On behalf of the Virginia Chapter of the American Academy of Pediatrics (VA-AAP), thank you for your leadership in promoting the safe and evidence-based practice of medicine in our state.  Today, we write to comment on the recent petition to amend 18VAC85-21-150 and 18VAC85-21-160. 

To best care for children and adolescents in Virginia affected by the opioid crisis, we strongly support the following evidence-based recommendations proposed by the Virginia Society of Addiction Medicine (VASAM):

1. Remove the restriction on prescribing buprenorphine to patients younger than 16 years of age
2. Remove documentation requirements of the rationale for prescriptions of buprenorphine which exceed 24 mg per day
3. Remove provision of counseling services or provision of a referral for counseling services to the patient

Data from the Virginia Department of Health showed that from 2020-2024, Virginia lost 39 children (under the age of 16) to an opioid overdose death.  This is still an underestimate, as data for 2024 is incomplete.  From 2020-2023, there were over 500 pediatric emergency department (ED) visits per year related to an opioid or unspecified overdose for children under the age of 16.  Furthermore, in 2024, the rate of opioid or unspecified overdose ED visits for adolescents 12-15 years old was 50/100,000 Virginia residents, making them the 2^nd highest pediatric age group affected.  This data still does not capture the negative health impacts for children who have adults and caretakers in their lives struggling with opioid use disorder.  

§18VAC85-21-160 regulates treatment for special populations with opioid use disorder (OUD), and states that patients under 16 years old “shall not be prescribed buprenorphine for addiction treatment unless such treatment is approved by the FDA.”  The American Society of Addiction Medicine National Practice Guideline (ASAM NPG) notes that there are no major safety concerns with buprenorphine in the treatment of OUD for adolescents younger than 16.¹  Several studies also note superiority of buprenorphine-containing treatment plans, in comparison to those without, for adolescents as young as 13 years of age.^2-3  Benefits included better retention in treatment and less opioid and injection drug use.  Removal of this unnecessarily restrictive regulation would allow providers to offer individualized care to adolescents in need of medication for OUD. 

While §18VAC85-21-150 highlights the importance of basing treatment dosages on a patient’s opioid usage, it also places additional administrative burden for doses of buprenorphine exceeding 24 mg.   The potency of synthetic opioids has increased significantly, leading to the need for higher doses of medication to address a patient’s treatment needs.  Providers should have the ability to adjust buprenorphine doses based on a patient’s history and current needs without additional documentation barriers which may delay care or treatment coverage. 

Lastly, §18VAC85-21-150 also requires that practitioners prescribing medication for OUD also incorporate counseling or document referral to a mental health service provider.  While we strongly support concurrent mental health counseling for adolescents and adults with OUD, a patient’s initial decline or inability to access counseling should not prevent or delay the start of pharmacotherapy.  Allowing providers to meet patients where they are at can help decrease barriers to initiating care and promote trust, while affording providers the opportunity to encourage and navigate counseling services for their patients in the long-run. 

As pediatric providers, our goal is to promote the health and well-being of all children.  In summary, to continue to address the opioid crisis in Virginia, we support the petition brought forth by VASAM and their recommendations to limit barriers for adolescents and the adults in the access of evidence-based medication for opioid use disorder.  

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1. American Society of Addiction Medicine - ASAM. (2020). The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. Journal of Addiction Medicine, 14(2S), 1–91. https://doi.org/10.1097/adm.0000000000000633

2. Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial. Arch Gen Psychiatry. 2005;62(10):1157–1164

3. Woody GE, Poole SA, Subramaniam G, et al. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial [published correction appears in JAMA. 2009;301(8):830]; [published correction appears in JAMA. 2013;309(14):1461] JAMA. 2008;300(17):2003–2011