Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults, and Families.

Pediatricians across the United States encounter infants, children, adolescents, young adults, and families affected by substance use disorders in their daily practice. For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame; however, as addiction became understood as a medical disorder, clinical terminology has shifted along with a growing awareness of harm of stigmatizing language in medicine. In issuing this policy statement, the American Academy of Pediatrics (AAP) joins other large organizations in providing recommendations regarding medically accurate, person-first, and nonstigmatizing terminology. As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of infants, children, adolescents, young adults, and families. In this policy statement, the AAP provides 3 specific recommendations, accompanied by a table that presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and explanations for each. Pediatricians have an important role in advocating for the health of children and adolescents in the context of families affected by substance use and are optimally empowered to do so by avoiding the use of stigmatizing language in favor of medically accurate terminology that respects the dignity and personhood of individuals with substance use disorders and the children and adolescents raised in families affected by substance use.

Research to law: A qualitative study of Massachusetts' 2018 Care Act expanding emergency department initiation of medication for opioid use disorder.

BACKGROUND: Initiating medication for opioid use disorder (MOUD) during emergency department (ED) visits is an important innovation to engage individuals in addiction treatment. In 2018, Massachusetts passed the CARE Act, becoming the first state to legislate that hospitals with EDs must be able to offer MOUD. We performed a qualitative study to explore factors influencing policy enactment. METHODS: Semi-structured interviews were conducted in 2019 with ten key stakeholders involved in the policymaking process representing state government, hospitals, physician professional societies, and recovery/behavioral health organizations. Data were analyzed in 2020-2021 using a hybrid inductive-deductive approach. RESULTS: The first key theme stakeholders expressed was the importance of research and public health consensus; they described consensus building within existing coalitions regarding the pressing need for action, and supporting expansion of treatment with this evidence-based strategy. Second, stakeholders discussed overcoming financing and feasibility concerns by passing budget-neutral legislation and ensuring flexibility for diverse hospital types. Lastly, stakeholders looked towards implementation, describing the implementation guide development process and ensuring capacity for continuing treatment existed throughout the state. CONCLUSIONS: This study suggests that research supporting the effectiveness of ED MOUD induction drove the passage of this state legislation. Long-term collaboration between diverse stakeholders towards a common goal of increasing access to evidence-based treatment to address the opioid epidemic was also perceived as facilitating the law's passage. Policymakers and advocates in other states may look towards Massachusetts's legislative process as a model for implementing similar legislation as part of their strategies to address the drug overdose crisis.

Treatment of Opioid Use Disorder With Buprenorphine Among US Adolescents and Young Adults During the Early COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic's impact on buprenorphine treatment for opioid use disorder among adolescents and young adults (AYAs) is unknown. METHODS: We used IQVIA Longitudinal Prescription Claims, including US AYAs aged 12-29 with at least 1 buprenorphine fill between January 2018 and August 2020, stratifying by age group and insurance. We compared buprenorphine prescriptions in March-August 2019 to March-August 2020. RESULTS: The monthly buprenorphine prescription rate increased 8.3% among AYAs aged 12-17 but decreased 7.5% among 18- to 24-year-olds and decreased 5.1% among 25- to 29-year-olds. In these age groups, Medicaid prescriptions did not significantly change, whereas commercial insurance prescriptions decreased 12.9% among 18- to 24-year-olds and 11.8% in 25- to 29-year-olds, and cash/other prescriptions decreased 18.7% among 18- to 24-year-olds and 19.9% in 25- to 29-year-olds (p < .001 for all). DISCUSSION: Buprenorphine prescriptions paid with commercial insurance or cash among young adults significantly decreased early in the pandemic, suggesting a possible unmet treatment need among this group.

Unsolicited reporting notifications (URNs) through Maryland's prescription drug monitoring program (PDMP): Characteristics of providers.

Objectives: Unsolicited reporting is the activity of analyzing Prescription Drug Monitoring Program (PDMP) data and then sending unsolicited reporting notifications (URNs) to prescribers to notify them of their outlier prescribing behavior. We aimed to describe information about prescribers who were issued URNs. Methods: A retrospective study of Maryland's PDMP data from Jan.2018-Apr.2021. All providers who were issued ≥ one URN were included in analyses. We summarized data on types of URNs issued by provider type and years in practice using basic descriptive measures. We also performed logistic regression analysis to provide odds ratio and estimated marginal probability of issuing ≥ one URN to providers in the Maryland health care workforce in comparison with physicians as reference group. Results: A total of 4,446 URNs were issued to 2,750 unique providers. Odds ratio (OR) and the population estimated probability of issuing URNs were higher among nurse practitioners [OR: 1.42, 95% Confidence Interval (CI): 1.26-1.59] followed by physician assistants [OR: 1.87, 95% CI: 1.69-2.08], compared to physicians. Physicians and dentists with >10 years in practice comprised the majority of providers who were issued URNs (65.1% and 62.6%, respectively), while majority of nurse practitioners had been in practice for <10 years (75.8%). Conclusion: Findings indicate a higher probability of issuing URN for Maryland's physician assistants and nurse practitioners, compared to physicians, and an overrepresentation of physicians and dentists with longer and nurse practitioners with shorter practice experience. The study suggests education programs on safer prescribing practices and management of opioids should target certain types of providers.

Provider and Practice Characteristics and Perceived Barriers Associated With Different Levels of Adolescent SBIRT Implementation Among a National Sample of US Pediatricians.

Pediatrician Screening, Brief Intervention, and Referral to Treatment (SBIRT) practices vary widely, though little is known about the correlates of SBIRT implementation. Using data from a national sample of US pediatricians who treat adolescents (n = 250), we characterized self-reported utilization rates of SBIRT among US pediatricians and identified provider- and practice-level characteristics and barriers associated with SBIRT utilization. All participants completed an electronic survey querying the demographics, practice patterns, and perceived barriers related to SBIRT practices. Our results showed that 88% of respondents reported screening for substance use annually, but only 26% used structured/validated screening instruments. Furthermore, 40% of respondents provided evidence-based brief interventions, and only 11% implemented all core SBIRT practices. Common barriers (eg, confidentiality and insufficient time) and unique provider- and setting-specific barriers to implementation were identified. These findings indicate that although most pediatricians deliver some SBIRT components in their practice, few implement the full SBIRT model, and barriers persist.

Opioid Use Disorder Treatment Facilities With Programs for Special Populations.

INTRODUCTION: Special populations, including veterans, pregnant and postpartum women, and adolescents, benefit from opioid use disorder treatment tailored to their specific needs, but access to such services is poorly described. This study identifies the availability of opioid use disorder treatment facilities that use medications and have special programming and contextualizes facilities amid counties' opioid-related overdose mortality. METHODS: Data were compiled on 15,945 U.S. treatment facilities using medications for opioid use disorder listed in the Behavioral Health Services Treatment Locator in 2018. Facilities with programs tailored to special populations (veterans, pregnant and postpartum women, and adolescents) were identified and geocoded. Counties with such facilities were characterized. Cold spots (county clusters with poor treatment availability) were identified using Getis-Ord Gi* statistics. Data were extracted in October 2018 and analyzed from October 2018 to May 2019. RESULTS: Of all 3,142 U.S. counties, 1,889 (60.1%) had opioid use disorder treatment facilities. Facilities with tailored programs for veterans, pregnant and postpartum women, and adolescents were located in 701 (22.3%), 918 (29.2%), and 1,062 (33.8%) of the counties, respectively. Specific medications provided for opioid use disorder varied, with only a minority of facilities offering methadone (among facilities with tailored programs for veterans, 6.0%; pregnant and postpartum women, 13.2%; adolescents, 1.3%). Many counties reporting opioid-related overdose deaths lacked programs for special populations (veterans, 72.6%; pregnant and postpartum women, 54.8%; adolescents, 30.6%). Cold spots were located throughout the Midwest, U.S. Southeast, and portions of Texas. CONCLUSIONS: Facilities using medications for opioid use disorder with tailored programs for veterans, pregnant and postpartum women, and adolescents are limited. There is a need for improved access to evidence-based programs that address the unique treatment needs of special populations.

Adolescent-Serving Addiction Treatment Facilities in the United States and the Availability of Medications for Opioid Use Disorder.

PURPOSE: Adolescents with opioid use disorder are less likely than adults to receive medications for opioid use disorder (MOUD), yet we know little about facilities that provide addiction treatment for adolescents. We sought to describe adolescent-serving addiction treatment facilities in the U.S. and examine associations between facility characteristics and offering MOUD, leading to informed recommendations to improve treatment access. METHODS: This cross-sectional study used the 2017 National Survey of Substance Abuse Treatment Services. Facilities were classified by whether they offered a specialized adolescent program. Covariates included facility ownership, hospital affiliation, insurance/payments, government grants, accreditation/licensure, location, levels of care, and provision of MOUD. Descriptive statistics and logistic regression compared adolescent-serving versus adult-focused facilities and identified characteristics associated with offering maintenance MOUD. RESULTS: Among 13,585 addiction treatment facilities in the U.S., 3,537 (26.0%) offered adolescent programs. Adolescent-serving facilities were half as likely to offer maintenance MOUD as adult-focused facilities (odds ratio, .53; 95% confidence interval, .49-.58), which was offered at 23.1% (816) of adolescent-serving versus 35.9% (3,612) of adult-focused facilities. Among adolescent-serving facilities, characteristics associated with increased unadjusted odds of offering maintenance MOUD were nonprofit status, hospital affiliation, accepting insurance (particularly, private insurance), accreditation, Northeastern location, or offering inpatient services. CONCLUSIONS: The one-quarter of U.S. addiction treatment facilities that serve adolescents are half as likely to provide MOUD as adult-focused facilities, which may explain why adolescents are less likely than adults to receive MOUD. Strategies to increase adolescent access to MOUD may consider insurance reforms/incentives, facility accreditation, and geographically targeted funding.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Practice: A Quality Improvement Project in the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network.

The American Academy of Pediatrics recommends pediatric providers routinely screen for, assess, and treat substance use and substance use disorders among adolescents, a process called "Screening, Brief Intervention, and Referral to Treatment," or "SBIRT." Because there are limited data on how Maryland pediatric practices have adopted SBIRT, a quality improvement initiative was developed within the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network using a "Plan/Do/Study/Act" approach. A 2-part provider training was conducted regarding screening and motivational interviewing, and the "CRAFFT" screening tool was integrated into the practice's electronic medical record. Results from evaluation demonstrated significant improvements in provider knowledge, attitudes, and screening behavior. The association between substance use and sexual behavior suggests a need for further expansion of this model with inclusion of sexual health screening. Overall, this study demonstrates that SBIRT implementation into a general pediatric practice is highly feasible, acceptable, and shows preliminary effectiveness.

Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults.

Importance: Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown. Objective: To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment. Design, Setting, and Participants: This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4 039 216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019. Exposures: Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids. Main Outcomes and Measures: Receipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified. Results: Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100 000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20 700 per 100 000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83). Conclusions and Relevance: After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.