(130) Importance of Collaborative Care for Adolescents with OUD: A Case Report

Background & Introduction: While illicit drug use among adolescents is declining, drug deaths are increasing and overdose is now the 3rd leading cause of mortality among US adolescents. Those who use at a younger age are at higher risk of developing severe opioid use disorder (OUD). There is a lack of providers with experience caring for adolescents with OUD. Additionally, adolescents have poor access to evidence-based treatment (1 in 21 receive medications for OUD [mOUD] within 3 months of diagnosis) and poor retention rates even when connected to care (9% remained in treatment at 1 year). The American Academy of Pediatrics has recommended a focus on innovative models to increase success of and access to SUD care to help meet adolescents where they are. This case highlights the immense importance of an alternative care model, the School Based Health Center (SBHC) for an adolescent with OUD.

This case report aims to:
1. Describe opioid use, OUD, and overdose in adolescents
2. Highlight issues around consent and confidentiality in providing substance use disorder care for adolescents
3. Review existing literature, practices, and special considerations for treatment of OUD in adolescents
4. Explain the SBHC model as an important partner in treating adolescents with OUD

Case Description: Setting/Context:
This case describes a 17 year-old male without significant past medical history who initially presented to the ED with palpitations and anxiety after taking "percocet" the day prior. Urine drug screen was positive for fentanyl. He was scheduled for follow-up with his SBHC, where he disclosed a longer history of substance use and was noted to have opioid withdrawal symptoms. He was referred to a low-barrier, adult outpatient addiction clinic.

Substance Use History:
He described daily use of 3-4 pills for the past 6 months. He wanted to cut back on use of pills but could not due to withdrawal and cravings. He felt that use was impacting school, stressing family relationships, decreasing extracurricular activities, and increasing anxiety. He had not heard of fentanyl or naloxone. He had no prior overdose or interaction with substance use treatment. He disclosed cannabis use and rare alcohol use.

Other History:
There was no family history of substance use disorder (SUD). Social history was notable for prior immigration to the US from Central America and time spent in a detention center prior to entry. He was a senior in public high school. He spoke primarily Spanish though understood most English.

Exam:
Patient noted to be in withdrawal with a clinical opiate withdrawal scale (COWS) score of 5 for anxiety and restlessness.

Diagnosis:
Patient met DSM 5 criteria for severe opioid use disorder.

Treatment:
Patient had extensive education around OUD and mOUD, use of intranasal naloxone, and rules around confidentiality/privacy. Given that his last use of fentanyl was not certain, he was given 2-0.5mg buprenorphine/naloxone in clinic and monitored for an hour, after which he noted improvement in withdrawal symptoms. He was sent home with a supply of buprenorphine/naloxone 2-0.5mg twice daily with a plan to increase to 4-1mg twice daily for further cravings or withdrawal symptoms. A warm handoff was made back to his SBHC.

Outcomes:
Patient was seen at his SBHC and was happy about how he felt on buprenorphine. He connected with an adolescent-specific addiction clinic as well as a recovery coach, who served as a low-barrier support and advocate. He had several missed/rescheduled appointments that required much coordination between the SBHC, recovery coach, the patient, and his family. He interacted with his SBHC team multiple times per week. He eventually chose to stop buprenorphine and had a long period of abstinence before a more recent return to use.

Conclusion & Discussion: This case highlights that adolescents with SUDs are a unique, high-risk population who need services that are appropriate and specifically tailored to their unique needs while maintaining autonomy and confidentiality. The SBHC, in collaboration with providers trained in addiction medicine, provides an innovative model for adolescent healthcare with frequent, low-barrier touch-points that can be especially effective for treating SUDs in adolescents, as it was for this patient. Adolescents are protected by title 42 of the Code of Federal Regulations (CFR), with some exceptions. The age and details of consent to SUD treatment varies by state. Though access to care may be limited, the use of mOUD (primarily longer > shorter courses of buprenorphine), has been shown to be associated with better outcomes. The American Society of Addiction Medicine recommends that mOUD be offered to youth presenting for care.

Other relevant issues in caring for adolescents with OUD include harm reduction, integration of family into SUD treatment, policy-level interventions, and the intersection of SUD and mental health in adolescents; these issues are beyond the scope of this case presentation but are nonetheless important as we think about improving care for youth.

References: 2022 National Survey on Drug Use and Health (NSDUH) methodological resource book, Section 8. Substance Abuse and Mental Health Services Administration. (2023). https://www.samhsa.gov/data/sites/default/files/reports/rpt44477/2022-nsduh-mrb-dcfr.pdf

Friedman, J., Godvin, M., Shover, C. L., Gone, J. P., Hansen, H., & Schriger, D. L. (2022). Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021. JAMA, 327(14), 1398–1400. https://doi.org/10.1001/jama.2022.2847

Hadland, S. E., Wharam, J. F., Schuster, M. A., Zhang, F., Samet, J. H., & Larochelle, M. R. (2017). Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. JAMA Pediatrics, 171(8), 747–755. https://doi.org/10.1001/jamapediatrics.2017.0745

Terranella, A., Guy, G. P., & Mikosz, C. (2023). Buprenorphine Dispensing Among Youth Aged ≤19 years in the United States: 2015-2020. Pediatrics, 151(2), e2022058755. https://doi.org/10.1542/peds.2022-058755