Dr. Jason Reynolds still thinks about the girl he could not save.
The teenager was homeless and shooting heroin. Once, she ended up in a hospital with a severe skin infection, a common consequence of injecting drugs. She received treatment for the infection, but not for her obvious addiction, and was referred to Reynolds, her Wareham pediatrician.
He could not find a treatment program for her. And the last he heard, the girl was roaming the shelters in Boston.
Such heartbreaking dilemmas occur often, a constant frustration for pediatricians suddenly unable to help children they’ve known for years, Reynolds said. But now he has reason to hope that it won’t happen again at his practice.
Since March, the providers at Wareham Pediatrics have been treating substance misuse within their primary-care office, in a pilot project that might be unique in the nation.
Instead of hunting for a treatment program for patients, Reynolds introduces them to a trained drug counselor working in his office. And most notably, he and his colleague, Dr. Steven J. Mendes, are among the rare pediatricians who prescribe Suboxone, a medication for addiction, to youths age 16 and up.
As a result, said Jonas Bromberg, a psychologist who helped launch the project, two youngsters who recently overdosed “are getting this lifesaving treatment from their neighborhood doctor, their pediatrician, the one they have known since they were little.”
The doctors hope their experience — made possible by a foundation grant, guidance from Boston specialists, and months of planning — will provide a roadmap for other practices.
Addiction is an illness that typically takes hold during adolescence. And the adolescent’s developing brain is especially vulnerable to lasting damage from drug use. Yet only 1 in 10 adolescents who misuses drugs receives any treatment, and a tiny fraction of those using opioids take medications such as Suboxone and Vivitrol, considered critical tools in treating opioid addiction at any age.
“It’s unconscionable, really,” said Dr. Sheryl A. Ryan, chairwoman of the American Academy of Pediatrics Committee on Substance Use and Prevention and a pediatrics professor at the Yale School of Medicine. “We know it’s a problem, and we know if young people are not treated, they will continue with their addiction.”
In September, the pediatrics academy adopted a policy statement urging pediatricians to make drug counseling and medications for addiction a part of primary care practice.
The US Food and Drug Administration allows the use of Suboxone in people as young as 16. But only an estimated 300 to 400 pediatricians nationwide have undergone the eight-hour training that the federal government requires before a doctor can prescribe it. Even among the few pediatricians authorized to prescribe, Ryan said, few are doing so.
Pediatricians often feel out of their depth dealing with substance misuse and addiction, and worry about the logistical burdens. Some fear that if they treat kids with drug problems, their practice will become a magnet for the most difficult patients. And youngsters with drug problems often have mental health issues that make their care especially complex.
Also, Ryan said, “There is stigma attached with substance use. There are many pediatricians who will say, ‘I don’t want to deal with that population.’ It’s just not seen as a medical disorder when it really is.
“We have a long way to go before we get our pediatricians to be comfortable with this,” she said.
The Wareham project aims to overcome all those barriers, and the lessons learned there will guide a second medical group, Bridgewater Pediatrics, which is scheduled to adopt the same program in January.
The idea originated with the Pediatric Physicians’ Organization at Children’s, a network of 96 independent practices around the state that are affiliated with Boston Children’s Hospital. The group, which includes the Wareham and Bridgewater practices, teamed up with the Adolescent Substance Abuse Program at Children’s. That program has been helping adolescents since 2000 — but only those who can get to Boston.
The network obtained a $450,000 three-year grant from the Blue Cross Blue Shield of Massachusetts Foundation to figure out how to integrate addiction treatment — including medication — into a private pediatric practice in the community.
Dr. Sharon Levy, director of the Children’s substance abuse program, said the teenagers affected by addiction outnumber the treatment beds available for their age group. But inpatient care usually isn’t necessary anyway, she said.
“Everything they need can be accomplished in the primary care office,” Levy said. “It’s just like managing any other chronic disease.”
Wareham Pediatrics volunteered to lead the effort, the first of the network’s practices to dive in. The specialists at Children’s said they are not aware of any other pediatric practice in the country that is trying a similar program.
Reynolds and Mendes underwent the training to prescribe Suboxone and opened a hotline to Children’s so they could quickly consult addiction specialists. In January, a drug counselor from Children’s, Shannon M. Mountain-Ray, started working 20 hours a week at Wareham Pediatrics.
Mountain-Ray helped the practice adopt a screening tool to identify youngsters with potential drug issues, prepare protocols such as the urine testing needed to monitor drug use, and arrange logistics such as billing.
Even with all the details worked out, the doctors didn’t know whether teenagers would show up for substance abuse services, said Levy, the Children’s addiction specialist. But they did: Of the first 15 referred, about a dozen have been keeping regular appointments with their counselor and physician.
Many were having trouble with marijuana or alcohol, the most common drugs used by teenagers. But some were involved with opioids, and a couple had overdosed. Those two patients received prescriptions for Suboxone, and a third is expected to start the drug soon.
Levy recommends keeping the patients on Suboxone for a year after their last illicit drug use, and then discuss tapering off.
She considers the drug very safe, although few have studied its effects on adolescents. Suboxone’s effectiveness in preventing relapses and overdoses in adults is well-documented, Levy said, and there is no physiological reason why Suboxone won’t work as well in adolescents. The American Academy of Pediatrics policy statement, which Levy wrote, cited two studies in adolescents suggesting that opioid-addicted patients who stay on Suboxone are more likely to stay sober.
Suboxone can be sold illicitly on the street, often to addicts seeking relief from withdrawal symptoms, but the Wareham program takes precautions. Prescriptions are written on a weekly basis, urine testing ensures the drug is being taken, and parents sometimes hold and dispense the drug. The risk of diversion, Levy said, “is not a reason to not use a medication. We know it prevents overdoses and saves lives, plain and simple.”
One of the recent Wareham patients had overdosed three times before he turned to Reynolds. This time, the pediatrician had tools at his disposal. He prescribed Suboxone and sent the patient for counseling with Mountain-Ray.
The patient, who asked to remain anonymous, said Suboxone helped a lot, stopping his cravings and making it easier to avoid using again.
But he said he wouldn’t have taken the medication if Reynolds didn’t prescribe it. “I didn’t want to go to a Suboxone clinic and go through all that trouble,” the patient said. “It made me feel more comfortable that I was at my own doctor’s office.”