Pediatric emergency departments (EDs) in the United States are facing a rise in the number of children and adolescents who present with opioid use disorder (OUD), often driven by illicitly manufactured fentanyl. Medication treatment of pediatric OUD in the ED setting is often limited to symptomatic treatment of opioid withdrawal. Pediatric patients are rarely offered medications for OUD, especially in the ED setting. Buprenorphine is a partial opioid agonist that is Food and Drug Administration–approved for the treatment of OUD in patients aged 16 years and older. Adult studies have demonstrated that ED initiation of medication for OUD such as buprenorphine is feasible, safely treats withdrawal symptoms, and can improve patient compliance with outpatient follow-up. However, initiation of buprenorphine in the ED has not been well-studied in the pediatric population. We present 2 cases of adolescent patients, a 16-year-old male and 17-year-old female, who presented to the ED with opioid withdrawal. They were both diagnosed with severe OUD because of their use of counterfeit pills containing fentanyl. Both patients were successfully started on buprenorphine/naloxone in the pediatric ED before transitioning to an outpatient addiction clinic for continued treatment. The case series demonstrates the feasibility of ED-based buprenorphine initiation for adolescents, an important and timely intervention for adolescents with OUD.
Drug-related overdoses were the third leading cause of death in children and adolescents in 2020, and yearly deaths from overdose continue to increase in the pediatric population.1,2 Illicitly manufactured fentanyl has been involved in ∼75% of overdose deaths,3 and ∼15 000 pediatric emergency department (ED) visits are related to opioid use each year.4 Additionally, the number of counterfeit pills containing fentanyl entering the market has recently surged.5 The rising mortality from opioid use in adolescents necessitates urgent and effective treatment of opioid use disorder (OUD) using various approaches. In adults, medications for opioid use disorder such as methadone, buprenorphine and naltrexone are commonly used and have reduced overdose rates.6 Buprenorphine is a partial opioid agonist that is Food and Drug Administration approved for the treatment of OUD in patients aged 16 years and older. It has proven to be an effective therapy for OUD by treating withdrawal symptoms and reducing cravings, but data are more limited in the pediatric population. Buprenorphine is not often offered to pediatric patients7 in the ED because of a lack of provider comfort in prescribing the medication, as well as a lack of resources for outpatient follow-up.8
A national survey of pediatricians revealed that lack of supportive personnel was a significant barrier to prescribing OUD medications.9 From 2015 through 2020, the rate of buprenorphine dispensing to those younger than age 19 years as well as the proportion of under-19 patients who were prescribed buprenorphine declined, suggesting that many adolescents who may have benefitted from the treatment were not receiving it.10 Furthermore, there is a lack of inpatient or residential level care for adolescent patients with OUD, with only 26% of facilities in the United States offering adolescent services, and those centers being half as likely to offer medications for OUD.11,12 With limited availability of pediatric addiction providers and high out-of-pocket costs for appointments, an ED encounter may be the first opportunity for many adolescents to be treated with buprenorphine for OUD. The rise in patient use of illicitly manufactured fentanyl and other high-potency synthetic opioids complicates the initiation of buprenorphine in an outpatient setting because of a higher risk of precipitating withdrawal.13 The pediatric ED may play a role in addressing this challenge. We present 2 cases of adolescent patients diagnosed with severe OUD who presented to a pediatric ED in Washington, DC, and successfully underwent buprenorphine/naloxone initiation in the ED.
Case 1
A 16-year-old male with a history of substance use presented to the ED with a chief complaint of opioid withdrawal symptoms including body pain, diarrhea, nausea, and anxiety. He admitted to smoking M30 pills purchased at school that were determined to be counterfeit because his urine drug screen was negative for opioids (Fig 1). He had smoked the counterfeit pills daily since age 15 and had recently reduced his use to every 2 to 3 days, with the last reported use 3 days before presentation. He denied other routes of administration and had no previous overdoses. The patient reported having suicidal thoughts every time he experienced opioid withdrawal. His vital signs were unremarkable, and his physical examination was notable for an anxious mood. Buprenorphine/naloxone had been prescribed to him by an outpatient provider, but he failed outpatient induction after experiencing worsening of withdrawal symptoms. The patient voiced concern that he would return to opioid use without new intervention. Shared decision-making with his outpatient psychiatrist led to a decision to initiate buprenorphine/naloxone in the ED. The severity of his opioid withdrawal was measured using the Clinical Opioid Withdrawal Rating Scale (COWS). The patient had a COWS of 15 (restlessness: 3, bone/joint pain: 2, sweating: 1, gastrointestinal upset: 1, yawning: 2, anxiety: 3, gooseflesh: 3). Considering the time from his last use of opioids and his elevated COWS score, it was presumed that he would tolerate buprenorphine/naloxone initiation without the precipitated withdrawal he experienced when he had initiated outpatient treatment. After medication administration, the patient’s withdrawal symptoms improved and his COWS score decreased to 2 (Table 1). He denied suicidal ideation and did not require psychiatric admission. Given his symptomatic improvement and stable vitals, he was discharged. The patient successfully followed up with the pediatric addiction clinic. His point-of-care urine drug screens have remained negative to date, and he has continued to use buprenorphine.
Drug Enforcement Administration images. Top, authentic oxycodone; bottom, counterfeit pills containing fentanyl.
Drug Enforcement Administration images. Top, authentic oxycodone; bottom, counterfeit pills containing fentanyl.
COWS Score and Subsequent Buprenorphine/Naloxone Dose Administered for Case 1
| Time | COWS | Buprenorphine/ Naloxone Dose |
|---|---|---|
| 0950 | 15 | 4/1 mg |
| 1105 | 12 | 2/0.5 mg |
| 1315 | 2 | No more buprenorphine given |
| Time | COWS | Buprenorphine/ Naloxone Dose |
|---|---|---|
| 0950 | 15 | 4/1 mg |
| 1105 | 12 | 2/0.5 mg |
| 1315 | 2 | No more buprenorphine given |
Dose reported as (mg of buprenorphine/mg of naloxone). COWS, Clinical Opioid Withdrawal Rating Scale.
Case 2
A 17-year-old female with a history of OUD presented to the ED because of opioid withdrawal symptoms. She described abdominal discomfort, vomiting, presyncope, and tremors after smoking 3 counterfeit M30 pills and ingesting acetaminophen approximately 12 hours before presentation. The patient reported smoking 5 counterfeit M30 pills daily that she had purchased at school for 6 months. She first used opioids at age 16 and had 1 suspected overdose during which her friends administered intranasal naloxone. Physical examination in the ED was unremarkable with stable vital signs, COWS was 7 on presentation, and urine drug screen was negative for opioids and all other substances (fentanyl was not included in standard urine panel). In previous visits, the patient’s urine had tested positive for fentanyl when the sample was sent to a laboratory that had the capacity to test for it. She was seeking inpatient or residential care to help with her opioid use, but no residential treatment program would accept her insurance. After discussion with her family, the patient agreed to start buprenorphine/naloxone with outpatient follow-up. Buprenorphine/naloxone was initiated in the ED with subsequent symptomatic relief (Table 2). She was discharged from the ED after her withdrawal symptoms subsided and vital signs remained stable. She transitioned to outpatient care as confirmed by her psychiatrist and attended follow-up appointments. After 3 weeks, she successfully transitioned to an extended-release injectable formulation of buprenorphine.
COWS Score and Subsequent Buprenorphine/Naloxone Dose Administered for Case 2
| Time | COWS | Buprenorphine/ Naloxone Dose |
|---|---|---|
| 2215 | 7 | 4/1 mg |
| 1301 | 0 | No buprenorphine given |
| 1448 | 7 | 4/1 mg |
| 1730 | 0 | No more buprenorphine given |
| Time | COWS | Buprenorphine/ Naloxone Dose |
|---|---|---|
| 2215 | 7 | 4/1 mg |
| 1301 | 0 | No buprenorphine given |
| 1448 | 7 | 4/1 mg |
| 1730 | 0 | No more buprenorphine given |
COWS, Clinical Opioid Withdrawal Rating Scale.
Discussion
Buprenorphine/naloxone is a critical component of treatment of OUD in adolescents because it can treat withdrawal symptoms and cravings, limit overdose mortality, and improve long-term outcomes such as retention in treatment.14 Early treatment of withdrawal symptoms improves the likelihood that adolescent patients will engage in ongoing care. Developmental differences in adolescent patients increase their risk for returning to opioid use. Initiating buprenorphine/naloxone in the ED and bridging patients to outpatient care can help to ensure more a successful initiation and treatment outcome.
Many methods to initiate buprenorphine/naloxone in the ED setting have been studied in adults but not in adolescents. Illicitly manufactured fentanyl, often in the form of counterfeit pills, have further complicated the standard induction process because of their unique pharmacological properties, which makes precipitating withdrawal more likely during initiation.13,15 Both patients used counterfeit pills by smoking them, which is notable given a recent study showing that the percentage of overdose deaths attributable to smoking has increased by nearly 80%.16 In the pediatric age group, evidence for a standardized induction process and timeline for monitoring patients is still lacking. In both cases outlined here, the attending physician in the ED chose the dose of buprenorphine/naloxone to provide symptom relief while allowing for appropriate adverse effect monitoring. Both patients required a lower dose of buprenorphine/naloxone for managing withdrawal symptoms in the ED but subsequently had their doses increased to 16 mg daily by their outpatient psychiatrist to address cravings. In some instances, patients might require doses of buprenorphine increased to 12 mg or even more on day 1 of initiating the medication to adequately address their withdrawal symptoms.
Partnering with adolescent patients requires respecting their autonomy and decision-making ability, including when managing their OUD. Issues with buprenorphine initiation can arise because the medication can precipitate withdrawal depending on the recent history of use. Fear of withdrawal can disincentivize patients from consenting to the medication and may limit outpatient initiation success, as noted in case 1. One of the greatest benefits of ED-based induction is that withdrawal symptoms can be rapidly treated and monitored, allowing for a more successful induction. Although there are no studies that evaluate follow-up after ED-based initiation, outpatient buprenorphine initiation is known to improve follow-up, with 1 study noting that adolescents aged 13 to 18 years who received 2 weeks of buprenorphine treatment were more likely to continue medical care compared with other medication options in the outpatient setting.17
Two important limitations of ED-based initiation of buprenorphine are access to follow-up care and physician comfort. Adherence to buprenorphine is often difficult for adolescents because of limited access to outpatient providers and difficulty keeping appointments. Therefore, patients must be linked to appropriate outpatient providers who can continue to prescribe buprenorphine after discharge and monitor their condition. In both cases described here, the patients had access to a specialized pediatric addiction clinic for continued care; however, this option is not available to many patients across the country. With national shortages of pediatric addiction physicians, it is crucial to complete a thorough assessment of the availability of local providers and the financial status/insurance coverage of the patient before considering buprenorphine initiation. Additionally, the patients in this case were treated by ED physicians who were comfortable with the initiation procedure, a fortuitous situation which is shared by most pediatric EDs. A cross-sectional survey of pediatric emergency medicine physicians noted that 52% of providers lacked comfort managing withdrawal and 73% showed no interest in prescribing buprenorphine.8 It is therefore critical to ensure expanded education on buprenorphine for pediatric emergency physicians so they can feel confident to prescribe the medication for adolescent patients with OUD.
Our case series shows that buprenorphine can be safely initiated in the pediatric ED to treat withdrawal and bridge the patient with OUD to outpatient maintenance treatment. Providing examples of ED-based initiation can help to fill the gaps in the literature and encourage further research on this treatment method in the ED setting, especially as morbidity and mortality from OUD in children and adolescents continue to rise.
Acknowledgment
Thank you to Dr Meghan Schott for providing care for both patients in the emergency room.
Ms Kumar drafted the initial manuscript and critically reviewed and revised the manuscript; Dr Kaliamurthy conceptualized the case series, participated in the care of both patients, and critically reviewed and revised the final manuscript; Dr Thomas made significant contributions to data acquisition and analysis/interpretation and critically reviewed and revised the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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