Family-Focused Universal Substance Use Prevention in Primary Care: Advancing a Pragmatic National Healthcare Agenda.

This article advances ideas presented at a National Academies of Sciences, Engineering, and Medicine workshop in 2022 that highlighted clinical practice and policy recommendations for delivering universal, family-focused substance use preventive interventions in pediatric primary care. Pediatric primary care is a natural setting in which to offer families universal anticipatory guidance and links to systematic prevention programming; also, several studies have shown that offering effective parenting programs in primary care is feasible. The article describes a blueprint for designing a pragmatic national agenda for universal substance use prevention in primary care that builds on prior work. Blueprint practice schematics leverage efficacious family-focused prevention programs, identify key program implementation challenges and resources, and emphasize adopting a core element approach and utilizing digital interventions. Blueprint policy schematics specify avenues for improving cross-sector policy and resource alignment and collaboration; expanding, diversifying, and strengthening the prevention workforce; and enhancing financing for family-focused prevention approaches. The article then draws from these schematics to assemble a candidate universal prevention toolkit tailored for adolescent patients that contains four interlocking components: education in positive parenting practices, parent and youth education in substance use risks, a parent-youth structured interaction task, and parent and youth linkage to in-person and web-based prevention resources.

Patterns and perceptions of nicotine use among U.S. adolescents and young adults receiving medication treatment for opioid use disorder.

Nicotine use among U.S. youth is cause for concern, as previous studies have shown that nicotine use in adolescence increases the risk of developing substance use disorders later in life. This exploratory study aimed to understand patterns of nicotine use and perceptions of various nicotine products among adolescents and young adults (AYA) receiving medication treatment for opioid use disorder (MOUD). We administered an adapted version of the National Youth Tobacco Survey via REDCap to AYA (n = 32) receiving outpatient care in the Medication-Assisted Treatment of Addiction at Nationwide Children's Hospital in Columbus, Ohio, U.S.A. Thirty (97%) participants had tried a combustible cigarette and 27 (90%) had tried an electronic cigarette. By age 13, nineteen (61%) participants had tried combustible cigarettes and eight (25%) had tried opioids. Twenty-two (71%) participants reported smoking combustible cigarettes every day for the past 30 days, and 15 (48%) reported smoking more than 10 cigarettes per day on average. Only ten (32%) participants reported e-cigarette use in the last 30 days. Participants universally agreed that tobacco products are dangerous, and twenty (67%) current tobacco users reported that they planned to quit in the next year. Nicotine use patterns among AYA receiving MOUD differ from that previously shown in the general population, primarily by high prevalence of nicotine use in early adolescence and high current combustible cigarette use. Interventions such as universal screening for nicotine use before age 13 and tailored smoking cessation programs for AYA with OUD may help optimize care for these individuals.

Trauma and Resilience in Adolescents and Young Adults With Opioid Use and Eating Disorders.

Substance use disorders and feeding and eating disorders (FEDs) often manifest in early adolescence, are difficult to treat, and tend to co-occur. Despite their co-occurrence, little is known about their shared risk factors. A cross-sectional study was conducted to compare standardized measures of adverse childhood experiences (ACEs) and protective factors among 90 adolescents and young adults seeking outpatient treatment for either opioid use disorder (OUD) or an FED. These were assessed using the Modified Adverse Childhood Experience Survey and Southern Kennebec Healthy Start Resilience Survey. Reported ACEs were high in both groups compared with the national average, and those with OUD were more likely to endorse ≥4 resilience factors. Meanwhile, the prevalence of emotional neglect, household mental illness, and peer victimization/isolation/rejection was similar between groups. Opioid use disorder patients were also less likely to endorse ≥9 resilience factors. Health providers should be mindful to assess for trauma and resiliency in both these populations.

A Descriptive Study on Opioid Misuse Prevalence and Office-Based Buprenorphine Access in Ohio Prior to the Removal of the Drug Addiction Treatment Act of 2000 Waiver.

Background Medications for the treatment of opioid use disorder (MOUD) are effective evidence-based strategies to reduce opioid overdose deaths. Strategies to optimize MOUD availability and uptake are needed. Objective We aim to describe the spatial relationship between the estimated prevalence of opioid misuse and office-based buprenorphine access in the state of Ohio prior to the removal of the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver requirement. Methods We conducted a descriptive ecological study of county-level (N=88) opioid misuse prevalence and office-based buprenorphine prescribing access in Ohio in 2018. Counties were categorized into urban (with and without a major metropolitan area) and rural. The county-level prevalence estimates of opioid misuse per 100,000 were derived from integrated abundance modeling. Utilizing data from the Ohio Department of Mental Health and Addiction Services, as well as the state's Physician Drug Monitoring Program (PDMP), buprenorphine access per 100,000 was estimated by the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and the number of patients served by office-based buprenorphine (prescribing frequency) for opioid use disorder. The ratios of opioid misuse prevalence to both prescribing capacity and frequency were calculated by county and mapped. Results Less than half of the 1,828 waivered providers in the state of Ohio in 2018 were prescribing buprenorphine, and 25% of counties had no buprenorphine access. The median estimated opioid misuse prevalence and buprenorphine prescribing capacity per 100,000 were highest in urban counties, particularly those with a major metropolitan area. Although the median estimated opioid misuse prevalence was lower in rural counties, all counties in the highest quartile of estimated misuse prevalence were rural. In addition, the median buprenorphine prescribing frequency was highest in rural counties. While the ratio of opioid misuse prevalence to buprenorphine prescribing capacity was lowest in urban counties, the ratio of opioid misuse prevalence to buprenorphine prescribing frequency was lowest in rural counties. Opioid misuse prevalence and buprenorphine prescribing frequency demonstrated similar spatial patterns, with highest levels in the southern and eastern portions of the state, while office-based buprenorphine prescribing capacity did not. Conclusion Urban counties had higher buprenorphine capacity relative to their burden of opioid misuse; however, access was limited by buprenorphine prescribing frequency. In contrast, in rural counties, a minimal gap was evident between prescribing capacity and frequency, suggesting that buprenorphine prescribing capacity was the major factor limiting access. While the recent deregulation of buprenorphine prescribing should help improve buprenorphine access, future research should investigate whether deregulation similarly impacts buprenorphine prescribing capacity and buprenorphine prescribing frequency.

Patient and Clinician Perspectives on Adolescent Opioid Use Disorder Treatment During a Pandemic: One Step Back, but Two Forward?

Opioid use disorder (OUD) is one of the most pressing public health problems in the United States and is highly prevalent among adolescents and young adults (AYAs). However, only a small percentage of AYAs with OUD ever receive treatment. Further, among those that do receive treatment, a substantial proportion of patients continue to struggle with OUD, and many prematurely drop out of treatment. These challenges have only been heightened in the face of the COVID-19 pandemic, but greater utilization of telehealth and mobile technologies by OUD patients may help counter these barriers, which ultimately may improve AYA OUD treatment in the postpandemic period. This viewpoint presents the perspective of a person in OUD recovery using online and mobile technology to support his own OUD recovery combined with thoughts from two clinicians supporting AYAs with OUD. Their perspectives may provide insights to help counter COVID-19-related consequences and offer clues to improving AYA OUD treatment in the long term.

Immunity to Hepatitis B is Undetectable in the Majority of Adolescents and Young Adults Seeking Outpatient Medication Treatment for Opioid Use Disorder.

OBJECTIVE: To assess prevalence and predictors of hepatitis B immune status among adolescents and young adults (AYA) seeking outpatient medication treatment for opioid use disorder (MOUD). STUDY DESIGN: A retrospective medical chart review was conducted of AYA seeking MOUD between January 1, 2013 through December 31, 2015. Inclusion criteria included: diagnosis of opioid use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; received hepatitis serologic testing; and no evidence of prior or current hepatitis B infection. Hepatitis B immunization initiation was defined as a record of at least 1 hepatitis B vaccination; while receipt of at least 3 vaccinations indicated immunization completion. The presence of hepatitis B surface antibody (anti-HBs) was the primary outcome measure. RESULTS: Of the 193 patients that met eligibility criteria, the presence of anti-HBs was evident in 62 (32.1%). Hepatitis B immunization initiation and completion before presenting for MOUD was documented in 102 (52.9%) and 84 (43.5%). In multivariable logistic regression modeling, hepatitis B immunization initiation after infancy was associated with increased odds of having protective anti-HBs relative to immunization series initiation in infancy (OR 8.96, 95% CI 1.57-51.05). Completion of hepatitis B immunization series after infancy as compared to completion in infancy also increased the odds of protective anti-HBs (OR, 6.68, 95% CI 2.10-21.24). CONCLUSIONS: Rates of immunity to hepatitis B were low in AYA seeking MOUD. It is important to immunize patients seeking MOUD for hepatitis B and follow up with checks for seroconversion.

Impact of Office-based Opioid Treatment on Emergency Visits and Hospitalization in Adolescents with Opioid Use Disorder.

OBJECTIVE: To determine if engagement in office-based opioid treatment decreases emergency department, urgent care visits, and hospitalizations for acute opioid-related events (OREs) among adolescents with opioid use disorder. STUDY DESIGN: This retrospective cohort study identified all emergent and outpatient visits among adolescents, age 10-19 years, referred for office-based opioid treatment between January 1, 2006 and December 31, 2016. Patients were dichotomized into 2 cohorts: those who did and did not engage in office-based opioid treatment. The primary end point was the difference in the proportion of visits over the study period for acute OREs between cohorts and within the office-based opioid treatment cohort before and after referral. Secondary end points assessed change in the proportion of outpatient visits for treatment unrelated to opioid use disorder. RESULTS: Four hundred five emergent and outpatient visits were identified: 285 (70.4%) in the office-based opioid treatment cohort and 120 (29.6%) in the non-office-based opioid treatment cohort. After office-based opioid treatment engagement, 27.8% of visits in the office-based opioid treatment cohort were for acute OREs vs 80.8% in the non-office-based opioid treatment cohort (OR, 0.092; 95% CI, 0.052-0.160; P < .001). Outpatient visits in the office-based opioid treatment cohort were 10.9 times that of non-office-based opioid treatment (OR, 10.9; 95% CI, 6.23-19.16; P < .001). Within the office-based opioid treatment cohort, emergent visits decreased from 76.1% to 27.8% (OR, 0.121; 95% CI, 0.070-0.210; P < .001) and the odds of outpatient services was 8.3 times more after engagement (OR, 8.27; 95% CI, 4.78-14.4, P < .001). CONCLUSIONS: The absolute decrease in emergent visits for acute OREs was 53% in adolescents engaged in office-based opioid treatment, representing a relative decrease of 65.6% compared with adolescents not engaged. An analysis of visits before and after office-based opioid treatment demonstrated similar decreases, suggesting that office-based opioid treatment has a significant impact in decreasing acute OREs in the adolescent population.

An exploratory study of depot-medroxyprogesterone acetate and bone mineral density in adolescent and young adult women with cerebral palsy.

OBJECTIVE: To explore whether use of depot-medroxyprogesterone acetate (DMPA) in adolescent and young adult females with cerebral palsy is associated with lower bone mineral density (BMD). METHODS: A chart review of adolescent and young adult females with cerebral palsy who had undergone dual-energy X-ray absorptiometry, comparing BMD among those with (n = 19) and without DMPA (n = 84) exposure. RESULTS: BMD was similar in patients with and without DMPA exposure. All patients had low BMD, with average Z-scores of less than -2 at most sites. CONCLUSION: Results suggest that DMPA is not associated with lower BMD in non-ambulatory adolescent and young adult females with cerebral palsy.

Multifaceted Quality Improvement Initiative Improves Retention in Treatment for Youth with Opioid Use Disorder.

INTRODUCTION: There is a critical need to develop interventions that help adolescents and young adults with opioid use disorders (OUDs) connect with, engage in, and remain consistent with the treatment given that patients who develop long-term OUDs experience long-term medical and mental health sequelae. METHODS: We implemented quality improvement (QI) processes to increase early engagement and 6-month retention within a medication-assisted treatment clinic for youth with OUDs. QI interventions included motivational interviewing (MI) staff training, implementation of reduced initial treatment requirements, reduction of access barriers to treatment, and enhancement of patient treatment motivation. We monitored the impact of the interventions via a p-chart. RESULTS: A statistically significant shift was seen in the 6-month retention rate following both MI staff training and the use of reduced initial treatment requirements. Second visit return rate also experienced a statistically significant shift following transportation support and an incentive program. DISCUSSION: Our data demonstrate that following MI staff training, reduced initial clinic requirements, transportation support, and utilization of an incentive program, the second visit return rate, and 6-month retention rate improved within an outpatient medication-assisted treatment clinic for youth with OUDs.

Statewide opioid prescriptions and the prevalence of adolescent opioid misuse in Ohio.

BACKGROUND: Little is known about the relationship between opioid prescribing practices and the prevalence of adolescent opioid misuse. OBJECTIVE: To examine the relationships between both opioid prescriptions filled by adolescents and adults and adolescents seeking treatment for opioid misuse in Ohio. METHODS: Analyses of large statewide databases from 2008 to 2012, including all 88 counties in Ohio. The Ohio Board of Pharmacy provided data regarding prescription opioids filled by adolescents (12-20 years, N = 50,030,820 doses) and adults (>20 years, N = 3,811,288,395 doses) by county of residence. The Ohio Department of Mental Health and Drug Addiction Services provided annual treatment admissions for adolescent opioid misuse by county of residence (N = 6446). RESULTS: Adults filled prescriptions for nearly 100 oral opioid doses per capita annually, while adolescents filled prescriptions for approximately 7 oral opioid doses per capita annually. In Bayesian Poisson modeling examining the effect of annual adult per capita dose on adolescent treatment admissions, adjusted for annual adolescent per capita dose and year, an increase of one in the annual adult per capita opioid dose resulted in an increase of 1.3% (RR = 1.013, 95% HPD CI = [1.008, 1.017]) in the rate of adolescent treatment admissions. This association corresponds to a 99.99% chance that the adolescent treatment rate increases when the annual per capita adult dose is increased by one unit. CONCLUSION: The amount of opioids filled by adults in Ohio, although relatively stable from 2008 to 2012, is approximately 13 times that filled by adolescents and is significantly associated with adolescents seeking treatment for opioid misuse. Efforts to decrease adolescent opioid misuse should also focus on reducing adult opioid prescriptions.