Treatment Shortfall for Opioid-Dependent Youth

Diana Swift

June 20, 2017

The rate of opioid dependence has surged in recent years among teenagers and young adults, yet just 1 in 4 youth with opioid use disorder (OUD) received pharmacotherapy within 6 months of diagnosis, according to a nationwide study.

Scott E. Hadland, MD, MPH, a specialist in adolescent and addiction medicine at Boston University School of Medicine and Boston Medical Center in Massachusetts, and colleagues published the results of their study online June 19 in JAMA Pediatrics.

The team examined the dispensing of naltrexone, an opioid antagonist, and buprenorphine, a partial opioid agonist, to more than 20,000 youth (ages 13 - 25 years) with OUD between 2001 and 2014.

They found that between 2002, which was the year buprenorphine was introduced into the US market, and 2009, the percentage of young people receiving medication increased by more than 10-fold from 3.0% to 31.8%. However, by 2014, the prescription rate had declined to 27.5%, even in the face of increasing diagnosis.

Patients who were younger or female were less likely to receive pharmacotherapy in adjusted analyses. In addition, non-Hispanic black or Hispanic youth were less likely to receive medication compared with white youth.

"Amidst emerging recommendations calling for expanded access to pharmacotherapy for youth with [OUD], medications may have been historically underutilized and disparities may exist by age, sex, and race/ethnicity," Dr Hadland and colleagues write.

Using de-identified records in the Optum database from a large US commercial health insurer, the researchers found 20,822 youth who met criteria for OUD (0.2% of total sample of 9.7 million youth). Their average age at diagnosis was 21 years, with the majority (53.1%) diagnosed at ages 21 to 25 years, and only 3.2% diagnosed at ages 13 to 15 years.

Among those 20,822 patients, 13,698 (65.8%) were male, and 17,119 (82.2%) were non-Hispanic white. The majority (67.8%) lived in metropolitan areas, 67.4% resided in high-education neighborhoods, and only 5.6% lived in neighborhoods with a high level of poverty.

The results highlight a critical treatment gap, with only 5580 (26.8%) patients prescribed either of the two OUD drugs within 6 months of diagnosis. Buprenorphine was prescribed for most patients (89.2%) compared with naltrexone for 10.8%, with the latter drug more commonly dispensed to female and younger patients, as well as those living in metropolitan areas, high-education neighborhoods, and lower-poverty-level neighborhoods.

Multivariable analyses pinpointed demographic treatment gaps. The adjusted probability of receiving medication among those aged 13 to 15 years was 1.4% (95% confidence interval [CI], 0.4% - 2.3%) compared with 9.7% (95% CI, 8.4% - 11.1%) for those aged 16 to 17 years, 22.0% (95% CI, 21.0% - 23.0%) among patients aged 18 to 20 years, and 30.5% (95% CI, 30.0% - 31.5%) for those aged 21 to 25 years (P < .001 for difference).

Females were less likely than males to receive medications (20.3% vs 24.4%; P < .001), and both non-Hispanic black (14.8%) and Hispanic (20.0%) patients were less likely to receive pharmacotherapy vs their non-Hispanic white (23.1%) counterparts (P < .001).

The reasons for these discrepancies are not known, but may include clinician bias and access to or denial of care, even in an insured population such as this one. "Prior studies have shown that poorer access to substance use treatment among minorities is in part explained by disparities in health insurance coverage," the authors write. "However, our results indicate that, even with coverage, non-Hispanic black and Hispanic youth are less likely than non-Hispanic white youth to receive medications for OUD."

They concede, however, that the study could not assess addiction severity, although age or other demographic variables might be associated with more severe OUD requiring prompt therapy.

The findings affirm the 2016 surgeon general's report highlighting untreated addiction in many young people and supports the recent American Academy of Pediatrics policy statement urging greater access to medication for addicted youth.

"In the face of a worsening opioid crisis in the United States, strategies to expand the use of pharmacotherapy for adolescents and young adults are greatly needed, and special care is warranted to ensure equitable access for all affected youth to avoid exacerbating health disparities," Dr Hadland and coauthors write.

In a related editorial, Brendan Saloner, PhD, an assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and colleagues stressed the urgent need to close the troubling medication-assisted treatments (MATs) gap for patients with OUD.

They note that fatal drug overdoses increased 3.5-fold for youth aged 15 to 24 years from 1999 to 2014. "Amidst this epidemic, relatively little is known about how primary care clinicians treat youth with OUD," Dr Saloner and associates write.

"These findings suggest that provision of MAT is not keeping up with the growing need for these treatments among youth."

They point out that the new findings may reflect the limited research on use of MAT in adolescents. Yet evidence from two trials has suggested that opioid-dependent adolescents receiving MAT are more likely to remain in treatment and less likely to resort to injectable drugs.

Helping to drive the underutilization, perhaps, is a culture of misinformation and stigmatization around MAT, which needs addressing before progress can be made, according to the editorialists: "The discourse surrounding 'opioid substitution' has created a misconception among both patients and prescribers that medications simply 'substitute one addiction for another' rather than treating the underlying disorder." Dr Saloner and associates call for sweeping policy and practice changes to give more opioid-dependent youth the benefit of MAT.

Such a change would require building capacity in pediatric primary care and expanding the number of physicians with the knowledge and support to prescribe MAT, as well as perhaps integrating primary and specialty care to link pediatricians and family physicians with MAT-training linked to specialized opioid treatment programs.

"Expanding our knowledge base and evidence based treatment to youth with OUD can avert needless loss of life, disability, incarceration, and unemployment," the commentators write, urging public health professionals to advocate for federal and state investments in access to youth substance use treatment.

The authors and editorial commentators have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online June 19, 2017. Article full text, Editorial extract

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