P3.004: Buprenorphine/Naloxone therapy for opioid withdrawal, medication-assisted treatment, and pain management in an adolescent patient

Introduction: Opioid addiction is a chronic disorder centered around craving and compulsive use of prescription or non-medical opioids. The last three decades have seen a dramatic increase in opioid use order (OUD) in the United States, with about 87,000 adolescents in the 12–17 age group estimated to have OUD in 2019. Less than 10% receive medication-assisted treatment (MAT). We present a case of a 17-year-old male who received treatment with buprenorphine-naloxone (Suboxone) for withdrawal management, MAT and acute pain.

Case Description: A 17-year-old-male with a history of anxiety, depression, and attention deficit/hyperactivity disorder (ADHD) presented to the emergency department (ED) for increasing poly-substance use and acute withdrawal symptoms. For two months he had been using various opiates, ecstasy and psychedelics, overusing his ADHD medication, and quit "cold turkey" three days ago. His urine drug screen was positive for amphetamines, cannabinoids and tramadol metabolites and negative for other opioids. After consulting with the Pain/Addiction medicine service, he was admitted to the pediatric floor. Following shared decision making with the patient and parents, he was started on sublingual buprenorphine-naloxone with close monitoring for precipitated withdrawal. He required an increase in scheduled doses, addition of as-needed buprenorphine-naloxone for high clinical opioid withdrawal score (COWS) and symptomatic treatment with clonidine. Hospital policy on COWS was communicated with pediatric nurses and residents. His multidisciplinary care team included pediatrics, addiction medicine, psychiatry and social work— culminating in a referral to community mental health and an outpatient adolescent addiction medicine provider for maintenance MAT. Three weeks later, he returned to the ED with severe abdominal pain and was diagnosed with spontaneous splenic rupture secondary to infective mononucleosis. He was managed non-operatively in the pediatric ICU with oxycodone and hydromorphone for acute pain. As he was on MAT, addiction medicine was again consulted and the pain regimen was switched to buprenorphine-naloxone in lieu of full opioid agonists. This improved pain and functionality. On discharge, he continued MAT taper with his outpatient provider.

Discussion: Buprenorphine is a partial opioid agonist approved for OUD treatment in adolescents by the US Food and Drug Administration. Clinical trials have displayed reduced rates of adolescent opioid use by initiating MAT and substance use counseling, helping them achieve long term sobriety. The 2016 policy statement by the American Academy of Pediatrics endorsed a buprenorphine prescriber course and MAT training for pediatricians. In addition, pediatric inpatient training on medically supervised opioid withdrawal is essential. Patients on buprenorphine-naloxone maintenance therapy may also undergo dose titration for acute pain management, avoiding addition of full opioid agonists.

Conclusion: This case highlights the various indications of buprenorphine-naloxone in the adolescent population — withdrawal, MAT and acute pain. Pediatric providers may consult pain/addiction providers at their practice sites to improve access to MAT for OUD.