In September of last year, the American Academy of Pediatrics (AAP) issued a policy statement calling for making drug therapy available to adolescents with opioid use disorder (OUD).
The statement caused hardly a ripple. Those who treat adolescents reported that some families, clinicians, even some patients, consider the medications—methadone, buprenorphine/naloxone, naltrexone—a last resort.
Now, a year later, several articles have addressed this issue and offer recommendations. One article underscores the risks of waiting “until things get worse” (see “Recommendations” under “Commentary,” below). This AT Forum article summarizes the recent findings and the many recommendations from these articles.
Rise in Opioid-Related Deaths Follows a Two-Year Hiatus
In 1999, adolescent death rates from overdoses involving opioids began rising sharply. Rates have zigzagged downward since about 2007, but began rising again between 2014 and 2015 (see figure below). How many young people have died from overdoses involving opioids isn’t known, but following the trend of the line in the figure below gives a clue to the severity of the situation.
Drug Overdose Death Rates Involving Opioids;
Adolescents Aged 15–19, United States, 1999–2015
Adapted from NCHS, National Vital Statistics System, Mortality. Curtin SC, Tejada-Vera B, Warner M. Drug overdose deaths among adolescents aged 15–19 in the United States: 1999–2015. NCHS data brief No. 282, August 2017. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db282.pdf.
Timely, appropriate treatment would have saved some of these young lives. Especially tragic: in 2015, about 80% of adolescent deaths were unintentional. Attitudes are beginning to change, however: many clinicians now realize that the need for treating adolescents with OUDs has indeed become urgent.
The AAP Policy Statement—
American Academy of Pediatrics. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics, 2016.
The 2016 publication, the first official policy statement on treating OUDs from a professional pediatric organization, indicated an important shift in professional thinking. Starting out by briefly reviewing the history, consequences, and treatment of opioid misuse, it went on to note the availability but underuse of effective medications and counseling, and the impediments to treating young patients: federal regulations that block most methadone programs from enrolling patients younger than age 18, and restrictions limiting buprenorphine treatment in patients younger than age 16.
Recommendations. The Policy Statement called for offering available treatment to adolescents with OUDs, and developing new treatments “to save and improve lives of youth with opioid addiction.” (The term “youth” in this context refers to adolescents and young adults.)
The AAP group recommends improving access to medication-assisted treatment (MAT) in the young, both in primary care and through counseling in community centers; conducting further research on “primary and secondary prevention, behavioral interventions, and medication treatment. It also recommends that pediatricians consider offering MAT to patients, or discussing referrals.
Addressing Stigma in Medication Treatment of Adolescents With Opioid Use Disorder. Bagley et al. American Society of Addiction Medicine, 2017.
Regarding the AAP Policy Statement, the clinical experience of the Commentary’s authors indicated that some patients, families, even clinicians perceive using medications to treat OUDs in adolescents “a last resort;”—believing it’s necessary to wait to treat “until things get worse.”
The authors, who are addiction specialists with the American Society of Addiction Medicine (ASAM), strongly disagree. Stressing that their role requires them to identify and prevent risky use and use disorders, intervene early, “and offer timely, evidence-based treatment,” they see treating adolescents not as a last resort, but as an opportunity “to prevent the long term medical, psychiatric, and social consequences of ongoing substance use.”
And they note that caregivers and patients may incorrectly assume that young people may need to continue medication for life, a misconception the authors attribute to stigma, possibly explaining the resistance to treating OUDs with medication.
The authors stress that the medication course can in fact be limited in younger patients, and “it is possible that earlier treatment in adolescence may lead to sustained recovery in adulthood.”
They acknowledge, however, that more needs to be known about selecting the medication and the length of treatment.
Recommendations. To destigmatize medication treatment, the authors recommend launching a coordinated effort that begins with the federal government, uses evidence-based interventions, and targets all players—parents, behavioral health providers, and state agencies. They say that the treatment models used in younger patients may need to be adapted to include family in treatment, and to account for developmental differences. They also emphasize reducing the stigma associated with using medications in treating this group.
MAT for Adolescents in Specialty Treatment—
Medication-Assisted Treatment for Adolescents in Specialty Treatment for Opioid Use Disorder. Feder et al. Journal of Adolescent Health, 2017.
This study, covering 139,092 patients, found that only 2.4% of adolescents treated for heroin use received MAT, compared to 26.3% of adults treated. For treatment related to prescription opioids, the corresponding numbers were only 0.4% of adolescents and 12.0% of adults. The data were from publicly funded programs in specialty treatment programs.
The authors noted severe restrictions on methadone access for patients aged 16 and 17 years. Methadone clinics need special wavers to treat adolescents, and require proof of two failed attempts by the patient to discontinue drug use.
Recommendations: Regarding Medicaid and CHIP (Children’s Health Insurance Program): include MAT in the early periodic screening, detection, and treatment benefit of state Medicaid programs, and include adolescents in ongoing Medicaid demonstrations to expand MAT. In addition, “policy and practice changes are needed to expand access,” as recommended by the AAP.
Trends: An Original Investigation—
Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. Hadland et al. JAMA Pediatrics, 2017.
A large retrospective study looked at insurance and treatment data from 20,822 commercially insured OUD patients aged 13 to 25 years. Although medication dispensing fluctuated, only one out of every four commercially insured youth ever received medication (buprenorphine or naltrexone). Moreover, investigators observed “disparities based on sex, age, and race/ethnicity.”
Those less likely to receive medication were younger, or female, or nonwhite. The authors commented, “Intervening early in the development of OUD is critical for preventing premature death and lifelong harm.”
Both the AAP policy statement and the 2016 surgeon general’s report reiterate the need to intervene early; in fact, two-thirds of patients being treated first used opioids before age 25; one-third, before age 18.
The team criticized the AAP Committee for not releasing a policy statement until September of 2016—during a worsening youth opioid epidemic, “despite preexisting recommendations from the Substance Abuse and Mental Health Services Administration.” This, the Committee said, may have delayed pediatricians’ adoption of drug therapy for their young patients.
Recommendations. Include drug therapy in pediatric primary care, and improve access to evidence-based treatment for adolescents—for example, by adding pediatric addiction subspecialists. In addition, expand the use of pharmacotherapy for youth, and ensure equitable access for all affected youth.
Editorial: Closing the Gap—
Closing the Medication-Assisted Treatment Gap for Youth With Opioid Use Disorder. Saloner et al. JAMA Pediatrics, 2017.
An editorial in the same issue of JAMA Pediatrics as the Hadland article includes many recommendations. We list some of them below.
- Have pediatricians refer youth to a methadone clinic or other specialty treatment for MAT
- Build capacity in pediatric primary care, giving physicians knowledge and support to prescribe MAT
- Expand the office-based prescriber workforce; include pediatricians
- Integrate primary and specialty care (for example, adapt “hub-and-spoke”)
- Reduce stigma toward MAT
- Improve health insurance policy support of youth access to MAT
- Arrange for payment through insurance programs for counseling and recovery management;
- Close the gap in evidence-based care for youth through comprehensive policy changes and individual practice changes.(See the published articles for details of all studies.)
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AAP Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893. doi:10.1542/peds.2016-1893.
Bagley SM, Hadland SE, Carney BL, Saitz R. Addressing stigma in medication treatment of adolescents with opioid use disorder. J Addict Med. 2017 [Epub ahead of print]. PMID: 28767537. ISSN: 1932-0620/16/0000-0001. doi:10.1097/ADM.0000000000000348.
Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder. Adolescent health brief. J Adolesc Health. 2017;60:747e750. PMID: 28258807. doi:10.1016/j.jadohealth.2016.12.023.
Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, Larochelle MR. Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001-2014. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8):747-755. PMID:28628701. doi:10.1001/jamapediatrics.2017.0745.
Saloner B, Feder KA, Krawczyk N. Closing the medication-assisted treatment gap for youth with opioid use disorder. Editorial. [Epub June 19, 2017.] JAMA Pediatr. 2017;171(8);729-731. PMID:28628699. doi:10.1001/jamapediatrics.2017.1269.