the United States remains a growing public health problem. Understanding opioid prescribing for children, adolescents, and young adults is essential for developing targeted interventions and policies at both national and local levels for this population. In this study, we investigate temporal trends in opioid-prescribing practices in children, adolescents, and young adults in the United States from 2006 to 2018.
Study Design: Cross-sectional analysis of opioid prescriptions from retail pharmacies. Primary outcomes included total number of opioid prescriptions, duration of prescription (overall mean, <=3 days, and >=30 days), amount prescribed in mean morphine milligram equivalents (MME) dispensed per day, and high-dose prescriptions (prescriptions for doses >90 MME/day for those >14 years). Yearly values were reported overall and stratified by age for 2006, 2012, and 2018, with relative percentage change between point estimates for 2006 and 2018. Population Studied: Opioid prescription data from January 1, 2006, to December 31, 2018, for children, adolescents, and young adults <25 years were extracted from the IQVIA XPonent database which accounts for 90% of retail outpatient prescriptions in the United States. Principal Findings: The opioid prescription rate (per 100 persons) decreased by 58.9% overall from 2006 to 2018, declining from a rate of 4.6-1.4 for children 0-5 years, 4.3-1.4 for those 6-9 years, 6.6-2.7 for those 10-14 years, 20.4-10.8 for adolescents 15-19 years, and 35.1-15.3 for young adults 20-24 years. The total MME/day was 36.5 in 2006, 34.4 in 2012, and 31.2 in 2018 (decrease of 14.7% by 2018), with decreased amounts prescribed in all ages, except those <=5 years. The total mean opioid prescription duration remained relatively stable, with duration of 6 days in 2006, 6.8 days in 2012, and 6.2 days in 2018. The number of prescriptions with duration <=3 days was unchanged, but the number of prescriptions with duration >=30 days increased by 31.8%, with the largest increases in children <15 years. High-dose prescriptions for the 15-24 years cohort decreased by >50% between 2006 and 2018.
Conclusion(s): Since 2006, total opioid prescriptions have decreased for children, adolescents, and young adults, and there has been a reduction in the prescription amount and in high-dose opioid prescriptions for adolescents and young adults. However, despite current opioid-prescribing guidelines, as well as policies that limit days' supply, opioids continue to be frequently dispensed and opioid prescriptions with duration >=30 days have increased. Implications for Policy or Practice: Continued policy efforts and the development of clinical practice guidelines for youths are necessary to ensure safe and judicious opioid prescribing for children, adolescents, and young adults. Further study, including investigating geographic patterns and patient-and prescriber-level characteristics, will help inform targeted interventions for appropriate prescribing practices in this population