#127: Holy Smokes! Learning the Basics and Beyond of Opioid Use Disorder in Teens

December 4, 2024 | By Sam Masur

Audio

Summary:

Every week, the equivalent of a high-school classroom’s worth of students (an average of 22 adolescents) dies of drug overdoses in the United States. Join us and expert guest Dr. Scott Hadland (Mass General for Children, Harvard Medical School) as we explore Opioid Use Disorder, a rapidly evolving disease affecting our youth. Dr. Hadland provides a big picture understanding of this complex problem but also gives practical day to day tools for tackling OUD in teens. Come and be surprised by how much better you can navigate opioid use among teens.

Opioid Use Disorder in Pediatrics Pearls

1. Drug overdoses and poisonings are now the third-leading cause of pediatric deaths in this country and fentanyl is involved in at least 75% of adolescent overdose deaths.
2. Most teens are overdosing and dying at home; we need Naloxone everywhere! You can even now get it on Amazon!
3. Teens newly experimenting with street drugs and those with mental health conditions looking for relief are especially at risk of overdosing given their lack of opioid tolerance. 
4. Opioid use may have evolved to substance use if there is 1) Loss of control 2) Negative consequences involving use 3) Physiologic changes like withdrawal and tolerance in the teen patient 
5. Consider disclosing a concerning teen’s substance use to parent/guardian given lethality of available street drug supply 
6. With regards to behavioral treatment for OUD in teens, for now, any chosen behavioral intervention is acceptable, especially if tailored to focus on co-occurring conditions. 
7. Buprenorphine is the only medication for OUD that is FDA approved for people aged 16-18, however, many are using buprenorphine off label in younger age groups. Methadone has promising data in teens but is off label and logistically difficult to get for those under 18.  
8. Different to adult buprenorphine induction, in teens, start low and slow as teens often have less tolerance than adults. Consider Buprenorphine 4mg or 8mg daily on day one. 
9. Among Medicaid enrolled adolescents and young adults, only 1 in 54 receive MOUD after surviving an opioid overdose. We need to increase the number of pediatric practitioners who are comfortable prescribing MOUD to improve the number of teens going untreated.

Opioid Use Disorder Notes 

Epidemiology 

Better but worse 

Although drug use, to include illicit drug use, in adolescents has decreased in recent years, overdose deaths among adolescents 14 to 18 years of age more than doubled between August 2019 and March 2020. Drug overdoses and poisonings are now the third-leading cause of pediatric deaths in this country. This increase in mortality despite decrease in general drug use can be attributed to the widespread availability of a more potent and dangerous drug supply. Every week, the equivalent of a high-school classroom’s worth of students, an average of 22 adolescents, dies of drug overdoses in the United States (Friedman & Hadland, 2024).

Large disparities exist in overdose deaths based on race and ethnicity. For example, the mortality for  non-Hispanic American Indian or Alaska Native adolescents was 1.82 times as high as that among non-Hispanic White adolescents between 2020 and 2022 (Friedman & Hadland, 2024).

More on Fentanyl and overdoses 

Fentanyl is largely responsible for that more potent and dangerous drug supply; it is involved in at least 75% of adolescent overdose deaths (Friedman & Hadland, 2024). Fentanyl is a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine. There are two types: pharmaceutical fentanyl and illicitly manufactured fentanyl. Most recent cases of fentanyl related overdose are linked to illicitly manufactured fentanyl, which is distributed through illegal drug markets. Illicit fentanyl is commonly mixed with drugs like heroin, cocaine, and methamphetamine and made into pills that are made to resemble other prescription opioids, like oxycodone. Teenageers may be trying to buy a medicine for anxiety or pain and actually get fentanyl.  These street drugs can contain deadly levels of fentanyl that a teen would not be able to see, taste, or smell (CDC, 2024).  Currently, there are three main teenage group categories that are overdosing:

1. Young people who are experimenting (not necessarily for mental health reasons). These teens likely do not have built up tolerance and so they are more likely to overdose during first uses.
2. Young people who have untreated mental health conditions or pain looking for relief . Also unlikely to have built up tolerance and more likely to overdose during first uses. 
3. Young people with Opioid Use Disorder. This group has tolerance by definition. Before counterfeit pills were prevalent, this used to be the main group of teens suffering of overdose 

Location of overdoses 

Unfortunately, most teens are overdosing and dying at home. During two thirds of those overdoses, there was another person in the house. However, usually by the time the teen is found and 911 is called, the teen is pulseless. This is why it is critically important that all families have Naloxone at home and that they know where it is. For those families who say, “ Not in my home,” consider the fire extinguisher analogy: we keep fire extinguishers in our homes not because we expect there to be a fire in our home, but if there is one, we want to be prepared.  

Diagnosis  

There is a difference between teens briefly or intermittently using opioids and developing an opioid use disorder (OUD).  Since the DSM-5 criteria for diagnosing an OUD can be difficult to remember, consider this simplified approach suggested by Dr. Hadland. The following three categories must be true with regards to a teens use of opioid to be considered a disorder:

1. Loss of control 
2. Negative consequences (i.e. losing jobs or relationships)
3. Physiologic changes (i.e Withdrawal and Tolerance) 

An estimated 1 in 100 adolescents aged 12 to 17 years has an opioid use disorder (OUD). (Hadland, 2024). 

Risk Factors to developing 

There are four main risk factor categories for developing an OUD:

1. Prior substance use 
2. Early age of exposure; the younger they start using, the more likely they are to keep going
3. Concomitant mental health concerns. About 41% of teens who died from overdose had documented mental health history including mental health treatment (23.8%), diagnosed depression (19.1%), or suicidal or self-harm behaviors (14.8%). 
4. Family history of substance use. 

Medical and Psychosocial consequences 

This list is not exhaustive, but some of the top risks to developing an OUD include: 

1. Overdose and death 
2. Likelihood of having substance use throughout lifespan
3. Worsening concomitant mental health conditions 
4. Impaired development that will make it more difficult to succeed in life. More likely to get bad grades, drop out of school, and have more difficulty with jobs. 

Screening and Disclosing 

Although the USPSTF has no formal screening recommendations for teens, the AAP recommends universal substance use screening, brief intervention, and/or referral to treatment (SBIRT) as part of routine health care (Sharon, 2016). Expert opinion: CRAFFT survey (Car; Relax; Alone; Forget; Friends; Trouble), is a good short survey that can be used to identify if a teen is experiencing consequences from substance use. Do this at least at every well child visit. 

Given that exposure to fentanyl is life threatening and given how common it is to obtain on the street as counterfeit pills,  Dr. Hadland advises to disclose to parent/guardian if you as the provider have concern for the teen’s substance exposure. Consider using the following language when letting the teen know you are disclosing their substance use to their parents: 

1. I am concerned about your safety and I think your parents should know. 
2. How would you like this to happen? 
3. Do you want to tell them or do you want me to tell them? 

Treatment- Part 1

Briefly on Motivational Interviewing

As you may know, motivational interviewing is a collaborative, person-centered conversational tool that explores patient values, goals, and aspirations with the hope of resolving ambivalence for change. Change is more likely to happen when our patients feel empowered and in control of their decision. How can we help them discover their own desires for change?  If you do discover that a teen is experimenting with substances, explore:

1. Motivations for using (i.e., wanting to socialize, fit in, relax).
2. What cons the teens has already identified (i.e., substances have caused problems with their relationship or sports coach is worried)
3. Their current goals whether short or long term (i.e. passing classes to play on sports teams). This helps develop discrepancy between their goals and current behaviors. 

Harm reduction 

Our teens deserve services that promote health, regardless of whether they use drugs or not. Evidence-based harm reduction strategies minimize negative consequences of drug use. Our goal as providers is to keep our patients as safe as possible within the framework of what they are willing to do. Partnering with our teens, meeting them where they are without judgment, stigma, or discrimination is key to trust now and possible behavior change later. 

Education, Naloxone, and Themselves

Education is power. We should teach teens about the reality of street supply and counterfeit pills so they understand the risk in consuming street substances and can better protect themselves. Education should avoid using fear-based tactics or dramatic statements and instead focus on promoting their strengths to include their capacity for thoughtful decision making and desire for safety and resilience. (Friedman & Hadland, 2024).

One of the most powerful harm reduction interventions has been the growing availability of Naloxone. In a study completed from 2019-2021, Naloxone administration was only documented in 30 % of overdose deaths among persons aged 14-18. As providers, we can help increase the knowledge and usage of Nalaxone. Teach teens that:

• Naloxone became over the counter in Fall 2023. You can even get it on Amazon. 
• In certain states, patients can ask their pharmacy for Naloxone through a “standing order,” which means they can pick it up from the pharmacy without a doctor’s prescription. If there is insurance on file, the pharmacist will bill. 

Here are some tips suggested by our expert to share with teens that are likely to continue using: 

• Do not take the whole pill at once 
• Wait half an hour before you take more
• Do not use alone 
• Have Naloxone nearby 
• Call 911 if you see anyone else overdose 
• Encourage them to be the “designated carrier.” Teens are an underappreciated resource in overdose prevention. They usually are enthusiastic about helping keep others safe. Similar to the designated driver idea, empower teens to be the ones to carry Naloxone. 

Fentanyl Test Strips (FTS)

FTS are often free and are designed to detect the presence of fentanyl and its analogs in various substances. They are highly sensitive and specific for fentanyl, although their performance can be influenced by the presence of other substances. FTS are commonly used by dissolving a small amount of the drug in water and then dipping the strip into the solution. When two lines on the test strip turn to ONE (opposite to COVID test), that means there is fentanyl in the supply. 

However, the pretest probability of a street drug containing fentanyl is so high, that a negative test should not reassure you and should likely still recommend not to use. Dr. Hadland suggests that FTS should serve as a centerpiece for talking about safety and aiding therapeutic alliance.

Encouragement for the provider  

Dr. Hadland reminds us that behavior change in general is complex and slow. It can be difficult to watch our young patients make high- risk decisions, especially when it seems they are not interested in our thoughts. His encouragement to us is to: 

1. Give ourselves grace. It is okay if you don’t “win” in every conversation. Teens engaging in conversation and growing rapport is plenty to celebrate. 
2. You have more impact than you think. 

Treatment Part 2

As with many things in pediatrics, most OUD treatment data is derived from adults. Dr. Hadland comments that the best treatment is a comprehensive treatment plan tailored to the individual needs of the adolescent, considering developmental stage and co-occurring conditions.

Behavioral Therapies

Where is the evidence?

There is a sparse evidence base for best behavioral approaches in this population. However,  there is a recent meta analysis synthesizing findings from 61 controlled studies meant to examine comparative effectiveness of different treatment modalities for adolescents with substance use. They found evidence of effectiveness for several treatment modalities. ACC, behavioral therapy, CBT, MET, and family therapy had the strongest direct evidence of effectiveness in the literature while generic practice as usual conditions, which typically involved referral to standard community services, were consistently less effective than these treatment types. Dr. Hadland comments that for now, any chosen behavioral intervention is acceptable, especially if tailored to focus on co-occurring conditions. 

Our expert taught us to consider inpatient rehab when: 

1. Home life is unstable and providing structure at rehab would be therapeutic to teenager 
2. Teen has poorly controlled concomitant mental health diagnosis where rehab would also provide a space to optimize those 

Dr. Hadland recommends a Netflix documentary focused on the journeys of four young men going through a farm- based rehab program. 

Medications for opioid use disorder (MOUD)

A study led by Dr. Hadlnd in 2018 found that buprenorphine, methadone, and naltrexone, when provided in real-world treatment settings, were associated with enhanced retention in care compared with receipt of behavioral health services alone. We will focus primarily on buprenorphine in this presentation in part because ​​it is the only medication for OUD that is FDA approved for people aged 16-18.   

Buprenorphine Basics

Buprenorphine is a partial opioid agonist with high affinity for the opioid receptors.  Given this features, it can treat withdrawal symptoms and craving as desired while also:

• Having lower abuse potential
• Having less withdrawal discomfort
• Having a ceiling effect at higher doses exhibiting greater safety in overdose compared to full agonists. The ceiling effect means that if a teen were to overdose on buprenorphine, it is less likely to cause fatal respiratory depression than full mu opioid agonist. 

Oral Buprenorphine is FDA approved for those 16 and up. Injectable buprenorphine is FDA-approved for patients aged 18 years and older and this serves as an effective tool for adherence in teens. In the US, some professional societies use buprenorphine off label for those younger than age approved for. Thankfully, in 2023, the US removed the “X waiver” requirement. This was a federal requirement that required practitioners to have a waiver to prescribe medicines like buprenorphine for OUD. This removal allows ANY practitioner who has a DEA registration with Schedule III authority to prescribe. This makes it easier for a patient with OUD to get this lifesaving prescription.

Low and Slow dosing 

In the era of fentanyl for adults, people are starting at higher doses such as 8 or 16 mg on day one. 

However, teens tend to have less tolerance and get sedated at higher doses. Therefore, start lower and slower for teens. Dr. Hadland recommends starting with Buprenorphine 4mg or 8mg daily on day one. An optimal dose is described by a smallest dose that successfully controls withdrawal and cravings. 

It is important to get buprenorphine induction correct to avoid sending teens into precipitated withdrawal. Time to withdrawal varies per patient body fat composition and how much they have been using but generally, you need at least 24 hours to start withdrawing. At the point at which teens start feeling the beginning of withdrawal symptoms is when buprenorphine should be initiated. 

How long should teens be on Buprenorphine? 

Though adult data reveals that long term buprenorphine provides mortality benefit, such data is sparse for teens.  Key differences between adults and teens is that adults usually have more decades of opioid exposure and young people tend to not want to be on meds for a long period. So far, there is no data suggesting “lifetime” as the proper duration of medication treatment for teens with OUD, but recommendations focus on quick and early introduction of MOUD and longer treatment periods. If the risk/benefit decision is made to take a teen off of MOUD, consider Dr. Handland’s approach: 

• Consider taking off buprenorphine as you approach taking off SSRIs. We usually keep SSRIs on for months to a small number of years before we consider taking off.  If you do decide to try to come off buprenorphine, do it in a controlled way with good follow up and not during a particularly stressful time in their life. 

Methadone 

Methadone is FDA approved for those 18 and older and can only be obtained at Methadone clinics, which tend to cater to older populations. In general, it is difficult to find methadone programs to take people under 18 years old. Evidence for methadone in teens is sparse too. We will have to systematically work on making methadone accessible to young people in a way that is developmentally appropriate.  That will take policy change.  We have evidence to suggest that youths who received methadone were 68% less likely to discontinue treatment compared with youths who received behavioral treatment only. This is higher than the percent for Buprenoprhine (42%) and Naltrexone (46%). 

Naltrexone 

Given that evidence is the most sparse for Naltrexone in treating adolescents with OUD and its off-label use in those under 18 years is most questioned, we will not discuss here. Look here for a quick reference. 

Going untreated

Despite the known benefits of MOUD and the American Academy of Pediatrics endorsing the use of MOUD for adolescents and adults, OUD treatment in this population is often delayed and lacks use of evidence-based strategies. A study published by Dr. Hadland et al in 2018 showed that only 4.7% of adolescents and 26.9% of young adults receive MOUD within 3 months of OUD diagnosis. Also shockingly, among Medicaid enrolled adolescents and young adults, only 1 in 54 receive MOUD after surviving an opioid overdose. 

Barriers to treatment include:

• More issues with insurance coverage, i.e. prior authorizations and copays
• Insufficient pediatric prescribers as outlined by a “secret shopper” study published January 2024. A couple findings from this study included that there were ten states with no adolescent treatment facilities, there were 13 states where no facilities that accepted Medicaid, less than half of adolescent residential treatment facilities had an immediate spot available 
• Poor familiarity with medications among clinicians 
• Systemic barriers to accessing methadone 
• Stigma surrounding medication use

Take Home Points from Dr. Hadland

1. Don’t shy away from talking about substances with teens 
2. Teach them about safety via harm reduction approach 
3. When you have these conversations with teens, approach them from a place of curiosity.  Explore their reason for using, share your recommendations, but let it be clear that you will still partner with them on their safety even if they choose to not follow your recommendations 
4. Don’t be hyperbolical when it comes to consequences from using drugs, especially with cannabis. I.e. Do not do that because it will kill you. Be realistic and measured about each recommendation so that when you do talk to them about serious and more lethal substances, they are more likely to listen. 

Goal

Listeners will explain the current state of opioid use disorder and overdoses in adolescents, the importance of fentanyl in the increase in fatal overdoses, how to diagnose and treat OUD in adolescent patients. 

Learning Objectives

After listening to this episode listeners will…  

1. Recall the differences between substance use and substance use disorder 
2. Recognize how fentanyl has changed the overdose demographics and location of overdose 
3. List two tools for screening for OUD in teens in the office 
4. Describe multiple tools to harm reduction for opioid use in teens 
5. Learn about how buprenorphine dosing is different between adults and teens and why
6. Explain why providers might hesitate to prescribe more buprenorphine and why they should be reassured 

Disclosures

Dr Hadland reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Zhang A, Silvas A, Hadland S, Masur S, Chiu C, Berk J. “#127: Holy Smokes! Learning the Basics and Beyond of Opioid Use Disorder in Teens”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ December 4, 2024.