Youth Access to Naloxone: The Next Frontier?

Recent statistics from the Centers for Disease Control point to a potential slowing of the number of opioid overdose deaths in the U.S. for the first time since 1990 [1]. Although this suggests that we may at last be seeing positive impacts of some of the public health measures deployed across the country, several important gaps remain to be filled. For instance, although the number of prescriptions for naloxone—currently the only proven and readily accessible overdose reversal medication [2]—has increased tremendously, it remains 69 times lower than the number of high-potency opioid prescriptions filled [3]. Even more concerning, naloxone prescription rates differ 25-fold between some urban and rural regions.

Although most opioid overdose deaths are seen in older adults, nearly 10% occur in youth aged younger than 26 years [4]. In addition, adolescence and young adulthood represent a critical time in a trajectory that may eventually lead to opioid-related mortality. In fact, nearly three-fourths of individuals admitted to opioid use disorder treatment first used opioids before their 26th birthday, and this proportion is even higher for early use of other substances, including alcohol and marijuana [5]. Primary prevention is critical to delay the initiation of substance use among youth, but once opioid use has begun, harm reduction approaches specifically tailored to youth are essential.

In their article, Jimenez et al. [6] report on a phone-based survey of pharmacy employees conducted between December 2018 and June 2019 in the 12 U.S. states with the highest opioid overdose mortality. Surprisingly, the authors found that nearly one in five pharmacies (including major U.S. retail chain and independent pharmacies) did not stock naloxone. The authors also found that almost half of pharmacy employees were unable to answer questions regarding age restrictions (i.e., minimal age) for purchase of naloxone for overdose prevention.

In theory, naloxone should be a relatively low-barrier medication. Although it is typically prescribed, a majority of U.S. states have standing orders for naloxone, meaning that a prescription is not required for purchase. Naloxone is covered by most insurance plans with no age limitations or restrictions. However, the work of Jimenez et al. [6] suggests that, in practice, barriers to naloxone receipt may lie beyond legislative or insurance hurdles. Rather, they may reside in a lack of clinician and pharmacy staff familiarity with and adherence to policies regarding access to naloxone, particularly for adolescents.

The workforce of clinicians caring for adolescents bears some of the responsibility for low naloxone uptake. Although substance use disorders often begin during adolescence, only a small minority of addiction medicine providers are pediatricians. In fact, in 2019, only 1% of addiction medicine fellowship graduates were pediatricians, far behind many other specialties. Although more opportunities for training and continuing education in addiction medicine are emerging, very few pediatric providers actually prescribe medications for opioid use disorders [7]. Similarly, very few pediatric providers make optimal use of available harm reduction strategies such as prescribing naloxone to their patients who take opioid medications on a regular basis or who have a history of opioid misuse [8]. Stigma around the treatment of adolescent opioid use disorder, which remains present in many health systems and communities, likely contributes to this low use of youth-focused harm reduction [9].

The findings of Jimenez et al. [6] highlight that pharmacists and pharmacy staff also contribute to low naloxone dispensing among adolescents. Poor familiarity with standing orders among pharmacists and pharmacy staff has been reported [10], and compounding this, studies suggest that pharmacy staff may specifically limit access to minors for some medications related to risk behaviors [11].

Youth-targeted harm reduction strategies already exist for other substances. The many successful public health campaigns that delivered the message “if you drink, don't drive” probably represent the best known example [12]. However, many harm reduction strategies are designed primarily by adults without youth input, have a strong emphasis on abstinence, and adopt a “one-size-fits-all” approach [13]. A youth-centered, community-driven, and participatory approach is needed to increase the effectiveness of harm reduction for young people and improve its integration into the continuum of addiction care.

Evidence supports several highly promising harm reduction strategies for opioid use disorder. Local syringe/needle exchange programs, pharmacy-based sterile needle distribution programs paired with safe injection facilities (which exist in Canada, Australia, and parts of Europe) all work to minimize infectious disease and opioid overdose risk without increasing rates of substance use [14]. Other promising and underused approaches include school- and college-based distribution of naloxone kits as well as peer mentorship and education delivered by grassroots organizations and youth in recovery.

There is unprecedented need for increased provider, community, and youth awareness and use of harm reduction services for opioids. Naloxone needs to become broadly available in all communities, for individuals of all ages, certainly including adolescents. Concerted advocacy efforts and greater knowledge translation of evidence-based research are required to ensure broad access to developmentally appropriate harm reduction services. To curb the opioid crisis, action is needed on all fronts; providing adolescents with unrestricted access to the only life-saving overdose reversal medication available is a critical place to start.