(46) Provider Experiences of SUD Management in Pediatric Hospitals: A Qualitative Study

Background & Introduction: Substance use disorders (SUDs) affect up to 11% of adolescents and young adults (AYAs) based on recent estimates, and it has been demonstrated that most adults with a SUD began use prior to age 18 (1). Despite this, clear evidence and guidelines related to pediatric and adolescent addiction are lacking. Pediatric interventions often focus on outpatient settings, but inpatient hospitalizations provide an opportunity for screening for health maintenance gaps, including immunizations, sexual health screening, and depression screening (2). Thus, we should consider the ability of the pediatric workforce in the inpatient setting to screen for, diagnose, and refer to/provide treatment for SUDs in this population.

Recent data has demonstrated that substance-related hospital and ER visits for youth have increased by almost 50% yet this continues to be an underrecognized area of clinical care in the field of pediatrics (3). Case reports and individual institutions’ experiences have described approaches to substance use-related issues in pediatric inpatient hospitals (4), but patterns of care have not yet been described. Our qualitative study seeks to describe the current state of inpatient care of AYAs who are treated for a substance-use related issue in pediatric hospitals via descriptive analysis of qualitative, semi-structured key stakeholder interviews.

Methods: We interviewed providers from all nine institutions that currently receive funding through the Maternal and Child Health Bureau’s LEAH (Leadership Education in Adolescent Health) grant program. Descriptive, semi-structured interviews (n=12) were conducted with representatives designated by the grant program directors of each institution. Interviews were recorded, transcribed via Microsoft Teams and its embedded AI Transcription software, and securely saved in encrypted files. The transcripts were double-coded and reviewed to consensus by the first two authors. After recruitment was completed and thematic saturation was achieved, generated themes were member-checked by two AYA addiction experts at non-LEAH institution. This study was exempt from the Institutional Review Board after review.

Results: The analysis was divided into description of clinical services (what care happens at an institution) and perceived factors that influence care (what impacts care at an institution). In describing clinical services, similarities existed regarding disciplines involved in care: general pediatrics, intensive care, adolescent medicine, child & adolescent psychiatry, psychology, social work, and toxicology. Most institutions offered care for SUD in the outpatient and inpatient settings in some capacity, and all institutions provided symptom-control medications for withdrawal. Differences between institutions included the ability to offer SUD-specific treatment (such as buprenorphine for opioid use disorder), methods of connecting inpatients to outpatient SUD resources, and the robustness of psychological/family supports.

Thematic analysis generated 8 themes: (1) There is insufficient training and experience in addiction care and SUD care systems in younger populations; (2) Clinical pathways/algorithms standardize practice; (3) Medical problems are prioritized over SUD care during admissions; (4) Access to SUD care has many facilitators/barriers, including systemic factors (e.g., insurance & geography), legal factors (e.g., consent & confidentiality), and institutional factors (e.g., electronic health record & formulary); (5) Lack of data related to SUD in children’s hospitals is associated with lack of resource allocation; (6) Attitudes towards addiction and AYAs generally hinder or facilitate care; (7) SUD in AYAs has been underrecognized and the need for care is increasing; and (8) Individuals and/or collaborative champions promote positive change.

Conclusion & Discussion: Ours is the first qualitative descriptive study to characterize the management of substance-use related issues in pediatric hospitals. Not only did we identify multiple similarities and differences in the clinical care at different institutions across the United States, but also we identified various themes related to facilitators and barriers to SUD-related inpatient medical care for AYAs. By characterizing the breadth of the issue and the current state of medical inpatient SUD management, we can begin to understand potential targeted solutions and advocate for changes within hospitals, public policies, and training programs to address this unmet need under the umbrella of adolescent mental health. Future steps of this research include quantitative descriptions of SUD-related services in pediatric hospitals, quality improvement efforts to bring evidence-based strategies to clinical practices in the pediatric setting, and addiction-related education expansion for pediatric general providers across settings.

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2. Breuner CC, Alderman EM, Jewell JA, et al; AAP Committee on Adolescence, Committee on Hospital Care. The Hospitalized Adolescent. Pediatrics. 2023;151(2):e2022060647

3. Ball, A., Hadland, S., Rodean, J., Hall, M., Mendoza, J., & Ahrens, K. (2024). Trends in Substance-Related Visits Among Youth to US Children's Hospitals, 2016-2021: An Analysis of the Pediatric Health Information System Database. The Journal of adolescent health: official publication of the Society for Adolescent Medicine, 75(1), 76–84. https://doi.org/10.1016/j.jadohealth.2024.02.016

4. Trope LA, Stemmle M, Chang A, Bashiri N, Bazazi AR, Lightfoot M, Congdon JL. A Novel Inpatient Buprenorphine Induction Program for Adolescents With Opioid Use Disorder. Hosp Pediatr. 2023 Feb 1;13(2):e23-e28. doi: 10.1542/hpeds.2022-006864. PMID: 36683456.

5. Priest KC, McCarty D. Role of the Hospital in the 21st Century Opioid Overdose Epidemic: The Addiction Medicine Consult Service. J Addict Med. 2019 Mar/Apr;13(2):104-112. doi: 10.1097/ADM.0000000000000496. PMID: 30608266; PMCID: PMC6417955.