|by Muir Wood Medical Director, Nicholas Reeves, MD|
|There has been a significant surge in overdose deaths among American adolescents. A new study published in the Journal of the American Medical Association points to synthetic opioids, primarily fentanyl, as driving a troubling spike in overdose deaths among teens.|
According to the research by Friedman, Godvin, Shover, et al., the overdose mortality rate among US adolescents 14–18 years old almost doubled between 2019 and 2020, from 2.36 deaths per 100,000 population to 4.57 per 100,000.
“The increase in the overdose death rate marks a stark surge from what was a stable rate over the past decade,” reported Steven Ross Johnson for US News & World Report. “In 2010, for example, the fatal overdose rate was 2.4 deaths per 100,000. By contrast, according to the study, the overdose mortality rate among the overall US population rose steadily over the decade, and went from 12.4 deaths for every 100,000 people in 2010 to 21.5 per 100,000 in 2019.”
Fentanyl and other highly potent synthetic fentanyl analogs and designer drug opioids like isotonitazene are now the only opioids misused by most teens admitted to Muir Wood Adolescent and Family Services for opioid use disorder (OUD). The change to synthetics marks a dramatic shift from when I began working as Muir Wood’s medical director in 2018 when most OUD cases involved the prescription painkiller oxycodone.
“Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls,” wrote the study authors. “In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.”
Illicit use of fentanyl—a narcotic 80–100 times stronger than morphine—is currently driving a resurging opioid epidemic across the United States. More than 100,000 Americans died from drug overdoses between May 2020 and April 2021—the most ever recorded in a single year—according to the latest data provided by the Centers for Disease Control and Prevention in November. According to the Drug Enforcement Administration, four out of ten pills containing fentanyl hold a potentially lethal dose.
Many experts partially blame the impact of the COVID-19 pandemic for the current situation. Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health, stated in November that the pandemic has been a perfect storm in many ways.“People face enormous financial difficulties, mass unemployment, isolation, the fear and anxiety and uncertainty of the pandemic itself. All of those things can test anyone’s resilience to addiction.”
Sadly, we have heard of at least three fatal overdoses caused by fentanyl use of former Muir Wood patients since I started working at Muir Wood. Those fatal overdoses were all in boys who had not been treated for primary opioid addiction during their time at Muir Wood, so there was nothing we could have done to prevent these tragic and untimely deaths.
I have also treated several boys who nearly died but were resuscitated from a fentanyl overdose with the lifesaving opioid antagonist naloxone (Narcan), sometimes followed by CPR. That is why fellow Muir Wood psychiatrist Margaret Grimley and I always recommend that parents of opioid-using teens obtain at least two naloxone auto-injector devices (Evzio, requires a prescription) or Narcan nasal spray kits (available nationwide without prescription).
We teach parents to identify a possible opioid overdose and how to use this medication to reverse the effects of any opioids their child may have taken. Every day, teens are saved from tragic overdose deaths by the timely applications of naloxone by loved ones or paramedics. Fentanyl interacts so strongly with the opioid receptors in the brain that it sometimes requires repeated applications of naloxone to ensure continued breathing and survival.
The Muir Wood team has a comprehensive, evidence-based approach for treating opioid addiction in youth people. In some cases, treatment starts with opioid detoxification using a variety of medications for symptomatic relief and, in more severe cases, a buprenorphine taper to mitigate more severe opioid withdrawal presentations.
After the teens have been detoxed, intensive attention is given to any underlying psychiatric disorders (depression, anxiety disorders, post-traumatic stress disorder (PTSD), borderline personality disorder traits, bipolar disorder, and psychosis, in approximate order of prevalence in the Muir Wood male patient population). These psychiatric disorders—including substance use disorder (SUD)—are treated with a combination of therapies such as family therapy, cognitive behavioral therapy (CBT), motivational interviewing, 12-Step/community recovery program facilitation, and various group therapies in addition to psychiatric medication management whenever appropriate.
Once the underlying reasons for seeking escape from emotional pain and trauma through drug use have been treated, and the symptoms have improved markedly, the risk for relapse has been reduced by addressing the root causes that triggered the initiation and perpetuation of the SUD.
Following (or simultaneous with) psychiatric stabilization, we start every opioid use disorder patient on oral naltrexone, then transition to a long-acting injectable formulation of naltrexone called Vivitrol. Naltrexone is an opioid antagonist that blocks opioid receptors in the brain, which prevents the euphoria/“high” that opioid users are seeking from using opioids such as fentanyl, oxycodone, and heroin.
This approach is the most powerful and effective medication treatment strategy we have in modern medicine for the treatment of any addiction, and we have undoubtedly saved many lives by getting boys started on Vivitrol prior to discharge, then setting parents up with instructions on how to maintain the Vivitrol treatments after the teens return home.
Vivitrol not only prevents recurrent use of opioids and thus possible overdoses, but the medication also dramatically reduces cravings for opioids, so the addicted individual is spared the intense suffering induced by such cravings.
Helping patients establish a robust recovery program and community/sponsorship in Narcotics Anonymous (NA) is a critically important way we utilize to help facilitate recovery in teens, but I also believe that the Four Noble Truths of Buddhism offer an important alternative path to recovery from addiction for those boys and girls who are unwilling to engage with or participate in a traditional 12-Step recovery program such as NA—for a variety of reasons, those programs do not appeal to many teens in early recovery.
I encourage such patients to read Buddhist recovery literature such as texts utilized by Refuge Recovery or Recovery Dharma, to initiate a regular meditation practice, and to engage deeply with Buddhist recovery meetings such as Recovery Dharma, which always involve a 20–30 minute guided meditation, helping people in early recovery start a regular meditation practice and derive the immense benefits made possible through such practice.
Finally, family and group therapy are two of the most important cornerstones in our approach to treating all addictions, as healing damaged family dynamics and helping the clients support one another in the recovery process through mutual support groups and therapy groups at Muir Wood can be critically important for facilitating a successful transition to recovery at home, with family and peer support being of central importance.
Drug use in modern teens has become increasingly perilous and life-threatening in the modern era due to fentanyl’s widespread and cheap availability in high schools nationwide, so we encourage teens and the parents of teens who are struggling with opioid addiction or misuse to seek treatment, whether at Muir Wood or another high-quality treatment provider, where they can receive cutting edge and comprehensive treatment for misuse of and addiction to increasingly dangerous substances.