The opioid crisis in adolescents is getting worse
Rita Agarwal MD, FAAP, FASA
Overdose deaths in adolescents in the US have increased.
Adolescent substance use has decreased.
Opioid Prescriptions have decreased. So why are deaths on the rise? 1,2
Adolescent substance use has decreased from 21 % of adolescents admitting use of substances other than cannabis in 2002, to 8% in 2020. Overdose deaths in adults have been steadily increasing, but until late 2019 adolescent OD deaths remained relatively stable. Now 22 adolescents die every week of drug OD, in fact overdose deaths are the 3rd leading cause of death in children aged 14-18.1
Today’s PAAD review focuses on why this increase may be occurring and suggests some solutions for physicians, parents and educators. While as anesthesiologists we often do not think we have much of a role in these areas, we do. Many of us are parents and educators, some of us are in pain medicine and recognizing, screening, and addressing issues may make a big difference in the lives of some of our patients.3
Editorial/Perspective
Friedman J, Hadland SE. The Overdose Crisis among U.S. Adolescents. N Engl J Med. 2024 Jan 11;390(2):97-100. doi: 10.1056/NEJMp2312084. Epub 2024 Jan 6. PMID: 38198189.
Original article
Bagley S, Barnes J, Blunt B, Foreman J, Hadland S, Mayen S, McMahan R, Punch LJ, Taichman D. Treating Opioid Use Disorder in General Practice - Diagnosis, Harm Reduction, and Medications. N Engl J Med. 2024 Jan 11;390(2):e3. doi: 10.1056/NEJMp2310171. PMID: 38197814.
Friedman and Holland1 are well respected experts in pediatric substance use prevention and treatment, raise the alarm about the continuing increase in OD deaths in adolescents and young adults (AYA) . The 2nd article2 is a video and links to other educational materials for those interested in learning more on diagnosis and treatment of substance use disorder (SUD) and opioid use disorder (OUD).
Why are deaths in adolescents increasing? Its simple—fentanyl. Illicitly manufactured fentanyl is cheap, plentiful, and often added to other substances that people may be using. Alcohol, cannabis and nicotine are the most common substances used by teens and young adults and cannabis and nicotine can be cut with fentanyl. Adolescents may not know that they are being exposed.
Fewer and fewer people are using heroin, but more are experimenting with or unintentionally using illicitly manufactured fentanyl. 75% of overdose deaths in adolescents were due to fentanyl, 84% of deaths were unintentional, many died with another person present, and 41 % of children who died had a known mental health diagnosis.
We should be screening our patients Substance Use Screening Preoperatively4, we should definitely be stocking Narcan in our perioperative areas, as well at nurses stations throughout out hospitals and institutions. We should be advocating for Narcan to be available in schools, recreational centers, sports facilities, and other places where young people regularly gather. We can recommend, encourage, or prescribe Narcan for any patient going home on an opioid medication.
There is a lot we as anesthesiologist, pain and critical care specialists can do. Often patients will reveal to us their experimentation or use of substances as we are rolling back to the OR. If we can phrase our questions in a way that is not stigmatizing language Words Matter: Substance Use Disorder,5 we are more likely to have an impact and encourage them to speak to their primary care physician or get treatment if needed.
Referral for treatment in many areas is challenging due to a huge need for more mental health services throughout the country, but increasingly primary health clinicians and pediatricians are helping. In an ideal situation we could share information that we discover with other trusted professionals, unfortunately in most cases, that is not possible.
PS: from Myron: intranasal naloxone is now available without prescription. As discussed in several previous PAADs, I believe, as citizens and physicians, we should all have this available in our homes, cars, fanny packs etc.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Friedman J, Hadland SE. The Overdose Crisis among U.S. Adolescents. The New England journal of medicine. Jan 11 2024;390(2):97-100. doi:10.1056/NEJMp2312084
2. Bagley S, Barnes J, Blunt B, et al. Treating Opioid Use Disorder in General Practice - Diagnosis, Harm Reduction, and Medications. The New England journal of medicine. Jan 11 2024;390(2):e3. doi:10.1056/NEJMp2310171
3. Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesthesia and analgesia. Jul 14 2023;doi:10.1213/ane.0000000000006623
4. Stone K, Rice-Weimer J, Tram NK, Tobias JD. Efficacy of an expanded preoperative survey during perioperative care to identify illicit substance use in teenagers and adolescents. Pediatric Anesthesia. 2023;33(10):808-815. doi:https://doi.org/10.1111/pan.14728
5. Alinsky RH, Hadland SE, Quigley J, Patrick SW. Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults, and Families. Pediatrics. Jun 1 2022;149(6)doi:10.1542/peds.2022-057529