The United States continues to face a drug overdose crisis largely fueled by nonprescribed fentanyl (hereunto referred to as fentanyl), its analogs and other novel synthetic opioids (NSOs).
The impacts of these opioids are not limited to adults or people with substance use disorders. Between 2019 and 2020, the years of life lost to unintentional overdose doubled among adolescents ages 10-19, with nonprescribed fentanyl and NSOs contributing to over 80% of these deaths.
Similarly, National Poison Control data show increases in nonfatal opioid-related poisonings across all age groups studied, including children ages 1-4 years.
These alarming trends correlate with the rising adulteration of the illicit and unregulated drug supply with nonprescribed fentanyl, fentanyl analogs and other NSOs.
Proliferation of fentanyl, analogs
Fentanyl is a synthetic opioid that is 50-100 times more potent than morphine. Pharmaceutical-grade fentanyl is an important therapeutic tool for managing severe pain. Fentanyl also can be manufactured illicitly, and its use outside of clinical settings readily leads to overdose.
Fentanyl re-emerged as a main ingredient added to (or replacing) heroin around the early 2010s. Subsequently, fentanyl analogs increasingly supplanted or accompanied fentanyl in the illicit drug supply.
In February 2018, the U.S. responded to rising opioid-related deaths with the emergent placement of fentanyl analogs into Class I (high addiction potential, no accepted medical use) of the Drug Enforcement Administration (DEA) drug schedule. This reclassification was followed by the appearance of NSOs in the illicit drug supply that differed from those within the DEA Class I drug schedule. These newer fentanyl analogs and other NSOs can escape detection by most laboratory tests, including fentanyl test strip kits.
The illicit drug supply is adulterated with fentanyl and NSOs, meaning people are being exposed unknowingly and unwillingly to these lethal substances. Lethal doses of fentanyl adulterants can be found in heroin, methamphetamine and “club drugs” (e.g., ecstasy) as well as counterfeit or “pressed” pills purported to contain only pharmaceutical-grade opioids, benzodiazepines or stimulants. The illicit drug supply also is adulterated by xylazine, a nonopioid tranquilizer that potentiates overdose risk when combined with fentanyl or other NSOs.
Guidance for pediatricians
Pediatricians can help prevent opioid-related deaths in both teens who are exposed unknowingly to lethal doses of fentanyl in counterfeit prescription pills and young children who are exposed unintentionally to another person’s drug supply.
First, pediatricians can educate patients and families about naloxone and prescribe it when indicated. Naloxone is an opioid antagonist that reverses opioid overdose. It comes in forms such as intranasal and auto-injector, making it easy to administer. It also is safe, with minimal side effects.
Naloxone does not encourage opioid or other substance use. After an overdose reversal, a patient can be connected to treatment options.
Naloxone can be purchased at a pharmacy without a prescription in all states. However, not every pharmacy participates, and self-paying may be cost-prohibitive. Therefore, it is critical for pediatricians to prescribe naloxone (see resources) and dispel myths about its use.
Pediatricians also can recommend and prescribe buprenorphine for adolescents and young adults diagnosed with opioid use disorder (OUD). Clinicians who prescribe buprenorphine for OUD must have a medical and DEA license and obtain a buprenorphine waiver (“X” waiver). Since 2021, federal guidelines made the eight-hour buprenorphine waiver training optional for physicians who treat up to 30 patients. Qualified physicians who want to treat up to 100 patients must take the eight-hour training (see resources).
Pediatricians also can do the following to protect children and teens from opioid-related injury and death:
- Counsel adolescents about the presence of nonprescribed fentanyl and novel synthetic opioids in the illicit drug supply.
- Counsel parents to share their concerns and expectations around substance use with their children and reinforce messages about the dangers of unknown chemicals in many substances youths may try.
- Counsel parents not to keep nonprescribed drugs in the home and to store prescribed medications in a locked medicine cabinet or box that is out of reach.
- Have a low threshold for prescribing naloxone for adolescents, especially those who have a history of drug overdose, use substances or are prescribed an opioid medication.
- Ask older adolescents and young adults if they have family/friends who experienced overdose and offer to prescribe naloxone to help empower them to prevent overdose deaths.
- Familiarize yourself with state-specific naloxone dispensing and prescribing requirements.
- Advocate for wider availability of naloxone in communities.
- Support schools and school nurses in efforts to incorporate opioid-related overdose management, including naloxone, into school emergency preparedness and response plans.
- Prescribe buprenorphine for adolescents and young adults diagnosed with opioid use disorder and connect them to psychosocial treatment.
- Connect patients and families to harm reduction resources near them (http://bit.ly/3U7cvcJ).
Dr. Gonzalez is chair and Dr. Camenga is a member of the AAP Committee on Substance Use and Prevention.
Resources
- For more information on training to treat opioid use disorder in adolescents, visit https://www.aap.org/mat.
- For information from the Providers Clinical Support System on opioid use disorder training and clinical mentoring, visit https://pcssnow.org.
- To apply for an X waiver to prescribe buprenorphine, visit http://bit.ly/3TKm41f.
- For information by state on civil and criminal immunity protections for naloxone prescribing and administration, visit https://bit.ly/3SFVOUn.
