CCPR: How big is the fentanyl overdose crisis in youth?

Dr. Quiggle: It’s among the largest public health crises in US history. Of over 100,000 drug overdose deaths annually (teens and adults), most are opioid related. The economic cost of the opioid epidemic in 2020 was $1.5 trillion. In pediatric and adolescent populations, overdoses now rank third in cause of death behind firearms and motor vehicle accidents, surpassing childhood cancers, and have risen over 100% since late 2019 among 14- to 18-year-olds. About a classroom a week dies from the opioid epidemic, largely from fentanyl (www.tinyurl.com/yc4psu4a).

CCPR: What are the risk factors for opioid overdose in youths? 

Dr. Quiggle: Teens overdosing by taking a pill without realizing it’s contaminated with fentanyl constitute the largest group by absolute numbers. Many of these teens do not have an opioid use disorder (OUD) or known mental health diagnosis. The second largest group is teens with mental health disorders (eg, depression, anxiety, trauma, ADHD) who are vulnerable to substance use due to heightened impulsivity, risk-taking behaviors, or efforts to manage negative affective states. The smallest group is teens with frank OUD, who have the highest relative risk of overdose death compared to other groups.

CCPR: How do social determinants impact rates of overdose and access to care for overdose treatment and prevention?

Dr. Quiggle: American Indian and Alaska Native adolescents have the highest rates of overdose death, about 80% higher than White teens. Next are Latinx youth, who must be distinguished from adult Latinx populations with lower overdose death rates (Friedman J et al, JAMA 2022;327(14):1398–1400). These vulnerable groups typically have lower treatment rates and are less likely to get prescribed life-saving medications, such as buprenorphine. Adolescent overdose death hotspots span the western US—Arizona, Colorado, and Washington—with rates twice the national average (Friedman J and Hadland SE, N Engl J Med 2024;390:97–100). (Editor’s note: For more on disparities and the fentanyl crisis, see: Zhu DT,  JAMA Psychiatry 2025;82(1):99–100.)

CCPR: How did we get here?

Dr. Quiggle: The first wave of the opioid epidemic in the 1990s/2000s was related to increased prescribing of pain medications. In the early 2010s, a second wave began as causes of death shifted from prescription opioids to heroin. A third wave emerged around 2013 with fentanyl and synthetics contaminating heroin. By late 2019, fentanyl appeared in counterfeit Xanax bars, Valium, and even Adderall or Ritalin, causing a spike in teen overdose deaths. Tiny amounts of fentanyl can be deadly (Friedman J and Shover CL, Addiction 2023;118(12):2477–2485).

CCPR: Why would suppliers endanger their customers? 

Dr. Quiggle: It’s perverse economics. If somebody does die from a known batch, it signals a particularly strong batch and drives up demand. But many youths take pills not knowing opioids are present, let alone fentanyl. 

CCPR: Are opioid prescriptions still common for routine outpatient surgical procedures? 

Dr. Quiggle: Opioids are prescribed less often and for shorter durations. But most often, kids obtain leftover prescriptions from home, friends, and relatives. Clinicians should routinely talk with parents and families about safe storage, lock boxes, and how to safely dispose of unused medications.

CCPR: What are legitimate uses of opioids in children and adolescents?

Dr. Quiggle: The American Academy of Pediatrics recently released guidelines on the use of opioids for children with acute pain (www.tinyurl.com/57fv53n5). Opioids can be safely used for short-term management of acute pain but should never be prescribed as a monotherapy, and pain control should involve a multimodal approach. Prescriptions for naloxone (Narcan) should be written to prevent risks of overdose, and families should be counseled on the signs and symptoms of overdose.

CCPR: What are your thoughts about drug testing?

Dr. Quiggle: Drug testing can help with diversion of medication or contingency management, but I haven’t seen many data supporting routine drug testing in youth (Levy S and Siqueira LM, Pediatrics 2014;13(6):e20140865). Testing can harm trust in clinicians and parents, and a positive test doesn’t equate to a substance use disorder (SUD). It shouldn’t be used to catch lies but more like thyroid and liver function tests: It’s helpful to know what drugs are present and monitor over time. My approach builds pro-social behaviors, fosters self-agency, and uses motivational interviewing (MI), parent training, and harm reduction. There’s more of a role for cannabis testing, showing patients their progress, which can be rewarding or generate insight: “I was more depressed last month when my cannabis level was through the roof.”

CCPR: What strategies can we use for harm reduction and prevention in everyday clinical practice?

Dr. Quiggle: The first strategy is education with consistent messaging about fentanyl dangers, including in pills. These messages should come from home, communities, schools, and health care settings. Peer-to-peer conversations can be especially effective. These shouldn’t be one-off discussions. Talk about the dangers of using drugs alone and recognizing overdose signs. Practical harm reduction strategies include Narcan access and training, safe medication storage, and using fentanyl test strips (Editor’s note: Learn to use them at: www.tinyurl.com/3jk462a7). Research highlights the gap between having knowledge of Narcan and using it during emergencies (Freibott CA et al, JAMA Pediatr 2024;178(6):618–620).

CCPR: What phrases do you use with youths when you talk with them about the risks of opioid overdose?

Dr. Quiggle: I usually see patients who already have an SUD. I recommend MI, listening more than telling: “Tell me about who you are and where you want to go.” Listen for ambivalence about staying the same and amplify the elements where the patient expresses a wish to change. This process unfolds over time, finding moments where change feels more important than the status quo. In addiction treatment, our primary outcome is retention in treatment. Telling someone “you should stop using” creates defensiveness, making them argue for their illness instead of health. Instead, listen for their motivations to change and partner with them. Offer psychoeducation, insights, or interventions collaboratively, building safety and trust over time.

CCPR: So harm reduction can take weeks or even years?

Dr. Quiggle: Yes, and it’s hard to do by yourself. Here at Mass General, we have a terrific interdisciplinary team providing parent guidance, teen/young adult groups, peer recovery coaching, individual psychotherapy, and medication management. It truly takes a village. 

CCPR: How do you talk to parents about how they can help? 

Dr. Quiggle: I tell them to start early with ongoing, direct, and proactive conversations, not just when problems arise (Pettigrew J et al, Health Commun 2018;33(3):349–358). Ask about what their child knows and is seeing among peers, at school, in sports: “What are other people doing? Are your friends talking about it?” Learn about the child’s world, linking to conversations about parental attitudes regarding substance use, autonomy, agency, good choices, and navigating peer groups. Parents need to build trust and collaboration, with regular check-ins, clear positions against substance use, and firm boundaries, expectations, and consequences. Negative parental attitudes toward substance use correlate with lower rates of teen drug use (Marziali ME et al, Subst Abus 2022;43(1):1085–1093). 

CCPR: How does this approach fit with what we know about the developing adolescent brain?

Dr. Quiggle: This is a period of impulsivity, taking risks, and craving rewards, accompanied by intensified senses of justice, right and wrong, morality, autonomy, and belief about the world. Parents can leverage teens’ sense of justice and what’s right to encourage them toward good decision making, pro-social behaviors, and supporting their communities.

CCPR: Meanwhile, should we all have Narcan in our offices and in our glove boxes?

Dr. Quiggle: Absolutely, and in schools, nightclubs, and throughout our communities. Use the messaging “one pill kills” and “never use drugs alone.” Good Samaritan laws in almost every state protect you when you give someone Narcan. Access to Narcan is critical, but so is training for kids and adults on how to use it. It’s easier than CPR, but people need to know how to identify overdoses and respond to them. Narcan is available over the counter at pharmacies, and there are programs to distribute it for free.

(Editor’s note: Learn how to administer Narcan at: www.narcan.com/en/resources.)

CCPR: What can you tell us about xylazine-related overdoses, which don’t respond to Narcan?

Dr. Quiggle: The White House has labeled xylazine an “emerging drug threat.” Xylazine, aka “tranq,” is FDA approved as a veterinary sedative and muscle relaxant. It’s not an opioid and is not reversible by Narcan. It’s entering the illicit drug supply alongside fentanyl and other opioids. We don’t yet have routine testing for it. In 2022, the DEA reported xylazine in about 25% of confiscated fentanyl powder and nearly 10% of fentanyl pills (www.tinyurl.com/mppss4ac). Xylazine can cause respiratory depression, bradycardia, somnolence, and skin infections. Treatment for xylazine is supportive care. People taking xylazine with opioids may need repeated Narcan doses. 

CCPR: How do we address substance use problems in kids with co-occurring mental health conditions? 

Dr. Quiggle: Ideally, we identify and treat mental health disorders before the development of an SUD. Studies show that early treatment of depression and ADHD, for instance, may mitigate the risk of developing an SUD (Curry J et al, J Consult Clin Psychol 2012;80(2):299–312). But co-occurring mental health conditions are the rule, not the exception. Treat them concurrently. 

CCPR: How can we reduce overdose risk in youths with opioid addiction?

Dr. Quiggle: Medications for opioid use disorder (MOUD) like buprenorphine are lifesaving, reducing overdose deaths by 40%–80% depending on the study. Yet stigma persists. About 38%–55% of US pharmacies don’t stock it (Weiner SG et al, JAMA Netw Open 2023;6(5):e2316089). Most residential addiction treatment centers don’t serve teens, and among those that do, only 25% offer MOUD (Alinsky RH et al, J Adolesc Health2020;67(4):542–549). (Editor’s note: Buprenorphine treatment in US adolescents dropped between 2020 and 2023, and a recent meta-analysis on adults favors methadone over buprenorphine for adherence (Lee E et al, JAMA 2024; Epub ahead of print; Degenhardt L et al, Lancet Psychiatry 2023;10(6):386–402).)

CCPR: How long should adolescents stay on buprenorphine? 

Dr. Quiggle: Initially, buprenorphine was used for short periods to help treat withdrawal symptoms during detox; however, 90% of patients returned to opioid use within a year. Now, we consider buprenorphine a long-term medication to help manage a chronic disease. Time on medication varies case by case, but the longer someone is on the medication, the lower the risk of relapse. 

CCPR: Is buprenorphine covered by insurance for continuing care? 

Dr. Quiggle: Yes, buprenorphine is FDA approved for OUD in people 16 and older. Long-acting naltrexone (Vivitrol) and methadone are FDA approved for those 18 and older. However, stigma remains a barrier. In commercial insurance databases, even after an OUD diagnosis, 75% of youth do not receive an MOUD within six months (Hadland SE et al, JAMA Pediatr 2017;171(8):747–755).

CCPR: How does stigma impede the care of these patients? 

Dr. Quiggle: Stigma impacts not only who presents for treatment, but also how we engage and treat our patients. Societal stigma, including among clinicians, often makes patients feel ashamed about treatment instead of inspired about recovery. As medical residents progress through training, they develop negative attitudes toward substance use (Avery JD et al, Prim Care Companion CNS Disord 2019;21(1):18m02382). Defense attorneys are more likely to have a brain-based conceptualization of addiction than physicians (Avery JJ et al, Am J Addict 2020;29(4):305–312). 

CCPR: Is there a way to address this stigma?

Dr. Quiggle: We need to treat SUDs as chronic diseases, like diabetes or hypertension. Treatment brings down opioid death rates, decreases urges and cravings, and helps people thrive in society. Patients can get married, hold jobs, and contribute to their communities. Promote these positive attitudes despite burnout and other pressures on clinicians. Find ways for health care workers to see patients doing well in sustained recovery. This is not something that traditionally has been well incorporated into medical education, but we can change that!

CCPR: Thank you for your time, Dr. Quiggle.