Continued Awareness About the Opioid Crisis and Growing Incidence in Adolescents

The ongoing opioid crisis is a global public health issue that imposes significant health and economic burdens on affected individuals, their loved ones, the health care system, and society. Despite diligent efforts nationwide to increase recognition of the impact of the opioid crisis, the consequences of addiction, and preventative measures, this crisis continues to grow, affecting individuals across diverse ethnic and socioeconomic groups. While most of the focus has been on the adult population, an abundance of data reveals that the issue is growing at an alarming rate among adolescents and has progressively increased over the last two decades.¹ Studies reveal that adolescents who are prescribed opioids before the 12th grade are at a 33% expanded risk of future opioid misuse, and since this patient population generally has limited knowledge about the dangers of opioid misuse, many are particularly vulnerable to opioid use disorder (OUD).^2,3

Clinicians, including pharmacists across all spectrums of clinical practice, have an expanding role in identifying OUD early on, implementing preventative measures to deter improper use and decrease related complications, promoting the safe and proper use of these analgesics, and initiating therapy for OUD early on when warranted. The solutions to this crisis are complex, but patient education and identifying the warning signs of OUD are critical.

According to the CDC, overdoses were responsible for more than 112,000 deaths in the US between May 2022 and May 2023, and when compared to 1999, the number of individuals who died from opioid overdoses was over 6 times more in 2021.^4,5 According to a new study from the CDC, among adolescents ages 14 to 18, opioid deaths increased by 94% between 2019 and 2020, and between 2020 and 2021, there was an increase of an additional 20%.⁶

Various sources have documented post-dental visits as the primary source of opioid prescriptions in adolescents, which is linked with a 6.8% absolute risk increase in persistent opioid use and a 5.4% surge in a subsequent diagnosis of OUD when compared with those without opioid exposure.^7,8 It is also well documented that the earlier the age of the patient when exposed to opioids, the higher the risk of developing OUD.^7-9 Causes of OUD are complex and multifaceted, and other examples of documented causes of opioid misuse in adolescents include peer influence, mental health issues, social and environmental factors, and family history of OUD.^2,3,7-9

According to a recent report, deaths attributed to drug overdoses among adolescents have more than doubled since the onset of the pandemic, reporting that “Data found that drug overdose deaths among adolescents increased from 253 deaths in 2018 to 723 deaths in 2022. During the same period, the share of these overdose deaths involving opioids increased from 57% to 78%.”¹⁰ Additionally, in 2022, the report notes that about 4 out of every 5 drug overdose deaths in adolescents were due to opioid use, and among adolescents, access to treatment, including medications for OUD, such as buprenorphine and residential addiction treatment facilities, is limited, even though the mortality rates due to drug overdoses among this age group have increased.¹⁰ The authors added that residential facilities often do not dispense buprenorphine to adolescents with OUD.¹⁰

According to the American Academy of Pediatrics (AAP), OUD is correlated with considerable morbidity and mortality, warranting prompt identification and clinical intervention for adolescents struggling with OUD. In 2016, the AAP issued a policy statement recommending that pediatricians offer medication for the treatment of severe OUD.¹¹

In a article published in Pediatrics, the authors wrote, “Treatment offered at the time of diagnosis with either buprenorphine or naltrexone should become the new standard of care, along with delivery of targeted harm reduction services and linkage to psychosocial supports.”⁷ Finally, the authors indicated that how best to incorporate treatment of OUD into clinical practice with regard to optimal therapies and duration of therapy in this patient population is still uncertain.⁷

One study sought to explore the perceptions of adolescents on prescription opioids, opioid safety and misuse, and sources of opioid information. The authors indicated that several misconceptions about opioid use need to be addressed and limited tools to educate adolescents about OUD, and promoting education initiatives targeting adolescents may aid in lowering the risk of OUDs.¹²

Highlighting the Role of the Pharmacist in the Opioid Crisis

A recent first-of-its-kind pilot study discovered that pharmacists and not just prescribers at clinics and doctor’s offices can safely and effectively initiate therapy with buprenorphine in patients with OUD. The study was also published in the New England Journal of Medicine and documented the experiences of 100 patients who began taking buprenorphine after visiting a specially trained pharmacist for medical care.¹³ Once stabilized on buprenorphine, 58 patients were randomly assigned to receive either usual care in a clinic or physician’s office or continued care in the pharmacy. Results revealed that after 30 days, the patients in the pharmacy care group demonstrated noticeably higher retention rates: 25 patients (89%) continued to receive treatment in the pharmacy compared to five (17%) in the standard care group.¹³ In a press release, Traci Green, lead study author and co-director of Rhode Island Hospital’s Center of Biomedical Research Excellence on Opioids and Overdose, stated, “To have so many people in the pharmacy group continue on with their care was completely unexpected. The results from this pilot study show how pharmacies can be an effective and viable pathway to treatment for opioid use disorder.”¹⁴

In October 2023, the National Association of Boards of Pharmacy (NABP) issued a press release regarding the role of pharmacists in treating substance abuse in adolescents. The NABP noted that pharmacists have a pivotal role in assisting patients with OUD via dispensing treatment options, working in collaboration with prescribers to identify patients with addiction issues, devising appropriate treatment plans, and providing resources to patients, parents, and caregivers. The NABP indicated that survey findings from 2021 revealed that access to treatment for adolescents dealing with OUD is often delayed, and while the AAP recommends the use of medications for OUD, only an estimated 4.7% of adolescents received therapy. Moreover, adolescents who had access to treatment with buprenorphine, naltrexone, or methadone were 42%, 46%, and 68%, respectively, less likely to discontinue treatment compared with adolescents who only received behavioral treatment.¹⁵

Proposed Strategies to Address Crisis

In February 2024, the American Dental Association (ADA) issued a new guideline for the management of dental pain, stating that non-opioid medications should be the first line of therapy for the management of dental pain and opioids should be reserved for clinical situations when the first-line treatment is inadequate in pain reduction or if contraindications to non-opioids are present.¹⁶ The ADA committee wrote, “Clinicians should avoid the routine use of just-in-case prescribing of opioids and should exert extreme caution when prescribing opioids to adolescents and young adults.”¹⁶

On March 29, 2023, the FDA approved naloxone hydrochloride nasal spray for OTC use. In the press release, FDA Commissioner Robert M. Califf, MD, stated, “The FDA remains committed to addressing the evolving complexities of the overdose crisis. As part of this work, the agency has used its regulatory authority to facilitate greater access to naloxone by encouraging the development of and approving an over-the-counter naloxone product to address the dire public health need.”¹⁷

Conclusion

As front-line health care providers, pharmacists can be instrumental in identifying issues related to opioid misuse and abuse and working collaboratively with other health care providers to implement effective preventative measures to deter misuse via effective education strategies for patients and families and promote safe prescribing practices. Due to their drug expertise, pharmacists can make clinical recommendations regarding the efficacy of the safety of medications for OUD, including proper administration, increased awareness about opioid addiction, and evidence-based recommendations to treat patients struggling with opioid addiction. The first steps to addressing the opioid crisis are prevention, early identification, and clinical intervention.

Resources

• The CDC provides several evidence-based strategies to prevent opioid overdose cases on its website.
• The American Pharmacist Association indicates that pharmacists have critical roles in preventing opioid misuse and in educating patients about safe drug use. The APHA Opioid Use And Misuse Resource Center provides pharmacists with valuable information and tools to assist in identifying and addressing opioid misuse.

References

1. Abraham O, Thakur T, Brown R. Prescription opioid misuse and the need to promote medication safety among adolescents. Res Social Adm Pharm. 2019;15(7):841-844. doi:10.1016/j.sapharm.2019.01.003
2. Miech R, Johnston L, O’Malley PM, Keyes KM, Heard K. Prescription opioids in adolescence and future opioid misuse. Pediatrics. 2015;136:e1169–e1177. doi:10.1542/peds.2015-1364
3. Abraham O, Peters J, Peterson KA. Characterizing pharmacist perspectives on utilizing a personalized family medication safety plan for opioid education with adolescents and parents. Pharmacy (Basel). 2023;11(1):22. doi:10.3390/pharmacy11010022
4. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2023. Updated February 15, 2023. Accessed February 9, 2024. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.html
5. Understanding the opioid overdose epidemic. CDC. Published August 8, 2023. Accessed February 7, 2024. https://www.cdc.gov/opioids/basics/epidemic.html
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7. Robinson CA, Wilson JD. Management of opioid misuse and opioid use disorders among youth. Pediatrics. 2020;145(Suppl 2):S153-S164. doi:10.1542/peds.2019-2056C
8. Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse. JAMA Intern Med. 2019;179(2):145–152.
9. Grant BF, Stinson FS, Harford TC. Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: a 12-year follow-up. J Subst Abuse. 2001;13(4):493–504.
10. Panchal N. Recent trends in mental health and substance use concerns among adolescents. KFF Health. Published February 6, 2024. Accessed February 7, 2024. https://www.kff.org/mental-health/issue-brief/recent-trends-in-mental-health-and-substance-use-concerns-among-adolescents
11. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893.
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13. Green TC, Serafinski R, Clark SA, Rich JD, Bratberg J. Physician-delegated unobserved induction with buprenorphine in pharmacies. N Engl J Med. 2023;388(2):185-186. doi:10.1056/NEJMc2208055
14. Pharmacists can start patients on road to recovery from opioid use disorder, study shows. Brown University. Published January 11, 2023. Accessed February 9, 2024. https://www.brown.edu/news/2023-01-11/pharmacy-addiction-treatment
15. Pharmacists’ role in treating substance use in adolescents. NABP. Published October 18, 2023. Accessed February 7, 2024. https://nabp.pharmacy/news/blog/pharmacists-role-in-treating-substance-use-in-adolescents/
16. Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V, et al. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania. J Am Dent Assoc. 2024;155(2):102-117.e9. doi:10.1016/j.adaj.2023.10.009
17. FDA approves first over-the-counter naloxone nasal spray. News release. FDA. Published March 29, 2023. Accessed February 8, 2024. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray