How Clinicians Caring for Youth Can Address the Opioid-Related Overdose Crisis

Considerable attention in the US and abroad has been paid to the dramatic rise in opioid-related overdoses that has occurred since the turn of the century. Adolescents and young adults have not been spared the enormous morbidity and mortality of this crisis. Adolescent overdoses from prescription opioids, heroin, and fentanyl rose 95%, 405%, and 2925%, respectively, from 1999 to 2016, and young adults have among the most rapidly increasing overdose mortality rates in comparison to all other age groups [1,2]. Mirroring these trends, nonfatal overdoses, diagnoses of opioid use disorder (OUD), and new infections with hepatitis C have also reached unprecedented levels among youth [3–5].

Clinicians of all disciplines who care for adolescents and young adults (collectively, “youth”) have a critical role to play in addressing the overdose crisis. One in three individuals in treatment for OUD report that their first use of opioids occurred before age 18, and two in three report that it occurred before age 25 [6]. Any sustainable solution to the opioid crisis will require much of the youth-focused clinical workforce. This Commentary highlights how clinicians can do their part to address this enormous public health problem.

Screening, brief intervention, and referral to treatment

Despite the clear need for a multifaceted long-term approach to addressing addiction, in the short term, clinicians working with youth can immediately implement numerous interventions in their own practices (Table 1). As a first step, all clinicians working with youth can become competent in screening, brief intervention, and referral to treatment (SBIRT), which are critical to identifying and addressing substance use disorders [7]. Validated screening tools such as the CRAFFT (Car, Relax, Alone, Friends, Forget, Trouble, available at http://crafft.org/get-the-crafft) or S2BI (Screening to Brief Intervention, available at https://www.drugabuse.gov/ast/s2bi) instruments are freely available, validated for use among youth, and ask simple single-item questions about the frequency of use of substances (including opioids) and problems resulting from use [8,9].

Table 1:

Steps clinicians can take now to address opioid use disorder (OUD) among youth.

— Routinely screen youth for substance use, including opioid use

— Be familiar with local evidence-based treatment programs to refer youth with OUD

— Integrate substance use treatment into primary care to provide addiction care in the same trusted setting where youth receive their other medical care

— Ensure that, either in specialty or primary care-based addiction treatment, youth have access to pharmacotherapy for OUD, including methadone, buprenorphine, and naltrexone

— Become waivered to prescribe buprenorphine, and encourage other physicians, nurse practitioners, and physician assistants to become waivered

— Educate all youth with OUD on how to reduce the risk of overdose, including not using alone, starting with a small amount of opioid as a test, avoiding polysubstance use, carrying naloxone, having a safety plan for addressing overdose, and calling 911 in states with ‘Good Samaritan’ laws

— Prescribe naloxone to youth with OUD and to their family members

— Prescribe opioids appropriately to reduce the risk for addiction and diversion

— Use language that minimizes stigma for youth and families who experience addiction

After screening, youth receive a brief intervention. Youth who do not use substances receive an affirming statement regarding their choices, and are offered the opportunity to return to speak to a clinician anytime should they initiate substance use [7]. Youth who have experimented with substances receive a recommendation not to use, and those with heavier use are challenged to reduce their use, ideally through the use of motivational interviewing techniques. Youth with problematic use also receive motivational interviewing, but are likely to require more intensive services (discussed in depth below). Although there are few data regarding brief interventions for opioid use, studies suggest that they can reduce substance use and related harms for youth who use alcohol and marijuana [7,10], and thus may deter some youth from initiating or intensifying opioid use.

SBIRT can be conducted by any member of an interdisciplinary team including non-physicians. Screening and brief intervention can also be achieved through a computer-based or mobile device-based platform [11–13], with positive screens followed up in person by a clinician. Traditionally the province of primary care physicians, SBIRT is increasingly being introduced into novel settings, including emergency departments and schools [12–14], offering new opportunities to identify youth with substance use disorders.

Whether OUD is uncovered through screening or is a presenting complaint, all clinicians should be prepared to refer youth to evidence-based addiction treatment [7]. In the US, the Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a publicly available list of addiction treatment programs (available at https://findtreatment.samhsa.gov). Youth, families, and clinicians can use the web-based locator to find nearby programs and search for specific characteristics, such as whether the program accepts adolescents <18 years or offers pharmacotherapy for OUD. Notably, large swathes of the US, particularly in rural regions, have extremely poor access to OUD treatment [15].

Integration of treatment into primary care

Addiction treatment for youth is likely to increasingly becoming integrated into primary care. Still, most treatment currently takes place in specialty settings where youth and their families may experience stigma and inconvenience [16]. Conversely, in primary care, youth can receive developmentally-appropriate addiction treatment in the same familiar setting where they receive the remainder of their medical care [17,18].

Numerous models for integrating addiction treatment into primary care have shown success. Three promising approaches include (1) Office-Based Addiction Treatment (OBAT), in which nurse care managers facilitate prescribing of pharmacotherapy for OUD, monitor patients’ recovery, and oversee urine drug tests; (2) the Hub-and-Spokes model, in which ‘hubs’ are regional specialized addiction treatment centers that care for complex patients with OUD and provide consultative services, and ‘spokes’ are primary care clinics that care for less complex patients with the support of clinicians at the ‘hub’; and (3) Project Extension for Community Healthcare Outcomes (ECHO), which links geographically distant primary care practices with addiction specialists who offer mentoring and education through online video conferencing [19].

Evidence-based treatment including pharmacotherapy

Regardless of where youth receive treatment for OUD, pharmacotherapy should be offered in addition to behavioral health services, particularly in severe cases of OUD [20]. The three US Food and Drug Administration-approved medications for OUD treatment are methadone, buprenorphine, and naltrexone. Medications reduce or eliminate illicit opioid use, reduce cravings, enhance retention in addiction treatment, and reduce mortality [21–24]. Unfortunately, the well-established medication treatment gap for adults with OUD is even larger for youth [25]. Most youth diagnosed with OUD receive only behavioral health services; only one in four receive pharmacotherapy [3,26]. Yet, youth who receive pharmacotherapy are less likely to drop out of behavioral health services [26]. Nonetheless, there is a widespread practice across the US of either denying entry to OUD treatment for youth who are on pharmacotherapy, or of discontinuing medications prior to entry; as of February 2019, of the 5,023 OUD treatment programs that accept adolescents listed in the SAMHSA Treatment Locator, 38% do not accept clients on pharmacotherapy [27]. Clinicians might consider developing relationships with local addiction treatment centers to determine whether these programs use evidence-based approaches, including pharmacotherapy when indicated.

A key barrier to accessing pharmacotherapy is a shortage of prescribers. Buprenorphine, the most commonly used medication for youth with OUD [3,26], can only be prescribed by physicians, nurse practitioners, and physician assistants who have completed an extensive training course (eight hours for physicians, 24 hours for nurse practitioners and physician assistants). Many addiction specialists advocate for eliminating this requirement, but regulations are unlikely to change in the near future [28]. Very few of the currently available buprenorphine prescribers have youth expertise; indeed, only 1 in 50 of US buprenorphine prescribers identify pediatrics as their specialty [29].

It is therefore imperative that more clinicians who work with youth undergo training to prescribe buprenorphine. Many clinicians argue that they do not envision themselves regularly prescribing buprenorphine (particularly if they have OUD treatment services to which they can refer) and thus feel that such training is unnecessary. However, maximizing the number of clinicians prepared to treat OUD using pharmacotherapy will guarantee that there are no “wrong doors” for youth seeking to enter treatment through traditional medical settings [30]. Adolescent-focused physicians, nurse practitioners, and physician assistants might therefore consider completing the buprenorphine waiver course (a list of in-person and online offerings is available at https://pcssnow.org/medication-assisted-treatment/).

Overdose education, naloxone distribution, and harm reduction

Robust overdose education and harm reduction services are also critical components of addiction care. Substance use disorder is a chronic medical condition marked by periods of recovery and relapse, and clinicians can help youth maximize their health and safety when they use substances. All youth and family members affected by opioid use disorder should be offered naloxone, the overdose reversal agent that is available in easy-to-administer intranasal or intramuscular formulations [31]. Many states have standing orders for naloxone, and thus any individual can receive it from a pharmacy without the requirement for a prescription. It is commonly covered by insurance and is also handed out for free by many community organizations.

Clinicians can also counsel youth about how to reduce the risk of overdose and injection-related harm. Youth can be advised not to use opioids alone, to start with a small amount of opioid as a test before using and see how their body responds, avoid polysubstance use (particularly benzodiazepine or alcohol use, both of which increase the risk of respiratory depression), carry and know how to use naloxone, have a safety plan in the event someone overdoses, and call 911 when needed. To help protect people who contact emergency services, many states have passed ‘Good Samaritan’ laws, which protect such from experiencing arrest from drug possession charges. A list of applicable states is available at http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx) [32].

Clinicians can also become aware of community-based harm reduction services to which they can refer youth, including local syringe/needle exchange programs, pharmacy-based sterile needle distribution programs, and safe consumption spaces, all of which help youth minimize the risk of infectious disease transmission [33–35]. These evidence-based services do not increase opioid use or encourage individuals to continue using opioids [36]. Rather, they offer points of contact for high-risk youth who may ultimately seek to enter treatment [37]. Although many harm reduction services were developed for adults, youth frequently use them, and clinicians can work closely with community programs to enhance the youth-friendliness of such services [38].

Safe opioid prescribing

Regardless of whether they are working with youth with known substance use disorder, adolescent-focused clinicians can prescribe opioids in a way that minimizes risk of a subsequent use disorder. Data suggest that of all adolescents and young adults prescribed an opioid, approximately 1 in 17 may go on to develop OUD [39,40]. Although for most non-severe pain, non-pharmacologic approaches, non-steroidal anti-inflammatory drugs, and acetaminophen are first-line, opioids have a role in treating some types of severe pain. Practitioners need not eschew prescribing opioids altogether, but rather prescribe in a way that minimizes the risk of OUD (Table 2).

Table 2:

Best practices for prescribing opioids for severe pain [45].

— Conduct assessment of risk factors for opioid use disorder (e.g., other substance use disorder; mental health diagnoses; family history; parents, siblings, or peers who use substances)

— Check prescription drug monitoring program to ensure patient is not receiving multiple prescriptions

— Use non-pharmacologic modalities (e.g., relaxation techniques, distraction, heat/cold stimulation, physical therapy) whenever possible to reduce acute and chronic pain

— Use non-opioid analgesics as first-line for mild or moderate acute pain, including nonsteroidal anti-inflammatory drugs, acetaminophen, and topical medications

— Ensure that the underlying diagnosis has a clear indication for opioids, and a definable endpoint for treatment

— When prescribing an opioid for severe acute pain, use the lowest effective dose of short-acting formulation

— Offer a short course (3 days or fewer are typically sufficient; laws in many states limit the duration of a first opioid prescription, particularly for minors)

— Notify parents of minors; review dosing, administration, safe storage and disposal

— Recall that in many states partial prescription fills are allowable (i.e., youth or families can decide to only receive some but not all of the prescribed tablets)

— Avoid opioids for most types of chronic non-cancer pain

— If considering opioids for chronic pain that involves daily or near-daily use, consult a specialist with expertise in pediatric pain management

Avoiding stigmatizing language

Lastly, clinicians and all clinical staff, beginning with front desk staff, can work to create a welcoming, non-stigmatizing environment for youth who use substances. Youth and families affected by substance use experience discrimination, labeling, stereotyping, victimization, social isolation, and rejection by friends and other family members – all of which contribute to stigma, a known barrier to addiction treatment [16,41]. Staff can warmly welcome youth with OUD at every clinical encounter regardless of their willingness to receive treatment, recognizing that harm reduction and other primary care services can be offered to keep youth safe and healthy until they are ready to receive treatment. Since language commonly used by staff may be stigmatizing and adversely affect care, clinicians should use scientifically accurate, person-first language (Table 3) [42,43].

Table 3:

Person-first, non-stigmatizing language to support youth and families who experience addiction [42].

Problematic language	Supportive language
“Junkie”	“Person with a substance use disorder”
“Druggie”	“Person with a substance use disorder”
“Addict”	“Person with a substance use disorder”
“Substance abuser”	“Person with a substance use disorder”
“Substance abuse”	“Substance use”, “substance misuse”, “substance use disorder”
“Clean”	“In recovery”
“Medication-assisted treatment (MAT)”	“Treatment”, “pharmacotherapy”, “medication for addiction treatment”
“Replacement therapy [with methadone or buprenorphine]”	“Treatment”, “pharmacotherapy”, “medication for addiction treatment”
“Born addicted”	“Born substance-exposed”

Long-term investment in research and education

Clinicians and researchers need to pursue a broad research agenda to determine the best approaches to preventing substance use and substance use disorders. The overriding national response to the overdose crisis has been to enhance downstream interventions (e.g., improving access to OUD treatment and the overdose reversal agent naloxone); this approach is akin to concentrating resources on the treatment of myocardial infarction without comprehensively addressing the medical, social, and economic determinants of heart disease that are established much earlier in life. Strong prevention is needed to stop the youth of today from becoming the overdose statistics of tomorrow.

Additionally, all disciplines, including medicine, nursing, social work, psychology, and others will need to greatly improve their training in substance use and addiction. For physicians, the recently approved subspecialty field of addiction medicine offers a new opportunity for board certification [44]. Nonetheless, all physicians regardless of specialty, and clinicians from all disciplines who work with youth, will require more robust training in addressing substance use disorders to establish a skilled and prepared workforce [17].

Conclusion

North America and numerous other regions worldwide are experiencing unprecedented youth morbidity and mortality owing to opioid misuse. Until now, the youth-focused workforce has largely been on the sidelines of the public health response. Given the clear onset of substance use disorders during adolescence and young adulthood, clinicians who care for youth will need to play a central role in sustainably decreasing the incidence and harms of OUD. Fortunately, numerous ready-to-implement strategies are available, and there is perhaps no workforce with stronger expertise in the prevention and treatment of complex conditions with social-behavioral underpinnings than clinicians committed to caring for youth.