BACKGROUND:

Morbidity and mortality from nonprescribed opioid use and opioid use disorder (OUD) in adolescents have risen dramatically. Medication for opioid use disorder (MOUD) with buprenorphine reduces nonprescribed opioid use and prevents overdoses, though <5% of adolescents with OUD have timely access, partly because of barriers associated with buprenorphine induction. Induction in an inpatient pediatric setting has the potential to address such barriers and improve adolescent MOUD access.

METHODS:

We developed and implemented a protocol for inpatient buprenorphine induction and linkage to MOUD care within a safety-net health system. After 1 year, we conducted descriptive analysis of participant characteristics, rates of induction completion and treatment linkage, and adverse events. We analyzed field notes from multidisciplinary huddles to identify implementation facilitators and barriers.

RESULTS:

During May 2021 to July 2022, we completed 46 admissions for 36 patients aged 12 to 21 years. All used fentanyl and no other opioids. Forty of 46 (87%) admissions resulted in completed induction, and 3 additional patients never developed withdrawal symptoms and were discharged with maintenance buprenorphine. Linkage to ongoing treatment occurred within 2 weeks for 31 of 43 (72%) admissions for which buprenorphine was started. We identified facilitators and barriers to program implementation and maintenance.

CONCLUSION:

These results provide promising preliminary evidence of the feasibility of inpatient buprenorphine induction for adolescents with OUD. Given the public health urgency and severe shortage of adolescent access to MOUD, these results prompt consideration of broader clinical implementation and research to facilitate rapid expansion of access to evidence-based OUD care.

The dramatic rise in opioid overdoses in adolescents with nonprescribed opioid use and opioid use disorder (OUD) is a public health emergency that calls for a swift and coordinated response from the pediatric community.13  Buprenorphine is a medication for opioid use disorder (MOUD) that has been shown to reduce overdose and all-cause mortality.4  The American Academy of Pediatrics recommends buprenorphine be offered to adolescents and young adults with OUD.5  Yet, fewer than 5% of US adolescents with OUD have timely access to treatment, and there are significant disparities based on race, ethnicity, gender, and age.1  Four randomized controlled trials have examined the effectiveness of buprenorphine for youth (ages 16 to 25 years) in a research context.6  However, there is a paucity of literature on real-world implementation of MOUD programs that can be scaled to meet the urgent needs of adolescents with OUD.

A key barrier to starting buprenorphine is the need to time initial administration with the onset of opioid withdrawal to prevent precipitated withdrawal. Precipitated withdrawal refers to the rapid and intense onset of withdrawal symptoms after administering buprenorphine because of its high affinity for the μ-opioid receptor and consequent ability to displace other bound opioids.7  Predicting withdrawal timing has become especially complex amid increasing use of fentanyl, a highly potent opioid that is cleared slowly because of accumulation in fatty tissues.8 

Adding to the challenges surrounding treatment initiation, adolescents have unique developmental needs that influence their ability to successfully complete induction in the typical settings used for adults, including home, outpatient clinics, or emergency departments. As they are still undergoing neurodevelopment of executive function and impulse control,3  adolescents may be relatively less equipped to time their last opioid use and withdrawal onset with presentation to a clinic or emergency department for buprenorphine induction, particularly if starting buprenorphine for the first time. Additionally, their relative impulsivity3  may make home-based or microdosing9  induction challenging in the setting of readily available nonprescribed opioids. Additional relevant factors for this age group are the urgency of starting treatment because of high risk of overdose10  and the time needed for caregiver education and guidance, which both present logistical challenges in typical induction settings. Considering adolescents’ developmental needs and our experiences with failed emergency department and outpatient inductions, we hypothesized that adolescent patients would benefit from an “open-access” (easily accessible, same-day)11  model with the added support and structure of an inpatient pediatric setting. Therefore, we developed and implemented a pilot program for inpatient buprenorphine induction with linkage to ongoing OUD care. To inform efforts to address the pressing need for treatment access, here we share our clinical protocol and preliminary implementation results.

This program was implemented in a public hospital in Santa Clara County, California with a 40-bed pediatric unit staffed by 9 pediatric hospitalists, rotating pediatric residents (approximately 100 per year), and 55 nurses. The hospital serves a racially and ethnically diverse, primarily Medicaid-insured patient population. Relevant preexisting resources within the county were: (1) MOUD providers (1 child psychiatrist a half-day per week for <18 y, multiple providers for 18 y), (2) a clinic- and school-based substance use therapy program, and (3) availability of outpatient and emergency department12  buprenorphine induction options. Eligible participants were ≤21 years of age per unit policy, met DSM-5 criteria for OUD,13  and elected inpatient induction (versus emergency department or outpatient options; Fig 1). We encouraged but did not require parent or guardian involvement during the inpatient treatment of minors, though consent was required for outpatient treatment per California law.14 

FIGURE 1

Inpatient buprenorphine induction protocol for the pediatric unit at Santa Clara Valley Medical Center, San Jose, California. *Pediatric hospitalists and program administrator discuss with referred patients available options for initiating treatment (inpatient, outpatient, emergency department). **Discharge planning includes shared decision-making with patient or caregiver and clinical team. ***Offer BUP-NLX 8mg daily as maintenance dose and complete discharge checklist. BUP-NLX, buprenorphine and naloxone sublingual film; COWS, Clinical Opiate Withdrawal Scale (Wesson and Ling 2003); IN, naloxone intranasal; MOUD, medication for opioid use disorder; naloxone.

FIGURE 1

Inpatient buprenorphine induction protocol for the pediatric unit at Santa Clara Valley Medical Center, San Jose, California. *Pediatric hospitalists and program administrator discuss with referred patients available options for initiating treatment (inpatient, outpatient, emergency department). **Discharge planning includes shared decision-making with patient or caregiver and clinical team. ***Offer BUP-NLX 8mg daily as maintenance dose and complete discharge checklist. BUP-NLX, buprenorphine and naloxone sublingual film; COWS, Clinical Opiate Withdrawal Scale (Wesson and Ling 2003); IN, naloxone intranasal; MOUD, medication for opioid use disorder; naloxone.

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We engaged a multidisciplinary team of clinical stakeholders from our county health system and national OUD experts12,15  to align published evidence, clinical expertise,16  and local context. Through discussion and consensus building, we iteratively developed a buprenorphine induction intervention that included: (1) training for pediatric hospitalists, residents, and nurses in trauma-informed OUD care, buprenorphine pharmacology and administration, and withdrawal scoring17 ; (2) an induction protocol for the inpatient pediatric unit (Fig 1); and (3) closed-loop referrals with warm handoffs to outpatient MOUD providers and residential treatment facilities. To facilitate coordination across inpatient and outpatient teams and to monitor and improve processes, we instituted standing, virtual multidisciplinary huddles facilitated by the program leads (pediatric hospitalist and unit nurse), 2 outpatient MOUD providers, a juvenile detention MOUD provider, and substance use therapists. All pediatric hospitalists obtained buprenorphine “X” waivers from the Substance Abuse and Mental Health Services Administration to permit discharge prescriptions of buprenorphine. To raise program awareness among potential referral sources, we presented to leadership at the local substance use therapy program, emergency and pediatric departments, and juvenile justice department.

After 1 year, we conducted descriptive analysis of patient characteristics, uptake (% completed induction, % linked to ongoing treatment within a 2-week target), and adverse events (precipitated withdrawal, opioid overdose within 2 weeks of discharge). Providers documented induction as complete once patients had received enough buprenorphine to adequately treat withdrawal symptoms, per withdrawal scoring and shared decision making with patients (Fig 1). Data sources included intake forms (self-report demographics and substance use), electronic health records (urine toxicology, medication administration record, induction completion, length of stay), and multidisciplinary huddle documentation (outpatient follow-up, adverse events). We reviewed field notes recorded by program leadership during multidisciplinary huddles, creating analytic memos to note our reflections on emerging implementation issues, decisions, and improvements.18  We analyzed memo content to identify salient implementation facilitators and barriers. We then shared our preliminary interpretation of these data with 4 key members of the clinical team and refined our summary of facilitators and barriers based on their input.19  This program was deemed quality improvement and thereby exempt from review by the Santa Clara Valley Medical Center Institutional Review Board.

Between May 2021 and July 2022, we completed 46 admissions for 36 patients; 5 patients had multiple admissions. Patients were 12 to 21 years (mean 17.4, SD 1.9) and 64% male. Patients identified as Asian (n = 4, 11%), Black (n = 1, 3%), Latinx (n = 26, 72%), white (n = 4, 11%), or multiple or other (n = 1, 3%). All patients were insured by Medicaid. All patients used fentanyl and no other opioids, per urine toxicology.

Forty of 46 (87%) admissions resulted in completed induction (Fig 2). Of the 6 patients with incomplete inductions, 3 chose to leave before receiving any buprenorphine. The other 3 patients did not develop withdrawal symptoms after >48 hours and were presumed to be outside the acute withdrawal window. They were given 1 dose of buprenorphine 8 mg while inpatient and then discharged with a maintenance dose of 8 mg daily and outpatient follow-up. Of the 43 patients for whom we arranged postdischarge treatment after complete induction or absence of acute withdrawal, 31 (72%) received MOUD care within 2 weeks, and another 3 (7%) later reengaged in care. Median discharge buprenorphine dose was 16 mg (range 8–32 mg). Mean length of stay was 40.5 hours (range 6.1–107.0, SD 19.3). Thirty-eight (83%) patients were discharged to home or community, 5 (11%) went to juvenile detention, and 3 (7%) went to residential treatment. No known adverse events occurred during or within 2 weeks of hospitalization.

FIGURE 2

Flow of patients who participated in an inpatient buprenorphine induction pilot program at Santa Clara Valley Medical Center, San Jose, California in 2021 to 2022.

FIGURE 2

Flow of patients who participated in an inpatient buprenorphine induction pilot program at Santa Clara Valley Medical Center, San Jose, California in 2021 to 2022.

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Per field notes recorded at multidisciplinary huddles, a key contributor to program success was strong buy-in from multiple stakeholder groups. Standing meetings with multidisciplinary inpatient and outpatient representatives to discuss patient cases and monitor implementation fostered successful transitions of care upon discharge and streamlined communication and processes. Huddle documentation also suggested that providers were developing strong rapport with patients and families, especially for patients with multiple admissions and subsequent transitions back to their outpatient providers. Inpatient clinical providers felt the protocol was straightforward and easily integrated into the existing workflow, particularly after the addition of an electronic health record order set. Administrative stakeholder support for continuation of the pilot program was in part due to financial viability, given Medicaid reimbursement for hospitalizations for acute opioid withdrawal. Opportunities for improvement included increased availability and integration of postdischarge treatment clinics and residential facilities, additional support for program maintenance and evaluation, and recurrent clinician training to fill identified gaps in knowledge and comfort with OUD treatment. Additional lessons learned are in Table 1.

TABLE 1

Key Contributors to Success and Opportunities for Improvement for an Inpatient Buprenorphine Induction Program for Adolescents in Santa Clara County, California in 2021 to 2022

Key Contributors to Program SuccessOpportunities to Improve Clinical Care and Program Implementation
■ Strong support at multiple levels (eg, county agencies, hospital administration, department leadership, clinical providers) ▪ Further program integration with family-based behavioral health services to address mental health comorbidities and support family functioning 
▪ Physician and nurse training on OUD and buprenorphine administration and monitoring, repeated periodically for new staff and rotating trainees ▪ Advocacy for state and county support to expand postdischarge outpatient MOUD access and residential treatment facilities for publicly insured patients 
▪ Trauma-informed and developmentally supportive clinical approach within structured inpatient setting ▪ Advocacy for funding to expand wrap-around services to address socioeconomic barriers to care (ie, transportation, homelessness, incarceration) 
▪ Straightforward protocol that was easily integrated into existing inpatient workflow (eg, electronic health record admission order set)  
▪ Standing multidisciplinary huddles for clinical coordination across inpatient and outpatient teams, and for continuous program monitoring; physician and nurse coleaders and champions  
▪ Financial sustainability because of Medicaid reimbursement of hospitalization for acute opioid withdrawal  
Key Contributors to Program SuccessOpportunities to Improve Clinical Care and Program Implementation
■ Strong support at multiple levels (eg, county agencies, hospital administration, department leadership, clinical providers) ▪ Further program integration with family-based behavioral health services to address mental health comorbidities and support family functioning 
▪ Physician and nurse training on OUD and buprenorphine administration and monitoring, repeated periodically for new staff and rotating trainees ▪ Advocacy for state and county support to expand postdischarge outpatient MOUD access and residential treatment facilities for publicly insured patients 
▪ Trauma-informed and developmentally supportive clinical approach within structured inpatient setting ▪ Advocacy for funding to expand wrap-around services to address socioeconomic barriers to care (ie, transportation, homelessness, incarceration) 
▪ Straightforward protocol that was easily integrated into existing inpatient workflow (eg, electronic health record admission order set)  
▪ Standing multidisciplinary huddles for clinical coordination across inpatient and outpatient teams, and for continuous program monitoring; physician and nurse coleaders and champions  
▪ Financial sustainability because of Medicaid reimbursement of hospitalization for acute opioid withdrawal  

OUD, opioid use disorder; MOUD, medication for opioid use disorder.

These preliminary findings demonstrate the successful initiation of MOUD for the majority of adolescents who participated in a novel, open-access program for inpatient buprenorphine induction and outpatient linkage within a safety-net health system. The rates of completed induction and outpatient linkage align closely with findings from emergency department induction programs20  and an adult inpatient induction program.21  Unlike these previously published studies of patients who used any type of opioid, here all participants used the highly potent and biochemically unpredictable opioid, fentanyl. This context for the success of our program is notable, given the fentanyl predominance in the current opioid crisis, and the relatively greater difficulty of buprenorphine induction for patients who use fentanyl.22 

Five patients had multiple admissions, which was unsurprising given the chronic and potentially recurrent nature of opioid use disorder.5  We interpret these readmissions not necessarily as treatment failures, but possibly an indication of the acceptability of our inpatient induction approach among adolescent patients who returned to use, though first-hand patient perspectives are an important future direction.

A strength of this pilot program was its implementation and expansion in a real-world setting. Successful implementation in a health system that serves a diverse patient population suggests that broader implementation has the potential to address disparities in OUD1  and promote equitable treatment access. An additional strength was our successful training and engagement of pediatric generalists in the intervention delivery, given inadequate addiction medicine subspecialists to meet the demand for OUD treatment.23  We also trained and engaged pediatric resident physicians as they rotated through the inpatient unit, demonstrating the potential for this model to contribute to developing a pediatric workforce with clinical skills and experience in OUD care. The generalizability of our findings may be limited to health systems and counties with a comparable health infrastructure and local landscape for opioid use. In addition, as a pilot program without a comparison group and without longitudinal outcomes, including for the patients who did not follow-up, we are unable to make conclusions about clinical effectiveness.

To build upon the limited evidence base around OUD health services for this age group, important future directions include longitudinal studies to compare inpatient, outpatient, and emergency department induction, with evaluation of clinical effectiveness, patient preferences, cost effectiveness, and implementation best practices. Another future direction is inpatient induction for adolescents with OUD who are admitted for other medical or psychiatric indications, as has been successfully demonstrated in adults.21,24  Such an approach could be particularly beneficial for patients with OUD admitted because of overdose, which has been shown in adults to be a timely opportunity to reduce the risk of subsequent fatal overdose.25,26 

In summary, this pilot provides promising preliminary evidence of the clinical feasibility of an inpatient approach to buprenorphine induction for adolescents, as an age-appropriate complement to the existing menu of induction options. Given the public health urgency and severe shortage of adolescent access to MOUD, these results prompt consideration of broader clinical implementation and ongoing investigation to facilitate rapid expansion of evidence-based OUD services.

We thank Tammy Devincentis, RN, MSN, FNP; Lindsey Stagnaro, RN, BSN; Gloria Tovar, RN, BSN; Stanford medical students and pediatrics residents; the Santa Clara Valley Medical Center Pediatric Hospital Medicine faculty; and the Opioid Response Network.

Dr Trope conceptualized and designed the intervention, recruited participants, led data collection, contributed to data analysis and interpretation, and drafted the initial manuscript; Drs Stemmle, Chang, and Bashiri contributed to the conceptualization and design of the intervention; Drs Bazazi and Lightfoot contributed to the data analysis and interpretation; Dr Congdon led data analysis and interpretation, and drafted the initial manuscript; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted.

COMPANION PAPER: A companion to this article can be found at http://www.hosppeds.org/org/cgi/doi/10.1542/peds.2022-006940.

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Competing Interests

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The funding organizations had no role in the design, preparation, review, or approval of this paper.