In two decades as a pediatrician, Jason Reynolds has had no success treating patients with opioid use disorder by sending them to rehab. But five years ago, when his Massachusetts practice, Wareham Pediatric Associates PC, became the first in the state to offer medication therapy to adolescent patients, he saw dramatic results.
The first patient he treated with medication, a young man named Nate, had overdosed on opioids twice in the 24-hour period before seeing Reynolds. But that patient has had no opioid relapses since starting drug therapy. Reynolds’ success received a lot of media attention, and one interviewer, he recalls, asked Nate if any of his friends would also consider starting the treatment.
“Nate paused, then said, ‘All of the people I was using with are now dead,’” Reynolds says.
Reynolds is among a small minority of pediatricians using medication to treat opioid use disorder in adolescents. Fewer than 2 percent of all physicians prescribing the medications are pediatricians, and many youth rehabilitation facilities don’t offer them at all.
Medication for opioid use disorder (MOUD) uses buprenorphine or methadone to reduce cravings and withdrawal symptoms, or naltrexone to block the high that users would otherwise get if they decided to use opioids. Though MOUD is often used to treat adults, several barriers have prevented it from being adopted more widely for youth. Reynolds and a handful of other practitioners across the country are now working to provide education and training to other healthcare providers, hoping to increase use of this life-saving treatment.
Opioid use among US youth is on the rise nationally, with diagnoses increasing from 0.26 per 100,000 person-years in 2001 to 1.51 in 2014. Overdose deaths have also spiked, more than doubling among youth ages 14 to 18, from 492 in 2019 to 1,146 in 2021.
Medication is an effective treatment for helping people cope with opioid use. Most studies have looked at adults, but a growing amount of research now focuses on people under the age of 18. A 2018 study, for example, compared behavioral health treatment with medication therapy among adolescents. It found that those who received buprenorphine, naltrexone and methadone were, respectively, 58 percent, 54 percent and 32 percent more likely to continue treatment than young people who received only mental health therapy.
This is important, note the study authors, because spending sufficient time in treatment has been shown, in adults, to reduce mortality for those with opioid use disorder.
Medications such as buprenorphine (shown here) and methadone reduce opioid users’ cravings and withdrawal symptoms. Another medication, naltrexone, blocks the high that users would otherwise get from opioids. Use of these medications is one of the most effective ways to treat opioid use disorder.
MOUD is now recommended as a first-line treatment for youth with opioid use disorder by the American Academy of Pediatrics, the American College of Emergency Physicians and the Society for Adolescent Health and Medicine. “It’s the gold standard for treatment,” says J. Deanna Wilson, a pediatrician and adolescent addiction and medicine researcher at the University of Pennsylvania Perelman School of Medicine. “We do a poor job of getting it to adults who need the medications, but a tragic job of getting it to all of the youth that need them.”
Among adolescents in publicly funded treatment programs, only 2.4 percent of those addicted to heroin and 0.4 percent of those misusing prescription opioids were receiving medication therapy, a 2017 study found. For adults, the numbers were 26 percent and 12 percent, respectively.
And the younger individuals are, the less likely they are to receive MOUD. In another study looking at more than 20,000 youth diagnosed with an opioid use disorder, only 1.4 percent of patients ages 13 to 15 were treated with medication within six months of diagnosis, compared with 9.7 percent of those 16 and 17 years old, 22 percent of people 18 to 20, and 30 percent of people 21 to 25.
There are several reasons adolescents lag in MOUD, wrote Magdalena Cerda, director of the Center for Opioid Epidemiology and Policy at NYU Grossman School of Medicine, and colleagues in the 2021 Annual Review of Public Health. These include “lack of training among pediatricians, limited insurance coverage and limited availability of medications in treatment programs that serve youth, and ongoing preferences for nonmedication treatments,” they wrote.
The most significant obstacle to greater adoption, experts say, may be the reluctance of healthcare providers to give the medications. “Pediatricians are not comfortable treating addiction, and adult substance-use providers are not comfortable treating teens,” Wilson says.
(Credit: P.M. Mauro ET AL/Jama Network Open 2022/Knowable Magazine
Researchers studied the medical records of more than 2 million Americans who needed treatment for opioid use disorder in 2019, to see what kind of treatment they received. Young users, age 12-17, were the least likely to receive any treatment at all, and none of the youth in the study were treated with medications.
Wilson adds that in medicine, it can take almost two decades for evidence to lead to a change in practice, and she says this is happening with MOUD for adolescents. Research has just recently started to bear out its safety and effectiveness, and the healthcare system hasn’t caught up.
Part of the reluctance of health care providers is due to barriers to prescribing that were put in place by the federal government. Methadone, for instance, can only be given at clinics certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). People younger than 18 also need the written consent of a parent or legal guardian and documentation of two recent unsuccessful treatment attempts.
And until January 2023, providers wishing to prescribe buprenorphine were required to receive a special waiver from the Drug Enforcement Administration.
Such regulations imply that the medications are more dangerous than other prescription drugs. “The government told us it was so complicated. They gave a subtle psychological message that tripped people up,” says Sharon Levy, chief of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. “But these are easy and safe and just like any other medications we prescribe.”
Addy Adwell, a nurse care manager and trainer in Seattle who treats patients with opioid use disorder, says that physicians worry about offering young people buprenorphine because, as with morphine, users can develop a physical dependence, and because there are no guidelines for when to end treatment for adolescents. The idea that people are simply trading one drug for another is a prevalent stigma that also keeps doctors from prescribing and patients’ families from acceptance, she says.
But the withdrawal symptoms from MOUD are less intense than from other opioids, and the benefits outweigh the potential side effects, Adwell says. People taking MOUD are more apt to go to school or work, stay out of legal trouble and interact with their family and community productively — perhaps because they are more stable and less likely to continue misusing opioids. What’s more, the numbers compare favorably with behavioral health treatment and rehabilitation: A 2020 study found that adults treated with methadone and buprenorphine were less likely to have an overdose, need acute care related to opioids within three months or be readmitted to rehabilitation after the original treatment.
(Credit: S.E. Wakeman ET AL/JAMA Network Open 2020/Knowable Magazine)
Researchers tracked the success of several different treatments for opioid use disorder in a group of more than 40,000 patients. Those who received medication treatment (MOUD) were much less likely than untreated individuals to experience an overdose in the next 3 months or 12 months. In contrast, those receiving behavioral treatment or inpatient detox services saw much smaller benefits.
Low prescribing among physicians isn’t the only hindrance to MOUD use. Adolescents tend to be skeptical about the health system and feel inherently invincible. And their parents may worry about putting their children on long-term medication, says Molly Bobek, associate vice president of Family and Adolescent Clinical Technology and Science at the Partnership to End Addiction.
To address these problems, Bobek advocates bringing family members or other trusted individuals into the decision-making process. She and her coauthors argue in a recent report that “concerned significant others” tend to financially and emotionally support these youth and play a major role in enrolling them in treatment. Including family in substance misuse treatment may also help increase engagement and improve outcomes.
“Pediatricians have all different kinds of protocols to support parents of youth with diabetes,” Bobek says. “What might it mean to have some support, collaboration and connection for parents of children with opioid use disorder?”
Part of the solution should be screening more youth for substance misuse, says Adwell, who notes that a range of tools already exists to help providers do such screenings, even in busy pediatric practices. To treat youth with MOUD, providers can receive training, and can work with social workers or case managers nearby or virtually.
It’s particularly important for pediatricians to provide this service because there is less stigma about seeking care from a pediatrician than from a drug rehab facility, says Reynolds, and this is where adolescents have the most contact with the health care system. The American Academy of Addiction Psychiatry, the American Medical Association and the American Society of Addiction Medicine all offer providers free online education and training about MOUD. Levy recommends that providers learn the basics and then seek out local mentors to help with questions or concerns.
Levy’s group spearheaded such training in the community. After realizing her program could never keep up with the mountains of referrals coming their way, they decided to reach out to local healthcare providers. Not all their patients needed an addiction medicine specialist, so they began training pediatricians in the Boston area to screen for, and provide medication to, youth with opioid use disorder. When the pandemic hit, they began working with doctors statewide through telemedicine and now have 100 in their network.
The physicians at Wareham Pediatrics were among those trained by Levy and this has enabled Reynolds to help a group of patients he couldn’t before, he says. When he began prescribing MOUD, some of his staff were concerned about working with patients with opioid use disorder and were worried how the community would respond to them offering this treatment. But after seeing its impact on patients, they’re convinced.
Patients would come to the office in withdrawal — anxious, sweating and nauseated — and a few days later, after treatment, come back looking like rested, healthy teenagers. “It really hits home,” Reynolds says. “It helped the staff understand we are really doing something important.”
Tammy Worth is an award-winning healthcare reporter who can be reached at www.tammyworth.net