It is time for an ethical, evidence-based approach to youth presenting to the ED with an opioid overdose

Abstract

Currently, there is a dangerous inconsistency between our current understanding of adolescent development and the effects of drugs on cognition when compared to our collective approach to youth who present in the emergency department with an opioid overdose. We call upon practitioners to embrace a new paradigm and we ask the Canadian Pediatric Society (CPS) to spearhead the development of guidelines to advise on best practices to manage youth who present to the emergency department with an illicit drug overdose.

Canada is in the midst of an opioid overdose crisis. In 2017, there were 3,996 apparent opioid related deaths of which 73% involved fentanyl or fentanyl analogues (1). Youth aged 19 years or younger accounted for 2% of these deaths. The most detailed data available with regard to youth overdose deaths are from British Columbia (BC).

According to the BC Coroners Service, there were 12 fatal overdoses and 335 documented nonfatal overdoses among youth in 2016. The BC Coroners Service has previously reported that 31% of youth with fatal overdoses had a previous nonfatal overdose (2). Extrapolating from this data, in 2016, the risk of a youth suffering a fatal overdose after a nonfatal overdose was 1 in 100. This is a 300-fold increase in risk of overdose death compared to youth who have never overdosed.

Within Canada, there is no standard of care for youth presenting to the Emergency Department (ED) with an illicit drug overdose. Parents and legal guardians are not consistently contacted. Some youth are admitted to hospital and others are discharged after a few hours of observation, often either alone or with another minor. In many instances, youth who have overdosed are discharged from hospital with less oversight than adults who have received opioids for surgical day procedures.

Given the extreme risk of subsequent death facing youth with fentanyl-related overdoses, there is an urgent need for health professionals to develop a coherent strategy to care for them. Special consideration must be given to the unique developmental aspects of the teenage brain as well as to the effects of opioids on cognition and therefore the ability to provide informed consent postoverdose.

THE TEENAGE BRAIN

The prefrontal cortex is the area of the brain most involved in attention regulation, inhibition of impulses and anticipation of the consequences of actions and is not fully formed until the mid to late twenties (3). In addition, due to the influence of gonadal hormones, many adolescents tend to underestimate risks and overvalue rewards (4), discount adult direction in favour of peers (5) and are disproportionately influenced by emotions (6). Youth in whom these problematic traits are present to a high degree are predisposed to substance misuse (7). These attributes tend to improve by age 20 to 25 years.

Many adolescents may be impulsive, show poor decision making and have difficulty following through with treatment despite the best of intentions. This is greatly accentuated while acutely intoxicated and during the period immediately afterwards. Problems are magnified when there is an absence of an involved, responsible, and supportive adult relationship and when the youth is left unsupervised with peers. Knowledge of the unique vulnerability of adolescents must guide all interventions aimed at them but this is especially true when life and death decisions are being made.

OPIOIDS, COGNITION, AND CONSENT

It is questionable whether a youth who has recently overdosed, or who may have been using illicit drugs for several days prior to presentation, has adequate capacity to refuse to grant health professionals consent to contact their legal guardian, to consent to or refuse treatment, or to choose to be discharged from hospital without competent adult support.

Acute intoxication with opioids can significantly impair an individual’s cognitive and behavioural capacities (8). Once an individual who has suffered an opioid overdose is given naloxone they “are unlikely to seek and engage wholeheartedly in addiction treatment …. [as they] will be having intense cravings to use opioids” (9). In the days following opioid abstinence there are demonstrable deficits in complex working memory, executive function and fluid intelligence (10).This dysfunction is partially transient with relatively rapid improvement over 1 to 2 weeks (11).

Youth who have suffered an illicit drug overdose often have concurrent mental health issues which increase subsequent risk of repeat overdose and death (12). The extent to which they are connected with community resources is usually unclear. Therefore, ancillary information must be gathered from caregivers to clarify and mitigate subsequent risks. Failure to contact a legal guardian may also result in the youth being discharged either with another minor or on their own recognizance.

It is inappropriate to expect a youth who has just received naloxone for a drug overdose to be capable of informed consent with regards to the notification of their legal guardian in order to gather vital information and to ensure a safety plan post discharge. It is equally inappropriate to expect the youth to be fully competent to consent to, or refuse, treatment options.

A fully informed discussion regarding treatment options and the provision of a safety plan cannot be adequately completed until there has been significant improvement in cognition which will not occur for at least 5 to 10 days postoverdose. These youth are at high risk for a fatal overdose and ethically deserve a thorough briefing of their treatment options at a time when they are capable of understanding and engaging in the process (13).

IMPLICATIONS FOR CURRENT PRACTICE

Many physicians are guided by the concept that adolescents are fully competent to make medical decisions and if they choose to continue on a path of life-threatening drug use it is within their rights to do so. This approach is inconsistent with our current understanding of adolescent neurodevelopment and existing laws to protect teens. It is also contradictory to our recognition that individuals rendered unconscious by opioids have compromised cognition for many hours after awakening and our awareness that chronic illicit drug users have diminished cognition for days after acute intoxication clears. In addition, this view is in stark contrast to the modern view that substance use disorders result from drug induced brain impairment rather than a series of voluntary hedonistic acts (14).

We share concern for respect for patient autonomy, however in the case of minors, we have a duty to protect. Autonomy must be balanced with the developmental level of the patient, impairment related to drug exposure and severity of risk. In the case of opioid overdose, premature discharge can be fatal.

A CALL TO ACTION

Developmental psychology, the science of addiction medicine and sound ethical principles mandate that physicians across Canada review and revise their approach to the care of youth who present to their emergency departments with a life-threatening opioid overdose. We believe that immediate notification of the youth’s legal guardian, as well as admission to hospital, involuntarily if necessary, is the most responsible first step in keeping the youth safe while allowing time to craft a care plan. Such a plan includes a thorough evaluation of mental health status, identification and optimization of community supports, discussion of substance use intervention and treatment programs, and the implementation of a harm reduction strategy.

We call upon the Canadian Paediatric Society to review this issue and we encourage the CPS to issue a statement advising caregivers accordingly.

Funding Information: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.