Anticipatory Guidance to Prevent Adolescent Overdoses

Drug overdoses and poisonings are now the third leading cause of death among American children and adolescents younger than age 19 years. 1 In 2022, overdoses claimed the lives of >1100 adolescents aged 14 to 182—approximately the equivalent of a high school classroom every week. From 2019 to 2021 alone, adolescent overdose mortality doubled, driven by the widespread infiltration into the US drug supply of highly potent, illicitly manufactured fentanyl, which now causes >3 of every 4 adolescent overdose deaths. 2, 3Pediatricians routinely provide anticipatory guidance to patients and families regarding the top 2 causes of death in children—firearm injuries and motor vehicle crashes. 1 As 2 pediatric addiction medicine specialists and a parent who lost her 18-year-old daughter to fentanyl poisoning, we believe there is now an urgent need for pediatricians to counsel adolescents and families on potentially lifesaving overdose prevention strategies. Pediatricians typically offer all patients and families anticipatory guidance regardless of risk status, and because many fentanyl-related deaths occur in adolescents without previously identifiable risk factors, pediatricians should apply a universal approach to discussing overdose prevention. To inform this anticipatory guidance, it is critical that pediatricians first understand the current context of adolescent overdoses. In many cases, adolescents overdose after using a counterfeit prescription pill that contains fentanyl and was illicitly manufactured to mimic opioid painkillers (eg, oxycodone) or benzodiazepines (eg, alprazolam). The US Drug Enforcement Administration reports that at least 6 of every 10 counterfeit prescription pills seized contain a dose of fentanyl that is potentially lethal (ie, ≥2 mg), 4 especially for adolescents who have little to no previous exposure to opioids. Pills are often available for purchase on social media platforms that adolescents commonly use, including Snapchat and TikTok. 5 Other drugs are also increasingly contaminated with fentanyl, including stimulants such as cocaine and methamphetamine, which also places adolescents who do not intend to use an opioid at risk. Adolescents may seek out what they believe to be a real prescription opioid or benzodiazepine to provide relief from depression, anxiety, or other mental health symptoms; in 2021, 41% of adolescent decedents had a known mental health problem. In other cases, adolescents may knowingly use fentanyl as part of an opioid use disorder. Nationwide, 1 in 100 adolescents aged 12 to 17 years has an opioid use disorder, 6 and approximately 1 in 3 adolescents who overdosed in 2021 had a known history of opioid use. 3The most recently available data from the US Centers for Disease Control and Prevention (show that, from 2019 to 2021, most overdoses occurred in an adolescent's home. 3 Tragically, two-thirds of the time, another person was in the home and could have intervened but may have been unaware the adolescent was using drugs. Naloxone—an easy-to-administer nasal spray that can reverse an overdose in minutes—was only administered in 1 of 3 deaths. Most commonly, by the time emergency respondents arrived, the adolescent was already pulseless, highlighting the need for family members to urgently intervene with naloxone in fentanyl overdoses, which unfold quickly. These data highlight the need to involve families in anticipatory guidance to prevent overdoses. Although pediatricians commonly discuss drug and alcohol use privately with adolescents, we assert that conversations about overdose prevention should begin by including both the adolescent and their family members to foster ongoing discussions at home. After inviting adolescents and their family members into a conversation about overdose prevention, pediatricians should provide accurate information about fentanyl (Table 1). They should counsel adolescents and family members about its widespread infiltration into the illicit drug market, including in counterfeit pills. Pediatricians should avoid fear-based approaches, which are not effective and may decrease credibility. Instead, pediatricians should speak to adolescents' strengths and empower them to keep themselves and their peers safe. Next, pediatricians should review the signs of an overdose (ie, somnolence, unconsciousness, paleness, slowed or stopped breathing, and cyanosis) and how to intervene. Adolescents and family members should immediately call 911 in the event of a suspected overdose, even if they plan to administer naloxone. Medical attention is critical because naloxone can wear off after 30 to 90 minutes, allowing a fentanyl overdose to resume, and because it is possible that an individual has overdosed on a nonopioid (naloxone is only effective for opioids) or has another medical explanation for their change in mental status. Nearly all states have Good Samaritan Laws that protect individuals if they are in possession of illicit drugs at the time first responders arrive. 7Pediatricians should counsel adolescents and families about naloxone, how to use it, and how to obtain it. Naloxone is typically covered by most health insurers with little or no copay when prescribed, is commonly distributed for free by local health departments, and became available over the counter in late summer 2023. Unfortunately, the over-the-counter price for a kit of 2 naloxone nasal sprays is 45, which is cost-prohibitive for many families. As another option, adolescents and families can obtain naloxone through a prescription, which can be billed to health insurance, minimizing out-of-pocket costs. The prescription can be written by a pediatrician, or alternatively, every US state has a "standing order" in which naloxone prescriptions can be dispensed by pharmacists (and billed to health insurance) without a physician having written for it first. Pediatricians should also spend time alone with the adolescent and, through a confidential interview, seek to learn whether they use substances or pills. The American Academy of Pediatrics recommends screening all adolescents for substance use with a validated tool (eg, Screening to Brief Intervention or Car, Relax, Alone, Forget, Family/Friends, Trouble, both of which are freely available online for use in clinical practice). Screening can open a confidential conversation about an adolescent's experiences with fentanyl and overdose. For adolescents who might be uncomfortable talking about their own behaviors, it may be helpful to frame the conversation around how to keep their peers safe. When adolescents disclose that they are using pills or other drugs that place them at risk for overdose, pediatricians should support them in stopping or decreasing their substance use. Although there is no clear ethical standard for whether a pediatrician should break confidentiality and share this information with a parent, because of an adolescent's potential risk to self, some pediatricians may elect to do so but should partner with the adolescent to determine the best way to disclose this information. Although disclosure may be necessary to protect an adolescent's life, it may erode the adolescents' trust and willingness to disclose sensitive information again in the future. In cases where an adolescent has a mental health concern, pediatricians can also prescribe evidence-based medications and support linkage to psychotherapy. For adolescents who continue to use opioids, pediatricians can offer advice to reduce risk. Strategies include starting with only a small amount of any substance to assess its potency, avoiding mixing drugs with other sedatives (eg, alcohol, benzodiazepines), and using fentanyl test strips to determine whether their drugs contain fentanyl. The nation's focus on the overdose crisis has long centered on adults, but increasingly, deaths involve younger ages. By applying an already-familiar framework—anticipatory guidance—pediatricians have a critical opportunity to equip adolescents and families with the knowledge and skills to stem the tide of rising adolescent overdose mortality.