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An Urgent Need to Focus on Youth With Opioid Use Disorder

  • J. Deanna Wilson
    Affiliations
    Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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  • Sarah M. Bagley
    Affiliations
    Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
    Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
    Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
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      See Related Articles on p.239
      Youth deaths are driven by the same patterns of thAs COVID-19 tore through communities, preliminary data suggest that overdose deaths climbed to greater than 100,000 during the 12-month period ending in September 2021 [
      Centers for Disease Control and Prevention
      COVID data tracker. Atlanta, GA: US Department of Health and Human Services.
      ]. Approximately 75% of those deaths were opioid-related, and most were fentanyl-involved [
      • Ahmad F.
      • Rossen L.
      • Sutton P.
      Provisional drug overdose death counts. National Center for Health Statistics.
      ]. This overdose crisis has not spared youth. Prior to the emergence of COVID-19, synthetic opioid-related overdose deaths increased 2925% between 1999 and 2016 among young people [
      • Gaither J.R.
      • Shabanova V.
      • Leventhal J.M.
      US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016.
      ]. Between 2019 and 2020, overdose death rates increased 49% among 15- to 24-year-olds. Starting in 2020, adolescents experienced a greater relative increase in overdoses than adults [
      • Friedman J.
      • Godvin M.
      • Shover C.L.
      • et al.
      Trends in drug overdose deaths among US adolescents, January 2010 to June 2021.
      ]. Furthermore, the pandemic has highlighted widening racial and ethnic disparities in overdose deaths among youth. American Indian or Alaskan Indian youth have the highest overdose death rate, and Latinx youth have the second highest. Between 2019 and 2020, the overdose death rate doubled among Black youth [
      • Friedman J.
      • Godvin M.
      • Shover C.L.
      • et al.
      Trends in drug overdose deaths among US adolescents, January 2010 to June 2021.
      ].
      Youth deaths are driven by the same patterns of the opioid type seen in older adults: in the early 2000s mainly prescription opioids with a transition to heroin around 2012 and then to fentanyl in recent years [
      Centers for Disease Control and PreventionNational Center for Health Statistics
      Multiple cause of death 1999-2017 on CDC WONDER Online Database.
      ]. Even the increase seen in stimulant-involved deaths mirrors the rising impact of these substances in adult populations. In 2017, fatal overdoses that included an opioid plus another substance surpassed the opioid-only deaths [
      • Lim J.K.
      • Earlywine J.J.
      • Bagley S.M.
      • et al.
      Polysubstance involvement in opioid overdose deaths in adolescents and young adults, 1999-2018.
      ]. During that time, we have continued to see high rates of unmet need for interventions that reduce opioid-related morbidity and mortality. Medications (such as buprenorphine) are recommended treatment for youth with opioid use disorder. Buprenorphine improves retention in care, reduces opioid use, and decreases behaviors associated with HIV [
      • Robinson C.A.
      • Wilson J.D.
      Management of opioid misuse and opioid use disorders among youth.
      ]. From adult studies, we can extrapolate that these medications are life-saving [
      • Larochelle M.R.
      • Bernson D.
      • Land T.
      • et al.
      Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study.
      ]. Despite this, use of buprenorphine prior to the emergence of COVID-19 use was decreasing among youth [
      • Olfson M.
      • Zhang V.S.
      • Schoenbaum M.
      • King M.
      Trends in buprenorphine treatment in the United States, 2009-2018.
      ]. Prior work found that among Medicaid-enrolled and commercially insured youth with a diagnosis of opioid use disorder, less than 25% received timely medication treatment. Black youth were even less likely to receive medication than their White peers [
      • Hadland S.E.
      • Wharam J.F.
      • Schuster M.A.
      • Zhang F.
      • Samet J.H.
      • Larochelle M.R.
      Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001-2014.
      ].
      The COVID-19 pandemic led to federal regulations related to substance use disorder treatment that allowed for providers to initiate buprenorphine over telehealth and loosened regulations related to methadone dosing. In this context, studies focused on understanding the impact of COVID-19 on treatment access, particularly among youth who are critical [
      • Gramlich J.
      Recent surge in U.S. drug overdose deaths has hit Black men the hardest. Pew Research Center.
      ]. In this issue of Journal of Adolescent Health, finding by Alinsky et al. [
      • Alinsky R.H.
      • Prichett L.
      • Hsien-Chang Y.
      • Alexander G.C.
      • Stein B.D.
      • Saloner B.
      Treatment of opioid use disorder with buprenorphine among US adolescents & young adults during the early COVID-19 pandemic.
      ] that during the early COVID-19 pandemic, buprenorphine prescription paid with commercial insurance or cash among young adults significantly decreased is especially striking. In their study, the authors examined patient-level buprenorphine prescription data between January 2018 and August 2020 to understand the potential impact of COVID-19. They stratified their analyses by three age groups: 12–17, 18–24, and 25–29 years.
      Youth deaths are driven by the same patterns of thAlinsky et al. found that although overall monthly prescriptions of buprenorphine decreased among those aged 18–29 years, this was driven by decreases in commercial prescriptions and cash prescriptions. A similar decrease was not seen among those filling medications with Medicaid. The significant decrease in buprenorphine prescriptions among young adults aged 18–29 years of age suggests worse access to life-saving opioid treatments during a time when opioid-related mortality was skyrocketing. As the pandemic evolved, layoffs and financial stressors may have contributed to reduced ability for patients to pay cash. Individuals who had commercial insurance may have lost it, and there was not a concurrent rise in Medicaid fills by this group. It is therefore possible that these young people may have fallen out of care. The persistent access to safety net insurance programs, like Medicaid, allows its recipients to have more consistent and stable access to addiction treatment. With the ongoing financial and social stressors experienced during the early years of the pandemic, this access is more critical than ever. This work highlights the importance of exploring policy changes that expand Medicaid eligibility, particularly among youth.
      Youth deaths are driven by the same patterns of thInterestingly, among 12- to 17-year-olds, the monthly rate of buprenorphine prescriptions covered by Medicaid or commercial insurance increased during the pandemic. It might be that more youths were identified with opioid use disorder and/or offered treatment with medication during this time. It could also reflect that more young people found it easier to access medication because of the flexible regulations around prescribing during the pandemic. As cash fills in this age group declined while insurance fills increased, it might also reflect greater willingness for the youngest cohort to use their family health insurance and to engage or involve their families in their addiction treatment.
      The syndemics of COVID-19 and the overdose crisis have had a profound impact on the lives of individuals across the United States, including youth and those from minoritized and marginalized communities. A recent study found 1.25 million years of life lost among young people aged 10–24 years to unintentional drug overdose between 2015 and 2019 [
      • Hall O.T.
      • Trimble C.
      • Garcia S.
      • Entrup P.
      • Deaner M.
      • Teater J.
      Unintentional drug overdose mortality in years of life lost among adolescents and young people in the US from 2015 to 2019.
      ]. The most potent intervention to flatten and reverse this trend is medications for opioid use disorder. We urgently need additional research to examine the factors influencing youth access and adoption of medications to treat opioid use disorder, focused educational initiatives to increase prescribing at the time of diagnosis, and increased advocacy to support structural and policy changes at the federal and state level to increase equitable and persistent access to life-saving treatment.

      Funding Sources

      Dr. Bagley is supported by K23DA044324. Dr. Wilson is supported by NIDA K23DA048987 .

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