Opioids and Impact on Speech Development: What You Need to Know

Editor’s note: This text-based course is an edited transcript of the webinar, Opioids and Impact on Speech Development: What You Need to Know, presented by Susan Holmes-Walker, PhD, RN.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

•       Discuss the impact of opioids on the central nervous system.

•       Identify populations at risk for delays in development of communication and swallowing.

•       Describe how the “Real Talk” technique can be used to have crucial conversations with patients and families.

Introduction

A foundational concept worth keeping in mind is that 80% of what influences life expectancy happens outside of the healthcare system. We know that life expectancy is dependent on many factors, some we can control and others we cannot. Our interactions with patients, regardless of the healthcare environment or setting that we work in, have a 20% impact on life expectancy. Therefore, when we are interacting with our patients or clients, whatever terminology you like to use, it is important that when people are seeking care, we be as engaging as we can with the goal of helping them to manage their health-related concerns as best they can when they return to the place that they call home, wherever or whatever that may be.

Why Me?

My experience working with speech-language pathologists has been consistently positive. You are definitely experts in communication. You work with patients of a variety of ages, and your experience treating many types of communication, language, and biomechanics of swallowing are well known. You work developing or assisting with improvement in speech sounds, language, social communication, voice, cognitive communication, and feeding issues. We also know that exposure to opioids may be a primary cause of communication challenges or barriers, and that oftentimes there are intentional and unintentional exposures which lead to impaired speech and language development.

Opioids and the Central Nervous System

What Are Opioids?

I like to remind people that opioids is the correct term to use, not the word narcotics. Narcotics indicates law enforcement and other types of illegal activities. For a long time, when we used the term narcotics, patients who actually needed prescribed opioids to treat certain illnesses were seen in a negative light. Always make sure to use the word opioids when discussing the prescribing and management of these medications.

Opioids are appropriate for treatment of many conditions. When we use the right terminology, that helps us to have a better grasp of what the actual need is for these prescribed opioids. We know that opioids are natural, semi-synthetic, and synthetic drugs. Examples of natural opioids are morphine, codeine, and anything that comes from the opium poppy plant. Semi-synthetic opioids are lab-modified natural opioids; heroin and oxycodone are examples. Synthetic opioids, such as fentanyl, tramadol, and methadone, are chemical agents created 100% in a lab and have no natural components.

Opioids include prescription medications to treat pain and are also in the category of illegal drugs. Using opioids alone or with other drugs is a major factor in the drug overdose crisis in the United States that still currently exists. A majority of opioid misuse-related deaths involve fentanyl and other potent synthetic opioids, and users are often not aware of the dangerous synthetic chemicals that are in these medications.

Pain Receptors

The goal of opioids is to interact with opioid receptors, or pain receptors, to impact the response to pain. Nociceptors is the overall category of these receptors. They respond to potentially harmful stimuli, function as complex predictors of harm through formation of pain stimulus, and their function and structures vary within different tissues. Pain receptors play a significant role in adaptive, protective, and behavioral reactions to pain.

Nociceptive pain is the most common type of pain that we deal with in healthcare. It occurs due to injury or tissue damage and alerts the body of potential harm. Chronic pain, which is generally pain that lasts longer than three months, does not always have a clear or triggered cause. Patients with chronic pain tend to be a little bit more challenging because the cause of their pain is not always easily identified. When a patient reports any type of pain, acute or chronic, we believe what the patient says and we do our best to work with them to find treatment options.

Receptors and Medication Side Effects

There are three types of opioid receptors: Mu, Kappa, and Delta. The Mu opioid receptors are the primary focus of our discussion today. They are located throughout the body and affect pain perception. It is good to know that opioids do not necessarily treat the cause of pain if it is an inflammatory response, but they do alter your perception so that the pain does not appear to be as severe. The medications treat the person receiving them by allowing them to manage the pain and not feel its full effect. The side effects of opioid medications are based on Mu receptor location and function in the body.

Mu Receptor Locations and Potential Side Effects: Respiratory, GI, and Cardiovascular Systems

Mu receptors are located throughout the body, and when you think of working with patients who are taking opioids intentionally or unintentionally, and you notice side effects, it makes sense that those side effects correlate to the body system where the receptors are being impacted or targeted. Keep in mind that all side effects are dose-related and also route-related. An intravenous medication will cause side effects more quickly than something taken orally or even topically.

In the respiratory system, opioids can cause decreased respiratory rate, shallow respirations, and issues with feeding coordination due to aspiration or swallowing-related problems. In the GI system, common side effects include nausea, vomiting, and constipation, which can also be impacted by respiratory system issues. In the cardiovascular system, opioids can cause bradycardia, or a slower heart rate, and hypotension, or lower blood pressure.

Mu Receptor Locations and Potential Side Effects: Central Nervous System and Auditory System

There are many effects of opioids, again dose dependent, that appear when the medication impacts the central nervous system. Some of those side effects can include dizziness, euphoria, or sedation, which can definitely impact speech and communication, as well as swallowing issues. There may be depression, anxiety, impaired decision-making, decreased motivation, and low cognitive function, all of which can create communication, swallowing, and other types of challenges. The central nervous system side effects can also include expressive language delays. Additionally, in the central and peripheral auditory system, sensorineural hearing loss and auditory processing are impacted by opioids as well.

Case Study: Mary

Mary is a 50-year-old metastatic ovarian cancer patient who is currently receiving intravenous chemotherapy. She may be inpatient or outpatient, as some patients receive chemotherapy at home. Mary has a comprehensive pain management plan including oxycodone, acetaminophen, and ibuprofen, with moderate pain control.

Could Mary be at risk for communication and swallowing challenges? Because she is taking oxycodone, which is a semi-synthetic opioid, it can have impacts on different areas in the central nervous system, respiratory system, and other body systems. So yes, she could be at risk for communication and swallowing challenges. Moderate pain control also indicates there may need to be some adjustments to her pain management plan, which could increase side effects. The combination of oxycodone and chemotherapy together could pose additional problems.

Populations at Risk for Delays in Development of Communication and Swallowing

Delays and challenges in communication and swallowing development can occur as we age and have varying exposure to opioid medications over time. Some of these risks may linger from childhood or be the result of a medication interaction. The following key populations are not an all-inclusive list, but represent groups that speech-language pathologists are likely to encounter.

Infants

When we think about infants specifically, we think about antenatal opioid exposure and its direct neurological impact on the developing brain. Neonatal Abstinence Syndrome (NAS) is the withdrawal condition that can result. There are also environmental factors that can compound antenatal opioid exposure, including caregiver stress or instability, foster or kinship care placement, and socioeconomic stressors that can lead to poor coordination of care.

Neonatal Abstinence Syndrome babies may present with faster breathing or tachypnea, excessive sneezing, yawning, and hiccups, feeding difficulties, and impaired coordination of sucking and swallowing, which can lead to poor weight gain. Hyperphagia may be present, particularly in cases of methadone withdrawal. Research has also shown that antenatal opioid exposure can increase the risk of cleft lip and/or cleft palate, a condition characterized by communication, swallowing, and feeding challenges related to the anatomical challenges these babies are born with.

School Age Children

Long-term neurodevelopmental disorders are a category of disorders that can develop based on opioid exposure. This may be an unintentional category, as children may gain access to opioids in their home, a grandparent’s home, or in the home of a family member on hospice. When we think about these long-term neurodevelopmental disorders, they can lead to communication disorders that involve persistent difficulties in the acquisition and use of language, speech, or social communication.

There can be language disorders involving difficulty understanding or producing spoken, written, or sign language. There can be speech sound disorder, characterized by persistent difficulty with speech production that interferes with verbal intelligibility. There can also be social or pragmatic communication disorder, which involves challenges in the social use of verbal and nonverbal communication, such as following conversational rules or adjusting speech to context.

A delay in language development may not become apparent until a child enters school. If they are in a home environment where people are impaired and not as observant, those who work in early childhood intervention or early childhood education may be the first people to interact with these families, identify these children, and make a definitive diagnosis. We have also noticed a higher incidence of ADHD-like symptoms, emotional regulation difficulties, and other issues that may impact school-age children in their learning. Trauma and adverse childhood experiences may compound delays in speech development as well.

Patients Who Are Prescribed Opioids

Patients with chronic pain, including musculoskeletal pain, oncology patients, and those in hospice who are prescribed opioids to help manage their pain, may be at risk for developing delays. Postoperative patients, including those in acute care settings receiving fentanyl or who are intubated and receiving opioids to keep them calm while their body recuperates, may exhibit challenges with swallowing and communication following a procedure. Patients who have uncontrolled coughs may take codeine in extreme situations, and patients receiving medication-assisted treatment for opioid use disorder, such as methadone or buprenorphine, may also develop some of these challenges in clinical settings.

County Opioid Dispensing Rates

The CDC publishes county opioid dispensing rate maps that provide a useful visual reference for understanding prescription patterns across the country. Areas with higher dispensing rates may correspond to a higher incidence of patients presenting with speech, language, and communication challenges. If you are practicing in an area where there are a lot of opioids being dispensed, it would make sense that you may see more people of various ages who are taking prescribed opioids and have a higher incidence of some of these conditions. The percentage of opioids being prescribed in your region may be directly correlated to what you are observing clinically. These maps are available through the CDC Overdose Prevention resources and can be a valuable tool for interdisciplinary team discussions.

Most Commonly Prescribed Opioid Medications

The most commonly prescribed opioid medications include oxycodone, primarily used for acute pain; hydrocodone; morphine, both short-acting and long-acting, which can be used for patients with oncology-related conditions; codeine, often used for cough; and fentanyl, which is used in rare occasions to manage acute pain. Methadone and buprenorphine, two drugs used to treat opioid use disorder, are also commonly prescribed. Any of these patients, based on the doses they are receiving, may have speech and language concerns that you will be treating and seeing in your communities and work environments.

Case Study: Mary (Continued)

Mary’s pain is increasing. Her oxycodone has been increased and a long-acting opioid, OxyContin, has been added. Chemotherapy continues. Mary is determined to be at risk for speech and language-related challenges.

What are some preventive strategies that can be used? These presentations of symptoms are dose dependent, and given the increase in doses, the addition of a long-acting medication, and continuing chemotherapy, this combination is likely contributing to some of the challenges she may be experiencing. As far as prevention, it is very important to communicate with the interdisciplinary healthcare team. If there is a pharmacist on your team, talk with them about dosing. Consider raising the topic in grand rounds or patient care rounds, discussing the possible impact of chemotherapy on communication and swallowing.

There may be conversations about Mary transitioning to hospice care and what that would mean for the type of treatment and interventions you want to consider. It is also worthwhile to keep in mind non-opioid pain management options. You are not pain management experts, but there is a growing science and evidence base around the use of non-opioid pain management options such as mindfulness and breathing techniques. As a speech-language pathologist, you can absolutely suggest whether there are non-medication options that could benefit the patient, particularly when increasing doses and chemotherapy are creating challenges.

Seasoned Patients

Patients who are aging and requiring different types of opioid medications to manage chronic musculoskeletal pain are at increased risk for developing some of these challenges. There are appropriate times when these medications can and should be prescribed, but they should be monitored appropriately to keep an eye on potential side effects and unexpected challenges, particularly within the scope of speech and language practice.

Chronic Musculoskeletal Pain

Patients with chronic musculoskeletal pain may be taking extra doses because their pain is out of control, which may indicate that a more in-depth assessment is needed rather than simply increasing medication. As patients age, organ function changes. The same dose taken previously may have more of an impact because kidney and liver function become less efficient as we age. Dosing may increase with new injuries or other age-related changes. Screening during primary care appointments is important, with attention to diet changes, swallowing issues, weight loss, and cognitive changes.

Polypharmacy

Some of our aging patients are taking several categories of medications that may interact with one another. Drug interactions can cause speech and language challenges. If a patient is seeing multiple providers and there is not that communication or a shared medical record, it may be a challenge for all providers to see all of the different medications ordered for a particular patient. It is very important that patients understand this, communicate with their pharmacist on a regular basis, and share their concerns with their primary care provider.

Multiple drugs for the same condition may lead to a compounding effect. If the person has not had a medication reconciliation done in a considerable amount of time, they may be taking more than one drug for the same condition. Removing one of those drugs that may not be necessary could help address some of their feeding and swallowing challenges.

As patients age, there are also dental procedures where opioids may be prescribed. If they are taken for a longer period of time than needed, or if multiple dental procedures are required, that is another factor to keep in mind when assessing patients. Doing a full assessment that includes questions about recent procedures, current medications, and opioid use are all good strategies as you evaluate the patients you interact with in your clinical settings.

Real Talk Technique

As healthcare professionals, we often need to have crucial conversations with our patients. When it has been determined that opioid exposure is one of the reasons a patient has developed issues with speech, language, or communication, it may be time to have a direct conversation with that patient. The ability to have real, transparent conversations and use proper communication skills so that patients and clients feel comfortable sharing is very important.

What Is Real Talk?

Real Talk is a strategy connecting people through meaningful conversations to reduce and prevent substance misuse. It is a valuable resource for healthcare professionals and focuses on improving communication skills and fostering open and honest conversations about opioid use and its implications. A lot of times it is not what we say, but how we say it. When dealing with patients who present with conditions that may be a result of opioid use, and particularly if there is misuse involved, having the right approach can make a significant difference.

Real Talk Training

Real Talk training involves workshops covering topics such as the science of addiction, the recovery process, and the impact of stigma. We know that there is implicit bias and stereotyping for patients who may misuse opioids, and so the level of comfort they have with sharing their specific challenges with healthcare providers may be limited. The training involves role-playing scenarios that allow participants to practice effective communication strategies, resource sharing to provide information about local recovery programs and support services, and community building to connect participants with a network of recovery allies.

Real Talk Recovery Allies

To be an ally, it takes specific skills. Listening without judgment means that allies provide a safe space for individuals to share their experiences without fear of criticism. Using inclusive language means understanding the power of words and striving to use language that uplifts rather than alienates. We do not call people drug abusers; we call them people who misuse drugs. Advocating for resources means working to ensure that individuals in recovery have access to the tools and support they need. Educating themselves and others means that allies continually learn about recovery and share their knowledge to promote a culture of empathy.

Case Study: Brian

Brian is a 20-year-old college student who presents to his provider with his girlfriend after she notices he is losing weight, coughs, and chokes while eating, and is unable to stay on task to complete assignments. He had a broken leg over the summer and still reports some pain. His girlfriend has noticed unknown pills in his bathroom and has become concerned. Brian is referred for speech-language pathology services due to these changes.

How would you initiate a conversation with Brian using Real Talk? You want to be open and non-judgmental. You want to offer Brian a safe space to share, and let him know that being honest about what he is taking is important because it may be directly causing the challenges he is experiencing. Building rapport is essential to helping him open up and share honestly what he is doing and what he may be using to manage his leg pain. When thinking about a college-age student, there may be other pressures and concerns that he may be using opioids inappropriately to manage. Using that Real Talk strategy and building rapport using these techniques can be a way to communicate with him effectively and allow him to share his concerns.

Summary

I hope you now have a better understanding of how opioids may cause communication delays and impact swallowing. Opioids are medications used to treat pain, and based on the receptors in the body and where they appear, they may lead to side effects and different issues related to communication delays and swallowing.

Early identification of populations at risk may help prevent long-term complications of opioid use. When we think of infants with antenatal exposure, we are aware of the conditions and challenges that exposure poses. For children who are in school systems or early intervention programs, understanding the impact that unintentional opioid use may have on speech and language development is important to keep in mind.

For seasoned patients—those aging with chronic conditions who may be taking prescribed opioids to manage them—it is important to remember that as we age, our organs are not as effective at clearing medications, and so the same dose may lead to complications and other issues. Polypharmacy is also a concern, as patients may be taking multiple medications for the same issue that are interacting and causing challenges with swallowing and speech.

Using Real Talk techniques, or whatever strategies you have learned over time to communicate with your patients, can guide honest, transparent communication with patients and community members. Being very open, building rapport, and having patients feel that they are not being stereotyped or looked down upon is a very important skill to have and utilize. Ongoing training on the impact of intentional and unintentional use of opioids improves the care we provide. The more you learn about different medications and different causes, the more fully informed you are to recognize that the dangers of opioid use and misuse are still out there, and they may cause issues that you will be treating with speech and language interventions.

Questions and Answers

What accounts for the difference along state lines, and why do some states have a lower incidence of opioid prescriptions?

Around 2015 and 2016 was when the opioid epidemic received significant attention as non-typical users were being exposed and opioid-related deaths increased substantially. There was a significant focus by the CDC on prescribing, and the reality that physicians, nurse practitioners, PAs, and others who prescribe opioids do not always receive adequate education on prescribing appropriately. Each state used the CDC guidelines to create different programs and ways to manage opioid prescribing, including prescription registries that require providers to review a patient’s opioid history before writing a new prescription. There may be various guidelines across state lines that impacted the different types of systems each state put in place. Some states may still have strong lobbying groups that promote certain prescribing practices. There are also conditions that do justify long-term use of opioids, and the prevalence of those conditions may explain some of the differences in prescribing across state lines.

Is there anything additional we need to address while assessing preschoolers with prenatal opioid exposure?

Whatever screening tools you use as speech-language pathologists, when things screen positive, you may want to think about whether there was a prenatal opioid exposure. There are screening tools where you ask those questions, and if the score is higher, that would indicate a possible prenatal exposure. Explore your educational materials and the screening tools you use, and when someone screens positive for certain conditions related to speech and swallowing, do not automatically assume an opioid exposure, but do not exclude it either. Being open to investigating further is key. Use Real Talk—those conversations with parents to find out more about the prenatal experience, the medications they were taking, and other relevant history.

Do you have recommendations or more information regarding opioid exposure in school-age children?

Prevention and education are critical areas that do not receive enough attention. I think some of the preventive education could occur at back-to-school events or when preparing for the school year. It is not a bad idea to talk about some of the things you are seeing in children and the possibility of accidental opioid exposure, making families more aware of those possibilities. There may be children who have older babysitters, who visit grandparents frequently, or who have a family member in hospice. Making sure opioids are properly secured should be emphasized just as gun safety is—securing medications and not having them accessible or being used inappropriately.

Do you have advice on educating families in hospitals or skilled nursing facilities about potential side effects in a way that is inclusive of pharmacy and nursing staff?

That would be a great conversation to have among your interdisciplinary team. Talk about what you are seeing when working with particular patients, identify the commonalities, and do not be afraid to have those conversations. You may need to be the one to lead that discussion. The CDC opioid dispensing rate data can be a useful reference point, helping to frame why your team may be seeing an increase in referrals for patients with communication and swallowing challenges. Coming up with appropriate education resources and having open and transparent conversations using available data may be all you need to propose putting together an educational program for your team.

To what extent can we engage in conversation with parents who have questions about opioids that can affect speech development without going outside of our scope of practice?

Some of these conversations are uncomfortable, and role playing is a valuable way to practice. You do not want to be accusatory. Most people know the negative impact they may have had on their child, and there may be significant guilt, which can take the conversation in an entirely different direction. Coming to them in truth and in partnership—saying that there are some medications or things you can be exposed to during pregnancy that can cause challenges for a child—and making them aware that there are interventions and strategies available to try to improve these issues is the right approach. Being as honest and transparent as you can without being judgmental is easier said than done, but the fact that you are asking this question shows that you are being empathetic to your patient population and trying to have open and transparent conversations about the impact that opioids may have.

References

Available in the handout