Management of Opioid Misuse and Opioid Use Disorders Among Youth

Comparison of postoperative and outpatient opioid use in adolescent idiopathic scoliosis patients treated with posterior spinal fusion surgery and vertebral body tethering

PURPOSE

Surgical treatments for adolescent idiopathic scoliosis (AIS) include posterior spinal fusion (PSF) and vertebral body tethering (VBT), but there is limited data that compares pain between these groups. We aimed to compare postoperative pain between these patients through inpatient opioid use and opioid prescriptions post-discharge.

METHODS

A retrospective review of patients diagnosed with AIS who underwent PSF or VBT surgery was reviewed to determine LOS, inpatient opioid use, and opioids prescribed post-discharge. Only PSF patients who received liposomal bupivacaine and intrathecal (IT) hydromorphone, and VBT patients who received a paravertebral catheter of lidocaine and in addition to IT hydromorphone were included. Opioid amounts were reported as oral morphine equivalents (OMEs).

RESULTS

Of 198 AIS patients that met inclusion, there were 89 PSF and 109 VBT patients. PSF patients had an increased LOS by 0.6 days compared to VBT patients (p < 0.001). Patients in the PSF group were administered a mean of 30.0 OMEs/day compared with the VBT group who received 12.5 OMEs/day (p < 0.001). At discharge, PSF patients were initially prescribed a mean of 227.7 OMEs while VBT patients' mean prescription was 139.7 (p < 0.001). PSF patients received more refills (Χ2 (1, n = 198) = 26.8, p < .001) and had a higher mean total of outpatient OMEs prescribed when compared to VBT patients (359.4 vs 185.8, p < 0.001).

CONCLUSION

In AIS patients undergoing surgical correction, those who underwent PSF had longer LOS, received more inpatient OMEs, and were prescribed more OMEs both at initial discharge and total as an outpatient, when compared to VBT patients.

LEVEL OF EVIDENCE

Level III: (retrospective cohort study).

Global, Regional, and National Epidemiology of Opioid Use Disorder Among Adolescents and Young Adults, 1990-2019

PURPOSE

Opioid use disorder (OUD) is a growing public health crisis. However, no study to date has systematically evaluated the burden of OUD among adolescents and young adults (AYAs). We aimed to report the global level and trends of OUD burden among AYAs.

METHODS

Data were obtained from the Global Burden of Disease study 2019, which was conducted from 1990 to 2019 in 204 countries. AYAs were defined as individuals aged 15-39 years, and the study period was 1990-2019. The burden of OUD was evaluated in terms of case numbers and age-standardized rates per 100,000 population.

RESULTS

In 2019, there were 2,396,734 incident cases, 14,502,031 prevalent cases, 43,447 deaths, and 8,651,931 disability-adjusted life years of OUD among AYAs globally. High-income North America had the greatest regional burden, with the United States having the highest burden nationally. From 1990 to 2019, age-standardized incidence rate (ASIR), age-standardized prevalence rate, age-standardized mortality rate, and age-standardized disability-adjusted life years rate (ASDR) showed upward trends, with average annual percentage change of 0.62, 0.81, 1.55, and 1.01, respectively. Despite the burden of OUD was higher in males than in females, the increment in ASIR was greater in females than in males after 2014. Nationally, OUD burden showed increasing trends in ASIR, age-standardized prevalence rate, and ASDR across 150+ countries, with the United States experiencing the greatest increase in age-standardized mortality rate and ASDR. Meanwhile, there was a positive correlation between sociodemographic index and OUD burden, with higher sociodemographic index associated with a higher burden of OUD in 2019.

DISCUSSION

OUD in AYAs is a major global public health issue, and the burden of OUD is increasing. This alarming trend underscores the urgent need for comprehensive prevention strategies, targeted interventions, and effective treatment options tailored to younger populations.

Exploring the Determinants of Treatment Completion Among Youth Who Received Medication-Assisted Treatment in the United States

BACKGROUND

An effective treatment for Opioid Use Disorder is Medication-Assisted Treatment (MAT). However, in the United States (US), this is still being underutilized by youth. Research indicates the need to develop strategies to reduce treatment barriers among these youth. Thus, we explored the rates of treatment completion and dropout among youth receiving MAT in US substance use treatment facilities and examined factors associated with treatment completion and dropout.

METHODS

This study used the 2019 Treatment Episode Data Set-Discharges. Our analysis was restricted to youth (12-24 years) who primarily used heroin at admission. Log-binomial regression was used to examine various determinants of treatment completion and dropout, guided by Andersen's Behavioral Model.

RESULTS

The final sample size was 4917. Among youth reporting heroin use with receipt of MAT, those showing a higher likelihood of treatment completion than dropout were males [ARR: 1.23; 95% CI: 1.088-1.381; p = 0.0008], had 1-7 times [ARR: 1.33; 95% CI: 1.115-1.584; p = 0.0015] and 8-30 times self-help group participation [ARR: 1.50; 95% CI: 1.246-1.803; p < 0.0001], had co-occurring mental and substance use disorders [ARR: 1.28; 95% CI: 1.133-1.448, p < 0.0001], were admitted to detoxification [ARR: 2.80; 95% CI: 2.408-3.255; p < 0.0001] and residential/rehabilitation settings [ARR: 2.05; 95% CI: 1.749-2.400; p < 0.0001], and were located in the Midwest/West [ARR: 1.18; 95% CI: 1.030-1.358; p = 0.0173]. Conversely, other races (excluding Whites and Blacks/African Americans) [ARR: 0.75; 95% CI: 0.609-0.916; p = 0.0051], those who used MAT [ARR: 0.81; 95% CI: 0.694-0.946; p = 0.0077], and youth in the South [ARR: 0.45; 95% CI: 0.369-0.549; p < 0.0001] were less likely to report treatment completion than dropout.

CONCLUSIONS

The majority of youth receiving MAT dropped out of treatment. We identified various factors that should be prioritized to address youth underutilization of MAT in the US.

A case of severe opioid and methamphetamine use disorder in a 14 year old

We present the case of a 14-year-old who established care at our primary care clinic after hospitalization for unintentional fentanyl overdose. They were diagnosed with severe opioid use disorder (OUD) and stimulant use disorder (StUD) and initiated buprenorphine while inpatient. They were then transitioned to the only known outpatient primary care clinic in her county who was actively providing medications for opioid use disorder (MOUD) in adolescents.At the first visit, they reported a history of 20 overdoses, struggling with adherence to buprenorphine and continued opioid cravings. An overdose safety plan was reviewed with them and their parent including providing them naloxone kits, fentanyl test strips, and education handout sheets. Due to their significant overdose history and adherence challenges with sublingual buprenorphine, they were started on long-acting injectable buprenorphine (LAIB) with weekly provider visits and urine toxicology screening. In collaboration with the treatment team, they initiated behavioral treatment with contingency management (CM), with incentives for appointment completion, expected urine results, and successful medication administration. Over the next 19 months, and to date, they have increasingly engaged with care and have remained abstinent. LAIB may be an appealing alternative for adolescents with OUD to improve adherence and reduce risk of recurrent use and overdose. Adjunctive treatment with CM may improve retention in MOUD and have the benefit of treating StUD. There is a need for further research to explore innovative, community-based treatment for youth with OUD.

Initiation and Receipt of Medication for Opioid Use Disorder Among Adolescents and Young Adults in 4 State Medicaid Programs in 2018: Improving Medicaid Quality Metrics

BACKGROUND

Medications for opioid use disorder (MOUD) in youth can reduce harms but many youths do not receive MOUD. Improving quality metrics of MOUD among youth can advance interventions for youth with opioid use disorder (OUD).

METHODS

We relied on 2018 Medicaid claims data from California, Colorado, Massachusetts, and New Mexico. We calculated the percentage of youth with OUD included in the quality metric for initiation, and the percentage who initiated by state. We also calculated the percentage excluded from the quality metric for initiation because they have an existing episode of OUD care and their MOUD receipt. We compared the characteristics of those who initiated/received MOUD to those who did not and compared state estimates after adjusting for age and health conditions.

RESULTS

Estimates of initiation exclude about half of the youth with OUD because they were in an existing episode of OUD care and could not be observed initiating. Among youth in a new episode of OUD care, only about 1 in 4 initiated and state estimates varied from 18.9% to 40.1%. Among youth with an existing episode of OUD care, more than half received MOUD and state estimates ranged from 35.2% to 71.3%. Youth who initiated MOUD or received MOUD with an existing OUD had more severe OUD but fewer co-occurring substance use disorders or mental or physical health diagnoses. After adjusting for age and health conditions, MOUD still varied substantially across states.

CONCLUSIONS

Most youth with a new OUD diagnosis do not initiate MOUD but more than half of the youth in an existing OUD diagnosis receive MOUD. MOUD quality metrics that are disaggregated, adjusted, and inclusive of youth in an existing episode of care provide additional insight into opportunities to better support youth who might choose MOUD. State differences should be further studied for insight into policies that may affect MOUD.

Patient and provider medication preferences affect treatment outcomes among adolescents and young adults with opioid use disorder

BACKGROUND

The opioid epidemic in the United States has not spared youth or young adults, as evidenced by a six-fold increase in opioid use disorder (OUD) diagnoses in the last two decades. Given this dramatic rise, a call for greater uptake and accessibility of medications for opioid use disorder (MOUDs) among youth and young adults has ensued, resulting in an increasing number of MOUD treatment pathways for this vulnerable population.

METHODS

This secondary data analysis seeks to characterize patient and provider preferences for MOUD treatment pathways, and test for associations between baseline MOUD treatment preferences and opioid use and treatment adherence outcomes. Participants included 288 youth and young adults (age 15-21 years), recruited from a residential treatment program in Maryland. The study assessed patient preferences at baseline (n = 253) and provider preferences at patient treatment discharge (n = 224). Mixed-effects negative binomial regression models were conducted for opioid use outcomes, and logistic regressions were conducted for treatment adherence outcomes.

RESULTS

Results indicate that congruence of treatment with patients' (Incidence Rate Ratio [IRR] = 0.65) and providers' (IRR = 0.66) preferences was significantly associated with reduced self-reported days of opioid use in the past 90 days, but only for patients receiving extended-release naltrexone (XR-NTX). Results also indicated that patients were less likely to switch medication treatment pathways (e.g., from XR-NTX to buprenorphine, or vice versa) during follow-up if they received their preferred treatment at baseline, a finding which held true for both XR-NTX (Odds Ratio [OR] = 0.32) and buprenorphine (OR = 0.22).

CONCLUSIONS

Receipt of MOUD congruent with patient and provider preferences was associated with reduced opioid use and greater treatment adherence in this sample of youth and young adults with OUD.

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

Evaluation of a Pilot Program to Prevent the Misuse of Prescribed Opioids Among Health Care Workers: Repeated Measures Survey Study

BACKGROUND

Overprescription of opioids has led to increased misuse of opioids, resulting in higher rates of overdose. The workplace can play a vital role in an individual's intentions to misuse prescription opioids with injured workers being prescribed opioids, at a rate 3 times the national average. For example, health care workers are at risk for injuries, opioid dispensing, and diversion. Intervening within a context that may contribute to risks for opioid misuse while targeting individual psychosocial factors may be a useful complement to interventions at policy and prescribing levels.

OBJECTIVE

This pilot study assessed the effects of a mobile-friendly opioid misuse intervention prototype tailored for health care workers using the preparation phase of a multiphase optimization strategy design.

METHODS

A total of 33 health care practitioners participated in the pilot intervention, which included 10 brief web-based lessons aimed at impacting psychosocial measures that underlie opioid misuse. The lesson topics included: addiction beliefs, addiction control, Centers for Disease Control and Prevention guidelines and recommendations, beliefs about patient-provider relationships and communication, control in communicating with providers, beliefs about self-monitoring pain and side effects, control in self-monitoring pain and side effects, diversion and disposal beliefs, diversion and disposal control, and a conclusion lesson. Using a treatment-only design, pretest and posttest surveys were collected. A general linear repeated measures ANOVA was used to assess mean differences from pretest to posttest. Descriptive statistics were used to assess participant feedback about the intervention.

RESULTS

After completing the intervention, participants showed significant mean changes with increases in knowledge of opioids (+0.459; P<.001), less favorable attitudes toward opioids (-1.081; P=.001), more positive beliefs about communication with providers (+0.205; P=.01), more positive beliefs about pain management control (+0.969; P<.001), and increased intentions to avoid opioid use (+0.212; P=.03). Of the 33 practitioners who completed the program, most felt positive about the information presented, and almost 70% (23/33) agreed or strongly agreed that other workers in the industry should complete a program like this.

CONCLUSIONS

While attempts to address the opioid crisis have been made through public health policies and prescribing initiatives, opioid misuse continues to rise. Certain industries place workers at greater risk for injury and opioid dispensing, making interventions that target workers in these industries of particular importance. Results from this pilot study show positive impacts on knowledge, attitudes, and beliefs about communicating with providers and pain management control, as well as intentions to avoid opioid misuse. However, the dropout rate and small sample size are severe limitations, and the results lack generalizability. Results will be used to inform program revisions and future optimization trials, with the intention of providing insight for future intervention development and evaluation of mobile-friendly eHealth interventions for employees.

Attitudes toward Social Issues Related to Opioid Use among Palliative Care Physicians

Purpose

This study investigated palliative care physicians' attitudes regarding social issues related to opioid use.

Methods

An email survey was sent to 674 physicians who were members of the Korean Society for Hospice and Palliative Care (KSHPC).

Results

Data from 66 physicians were analyzed (response rate, 9.8%). About 70% of participants stated that their prescribing patterns were not influenced by social issues related to opioid use, and 90% of participants thought that additional regulations should be limited to non-cancer pain. Under the current circumstances, pain education for physicians is urgently needed, as well as increased awareness among the public. Half of the respondents identified the KSHPC as the primary organization responsible for providing pain education.

Conclusion

Palliative care physicians' prescribing patterns were not influenced by social issues related to opioid use, and these issues also should not affect cancer pain control.

Barriers and Best Practices on the Management of Opioid Use Disorder

Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.

Substance use severity as a predictor for receiving medication for opioid use disorder among adolescents: An analysis of the 2019 TEDS

BACKGROUND

Medication for opioid use disorder (MOUD) is vastly underutilized in adolescents. Existing treatment guidelines for OUD largely focus on adults, providing limited guidance for pediatric populations. Limited information is known about use of MOUD in adolescents based on substance use severity.

METHODS

This secondary data analysis examined how patient-level variables influenced the receipt of MOUD in adolescents aged 12-17 (n = 1866) using the Treatment Episode Data Set (TEDS) 2019 Discharge data set. A crosstabulation and chi-square statistic evaluated the relationship between a proxy for clinical need based on high-risk opioid use (either reporting daily opioid use within the past 30 days and/or history of injection opioid use) for MOUD in states with and without adolescents receiving MOUD (n = 1071). A two-step logistic regression analysis in states with any adolescents receiving MOUD examined the explanatory power of demographic, treatment intake, and substance use characteristics.

RESULTS

Completion of 12th grade, a GED, or beyond, decreased the likelihood of receiving MOUD (odds ratio [OR]= 0.38, p = 0.017), as did being female (OR = 0.47, p = .006). None of the remaining clinical criteria were significantly associated with MOUD, although a history of one or more arrests increased the likelihood of MOUD (OR = 6.98, p = 0.06). Only 13% of individuals who met criteria for clinical need received MOUD.

CONCLUSIONS

Lower education could serve as a proxy for substance use severity. Guidelines and best practices are needed to ensure the proper distribution of MOUD to adolescents based on clinical need.

Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies

Across North America, overlapping overdose and COVID-19 emergencies have had a substantial impact on young people who use drugs (YPWUD). New risk mitigation guidance (RMG) prescribing practices were introduced in British Columbia, Canada, in 2020 to allow people to decrease risk of overdose and withdrawal and better self-isolate. We examined how the prescribing of hydromorphone tablets specifically impacted YPWUD's substance use and care trajectories. Between April 2020 and July 2021, we conducted virtual interviews with 30 YPWUD who had accessed an RMG prescription of hydromorphone in the previous six months and 10 addiction medicine physicians working in Vancouver. A thematic analysis was conducted. YPWUD participants highlighted a disjuncture between risk mitigation prescriptions and the safe supply of unadulterated substances such as fentanyl, underscoring that having access to the latter is critical to reducing their reliance on street-based drug markets and overdose-related risks. They described re-appropriating these prescriptions to meet their needs, stockpiling hydromorphone so that it could be used as an “emergency backup” when they were unable to procure unregulated, illicit opioids. In the context of entrenched poverty, hydromorphone was also used to generate income for the purchase of drugs and various necessities. For some YPWUD, hydromorphone prescriptions could be used alongside opioid agonist therapy (OAT) to reduce withdrawal and cravings and improve adherence to OAT. However, some physicians were wary of prescribing hydromorphone due to the lack of evidence for this new approach. Our findings underscore the importance of providing YPWUD with a safe supply of the substances they are actively using alongside a continuum of substance use treatment and care, and the need for both medical and community-based safe and safer supply models.

Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015-2020

BACKGROUND AND OBJECTIVES

Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine can reduce the risk of overdose, however they are underutilized. A better understanding of buprenorphine prescribing to youth will help inform interventions to expand access to treatment.

METHODS

We used IQVIA data to examine buprenorphine dispensing trends among youth aged ≤19 years from 2015 to 2020. Dispensing was examined by prescriber specialty, age, and sex. Data were weighted to provide national estimates.

RESULTS

The rate of buprenorphine dispensed to youth decreased 25% over the study period, from 0.84 to 0.63 prescriptions per 1000 youth per year. The proportion of youth dispensed buprenorphine also decreased 45%, from 7.6 to 4.2 persons per 100 000 per year. Over the same time, the proportion of adults aged ≥20 years dispensed buprenorphine increased 47%, from 378 to 593 persons per 100 000. Differences in dispensing by sex and temporal trends were also noted. Pediatricians accounted for less-than 2% of all prescriptions dispensed.

CONCLUSIONS

Buprenorphine dispensing to youth is low and declining in recent years. Given rates of opioid use disorder among youth, these findings suggest that many youth who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving training in opioid use disorder treatment of pediatricians and encouraging all clinicians who care for adolescents and young adults to obtain waivers to prescribe buprenorphine for MOUD.

Patterns and contexts of polysubstance use among young and older adults who are involved in the criminal legal system and use opioids: A mixed methods study

INTRODUCTION

Opioid prevention and treatment programs tailored to young adults involved in the criminal legal system are rare. We examined profiles of polysubstance use among younger and older adults involved in the criminal legal system who use opioids, and explored their experiences and motivations related to substance use. Information gleaned can inform the adaptation of existing programs and the development of novel approaches for young adults in the criminal legal system.

METHODS

Using a sequential mixed methods design we 1) quantitatively identified typologies of polysubstance users among adults aged 18-24 (n = 92) and those age 25 and over (n = 27) involved in the criminal legal system who use opioids, using latent class analysis and 2) qualitatively explored differences in personal motivations, cultural influences, and psychosocial contexts of substance use by class.

RESULTS

Our quantitative results supported a three-class typology: the majority of participants were in Class I (73 %, n = 87) and reported using primarily alcohol and marijuana. Participants in Classes II (15 %, n = 18) and III (12 %, n = 14) endorsed distinct and complicated polysubstance use profiles. Further, participants in Classes I and III were significantly younger than those in Class II. Qualitative analysis allowed us to understand associations between patterns of use, motivations, and contexts among young and older adults, comparing across classes.

CONCLUSIONS

Our results highlight the importance of attending to the needs of subpopulations based on age and use patterns to adapt and develop targeted treatment and prevention programs for high-risk adults involved in the criminal legal system.

Addressing adolescent substance use with a public health prevention framework: the case for harm reduction

Adolescence is a developmental stage defined in part by risk-taking. Risk-taking is critical to normal development and has important benefits including trying new activities and exploring new relationships. Risk-taking is also associated with the initiation of substance use. Because substance use often begins in adolescence, much focus has been on primary prevention with the goal of preventing initial substance use. Secondary or tertiary prevention approaches, such as counselling to eliminate substance use or offering treatment, are common approaches for adolescents with problematic substance use or a substance use disorder. While this is important, for some adolescents, treatment or cessation of use may not be desired. In these cases, Healthcare Practitioners (HCPs) can offer clear advice that incorporates harm reduction. Harm reduction, which is often applied for adults who use substances, reduces the negative impacts associated with drug use without requiring abstinence. Harm reduction is crucial to keeping adolescents safe and healthy and can offer opportunities for future engagement in treatment. The objective of this review is to describe strategies for integrating harm reduction principles in clinical settings that are developmentally appropriate. A patient-centered, harm reduction approach can validate perceived benefits of substance use, offer strategies to minimise harm, and advise reduction of use and abstinence.KEY MESSAGES:Substance use often begins in adolescence and traditional approaches are often rooted in prevention framework.Harm reduction should be incorporated for adolescents with problematic substance use or a substance use disorder.This review offers strategies for integration of harm reduction principles tailored towards adolescents.

Mental Health Conditions and Substance Use Disorders Among Youth Subsequently Diagnosed With Opioid Use Disorder or Opioid Poisoning

PURPOSE

This study examined receipt of services for mental health conditions and non-opioid substance use disorders (SUDs) among privately insured adolescents and young adults (ie, youth) with subsequent clinically diagnosed opioid use disorder (OUD) or opioid poisoning.

METHODS

Among individuals aged 12 to 25 years (N = 4926), healthcare service utilization claims for the 2 years before a newly clinically diagnosed OUD or opioid poisoning were assessed for mental health and nonopioid SUD service visits.

RESULTS

Over half (60.6%) of the youth with clinically diagnosed OUD or opioid poisoning received mental health or nonopioid SUD services in the 2 years before the opioid poisoning or OUD diagnosis.

CONCLUSION

Many adolescents and young adults with clinically diagnosed OUD or opioid poisoning interacted with the healthcare system to receive services for mental health conditions and nonopioid SUDs before the OUD or opioid poisoning being diagnosed. Opportunities exist to design better intervention strategies to prevent OUD or opioid poisoning among adolescents and young adults.

Opioid use disorder: a neglected human immunodeficiency virus risk in American adolescents

In 2017 alone, 783 000 children aged 12-17 years misused opioids with 14 000 using heroin. Opioid misuse and opioid use disorder (OUD) in adolescents and young adults are significant barriers to ending the HIV epidemic. To address these synergistic scourges requires dedicated practitioners and improved access to life-saving evidence-based treatment. Adolescents and young adults make up over one in five new HIV diagnoses even though they are less likely to be tested or know they are infected. Adolescents and young adults living with HIV are less likely to be retained in care or achieve virological suppression. OUD further leads to increased rates of risky behaviours (like sex without condoms), deceased retention in HIV care and decreased rates of viral suppression in this vulnerable population. Medications for opioid use disorder (MOUD) are recommended for adolescents and young adults with severe OUD and help retain youth in HIV treatment and decrease risk of death. However, due to stigma and lack of experience prescribing MOUD in adolescents, MOUD is often perceived as a last line option. MOUD remains difficult to access for adolescents with a shortage of providers and decreased options for treatment as compared to adults. Addiction treatment is infection prevention, and integrated addiction and HIV services are recommended to improve health outcomes. A multipronged approach including patient education, provider training and policy changes to improve access to treatment and harm reduction are urgently needed confront the drug use epidemic in youth.

Diagnosis of Opioid Use Disorder by Youths Assessed in Acute Care Settings in British Columbia, Canada

OBJECTIVES

To describe trends in the number of youths diagnosed with opioid use disorder (OUD) and to identify factors associated with OUD diagnosis in acute care settings.

STUDY DESIGN

Data from a population-based retrospective cohort study with linkage of 6 health administrative databases for 13 009 youth age 12-24 years identified with OUD between 2001 and 2018 in British Columbia, Canada were used to describe annual diagnoses. Using a multiple logistic regression model, we estimated the association between past-year health care utilization and OUD diagnosis in acute settings, controlling for sociodemographic and OUD-related comorbid conditions.

RESULTS

Annual OUD diagnoses quadrupled between 2003 and 2017 (from 326 to 1473). Among the 6579 youth diagnosed with OUD between April 1, 2013 and September 30, 2018, 88.1% had past-year health system contacts. Youth age 12-18 had higher odds of OUD diagnosis in acute care (aOR 2.04; 95% CI 1.78, 2.34). Compared with no health care contact, youth receiving outpatient care only were less likely to be diagnosed with OUD in acute care (aOR 0.69; 95% CI 0.56, 0.84) and those with >1 urgent hospitalization were more likely to be diagnosed with OUD in acute care (aOR 1.87; 95% CI 1.40,2.49).

CONCLUSIONS

More than 88% of youth had past-year health system contacts prior to diagnosis. Those age 12-18 years and with urgent hospitalizations in the year prior to diagnosis were more likely to have OUD diagnosed in acute care settings. Establishing an effective evidence-based system for early detection and intervention among youth with OUD must be a priority.

The cascade of care for opioid use disorder among youth in British Columbia, 2018

BACKGROUND

Medication for opioid use disorder (MOUD) is associated with substantial reductions in the risk of mortality, and American and Canadian guidelines recommend it as part of the full range of available treatments for youth with opioid use disorder (OUD). We estimated the OUD cascade of care for all adolescents (ages 12-18) and young adults (19-24) with OUD in British Columbia, Canada (BC) in 2018.

METHODS

Using a provincial-level linkage of six health administrative databases, we classified youth with OUD as adolescents (ages 12-18) or young adults (19-24) to compare with older adults (≥25) and described key factors known to influence engagement in health care. The eight-stage cascade of care included diagnosed with OUD, ever engaged in MOUD, recently in MOUD, currently in MOUD, and retained in MOUD for ≥1 month, ≥3 months, ≥12 months, ≥24 months.

RESULTS

We identified 4048 youth diagnosed with OUD as of September 30, 2018 (6.3% of all people with OUD). Most were young adults, aged 19-24 (n = 3602; 89.0% of all youth), a majority of whom were males (n = 1984; 55.1%). In contrast, adolescents diagnosed with OUD (n = 446; 11.0% of all youth) were mostly females (n = 287; 64.4%). Compared to adolescents, there were more young adults diagnosed with OUD ever engaged in MOUD (71.4% v. 36.5%), currently on MOUD (29.3% v. 16.8%), and retained in care for ≥1 year (8.6% v. 2.0%).

CONCLUSIONS

A high proportion of youth aged 12-24 diagnosed with OUD in a health care setting in British Columbia received MOUD yet continued engagement is infrequent, particularly for adolescents. Long-term treatment plans for youth need to consider including MOUD when appropriate as part of tailored, youth-friendly services.

A Systematic Review of Opioid Use Disorder and Related Biomarkers

The objective of this systematic review is to examine the relationship between opioid use disorder (OUD) and its related biomarkers, as well as the effects of pharmacotherapy for OUD on biomarkers. The eligibility criteria are the inclusion of human population studies focusing on biomarkers, including the immune system, related to OUD or opioid-related disorders. English, peer reviewed, original research, case studies or case series, and clinical trials were included in this review. Papers were excluded if they met one or more of the following criteria: animal studies, review articles, studies focusing only on OUD or opioid-related disorders without mention of potential biomarkers, studies focusing only on biomarkers and/or the immune system without relating to OUD or opioid-related disorders, and studies that focused on other substance use disorders other than OUD specifically. A PubMed, PsycINFO, and Cochrane databases search on August 25, 2020, yielded 101 results; only 14 articles met inclusion criteria that were included in this review. However, heterogeneity of study definitions and measurements should be noted. Various potential biomarkers indicated systemic, peripheral, and chronic inflammation in patients with OUD or opioid-related disorders. Medications, including buprenorphine and methadone, significantly decreased chronic inflammation in this population. Our results suggest that patients with OUD or opioid-related disorders have potential biomarkers that can be targeted to provide optimal treatment options for this population. A better understanding of potential biomarkers may assist to identify at-risk populations, monitor disease progression and treatment response, and develop therapeutic strategies for OUD. Systematic Review Registration: This review has been registered in PROSPERO (CRD42020202014).

Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder

PURPOSE

Young adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood.

METHODS

This secondary analysis compared young adults (aged 18-25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial ("XBOT") that randomized subjects to extended-release naltrexone or sublingual buprenorphine-naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report.

RESULTS

Among subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08-2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19-3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected.

CONCLUSIONS

Young adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.