Fentanyl is killing more kids, but treatment isn’t keeping pace

Amara Roberts was throwing a friend’s birthday party the night she accidentally overdosed. She swallowed a pill she thought was MDMA. Then she lost consciousness.

This was about a year and a half ago, long before Amara, 17, knew illicit pills of all varieties were suddenly carrying traces of fentanyl, a deadly opioid up to 50 times as potent as heroin.

There was no Narcan around. No one called 911.

“Nobody knew what to do,” she said. “We were all scared of getting caught.”

Amara didn’t make it to the hospital that night; medical care is expensive — sometimes too expensive for her family, she thought. The pill made her sick — something she didn’t share with her mom right away — and when she finally regained consciousness, she decided to go through the torment alone, crawling on all fours to the bathroom where she threw up “straight acid and bile” several times an hour.

Shame and fear washed over Amara when, a few days later, a drug test came back positive for fentanyl. Her mom Jessica Roberts didn’t know about the drug test but could tell something was wrong. She tried to quiz Amara for information.

But Amara couldn’t stop thinking about the drug. It wasn’t as easy to find fentanyl as it is now, so sometimes she’d travel downtown to buy pills. Eventually she found dealers who’d deliver to her home.

“I was hooked,” she said.

Teens are caught up in a progressively worse drug crisis that, because of their age, they have little control over. They’re contending with broken medical and social systems, Amara and other teens say, that have failed to keep up with the rise of especially powerful drugs on the West Coast, such as fentanyl.

Navigating the health care system and insurance is difficult, and several youth substance use programs have closed over the past few years, including Daybreak Youth Services, further limiting access to treatment.

Attitudes are also a barrier. Some people carry bias or have misunderstandings about the leading treatment for opioid use disorder: medications. And many people still view addiction as a choice instead of as a complex set of social and biological problems that must be addressed with an equally complex mix of support.

Amara hid her use. But her pain, Amara said, shouldn’t have felt so invisible.

“We’re all silently struggling because the adults are too judgy, biased, scared, busy or unbothered to help us,” Amara said. “There is no access to help for us that we can easily get ourselves.”

Five years ago, so few youth were dying from opioid overdoses that the state’s health department couldn’t report the data publicly because of privacy concerns. But deaths are rapidly multiplying. Last year, 38 Washington youths younger than 18 died from an opioid-related overdose, more than three times as many as in 2019. All but one were tied to synthetic opioids such as fentanyl, state Department of Health data obtained by The Seattle Times shows.

“Although the number and rate are relatively small, that is a dramatic and rapid increase in [overdose] deaths,” said Caleb Banta-Green, research professor in the University of Washington’s School of Medicine, noting that the trends in youth mirror what’s happening across Washington’s general population. “The years of potential life lost are enormous.”

Nonfatal youth opioid overdose emergency responses have more than doubled among agencies that supply data to the state; not all EMS agencies do. Hospitalizations are up, too.

“There are just so many kids that are walking in there now that are addicted to fentanyl that never [sought out] any kind of services before,” said Johnny Ohta, who works for the youth treatment center Ryther as well as two drop-in centers for unhoused youth. “The numbers just keep on increasing.”

Protocols lacking

In early 2021, when Dr. Chris Buresh started working at Seattle Children’s, he asked around about what the hospital was doing for kids with opioid use disorder. Colleagues told him, “‘Oh, it’s just not a thing, it doesn’t happen,” said Buresh, an emergency medicine physician at Seattle Children’s and Harborview Medical Center. “My second or third shift, I saw a kid with opioid withdrawal, and just kept seeing them.”

Buresh began canvassing hospitals across the state and nation to better understand whether Seattle Children’s was alone. It wasn’t, he said.

“There’s very few of them that have protocols for treating opioid use disorder in kids.”

Treating youth for substance use disorders has traditionally involved various types of psychosocial interventions, like counseling, 12-step programs and stays at residential rehabilitation facilities.

But teen addiction to fentanyl is a relatively new phenomena. How to get youth treatment is becoming an ever more urgent problem, some health professionals say.

Experts are now focusing on medications for opioid use disorder such as buprenorphine and methadone, which are forms of both harm reduction and treatment. They’ve overwhelmingly proved to reduce overdose deaths, help curb withdrawal symptoms and cravings and support long-term recovery.

In Washington, though, there’s no widely accepted medical protocol that consistently gets kids on a path to this kind of care. Too few prescribers feel comfortable prescribing to youth, many providers say, and medical systems have been slow to identify the burgeoning crisis.

“We’re behind the eight ball,” said Buresh. “I wish [medication] was standard care, and hope someday it will be. ... But I just think it’s premature to say it is the standard of care, especially in kids.”

It’s a frustrating reality for researchers and addiction medicine specialists, especially since teen opioid dependence isn’t new, and a vast majority of adults with substance use disorders started using in adolescence.

It’s also evidence for how hard it is to end bias against medications for opioid use disorder. And how tough it is to translate treatments — even lifesaving ones — to the pediatric medicine world.

Part of the problem is a practical one: Leading medications for opioid use disorder are approved only for people 16 and older — some are approved for 18 and up. Care planning for kids also often involves parents or caregivers, who may carry bias or have misunderstandings about medications for opioid use disorder, like the idea that these medications just replace one drug with another.

A large body of evidence supports medications for opioid use disorder in adults, and medications are now more widely available to adults in Washington because of an influx in federal opioid response dollars that the state has used, at least in part, to build new treatment programs.

But research in teens is more limited. A handful of randomized controlled trials — the gold standard for measuring effectiveness — suggests youth who take buprenorphine are less likely to use other illicit opioids and more likely to stay in outpatient treatment than those who don’t take the medication. And professional organizations including the American Academy of Pediatrics recommend that pediatricians consider medication when treating youth with opioid use disorder.

“We have a decent coverage for adults,” said Dr. Nathan Kittle, addiction medicine specialty director at Healthpoint, a nonprofit network of community health centers. “The magnifying glass is now being placed over youth.”

Seattle Children’s ER sees roughly 20 kids a month who screen positive for fentanyl, Buresh said, including the rare occasion when toddlers overdose on pills lying around at home. It’s “almost certainly an undercount,” he notes, since the hospital is still working out the validity of its opioid use disorder screening tool. The hospital is working on staff education and programs that help get naloxone in the hands of youth more quickly.

Even clinics that are well set up for opioid use disorder care have witnessed heartbreaking outcomes. A year and a half ago, Kittle was scheduled to see a 14-year-old whose dad had called in worried about his son’s behavior. The family never showed up for the visit, and shortly afterward, the teen was found dead from a fentanyl overdose.

“In an ideal world, we would have seen that patient sooner,” Kittle said, “And would have recognized some of the urgency.”

‘Changed my life’

Chai Owen envied the kids who went to Albertsons after school for doughnuts, or to Discovery Park for bonfires.

Growing up in Magnolia, he felt safe and well taken care of by his parents, who adopted him from Thailand when he was 18 months old. But it was difficult for him to make friends. On Halloween six years ago, he smoked cannabis for the first time, something he thought would mark him as cool.

He was 11.

Chai was 13 when he first tried cocaine, 15 when he became addicted to heroin. He eventually started smoking fentanyl.

“It was less about being high,” he said. “It was more about the uncomfortability of being sober. I was so uncomfortable in my own skin.”

To deal with fentanyl withdrawal, Chai got access to Suboxone, the brand name for buprenorphine, a synthetic opioid medication that reduces cravings and doesn’t result in euphoria. He is now prescribed Naltrexone, another medication for opioid use disorder. At a low point, Chai’s parents raced him to the hospital for urgent medical attention. And during moments of relapse, Chai’s family could afford to send him to expensive rehabilitation facilities — five times, in all.

Rehab “completely changed my life,” said Chai, who is now 17. “It just took five of them to finally click it in my brain that this is not a place I ever want to be again.”

Chai and Amara’s paths to recovery couldn’t look more different.

When Amara’s mom Jessica noticed changes in her daughter’s behavior, she begged a chemical dependency counselor for help. But the counselor said Amara didn’t meet criteria for substance use treatment, emails with Jessica show.

Jessica eventually found Amara an intensive outpatient program that focused primarily on mental health concerns, not substance use. But Amara refused. Amara found that even when she finally decided to get treatment for mental health problems, her biggest concern — fentanyl addiction — wasn’t addressed.

“I was continuously bringing it up. My fentanyl use and my pill problem,” Amara said, of conversations with her therapist. “They were focusing on all the wrong things.”

Medication for opioid addiction never came up in therapy, she said.

Even though treatment for substance use was difficult to secure, Amara grew up knowing what getting sober looked like. Her mom was in the recovery community, and spent time working at a rehabilitation facility.

Amara also understood the potential perils of her use. When she was in fifth grade, her dad, who was well known in the recovery community, overdosed and died from heroin.

“I told myself years ago I would never do the drugs that he did,” she said. “That was what really hit me and made me very, very, deeply ashamed. But I mean obviously it wasn’t enough to stop. Because that’s typically how it goes in addiction.”

Embracing recovery

One day last summer, Amara collected her pillow and a blanket and holed up in her bathroom to detox from fentanyl.

Her best friend had moved in with Amara’s family — someone Amara knew would judge her for using. So Amara decided to try to quit. She soon replaced her cravings with alcohol and other drugs. But by the fall, Amara was determined to stop using substances for good.

A small but growing network of providers are committed to smoothing the path to treatment for teens like Chai and Amara. It shouldn’t be so difficult, they say, to get quick, evidence-based care.

A clinic at Harborview used medication to treat its first adolescent patient in 2020, said Addy Adwell, assistant nurse manager for office based opioid treatment at Harborview. The adolescent program is still small — most patients hear about the clinic only after an overdose or other serious visit to an ER — but families can call and make an appointment directly, Adwell said.

Ohta, who works closely with prescribing physicians, said, “all you do is just call us.” He picks up or at least tries to respond the same day, he said.

Training more doctors to assess and prescribe teens for opioid use disorder will be a critical part of expanding access to care long-term, said Dr. Jasmin Zavala, who treats young people for opioid use disorder as the medical director at Sea Mar Adolescent Clinic. Sea Mar has an outpatient program that includes a wide range of services, like medication and individual and group counseling. But similar programs are rare — and they’re especially limited for youth under 18, she said.

Even if not every clinician gets training, clinics should consider training a provider “lead,” she said, so youth aren’t forced to go elsewhere for opioid use disorder treatment when they visit their doctor’s office.

This is especially important, she said, since so many counterfeit pills — like Amara’s — now contain fentanyl. Overdose deaths tied to counterfeit pills have more than doubled since 2019, data from a September Centers for Disease Control and Prevention report suggests.

Once Amara committed to treatment, she enrolled in a partial hospitalization program. She also left Ballard High School for a special recovery school called Interagency Recovery Academy, in Queen Anne.

There, she met a boy. It was Chai.

“That’s really what started my journey [to] slowly embracing recovery,” she said. Chai calls Amara a “tether” to his own sobriety.

Chai saw Amara as someone who, unlike him, had an understanding of the recovery community because of her parents’ experiences. Amara saw all the substance use care Chai had benefited from — resources she’d never had access to. They had a lot to share with one another. The couple, who wear necklaces with each other’s initials around their necks, say they have each been sober for about 10 months.

Their experiences were “very, very different,” Chai said. But, he added, they’re now “in the same boat, even though we went through very different paths to get here.”

Amara was more pointed: The contrast, she said, “reflects a lot on the failures,” of the youth substance use treatment system.