Opioid overdose deaths have increased over the last twenty years, initially fueled by prescription opioids but with a shift to fentanyl and other synthetic opioids in the last decade (Calcaterra et al., 2013, Park et al., 2021, Ciccarone, 2021, Ciccarone, 2019). Opioid use among adolescents has likewise increased over the last two decades and regional reports suggest an acceleration of emergency department (ED) presentations in the last few years (Borodovsky et al., 2018, Sidlak et al., 2023). Despite this, there is little data on the management of adolescents in the ED (Sidlak et al., 2023). Overall, presentations for opioid use disorder (OUD) to the ED are common, and the health care cost of managing these patients is high (Langabeer et al., 2021, Miron et al., 2022).

Evidence-based practices have been established in adults but have not been extensively studied in adolescents (Borodovsky et al., 2018, Santo et al., 2021). Opioid agonist therapy (OAT) including both buprenorphine and methadone reduce all-cause mortality and is recommended for adolescents with severe OUD (Borodovsky et al., 2018, Santo et al., 2021, COMMITTEE ON SUBSTANCE USE AND PREVENTION, 2016). Buprenorphine is effective in reducing subsequent opioid overdoses and treating opioid withdrawal symptoms (D’Onofrio et al., 2015, Wakeman et al., 2020, Sordo et al., 2017, Carroll et al., 2023, D’Onofrio et al., 2023). Induction in the ED is possible following standardized protocols (D’Onofrio et al., 2015, Carroll et al., 2023). Compared to symptomatic treatment of adolescents in withdrawal with clonidine, patients treated with buprenorphine have higher rates of continued treatment engagement (Marsch et al., 2005). Risk of precipitated withdrawal, worsening of symptoms after induction of buprenorphine, is possible and potentially increased with widespread fentanyl. However, recent prospective evidence shows the incidence of precipitated withdrawal is low (<1%) (D’Onofrio et al., 2023). Therefore, preliminary evidence exists that the beneficial effects seen in adults are likewise present in adolescents.

Nevertheless, initiation of treatment in adolescents remains underutilized. Adolescents are less likely to seek out treatment and, when they do, engagement may be limited (Winters et al., 2014, Breda and Heflinger, 2004). A perceived lack of risk, a shorter duration of opioid use, and normalization of drug use amongst peers may explain the reluctance to seek out treatment (Winters et al., 2014). Despite this, increasing presentations to the ED have been documented, which allow for a window where appropriate interventions can be initiated (Borodovsky et al., 2018). This window may be especially important given the vulnerability of this age group. There are both psychoemotional and neurophysiological factors that predispose adolescents to complications from opioid misuse (Walker, and Harrop, 2016). Adolescence is the developmental period in which individuals explore relationships and boundaries as a means of determining how best to survive and thrive as members of society. This corresponds to heightened social perceptions and attention to activities of peers, largely due to the earlier maturation of social-emotional centers of the brain (Hoft and Pletcher, 2020). Studies have suggested that an adolescent brain exposed to opioids is more likely to demonstrate neuronal receptor changes that correlate with higher risks of tolerance and dependence, while the prefrontal cortex appears most susceptible to injuries from use (Potenza, 2013, Ingram et al., 2006). It is in this context that those who initiate non-medical opioid use as adolescents face higher rates of lethal overdose and use disorders in adulthood than those who initiate use as adults (McCabe et al., 2022, Frank et al., 2015). These vulnerabilities are compounded by additional challenges to effective health interventions in this age group, where regulations have limited widespread use of OAT, as buprenorphine is only approved for ages 16 and older, and overall community resources to continue treatment are lacking (Borodovsky et al., 2018, McCormick, 2002, Subramaniam et al., 2009, Wu et al., 2016). One harm-reduction intervention that has been shown to be effective is naloxone. Naloxone is an opioid antagonist, which can reverse fatal respiratory depression from opioids (Wheeler et al., 2015). Naloxone has been distributed to laypeople, made available in public, and provided as take-home naloxone (THN) in the ED (Centers for Disease Control and Prevention (CDC), 2015, McDonald and Strang, 2016, Giglio et al., 2015). These latter programs have been shown to decrease mortality but are historically underutilized (McDonald and Strang, 2016, Giglio et al., 2015, McDonald et al., 2017).

In summary, there is evidence of increasing opioid-related ED presentations; however, there are no studies on current ED management. Therefore, we aimed to study adolescents presenting to the ED with opioid-related complaints, their demographics, and how they were managed. We also sought to identify the rate of revisit to the ED for opioid-related complaints and if there was any association to patient demographics or management on preceding visits.