Prevention and Management of Opioid use Disorder and Overdose in Adolescents and Young Adults.

The ongoing overdose crisis continues to adversely affect adolescents and young adults (AYAs) and has led to numerous preventable deaths. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have the potential to reduce opioid use and associated harms; however, there are concerns that AYAs lack access to these potentially life-saving medications. To systematically review peer-reviewed literature on MOUD access and associated factors to synthesize strategies that can improve MOUD access for AYAs who use opioids. The MEDLINE, Embase, PsycINFO, CINAHL, Sociological Abstracts, Web of Science, and Global Dissertations & Theses databases were searched from database inception until May 3, 2021. English, French, Russian, or Spanish peer-reviewed studies that evaluated the availability, prescription receipt, or initiation of MOUD were eligible for inclusion. This systematic review identified 37 cohort (n = 17), cross-sectional (n = 15), and qualitative (n = 5) studies that accounted for 179 785 AYAs (mean [SD] age, 24.4 [3.9] years; 148 779 [85%] were female; 67 771 [84%] were White) and examined access to methadone (30 studies), buprenorphine (26 studies), and naltrexone (10 studies). Findings reinforce concerns that AYAs were less likely to access MOUD and suggest that adolescents were more likely to receive naltrexone or buprenorphine-naloxone, which have a lower potential for abuse, in comparison with young adults. This review also identified other factors that were associated with MOUD access, including criminal justice involvement, residing in the US South, living in a limited-income area, Black race, and Hispanic or Latino ethnicity, suggesting ways in which treatment services may be improved to increase MOUD access and meet the treatment goals of AYAs. This systematic review found gaps in MOUD access between AYAs and non-AYA populations in addition to differences in MOUD access between adolescents and young adults. Considering that existing clinical guidelines recommend the use of MOUD among AYAs, and in light of the increasing number of opioid toxicity deaths, there is a need to improve MOUD access among AYAs by reducing barriers to MOUD and providing AYAs with a continuum of health and social supports alongside MOUD. Future research into ways to encourage MOUD uptake among AYAs may improve the treatment and health outcomes for this population.

Medication for Adolescents and Young Adults With Opioid Use Disorder

Background/Objectives: Adolescents and young adults (AYAs) with opioid use disorder (OUD) frequently have co-occurring psychiatric conditions and substance use disorders (SUDs). This study evaluated the association of psychiatric comorbidities and other SUDs with treatment retention and urine drug test (UDT) results in AYAs with OUD. Methods: This retrospective cohort study included AYAs enrolled in the Substance Use Treatment and Recovery clinic from 2009 to 2022. Participants were categorized into four groups: no comorbidities, only mental health disorders, only other SUDs, and both disorders. Treatment outcomes included retention time and UDT results for medication for OUD (MOUD) and illicit substances, including tetrahydrocannabinol (THC). Kruskal-Wallis tests were used to evaluate differences across groups, and regression models identified variables associated with outcomes. Statistical significance was set at p < 0.05. Results: Among 157 patients, the median retention time was 300 days. Depression (p = 0.04), post-traumatic stress disorder (p = 0.002), and alcohol use disorder (p = 0.04) were associated with prolonged retention, whereas cannabis use disorder predicted shorter retention (p = 0.02). The median proportion of positive UDTs was 0.9 for MOUD, 0.1 for illicit substances, and 0.0 for THC. Older age (p = 0.02) and the use of antidepressants and anxiolytics were associated with greater adherence to MOUD. Cannabis use disorder (p = 0.02) and male sex (p = 0.04) predicted positive UDTs for THC, while MOUD use was linked to lower THC positivity (p = 0.02). The main limitations of this study were related to its retrospective study design and single-center setting. Conclusions: Psychiatric and substance use comorbidities significantly influence retention and treatment adherence in AYAs with OUD. Integrated treatment may improve engagement and outcomes. Further research is needed to tailor interventions for AYAs with co-occurring disorders.

Background/Objectives: Rates of receiving opioid use disorder (OUD) treatment among adolescents and young adults (AYA) aged 16-25 are low. The current study qualitatively analyzed informants' perspectives regarding the availability of, developmental considerations relevant to, and barriers associated with OUD treatment for AYA. Methods: Thirty key informants involved with OUD treatment in the northeastern United States completed individual, semi-structured interviews, including treatment providers (N = 11) and clinic leaders in programs that provide medication and psychosocial treatments for AYA with OUD (N = 10), as well as opioid-related policymakers (N = 6) and patient advocates (N = 3). Interviews were transcribed and independently double coded. Template-style thematic analysis methods were used and revealed seven themes. Results: The first theme highlighted limited treatment program availability for adolescents (aged < 18 years) with OUD. Four themes related to developmentally optimizing OUD treatment for AYA, describing the importance of caregiver involvement, AYA peer connections, wraparound services, and early intervention. Two themes described barriers to AYA OUD treatment, including stigma and knowledge gaps about medications for OUD as well as deficits in AYA's access to basic resources (e.g., housing, food security) that prohibit effective participation in treatment. Conclusions: Results highlight concerns from systems-level key informants regarding gaps in OUD treatment options for youth under the age of 18 and a high need for OUD treatment that is developmentally tailored to AYA. Findings point toward potential modifications and additions to existing adult treatment programs to make OUD treatment more accessible, relevant, and engaging for AYA.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

The syndemic of substance use and human immunodeficiency virus (HIV) is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the National Institutes of Health "Ending the HIV Epidemic" initiative. There are few published studies on preexposure prophylaxis (PrEP) for adolescents and young adults (AYAs) with opioid use disorder (OUD) despite increasing availability of biomedical prevention options and Centers for Disease Control and Prevention recommendations to offer PrEP to this group. Healthcare providers who previously prescribed medications for OUD (MOUDs) and/or PrEP for AYA were purposively sampled. Audio-recorded in-depth individual interviews were conducted using chart-stimulated recall to explore barriers and facilitators to integrated MOUD and HIV prevention services. Interviews were double-coded, and qualitative analysis was performed using a modified grounded theory. Of 19 providers sampled, most were physicians (63%). All recommended HIV screening at varying intervals; however, few counseled on (19%) or prescribed (11%) PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (ie, stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider (perception of low risk, lack of training/experience), and system-level factors (including restricted visit types). Facilitators of PrEP prescriptions included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (ie, navigators, certified recovery specialists). Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. Further research is needed to develop interventions that increase the integration of PrEP delivery within the context of OUD care among this key AYA population.

Adolescents and young adults (AYAs) with opioid use disorder (OUD) have low rates of treatment engagement and retention. Their care-seeking experiences remain underexamined, and understanding these experiences is critical for improving engagement for this vulnerable population. We examined how AYAs navigate support for OUD, access medications for OUD (MOUD), and explored barriers and facilitators to care. We conducted semistructured interviews with English-speaking AYAs (ages 15-25years) who had accessed care for OUD. Participants were recruited through purposive and respondent-driven sampling and clinical referral. Interviews were conducted in-person or by phone, audio-recorded, and transcribed. Rapid qualitative analysis strategies were employed to expedite translation of findings to practice. From interviews with 20 AYAs, we identified 4 main themes: "chasing care," "needs first," "relationships matter," and "real talk and real options." "Chasing care" conveys the difficulty participants faced to establish viable care connections and the reliance on adults or a crisis moment to successfully access care. Treatment success was reported to be improved when programs addressed basic needs (housing, transportation, employment). Both "relationships matter" and "real talk" emphasized that authentic and informed engagement with AYAs was crucial for treatment retention. The AYAs we spoke with wanted appropriate and accessible care for their OUD. They wished they had learned about fentanyl and associated risks earlier. They also wished they had had learned about MOUD much earlier in their care engagement process. They valued providers who were nonjudgmental regarding multiple aspects of their identity and their substance use.

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). Secondary analyses of a statewide population-based cross-sectional survey. Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

COVID-19 Could Change the Way We Respond to the Opioid Crisis-for the Better.

Nine in 10 adults with a substance use disorder began using substances before age 18.1 Among youth, opioid and polysubstance overdose deaths have increased by 384% and 760%, respectively, since the late 1990s.2 Pediatricians need training in screening, brief intervention, and referral to treatment (SBIRT) for substance use disorders and in medication treatment of opioid use disorder (OUD), all of which are recommended as best practice by the American Academy of Pediatrics (AAP).3–5Pediatric residency training on substance use and opioid misuse is poorly described. The extent to which training relates to regional needs, perhaps most importantly, local overdose death rates, is also insufficiently characterized. We conducted a survey of US pediatric residency programs to assess training in youth substance use and compared findings with regional overdose mortality. We hypothesized that programs located in counties with elevated mortality would be more likely to offer substance use training, but that, overall, the percentage offering such training would be low.We developed an online survey on substance use education that was approved and distributed by the Association of Pediatric Program Directors. The 25-item survey assessed program leadership’s estimated content on substance use and the perceived quality of that training. The survey was distributed by e-mail to pediatric associate program directors from all 201 US pediatric residency programs in March 2019. Associate program directors were surveyed per recommendation by the Association of Pediatric Program Directors and were given the option of forwarding the survey to a faculty member with more knowledge about the curriculum. Results presented in this article are a subset of questions from the survey; the full survey and results are available online (https://hdl.handle.net/2144/41197).Opioid overdose mortality for each program’s county was obtained from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research.6 Counties were classified as having “high” or “low” mortality relative to the national 2018 age-adjusted mean of 14.6 per 100 000.7Descriptive statistics were used to summarize results, with χ2 analyses to evaluate associations between training and location within high versus low overdose counties. The study was considered exempt by the Boston University Medical Campus Institutional Review Board.Surveys were completed by 120 of 201 programs (60%; Table 1). Ninety-seven programs had county-level overdose data and were included in final analyses. Most programs offered some education on adolescent substance use (n = 80, 82.5%); 77 programs required it and 61 programs offered elective opportunities. Fewer than half provided training inclusive of AAP-recommended SBIRT (n = 40, 41.2%; Table 2).Programs in high-overdose counties were more likely to have education on opioids (including about substance-exposed neonates) as a part of their standard residency curriculum than those in low-overdose counties (79.7% vs 52.6%, P = .005; Table 2). Few programs offered a buprenorphine waiver course (n = 22, 22.5%), although programs in high-overdose counties were more likely to have any residents complete this optional training (22.0% vs 5.3%, P = .03).Overall, 97.5% of programs reported that training about opioid misuse was “important” or “very important,” although just 12.5% rated their overall education on opioid misuse as “good” or “very good.” The main barriers to providing education about adolescent opioid misuse included insufficient faculty expertise (62.8%), curricular time (50.4%), and available content (47.9%). Only 3.3% of programs identified lack of interest as a barrier. All (100%) respondents reported interest in a shared, web-based curriculum on adolescent opioid misuse and related topics.Although most US pediatric residency programs provide education about adolescent substance use, gaps remain, particularly with respect to opioid misuse. Programs in counties with a high opioid overdose burden had more training on OUD, but overall rates of training inclusive of treatment were low. Two AAP-recommended interventions, SBIRT and medications for OUD, were infrequently covered.4,5 Few programs offer education about how to prescribe naloxone, a life-saving intervention for opioid overdose, despite high regional overdose mortality and widespread availability of such training.This study had limitations. The survey collected self-reported data, which may be subject to social desirability bias, and some respondents may have been unaware of the full extent of the training offered.Given that substance use disorders often have their onset in adolescence and that opioid-related mortality among youth is rising, addressing gaps in training for pediatricians should be a priority.

With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. The multifaceted implementation intervention included education, external facilitation, and quarterly reports. The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Adolescents and young adults (AYAs) are at increased risk for negative opioid-related outcomes, including misuse and overdose. High-quality cancer care requires adequate pain management and often includes opioids for tumor- and/or treatment-related pain. Little is known about opioid use and misuse in children and AYAs with cancer, and we therefore conducted a systematic review of the literature using PRISMA guidelines to identify all relevant studies that evaluated opioid use and/or misuse among this population. Eleven studies were identified that met our inclusion criteria. The range of opioid use among the studies was 12-97%, and among the five studies that reported opioid misuse or aberrant behaviors, 7-90% of patients met criteria. Few studies reported factors associated with opioid misuse but included prior mental health and/or substance use disorders, and prior opioid use. In summary, opioid use is highly variable among children and AYAs with cancer; however, the range of use varies widely depending on the study population, such as survivors or end-of-life cancer patients. Few studies have examined opioid misuse and/or aberrant behaviors, and future research is needed to better understand opioid use and misuse among children and AYAs with cancer, specifically those who will be cured of their cancer and may subsequently experience adverse opioid-related outcomes.

BackgroundAmidst increasing opioid-related fatalities in adolescents and young adults (AYA), there is an urgent need to enhance the quality and availability of developmentally appropriate, evidence-based treatments for opioid use disorder (OUD) and improve youth engagement in treatment. Involving families in treatment planning and therapy augments medication-based OUD treatment for AYA by increasing treatment engagement and retention. Yet, uptake of family-involved treatment for OUD remains low. This study examined systems-level barriers and facilitators to integrating families in AYA OUD treatment in Rhode Island.MethodsAn online survey was administered to clinic leaders and direct care providers who work with AYA in programs that provide medication and psychosocial treatments for OUD. The survey assessed attitudes towards and experiences with family-based treatment, barriers and facilitators to family-based treatment utilization, as well as other available treatment services for AYA and family members. Findings were summarized using descriptive statistics.ResultsA total of 104 respondents from 14 distinct treatment programs completed the survey. Most identified as White (72.5%), female (72.7%), and between 25 and 44 years of age (59.4%). Over half (54.1%) of respondents reported no experience with family based treatment and limited current opportunities to involve families. Barriers perceived as most impactful to adopting family-based treatment were related to limited available resources (i.e. for staff training, program expansion) and lack of prioritization of family-based treatment in staff productivity requirements. Barriers perceived as least impactful were respondent beliefs and attitudes about family-based treatment (e.g., perception of the evidence strength and quality of family-based treatment, interest in implementing family-based treatment) as well as leadership support of family-based treatment approaches. Respondents identified several other gaps in availability of comprehensive treatment services, especially for adolescents (e.g. services that increase social recovery capital).ConclusionsFamily-based treatment opportunities for AYA with OUD in Rhode Island are limited. Affordable and accessible training programs are needed to increase provider familiarity and competency with family-based treatment. Implementation of programming to increase family involvement in treatment (i.e. psychoeducational and skills-based groups for family members) rather than adopting a family-based treatment model may be a more feasible step to better meet the needs of AYA with OUD.Trial registration: not applicable.

Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD)