Addiction treatment for kids and teenagers lags far behind demand

By the numbers: Pediatric opioid deaths began to spike with the rise in fentanyl availability in the mid-2010s.

• Median monthly overdose deaths among adolescents ages 10-19 increased by 109% between the second half of 2019 and the second half of 2021, according to Centers for Disease Control and Prevention data from last year. Deaths involving illicitly manufactured fentanyl increased by 182%.

The big picture: Opioid misuse is only one factor in a growing mental health crisis among children that was exacerbated by the pandemic, prompting children's health advocacy organizations to declare a national state of emergency two years ago.

• The national drug overdose crisis has also worsened since the beginning of the pandemic, with more than 100,000 Americans dying each year.
• Only a small portion of those deaths involve children and teenagers. But experts say it can be especially difficult to find treatment options for this group.
• When it comes to substance addiction, "most of the resources in this country have been geared towards adults," said Matthew Cook, CEO of the Children's Hospital Association.
• "We have a shortage of trained clinicians, whether they're physicians, social workers or other clinicians, who can help identify these issues and then treat these issues in kids."

Between the lines: Treatment options are often restricted by the availability of providers — including the availability of providers who take a child's insurance.

• As of last year, more than half of U.S. children are covered through Medicaid — which generally pays less than commercial insurance — or the Children's Health Insurance Program, per the Department of Health and Human Services.
• "Medicaid can't make providers appear out of thin air," said Lindsey Browning, director of Medicaid programming at the National Association of Medicaid Directors, pointing to workforce shortages.
• State Medicaid programs generally offer more comprehensive behavioral health benefits for kids than private insurance does, Browning said. But health care providers have long complained about Medicaid reimbursement rates being too low, and some don't accept it.
• "You can't make somebody take Medicaid," Browning said.

What's happening: Kids who need substance use care usually go to the ER — but instead of being moved to the appropriate setting or bed, they sometimes stay there, Cook said.

• "What you see is a delay in care, and perhaps an [inability] to arrange that care."

Zoom in: Sivabalaji Kaliamurthy, director of the addiction clinic at Children's National, said he is one of the few pediatric addiction specialists in the greater Washington, D.C., area, which includes parts of Maryland and Virginia.

• Children struggling with fentanyl use tend to enter the health care system following an overdose, to ask for help or seek care for a health condition related to use, he said.
• Kaliamurthy runs an outpatient treatment clinic, but he said that some children need more intensive treatment. In the D.C. area, he said, there are no residential treatment programs for kids that take Medicaid, and just a few accept private insurance.
• "I have a lot of kids who are struggling, and it's hard because I don't have a lot of treatment options for them … it's hard for me to motivate them to go to rehab when that option doesn't exist," Kaliamurthy told Axios.

• "Some of these kids, my goal is to keep them safe until they're 18 so they can access the adult treatment," he added.

But treatment shortages extend beyond residential treatment.

• "We don't have enough people trained to take care of young people with opioid use disorders, and we don't necessarily have the right people trained," said Sharon Levy, chief of the division of addiction medicine at Boston Children's Hospital.
• Levy runs a clinical outpatient program and also advises primary care physicians on how to provide substance abuse care for kids.
• Although residential care is "a very important part of the treatment system," she said, "it's really hard to get kids and families to accept residential treatment, in my experience."
• "I think the only way we'll really solve this problem is if addiction medicine specialists pair with physicians who care for young people," she added.

And despite expert recommendations, evidence suggests that children are much less likely than adults to receive effective medications treating opioid use disorder.

• In 2021, only 11% of children and adolescent Medicaid enrollees with opioid use disorder received medication treatment, compared with 70% of enrollees between the ages of 19 and 44, according to an HHS internal watchdog report.
• "I'm not arguing that every young person with an addiction should be on Suboxone, but if you're using intravenous drugs at 16, including heroin or now fentanyl … even 10 years ago it was still recommended as a course of treatment, but it's relatively infrequently accessed," said Jeffrey Wilson, a psychiatrist at Children's Hospital of The King's Daughters in southeastern Virginia.

The bottom line: "In adult addiction medicine, really what you're doing is managing a chronic disorder, for the most part," Levy said.

• "But for younger people for whom there's potentially more opportunity for recovery, if we get in and treat younger people, we really have the potential to change a life course."