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Non-Fatal Opioid-Related Overdoses Among Adolescents in Massachusetts 2012-2014

This study examines the characteristics of adolescents who experience non-fatal opioid-related overdoses and explores whether they subsequently receive medications for opioid use disorder (MOUD).

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Non-Fatal Opioid-Related Overdoses Among Adolescents in Massachusetts 2012-2014

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  1. Non-Fatal Opioid-Related Overdoses Among Adolescents in Massachusetts 2012-2014 Avik Chatterjee, Marc R. LaRochelle, Ziming Xuan, Na Wang, Dana Bernson, Michael Silverstein, Scott E. Hadland, Thomas Land, Jeffrey H. Samet, Sarah M. Bagley

  2. Disclosures • Dr. Bagley would like to acknowledge the 1K23 DA044324-01 award that supports her time, and Dr. Larochelle and Dr. Walley would like to acknowledge support from the 1UL1TR001430 grant from the National Center for Advancing Translational Sciences of the National Institutes of Health. • No conflicts of interest

  3. Opioid Epidemic Has Not Spared Adolescents In 2015: 772 Adolescent Overdose Deaths

  4. Opioid Use Disorder (OUD) Remains Undertreated in Adolescents • Medications for OUD (MOUD)—naltrexone, methadone, or buprenorphine—are life-saving • Yet in a 2010-2014 cohort of 27,677 youth aged 13-25 with OUD, <10% of adolescents got medications • 1/8th the rate of young adults • In 2016, the American Academy of Pediatrics released a statement encouraging MOUD in adolescents

  5. Why Aren’t Adolescents Receiving MOUD? • Providers • Federal restrictions on MOUD in adolescents • Methadone age • Buprenorphine 16+ • Stigma • Lack of preparation among adolescent providers • Patients • Low access to relevant providers • Reluctance to engage in outpatient care

  6. Non-Fatal Opioid-Related Overdose (NFOD) • NFOD is a high-risk event (100-fold increased mortality) • Could NFOD be a chance to intervene/start medications? • But little is known about adolescents who experience NFOD • Are they different from adults? • Are adolescents receiving MOUD after NFOD?

  7. Objectives • What are the characteristics of adolescents who experience NFOD, compared to adults? • Do adolescents who experience NFOD subsequently receive MOUD?

  8. Methods • Massachusetts Chapter 55 Dataset—mandated merging of individual-level data across multiple state agencies • Deterministic match protocol—requiring exact matches for several identifiers • Subsequently de-identified for research purposes

  9. All-Payer Claims Database Bureau of Substance Addiction Services Prescription Monitoring Program Chapter 55 Dataset Registry of Vital Records and Statistics Ambulance Trip Record Information System Acute Care Hospital Mix

  10. Methods • The cohort • Aged 11 and older • Experienced a non-fatal, opioid-related overdose between 1/1/2012 and 12/31/2014 • Outcome: receipt of MOUD in subsequent year • Co-variates: prior MOUD, Opioid, BZD prescription, anxiety, depression, location, MassHealth • High missingness for race variable • Excluded those who died within 30 days • Co-variate data available 1/1/2011 til 12/31/2015

  11. Methods • Descriptive statistics • Chi-square test for comparisons between those 11-17 and those 18+

  12. Results • 22,525 NFODs among adults in MA between 2012 and 2014 • 195 of those among adolescents (0.9%)

  13. Results

  14. Results

  15. Discussion • Adolescents who experienced NFOD in MA between 2012 and 2014 were different from adults in important ways • Gender • Prior receipt of opioids • NFOD is a missed opportunity for prescription of MOUD

  16. Discussion • Gender • Consistent with prior findings that younger girls are taught to use opioids by older man, as part of sexual, often violent, relationships: UFO study • Lack of prescription opioids • Consistent with other data that adolescents get prescription opioids from friends/family members

  17. Discussion • Why did so few adolescents receive MOUD? • This mirrors trend among adults (29% after NFOD in the same Chapter 55 dataset among adults) • Broader stigma about meds (“replacing one addiction for another”) • Stigma and lack of preparedness among pediatric providers • Federal restrictions on buprenorphine and methadone among adolescents • MOUD not available where adolescents interact with the treatment system (e.g., residential treatment)

  18. Discussion • Future directions • ED and hospital based interventions to start MOUD and connect to outpatient care • Gender-appropriate and trauma-informed approaches • Integrating MOUD into residential treatment programs, corrections, other institutions with which adolescents may interact after NFOD • Trainings specific to adolescent providers

  19. Discussion • Limitations • This is likely an undercount • 1 year of ambulance data not present • Some NFODs may not have gone in ambulance/to ER • The epidemic has changed since 2014 (fentanyl) • Still, the need for increased MOUD access for adolescents very likely persists

  20. Questions?

  21. References • An Assessment of Fatal and Nonfatal Opioid Overdoses in Massachusetts (2011 – 2015), 2017. . Boston. • Bagley, S.M., Hadland, S.E., Carney, B.L., Saitz, R., 2017. Addressing Stigma in Medication Treatment of Adolescents with Opioid Use Disorder. J. Addict. Med. 11. https://doi.org/10.1097/ADM.0000000000000348 • Balousek, S., Plane, M.B., Fleming, M., 2007. Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. J. Gen. Intern. Med. 22, 1268–1273. https://doi.org/10.1007/s11606-007-0257-6 • Bourgois, P., Prince, B., Moss, A., 2004. The Everyday Violence of Hepatitis C Among Young Women Who Inject Drugs in San Francisco. Hum Organ 63, 253–264. https://doi.org/10.1016/j.bbi.2008.05.010 • Center for Behavioral Health Statistics and Quality, 2014. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ [WWW Document]. www.samhsa.gov. • Cicero, T.J., Ellis, M.S., Kasper, Z.A., 2017. Increased use of heroin as an initiating opioid of abuse. Addict. Behav. 74, 63–66. https://doi.org/10.1016/j.addbeh.2017.05.030 • Committee on Substance Use and Prevention, 2016. Medication-Assisted Treatment of Adolescents With Opioid Use Disorders. Pediatrics 138, e20161893. https://doi.org/10.1542/peds.2016-1893 • Curtin, S., Tejada-Vera, B., Warner, M., 2017. Drug Overdose Deaths Among Adolescents Aged 15–19 in the United States: 1999–2015. • Feder, K.A., Krawczyk, N., Saloner, B., 2017. Medication-Assisted Treatment for Adolescents in Specialty Treatment for Opioid Use Disorder. J. Adolesc. Heal. 60, 747–750. https://doi.org/10.1016/j.jadohealth.2016.12.023 • Green, C.A., Perrin, N.A., Janoff, S.L., Campbell, C.I., Chilcoat, H.D., Coplan, P.M., 2017. Assessing the accuracy of opioid overdose and poisoning codes in diagnostic information from electronic health records, claims data, and death records. Pharmacoepidemiol. Drug Saf. 26, 509–517. https://doi.org/10.1002/pds.4157 • Hadland, S.E., Wharam, J.F., Schuster, M.A., Zhang, F., Samet, J.H., Larochelle, M.R., 2017. Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2000-2014. J. Adolesc. Heal. 60, S12–S13. https://doi.org/10.1016/j.jadohealth.2016.10.045 • Hasegawa, K., Espinola, J.A., Brown, D.F.M., Camargo, C.A., 2014. Trends in U.S. Emergency department visits for opioid overdose, 1993-2010. Pain Med. (United States) 15, 1765–1770. https://doi.org/10.1111/pme.12461 • Larochelle, M., Liebschutz, J., Zhang, F., Ross-Degnan, D., Wharam, J., 2016. Opioid Prescribing After Nonfatal Overdose and Assocation with Repeated Overdose. Ann Intern Med 164, 1–9. https://doi.org/10.7326/M15-0038 • Larochelle, M.R., Bernson, D., Land, T., Stopka, T.J., Wang, N., Xuan, Z., Bagley, S.M., Liebschutz, J.M., Walley, A.Y., 2018. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann. Intern. Med. https://doi.org/10.7326/M17-3107 • Patrick, S.W., Bauer, A.M., Warren, M.D., Jones, T.F., Wester, C., 2017. Hepatitis C virus Infection among women giving birth - Tennessee and United States, 2009-2014., MMWR Morb Mortal Wkly Rep. https://doi.org/10.15585/mmwr.mm6618a3 • Somerville, N.J., O’Donnell, J., Gladden, R.M., Zibbell, J.E., Green, T.C., Younkin, M., Ruiz, S., Babakhanlou-Chase, H., Chan, M., Callis, B.P., Kuramoto-Crawford, J., Nields, H.M., Walley, A.Y., 2017. Characteristics of Fentanyl Overdose — Massachusetts, 2014–2016. MMWR. Morb. Mortal. Wkly. Rep. 66, 382–386. https://doi.org/10.15585/mmwr.mm6614a2 • Tolia, V.N., Patrick, S.W., Bennett, M.M., Murthy, K., Sousa, J., Smith, P.B., Clark, R.H., Spitzer, A.R., 2015. Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs. N Engl J Med April, 1–9. https://doi.org/10.1056/NEJMsa1500439

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