September 21 is National Opioid Awareness Day and October is National Substance Use Prevention Month.
In a timely article and accompanying video abstract being early released this week in Pediatrics, Andrew Terranella, MD, Gery Guy, PhD, and Christina Mikosz, MD, from the Centers for Disease Control and Prevention (CDC) remind us that overdose deaths among youth aged 14–18 years doubled during the early years of the COVID-19 pandemic—an increase 3-fold higher than the mortality observed among adults (10.1542/peds.2023-065137). It is in this context that the authors analyzed naloxone dispensing trends to youth ages 10–19 years, based on prescription dispensing data from nearly 49,000 pharmacies (encompassing nearly 93% of all prescriptions written in the US) from 2017 to 2022.
Over the 5-year study period, dispensing rates increased nearly 700% (from approximately 7 to 51 prescriptions per 100,000), with pediatricians writing nearly 1000% more prescriptions by the end of that period! However, that increase accounted for less than 6% of all naloxone prescribed—a data point reinforced by the accompanying commentary by Drs. Erin McKnight and Cynthia Holland-Hall from Nationwide Children’s Hospital.
Drs. Terranella, Guy, and Mikosz correctly note that pediatricians are in a unique position to discuss substance use disorder and harm reduction in addition to prescribing naloxone, but few do. And while we are increasingly aware that youth suffer from and die as a result of substance use disorder, the data demonstrate that we (as a profession) are simply not doing enough to address this scourge.
Cost is a potential barrier noted by the authors that may reduce accessibility to naloxone—a fifth of all prescriptions dispensed had a copay of at least $25. Other “barriers” are deceptively more salient. Although youth are seen in the emergency department for opioid overdoses, few are dispensed naloxone on discharge—something that training, the authors argue, may ameliorate. And even when there are protocols in place to facilitate naloxone dispensing, the authors note that upward of 20% of pharmacies don’t have naloxone in stock, and nearly half of pharmacy employees mistakenly think there is an age requirement to dispense it.
It must be recognized that dispensing naloxone is only one (very important) part of treating substance use disorder. We must also remember to ensure patients have access to therapies (to include medication assisted treatment [MAT]) for substance use disorder using medications like methadone. Use of such medications can improve patient survival, increase retention in treatment, decreased illicit opioid use, reduce criminal activity among people with substance use disorder, improve employment retention, and improve birth outcomes among pregnant people. And there is now a pandemic-era federal rule that makes it easier to dispense MAT.
Unfortunately, less than one-third of adolescents and adults eligible for such therapy actually receive it. Some of the barriers (in addition to young age) are geographic, socioeconomic, race, and whether one has had an interaction with the criminal justice system.
During this National Substance Use Prevention month, let us all commit to discussing substance use disorder with our patients, providing developmentally appropriate counsel, prescribing naloxone as indicated, and educating ourselves on how to better provide long-term care for affected patients—their lives literally depend on it.
