Problem of Opioid Use Among Adolescents and Young Adults
Scope of Problem
Adolescents and young adults (youth) have been particularly affected by the opioid epidemic. Between 1999 and 2015, hospitalizations for opioid poisonings nearly doubled for teenagers aged 15-19 and the opioid-related overdose death rate tripled. Additionally, the rate of opioid uses disorder (OUD) diagnosis increased sixfold from 2001 to 2014 among youth (13-25 years old), with particular increase in diagnosis for young adults aged 21-25 years old. With a 72% increase in young adults deaths related to synthetic opioids such as fentanyl between 2014 and 2015, and 15% increase in heroin-related deaths over that time, it is clear that the epidemic among young people is shifting, and so too must our commitment to response and treatment.
Adolescence and young adulthood are particularly critical periods for intervention, as substance use can have lifelong effects. The National Institute on Drug Abuse reports 9 in 10 adults in treatment for substance use disorder first used a substance before age 18. Two thirds of individuals in opioid treatment reported first opioid use before age 25, while 1 in 3 report first use before age 18. Given these striking statistics, primary care and pediatric providers have an essential role to ensure access to timely and evidence-based treatment.
Complications of Use
Complications of intravenous drug use include endocarditis, abscesses, and infection with hepatitis C virus and human immunodeficiency virus (HIV) infection, all of which contribute significantly to the overall morbidity and mortality. Youth are especially affected with recent data from the CDC showing that the hepatitis C rate increased fourfold in Americans younger than 30 within the past 10 years, and after years of decline, decreases in new HIV infections among youth have stalled.
Polysubstance Use in Adolescence
Adolescents and young adults who misuse prescription opioid medications are also more likely to report use and misuse of other drugs. One study showed that patients aged 14-26 with two or more substances uses disorders were three times more likely to have experienced overdose, compared to those with just a single substance use disorder. While most adolescents and young adults do not escalate from sporadic use to substance use disorders, opioid use places these individuals at risk for other serious health and social issues, such as school failure, disengagement from health activities, driving under the influence, and contracting an infectious disease through unsafe sex or needle sharing. Benzodiazepine use, in particular , can increase an individual's risk of overdose when used in conjunction with opioids. This class of medications are strongly associated with adolescents and young adult opioid use, placing these individuals at a higher risk for overdose.
Diagnosis of Opioid Use Disorder (OUD)
The 2013 Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) defines an opioid use
disorder (OUD) as the repeated occurrence of 2 of the following 11 criteria within a 12-month period.
Tolerance and withdrawal are not sufficient to diagnose an OUD. Individuals who are prescribed
opioids for chronic pain may have physical dependence and withdrawal. OUD can be classified as
mild (2–3 symptoms), moderate (4–5 symptoms), or severe (6 or more symptoms), assessed over
the last 12 months.
These criteria are the same for adolescents and adults
| 1. Opioids are taken in larger amounts or over a longer period than was intended. | 7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. |
| 2. . A persistent desire or unsuccessful efforts to cut down or control opioid use. | 8. Recurrent opioid use in situations in which it is physically hazardous. |
| 3. Large amounts of time engaging in activities necessary to obtain the opioid, use the opioid, or recover from its effects. | 9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids. |
| 4. Craving or strong desire to use opioids. |
10. Tolerance, as defined by either:
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| 5. Recurrent opioid use resulting in failure to fulfill major role obligations at work, school, or home. |
11. Withdrawal, as manifested by either:
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| 6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. |
Treatment for Opioid Use Disorder - Medication for Addiction Treatment (MAT)
Medications for addiction treatment (MAT) and behavioral health treatment are effective for OUD, particularly in combination.
There are several behavioral therapies that are evidence based for this age group (see “Behavioral Health Treatment”). Programs differ in their approaches to integration of behavioral health care in MAT. Clinicians should encourage behavioral healthcare as an important adjunct to MAT, utilizing motivational interviewing strategies when youth and their family members are resistant to such therapies. Medications, however, should not be withheld for youth who do not participate in behavioral health treatment.
The American Society of Addiction Medicine published National Practice Guidelines in 2015 advocating for the use of pharmacotherapy in adolescent treatment16 and the American Academy of Pediatrics followed with a policy statement in 2016, arguing for increased access to MAT for adolescents and young adults with OUD.8 Research shows that use of MAT for adolescents and young adults assists in treatment retention, contributes to lower relapse rates, decreases engagement in risky behaviors,17 and increases abstinence.18–20 Among adults, MAT at least doubles the rate of opioid abstinence in randomized-controlled trials compared to no medication.21 MAT improves overall quality of life and reduces overdose risk, a significant contributor to mortality among individuals who use substances.
The US Food and Drug Administration approves the use of three medications for treatment of OUD: buprenorphine, naltrexone, and methadone. The general approach to providing buprenorphine and naltrexone in outpatient settings is provided in the following section. Methadone is an effective treatment; however, if considering it as an option for a young patient, we suggest referring to an addiction specialist. Individuals under 18 years old are not commonly treated with methadone.
Adolescent Access to Care and Pharmacotherapy
Fewer than 1 in 3 specialty drug treatment programs in the United States offers care to adolescents. Youth are not retained in treatment as well as adults, suggesting that young adults who do receive MAT are forced to get it from adult programs that are not structured to meet their developmental needs. As diagnoses of OUD increased substantially from 2001–2014, only 1 in 4 eligible youth aged 13–25 years received MAT nationally. Furthermore, researchers documented disparities in access and receipt of treatment based on gender, age, and race/ethnicity. Females were less likely to receive medications than males, with non-Hispanic black and Hispanic youth also less likely to receive medications compared to their Caucasian counterparts. Of those youth who received medication, buprenorphine was the most common medication used.3 These findings highlight the underutilization in MAT as a treatment modality for this age group, despite strong evidence for its efficacy among adolescent populations.