The opioid epidemic is an ongoing and worsening public health crisis affecting all age groups, including adolescents. In 2020, nearly 80 000 adolescents in the United States suffered from opioid use disorder (OUD),1 and opioids were implicated in the vast majority of drug overdose deaths in this age group.2 From 2019 to 2021, the number of drug overdose deaths among adolescents aged 14 through 18 nearly doubled, presumably due to the rising adulteration of the illicit and unregulated drug supply with nonpharmaceutical fentanyl, its analogs, and other potent novel synthetic opioids.3 Overall, overcoming the opioid overdose crisis requires a comprehensive public health approach that includes not only innovative prevention approaches but also solutions to improve OUD treatment access for adolescents.
In this month’s issue of Hospital Pediatrics, Trope et al4 directly respond to this need by presenting a pilot protocol for inpatient buprenorphine initiation and outpatient linkage for adolescents with OUD. Buprenorphine is a partial opioid agonist medication that treats OUD by reducing opioid cravings and drug reward.5 Most notably, buprenorphine is a life-saving medication that reduces all-cause mortality by >50%.6 Three randomized controlled trials in ambulatory settings have revealed the efficacy of buprenorphine in reducing opioid use and improving treatment retention among adolescents aged <18 years with OUD.7–9 Given its efficacy, the American Academy of Pediatrics recommends that pediatricians offer buprenorphine to adolescents with severe OUD or discuss referrals to other providers for this service.10 Any licensed physician or advanced practice provider can prescribe buprenorphine after obtaining an X-waiver from the Drug Enforcement Administration. However, to date, few pediatricians prescribe buprenorphine, and <5% of adolescents with OUD receive this life-saving treatment.11,12
In response to this treatment gap, Trope et al4 developed one of the first published protocols to help pediatric hospitalists treat OUD. They implemented the protocol in a safety-net hospital with a 40-bed pediatric unit staffed by 9 pediatric hospitalists and rotating pediatric residents. The protocol included a standard buprenorphine initiation protocol for the inpatient pediatric unit, an electronic medical record order set, and a closed-loop referral system for ongoing OUD treatment after discharge. Overall, treatment initiation and linkage rates for the 36 patients admitted under this protocol were similar or higher to those seen among hospitalized adults with OUD13,14 ; 87% of the admissions resulted in a successful buprenorphine initiation and 69% in treatment linkage (having at least 1 outpatient appointment for buprenorphine management) within 2 weeks. In addition, the majority of the admitted patients in this study were Black or Hispanic, which suggests future research should examine whether similar treatment models can help reduce racial/ethnic disparities in buprenorphine treatment access.
Several notable aspects of the treatment protocol deserve mention. First, although the buprenorphine dosing protocol reflected the traditional treatment guidelines that are used for less potent opioids, such as heroin,5 it was successfully applied to patients who used fentanyl. With repeated use, fentanyl can remain in the system for a longer period than heroin or other opioids, as fentanyl is lipophilic and can be slowly released from fatty tissues in the body.15 Because buprenorphine is an opioid agonist with a high affinity for the μ opioid receptor, it can quickly displace any other opioids from the receptor, thus precipitating the rapid onset of withdrawal symptoms. Thus, addiction medicine specialists have suggested that the clinical opioid withdrawal scale score be >12 (consistent with moderate withdrawal) when starting buprenorphine for patients who use fentanyl.16 However, the study’s protocol only required patients to be in mild opioid withdrawal (with a clinical opioid withdrawal scale score of at least 8) before administering buprenorphine. It is possible that the adolescents included in the study had a lower likelihood of experiencing withdrawal because they did not use fentanyl recently (within the past 48 hours) or for a long enough period of time to have substantial levels of fentanyl within the fatty tissues. Additionally, none of the patients used methadone or concurrent benzodiazepines before hospital admission, both of which increase the likelihood of precipitated withdrawal in the setting of fentanyl use.17
Second, the protocol revealed that it was feasible for pediatric hospitalists to directly admit patients who were referred by local treatment programs, therapists, or schools and verify that patients met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for OUD. Before hospital admission, patients with OUD were offered multiple ways to start buprenorphine, including via direct hospital admission, in the ED, or in outpatient clinics. Although the reasons for choosing the inpatient treatment location were not reported, it is arguable that the option for direct admission removed treatment barriers, such as those related to scheduling an appointment or waiting in the ED. Offering inpatient monitoring during buprenorphine initiation also may have reassured patients that they would receive timely nonmedication and medication support if they developed any withdrawal symptoms. Precipitated withdrawal is a non-life-threatening rare event, but it is highly uncomfortable for the patient and has been associated with a reduced willingness to start buprenorphine treatment.18 As noted by the authors, future studies are needed to determine if the ability of an adolescent to choose the setting for buprenorphine initiation helps improve its acceptability and effectiveness.
Finally, after receiving an X-waiver to prescribe buprenorphine, hospitalists, nurses, and staff reported that periodic training in OUD management and the use of an electronic medical record order set helped ensure program success. An X-waiver is not required to prescribe inpatient doses of buprenorphine; however, providers need to obtain an X-waiver from the Drug Enforcement Administration to prescribe buprenorphine for outpatient use. Since 2021, federal guidelines allow providers to apply for and obtain an X-waiver without documentation of 8 hours of formal training.19 Instead, providers can access multiple free and high-quality resources to receive training and technical assistance around the treatment of OUD (eg, www.pcssnow.org). Increasingly, providers who have obtained an X-waiver report that continued training and technical assistance help them start to prescribe.
Lastly, if larger pragmatic studies replicate the effectiveness of inpatient buprenorphine initiation protocols for adolescents, successful widescale implementation will require stakeholders to tailor the protocol to their hospital’s local context. In the current study, the stakeholders noted that Medicaid insurance reimbursement was an important facilitator of successful implementation. In many areas, payers generally do not reimburse for OUD treatment initiation as the sole reason for hospital admission among adults, suggesting that pediatric hospitalists in other states may need to advocate for adequate reimbursement by both public and private payors before the protocol can be sustainable.
The authors also note that, in accordance with their state laws, the minors in this study did not need parental consent for hospital admission or buprenorphine initiation. In most states, adolescents <18 years of age generally have the right to confidential care around substance use treatment and, therefore, can consent to their own care.20 The ability to consent for hospital admission or medications for substance use disorders varies by state,20 and providers may need to modify the protocol to explicitly include parental consent and parental involvement throughout the hospital admission. In addition, states may stipulate that minors are responsible for treatment costs if they consent to treatment and choose not to use their parents’ insurance benefit, which may limit the ability of some adolescents to receive treatment via this pathway.
It was opportune that the hospital was located in an area with outpatient OUD treatment options for patients <18 years of age with OUD. Overall, few outpatient substance use treatment programs and physicians offer medications for OUD in adolescents, limiting the ability to scale this treatment model to other hospitals and communities.21 However, if pediatric hospitalists aid adolescents and their families in starting treatment, outpatient offices may feel more comfortable in accepting adolescent patients for treatment continuation.
Overall, the published protocol serves as an excellent starting point and resource for pediatric hospitalists who care, or hope to care, for adolescents with OUD. Adolescence is a critical window of opportunity to treat OUD and prevent its downstream consequences, including overdose, legal involvement, and missed opportunities for education and employment.3,5 Overall, overcoming the opioid crisis requires a comprehensive public health approach that integrates OUD treatment access into multiple settings, including inpatient settings. We applaud Trope and colleagues for demonstrating that it is feasible for pediatric hospitalists to manage buprenorphine and improve adolescents’ access to life-saving OUD treatments. Pediatric hospitalists, nurses, and staff are experts in initiating life-saving treatment of many other conditions (eg, diabetes, asthma) and then transitioning patients to outpatient care, so it is not surprising that the application of these skills for OUD was highly successful. Adolescents with OUD deserve the option of receiving the excellent, developmentally appropriate, and timely care that pediatric hospitalists can provide.
Acknowledgments
We thank E. Jennifer Edelman, MD, for her critical review of an early draft of this commentary.
FUNDING: Dr Barelli’s effort contributing to this manuscript was in part funded by the Health Resources and Services Administration (grant T25HP37631). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2022-006864.
Dr Camenga drafted the initial manuscript and conceptualized, reviewed, and revised the manuscript; Dr Barelli conceptualized, reviewed, and revised the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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