Responding to the Youth Fentanyl Crisis: Practical Guidance for Child Psychiatrists

Deaths due to unintentional opioid overdose among youth living in the United States have risen at an extraordinary rate over the past 4 years.¹ After remaining stable over the preceding decade, the rate of drug overdose deaths increased more than 2.3-fold from 2019 to 2021 to a record high of 5.49 deaths per 100,000 youth.¹ This rise in fatal overdoses is largely due to increased prevalence of illicitly manufactured fentanyl in the drug supply. In 2021, fentanyl was identified in 77.1% of overdose deaths among US adolescents, a 23.5-fold increase from 2010, compared to 13.3% for benzodiazepines, 5.8% for prescription opioids, and 2.3% for heroin.¹ Compared to other phases of the opioid crisis, fentanyl-related overdoses are characterized by extraordinarily broad geographic and sociodemographic reach.

Notably, this sharp rise in fentanyl-related overdose deaths is occurring during a time when the prevalence of illicit substance use, other than cannabis, continues to decline.² The Monitoring the Future study found that past-year self-reported use of narcotics was 1.7% among US 12th graders in 2022, an all-time low from the peak of 9.5% in 2004.² Similarly, the 2021 National Survey on Drug Use and Health estimated that 1.0% to 1.3% of US youth aged 12 to 25 years met criteria for an opioid use disorder (OUD) in the past year.³ Taken in conjunction with data showing a sharp rise in fentanyl-related overdose deaths in this population, these findings highlight the unique risk that fentanyl exposure, whether via intentional or unintentional use, presents for youth who use illicit substances. Furthermore , only 3.5% to 4.1% of youth with any substance use disorder (SUD) received specialized SUD treatment,³ and fewer than 20% of youth who meet criteria for OUD received medication treatment.³ Thus, during this fentanyl crisis, only a small proportion of those youth who are at highest risk for mortality from opioid overdoses in the United States have received evidence-based prevention or treatment to reduce that risk. Collectively, the stark reality of fentanyl-related overdose deaths in US youth and low rates of treatment is an urgent call to action for child and adolescent psychiatric providers to engage youth in discussing the risks of fentanyl and overdose prevention and response planning, increasing access to the opioid antagonist naloxone, facilitating treatment engagement, and considering initiating medications for OUD to decrease the risk of fatal overdose.

CHALLENGES OF FENTANYL EXPOSURE IN YOUTH

Illicitly manufactured fentanyl is a synthetic mu (μ) opioid receptor agonist that is approximately 50 to 100 times more potent than heroin or morphine, respectively.⁴ Fentanyl is highly lipophilic, leading to rapid transit of the blood–brain barrier and redistribution into adipose tissue. This results in a fast onset of action, with short duration, that increases the positive reinforcing effects and misuse potential of fentanyl. Fentanyl also rapidly binds opioid receptors in the pons, which may result in respiratory suppression within minutes of use. Albeit less understood, fentanyl causes chest wall rigidity and cardiac arrhythmias, which may contribute to the higher risk of fatal overdose compared to other opioids.

Over the past few years, fentanyl has become pervasive in the US illicit drug supply. Varying amounts of fentanyl are often pressed into counterfeit pills containing other substances. Pressed pills combining fentanyl with other opioids, often oxycodone, are designed to resemble prescription oxycodone tablets and are often referred to as “blues,” “oxy,” or “fentanyl.” Recently, pressed pills are being manufactured in multiple colors, known as “rainbow pills,” which are more discreet and appealing to youth. The US Drug Enforcement Administration (DEA) recently warned that approximately 40% of counterfeit pills tested contained at least 2 mg of fentanyl, a potentially lethal dose.

Fentanyl is also pressed with non-opioid drugs, including amphetamines and benzodiazepines. Youth may be first exposed to fentanyl unintentionally and are at risk for fatal overdose with unintentional exposure. This presents a unique challenge, whereby youth consuming counterfeit pills intending to use a non-opioid substance may unknowingly be exposed to a lethal dose of fentanyl. Furthermore, many fatal overdoses involve more than 1 substance, and there is concern that the combination of fentanyl with stimulants or benzodiazepines may further elevate the risk of unintentional fatal overdose.

CLINICAL GUIDANCE

Given the rise in prevalence of fentanyl use among youth, child and adolescent psychiatric providers need to be proactive with their patients to mitigate the risk of overdose. A developmentally informed cascade of care that includes systematic screening and risk stratification of youth and families followed by delivery of tiered interventions provides a clinical framework to engage youth and reduce the risk of overdose.⁵ Interventions should target both proximal and distal upstream factors that are driving the fentanyl crisis, by means of the following: (1) focusing on acute life-saving strategies through population-wide risk screening and widespread provision of overdose response training and overdose rescue medications to youth, families, and communities who are at risk; (2) improving identification, treatment engagement, medication treatment for OUD (termed MOUD) receipt, and recovery support services for youth with OUD; and (3) expanding services targeting distal primary prevention and early intervention strategies for youth and families who are at risk for starting or are misusing non-opioid substances.

With the rising rates of opioid overdose deaths, clinicians should use a framework of risk factors to identify youth at elevated risk for overdose, and should work with youth and their family members to establish an overdose prevention and response plan. Amidst widespread fentanyl contamination of the US drug supply over the past 5 years, overdose risk factors are changing, impacting the risk calculation for certain factors (eg, illicit drug use is riskier) and driving a need for clinicians to shift their strategy and intervene earlier than in prior decades. In the current climate, use of any illicit or street-obtained drug carries an elevated risk of overdose secondary to fentanyl contamination. Furthermore, use of these drugs while the user is alone can be particularly deadly. As such, clinicians should expand their overdose prevention and response planning strategy to target all youth who have known risk factors for opioid overdose, even if they do not report intentional opioid misuse or meet OUD diagnostic criteria. Table 1⁶ provides a list of overdose and OUD risk factors for youth. Clinicians should become knowledgeable about risk factors for overdose and develop proficiency and comfort in talking with youth and their parents/families about risk factors, overdose prevention, and overdose rescue interventions. The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed an opioid overdose prevention toolkit to guide clinicians through prevention planning with families.⁷ Components of an opioid overdose prevention plan include teaching patients and families how to recognize and respond to a suspected opioid overdose. Many states have passed “Good Samaritan” laws that protect bystanders who help someone experiencing a medical emergency, including administering naloxone for a suspected opioid overdose. As part of care planning, clinicians should learn about their local and state laws to facilitate education of patients and families about overdose response.

TABLE 1.

Risk Factors for Opioid Overdose and Opioid Use Disorder in Youth

Opioid overdose risk factorsa	Targeted prevention/intervention strategies
History of non-fatal drug overdose	Overdose prevention planning including providing family education, prescribing naloxone to the youth and concerned family members, and assessing for OUD diagnosis and indications for MOUD
Fentanyl use	Educate youth and family about high risk of overdose and overdose death related to fentanyl use
Injection drug use	Educate youth and family that modes of administration that deliver opioids more quickly to the brain, such as injection drug use, place people at higher risk for overdose
Co-use of opioids with sedatives/hypnotics (eg, alprazolam), stimulants, and/or alcohol	Educate youth and family about elevated risk of overdose and overdose death when opioids are co-used with these other substances
Current or lifetime OUD diagnosis	For current OUD, engage in motivational interviewing to encourage treatment engagement and consider starting MOUD; for lifetime OUD, monitor for relapse and engage in relapse prevention interventions as indicated
Past-year opioid use/misuse or non-medical prescription drug use	Educate youth and family about the elevated risk of overdose from unintentional fentanyl exposure from use of illicit drugs and counterfeit prescription pills (“One Pill Can Kill” education campaign6)
Opioid use disorder risk factors	Targeted prevention/intervention strategies
Individual factors
Genetic and developmental factors	Education, testing, and early intervention
Childhood adversity, including sexual and physical abuse and neglect	Safety and monitoring, diagnosis and treatment of any stress-related disorders, and using a trauma-informed approach for treatment across disorders
Childhood-onset and persistent emotional distress or aggression	Diagnosis and provision of evidence-based treatment for psychiatric disorders
Psychiatric disorders (anxiety, depression, PTSD, externalizing disorders)	Diagnosis and provision of evidence-based treatment for premorbid or co-occurring psychiatric disorders
Physical health problems (eg, fatigue, headache)	Work with primary care and other specialists to determine treatment needs and treat underlying medical conditions or physical health problems
Acute or chronic pain condition	Work with primary care and/or pain specialist to determine treatment needs and treat pain condition with non-opioid medication and behavioral interventions
Being prescribed an opioid pain medication	Education about risk, recommendation to shift as quickly as possible to non-opioid pain treatment strategies, monitor for signs of misuse
Low perceived risk of harm related to substance use	Education with goal of correcting inaccurate risk perceptions and expectations; administer substance use prevention interventions; and strengthen positive affective and peer substance refusal skills
Substance use motivation for reward seeking (“getting high”) or pain relief	Work with youth to identify alternative, healthy, prosocial ways to pursue reward/sensation seeking (eg, sports); treat pain with non-opioid medication and behavioral interventions
Early-onset substance use (age <13 years)	Early-intervention and evidence-based substance use treatment; consider family interventions focused on resetting expectations, household rules, and parent monitoring
Use and misuse of cannabis, tobacco, alcohol, and non-opioid drugs	Early-intervention and evidence-based substance use treatment; consider family interventions focused on resetting expectations, household rules, and parent monitoring
Non-medical opioid prescription drug or counterfeit pill misuse	Early-intervention and evidence-based substance use treatment; engage family in cessation strategies and provide education about overdose risk and overdose prevention planning
Family and community factors
Low socioeconomic status	Address social determinants of health; strengthen protective factors including engagement in prosocial activities, early self-regulation and social skills
Family history of substance use and SUD	Family assessment and provision of family therapy and referral of family members with current substance use problems or SUD to treatment as indicated
Family dysfunction, conflict, parental divorce	Assessment of family system and provision of evidence-based family therapy
Availability of prescribed opioid medications or illicit opioids in the home	Assess for household safety; educate patients and families on proper disposal of opioid medications; assess for problematic substance use in caregivers and, if indicated, refer for treatment
Witnessing a family member or friend overdose	Education and provision of naloxone prescription and overdose prevention training to patient and family; assess for and treat trauma reactivity in youth
Favorable attitudes of substance use by parents/caregivers and community	Parent/family education about risks of youth substance use and clear medical recommendation for monitoring and to set household “no youth substance use” policy
Association/affiliation with peers who use drugs	Encourage parents/caregivers to set clear expectations and provide supervision; encourage engagement in prosocial activities in community to socially engineer peer group affiliation

Note: MOUD = medication treatment for opioid use disorder; OUD = opioid use disorder; PTSD = posttraumatic stress disorder; SUD = substance use disorder.

^aChild and adolescent psychiatric providers working with youth who have any of the listed opioid overdose risk factors should engage the youth patient and their parents/caregivers and family in overdose prevention and response planning and prescribe naloxone, as described in the targeted prevention/intervention strategy section of table for history of non-fatal opioid overdose.

An essential component of the overdose response plan targeted at reducing the risk of overdose death is to increase accessibility to the overdose rescue medication naloxone.⁷ Naloxone is an opioid antagonist that is used to reverse an opioid overdose. The US Food and Drug Administration (FDA) has approved an intranasal formulation of naloxone for opioid overdose, which was recently approved for sale without a prescription. The World Health Organization, as well as multiple professional organizations, have encouraged the broad dissemination of naloxone rescue medications to people likely to witness an opioid overdose, including family and friends. Clinicians who work with youth with opioid overdose risk factors should prescribe intranasal naloxone and provide education and training to youth and their families about its use in the event of a suspected overdose.⁸ As most fentanyl overdose deaths among US youth occur at home, clinicians should focus overdose response planning and naloxone training on parents and concerned significant others and family members of youth at risk for overdose. Having naloxone rescue medications available at home, school, and in other settings frequented by youth who are at elevated risk for overdose can save lives.

Early identification, diagnosis, and provision of evidence-based treatment and recovery support services for youth with OUD are central strategies for reducing adverse outcomes for youth during the fentanyl crisis.⁵ Within the OUD cascade of care, the first step of clinical management is to perform a comprehensive assessment.⁹ Evidence-based screening tools may be used to aid in the detection of high-risk substance use in youth. Any assessment for suspected substance use, non-medical prescription drug use, or opioid misuse should include a complete medical and psychosocial assessment, collateral from other sources (eg, caregivers), and urine drug screening (UDS). Related to urine testing, it is important to point out that fentanyl is not detected on standard UDS qualitative drug panels and that only 1 point-of-care UDS for fentanyl has been cleared by the FDA to date. When clinically indicated, clinicians should test for fentanyl in addition to the UDS. Street-purchased drugs containing fentanyl are difficult to distinguish from those that do not contain fentanyl. As such, there should be an increased focus of the assessment on the type and source of drugs used.

An OUD diagnosis requires an individual to engage in functionally impairing non-medical opioid use per DSM-5. Like other substance use disorders, OUD falls along a continuum of severity based upon the number of symptoms including mild (2 or 3 symptoms), moderate (4 or 5 symptoms), or severe (≥6 symptoms). Problems due to misuse in youth may not readily align with DSM-5 criteria, which are standardized to the adult population, and youth with 3 or fewer symptoms may still be at high risk for fatal overdose due to fentanyl use.

For youth with OUD, aggressive treatment is indicated, with the intensity of clinical management based upon the severity of OUD and accompanying prognostic factors (eg, treatment motivation, family engagement, living situation, presence of co-occurring psychiatric and medical conditions). The American Society of Addiction Medicine has established a 6-dimension assessment to identify the appropriate level of care, with residential treatment being considered for high-severity/high-risk cases. MOUD treatment with buprenorphine, methadone, and extended-release naltrexone has been shown to reduce morbidity and mortality in adults with OUD. Currently, buprenorphine is the only OUD medication that is FDA approved for the treatment of OUD in adolescents aged 16 years or older. The Society for Adolescent Health and Medicine recommends that MOUD should be offered in conjunction with evidence-based psychotherapy to all adolescents with OUD, regardless of disorder severity.¹⁰ However, MOUD remains greatly underused in adolescents and young adults. Beyond buprenorphine, there is also emerging evidence for the use of extended-release naltrexone and methadone for the treatment of OUD, as well as clonidine for the treatment of opioid withdrawal syndrome, in youth. In addition, recent studies suggest that MOUD initiation protocols and regimens may need to be modified to account for fentanyl’s higher potency. For example, data from adults receiving MOUD treatment show that people who regularly use fentanyl may require higher doses of buprenorphine or methadone and greater monitoring during medication initiation to achieve stabilization. Whether these fentanyl-related dose and regimen adjustments are needed for youth with OUD remain unanswered questions. Finally, in some states and jurisdictions in the United States, fentanyl test strips are available for people (young and old) who use opioids and other illicit substances and can be used as part of a harm reduction strategy, enabling these individuals to test their drug supply for fentanyl prior to using.

Beyond proximal strategies, more distal strategies focused on primary prevention and early interventions to prevent the onset of non-medical prescription drug use and opioid misuse in at-risk youth can be complementary and carry the potential to concurrently address the opioid crisis and reduce the risk from fentanyl for the next generation.⁹ Current strategies to avert the initiation of opioid misuse and progression to OUD address modifiable risk factors and provide targeted early interventions. Knowledge of modifiable risk and protective factors for opioid misuse may provide a roadmap to guide risk assessment and stratification and to inform primary and targeted prevention and early intervention efforts for youth (Table 1). Comprehensive evaluation of risk and protective factors includes characterization of family, school/educational, vocational, and mental health histories. Perpetuating factors identified during the assessment phase can later be targeted during treatment to reduce the risk of relapse. In addition, proactively treating mental health disorders and non-opioid substance use and SUD is warranted to mitigate the risk of developing OUD.

CONCLUSION

In summary, during this fentanyl-centric phase of the opioid crisis, illicit drug use, opioid misuse, and OUD carry increased risk of adverse outcomes, including death, related to fentanyl contamination. Child and adolescent psychiatric providers can play a key role in response to the opioid crisis by systematically screening youth for opioid use and OUD, as well as overdose risk factors, and providing tiered interventions targeting proximal and distal factors across 3 domains. First, responding to overdose risk screening by providing targeted “just-in-time” overdose prevention and response planning, as well as access to naloxone rescue medication, is recommended for all youth with overdose risk factors (eg, non-medical prescription drug use, illicit drug use, opioid misuse, and OUD) and should be done in collaboration with the family. Second, strategies focused on early identification and diagnosis of OUD and expansion of OUD treatment, MOUD access, and recovery support services are vital to addressing the opioid crisis. Finally, primary prevention and early intervention strategies focused on reducing the risk for initiating misuse of opioids and targeting non-opioid substance use represent important areas of focus for child and adolescent psychiatric providers that may disrupt the intergenerational transmission of opioid use and, in doing so, end the opioid crisis before it reaches the next generation.