Guide: Opioid Addiction Among Young Adults, Youths

We have noted the facts: At the same time that opioid addiction is a public health emergency, opioid addiction treatment is strengthening. But increasingly, the opioid addiction problem is seen among young adults and even youths. What’s happening?

Recent studies outline the trend. And in this guide, we connect the dots around:

• How young adults can get introduced to opioids
• The increase in prescription drug abuse in young adults
• The role of medication to combat addiction
• The need to reduce “stigma”
• Tips for parents

Can Medical Procedures Serve as Opioid Gateway?

In one study, Calista Harbaugh, MD, of the University of Michigan in Ann Arbor, and colleagues, found that young people can become addicted to opioids following common surgical procedures, according to MedPage Today. In the study, “a large database of nearly 90,000 patients, ages 13 to 21 years, with no history of prior opioid prescriptions. These patients underwent 13 common surgeries from 2010 to 2015. They were compared with a control group of patients without opioid prescriptions or procedural codes for surgery during a similar time frame.”

The results found:

• “Risk factors for new opioid use included older age, if the patient was a girl, higher comorbidity score, anxiety, and substance and drug use.”
• “New, persistent opioid use following surgery may represent a ‘significant pathway to nonmedical opioid use among adolescents,’ and that identifying alternative methods of perioperative pain management for this population should be a priority.”

And do these events lead to opioid addiction?

MedPage further reports that another group examined data from the Nationwide Emergency Department Sample. They “found over 250,000 visits to the ED during the study period among children up to age 21 that included diagnosis codes for opioid abuse or dependence. Nearly 90% of those visits were from patients ages 18 to 21 years, with only 8% among those ages 16 to 17 years. More than half (56%) of the patients were boys.”

Importantly: “Overall, the number of ED visits that included a diagnostic code for opioid abuse or dependence rose from over 33,000 visits in 2008 to nearly 50,000 visits in 2013. ‘Unspecified’ opioid abuse and opioid dependence were the most common diagnostic codes.”

Prescription Drug Abuse Among Young Adults

Meanwhile, the National Institute of Drug Abuse, part of the U.S. National Institutes of Health, published an infographic titled “Abuse of Prescription (Rx) Drugs Affects Young Adults Most.”

The agency reports that “Young adults (age 18 to 25) are the biggest abusers of prescription (Rx) opioid pain relievers, ADHD stimulants, and anti-anxiety drugs. They do it for all kinds of reasons, including to get high or because they think Rx stimulants will help them study better. But Rx abuse is dangerous. In 2014, more than 1,700 young adults died from prescription drug (mainly opioid) overdoses—more than died from overdoses of any other drug, including heroin and cocaine combined—and many more needed emergency treatment.”

Additionally:

• “The nonmedical use of prescription drugs is highest among young adults. Past year nonmedical use of prescription drugs is shown on a bar chart by age group. Six percent of 12- to 17- year-olds, 12 percent of 18- to 25- year-olds, and 5 percent of persons age 26 or older, used prescription drugs nonmedically in the past year.”
• “More than 1,700 young adults died from Rx drug overdose in 2014–a 4-fold increase from 1999, that’s nearly 5 persons per day. A line graph shows prescription-drug-related overdose deaths increasing among persons ages 18- to 25- years-old from 418 deaths in 1999 to 1,741 deaths in 2014.”
• “Among young adults, for every death due to Rx drug overdose, there were 22 treatment admissions6 and 119 emergency room visits.”

How Did We Get Here?

The American Academy of Pediatrics offers an excellent history of opioid epidemics in the U.S., including one that was addressed in the early 1900s. But then:

“Twenty years after the Vietnam War, powerful oral opioid pain medications entered the market, simplifying outpatient pain treatment. Around the same time, a National Academy of Medicine (formerly Institute of Medicine) report encouraged physicians to more aggressively treat pain, and the Joint Commission on Hospital Accreditation asked patients to rate physicians on the basis of how well they addressed pain. Opioids were marketed to both medical professionals and patients as safe and nonaddictive and were heralded for improving quality of life in patients who suffered from painful conditions. A cultural movement that demanded that all aspects of life be “pain free” put tremendous pressure on medical professionals. Patients were willing to consume a lot of opioid pills, and nonpatients, including adolescents and often their parents, believed these medications to be safe. Between 1999 and 2014, the number of opioids prescribed increased by threefold,14 creating a reservoir distributed among medicine cabinets throughout the country. The oral formulation that averted the need for intravenous injection lowered the bar for initiating opioid use and helped to ignite the current epidemic.”

The further identifies connections between the current opioid epidemic and behaviors that can start even pre-adulthood:

• “New strategies for prevention and treatment are required to reverse the current epidemic of opioid addiction.”
• Substance use initiation most often occurs during childhood or adolescence; hence, prevention efforts are well within the purview of primary care pediatricians.”
• “Furthermore, providing interventions for substance use, including OUD treatment that incorporates MAT within primary care pediatrics, is a logical strategy for creating developmentally appropriate access for youth with opioid addiction.”
• “In addition to helping bring the current epidemic to an end, the integration of SUD treatment into primary care offers the additional benefits of extending treatment for the more common alcohol, marijuana, and tobacco use disorders and also builds an infrastructure that helps to prepare us for the next epidemic of drug addiction.”

Opioid Use Can Start With Simple Dental Procedure

A key challenge to the opioid epidemic: Initial exposure to the drugs can occur following a simple dental procedure common among teenagers: The pulling of wisdom teeth.

The Journal of the American Medical Association asks: “Are opioid prescriptions from dental clinicians that are written for pain management of third molar extractions from adolescents and young adults associated with subsequent opioid use and abuse?”

The report notes that “through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults.” The study’s objective: “To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population.”

The findings were remarkable: “Index opioid prescriptions in opioid-naive adolescents and young adults compared with age- and sex-matched controls were associated with a statistically significant 6.8% absolute risk increase in persistent opioid use and a 5.4% increase in the subsequent diagnosis of opioid abuse.”

In other words: “The findings suggest that dental opioid prescriptions, which may be driven by third molar extractions in this age group, may be associated with subsequent opioid use and opioid abuse.”

Or, as the Stanford University write-up puts it: “Opioid prescriptions from dentists linked to youth addiction risk. In teenagers and young adults, receiving opioids from dental providers is linked with elevated risk for continued opioid use and abuse, a Stanford study has found.”

Medication Prescription for Young Adult Addiction Down

“Both the American Academy of Pediatrics and the 2016 surgeon general’s report highlight that intervention early in the life course of youth addiction is critical for preventing progression to more severe disease, yet our data indicate that medications are underutilized for youth.”

– JAMA

Another challenge for young adults: Access to proper medication for opioid addiction. Another JAMA report investigated an important question: “How often do youth with opioid use disorder receive buprenorphine or naltrexone, and how has this changed over time?”

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.”

– JAMA

The study highlights the underlying issues in stark relief — and incredible statistic-based detail:

• “Drug overdose deaths in the United States—the majority of which are caused by prescription opioids and heroin—have reached an unprecedented level, having tripled from 2000 to 2014 and surpassed annual mortality from motor vehicle crashes.”
• Hospitalizations and emergency department visits for overdose, drug treatment admissions,8 and new hepatitis C infections related to opioids have risen dramatically over a similar timeframe.”
• “Risk for opioid use disorder (OUD) frequently begins in adolescence and young adulthood, with 7.8% of high school seniors reporting lifetime nonmedical prescription opioid use.”
• “Two-thirds of individuals in treatment for OUD report that their first use was before age 25 years, and one-third report that it was before 18 years.8 Intervening early in the development of OUD is critical for preventing premature death and lifelong harm.”
• “However, only 1 in 12 adolescents and young adults (collectively termed youth) who need care for any type of addiction receive treatment. Compounding this situation, black and Hispanic youth are even less likely than white youth to receive addiction treatment.”

The study’s results are just as telling:

• “In this large national study of buprenorphine and naltrexone dispensing among commercially insured youth with OUD, we found that only 1 in 4 youth received pharmacotherapy within 6 months of diagnosis during the 2001-2014 study period.”
• “From 2002 (when buprenorphine was introduced) to 2009, the percentage of youth receiving medication increased more than 10-fold, but subsequently declined amidst escalating OUD diagnosis rates.”
• “The odds of receiving pharmacotherapy were lower with younger age and among females compared with males, and non-Hispanic black and Hispanic youth compared with white youth.”
• “Overall, buprenorphine was dispensed 8 times more often than naltrexone. Naltrexone was more commonly dispensed to younger individuals and females and to youth in metropolitan areas, higher educational level neighborhoods, and lower poverty level neighborhoods.”

The bottom line: “Both the American Academy of Pediatrics and the 2016 surgeon general’s report highlight that intervention early in the life course of youth addiction is critical for preventing progression to more severe disease, yet our data indicate that medications are underutilized for 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.”

Need to Reduce ‘Stigma’

MedPage Today notes that “an accompanying editorial by Brendan Saloner, PhD, of Johns Hopkins University in Baltimore, and colleagues, argued that in addition to changes in clinical practice, a “cultural change” towards medication-assisted therapy is needed to reduce ‘stigma.'”

The post continues: “‘There is a need for research on how physicians, patients, and families communicate about [medication-assisted treatments] and how youth-specific concerns about buprenorphine use could be addressed in office-based settings,’ they wrote, adding that it was ‘troubling’ that these medications were used less commonly among girls and youth from minority backgrounds.”

“Further work is needed to understand the source of these discrepancies,” Saloner’s group wrote.

Advice for Parents

The Philadelphia Inquirer offers important facts around opioids and young adults:

The piece also offers advice for parents:

• Be the gatekeeper for medications, including those prescribed after wisdom teeth extraction. Don’t just hand your teen the bottle of pills after surgery. And be sure to properly dispose of leftover prescription drugs. You can search online for convenient drug drop-off locations in Pennsylvania, New Jersey and Delaware.
• Talk with your adolescents about your expectations that they will not use drugs and alcohol because (sometimes) they really do listen to you. Research confirms that when parents talk to their children about drugs and alcohol, those children are much less likely to become users. Not sure how to start the talk? The American Academy of Pediatrics has a useful resource.