Evidence Based Strategies: Beyond the Tablet - Suboxone® Sublingual Films for Treating Opioid Withdrawal in Adolescents

Opioid use disorder (OUD) among adolescents and young adults is a growing public health concern.^1-3 Each year, thousands of young individuals face the challenges of opioid dependence, withdrawal, and the risk of overdose. Prescription opioid misuse and illicit opioid use are prevalent among this population and can lead to substance use disorder, specifically OUD. OUD is characterized by a pattern of chronic opioid use that leads to clinically significant distress or impairment, such as an overpowering desire to use opioids, an increased opioid tolerance, or signs of withdrawal when opioids are discontinued.³ In 2024, approximately 267,000 adolescents (12 to 17 years) were estimated to have an OUD, according to the National Survey on Drug Use and Health.³

National trends suggest that the prevalence of opioid use begins to increase when an adolescent is approximately 12 years of age and will continue to increase into young adulthood. Ninety percent of adolescent overdose-related deaths can be attributed to OUD; thus, recognizing the signs and symptoms of acute opioid withdrawal and when to initiate pharmacological management are imperative first steps to address OUD and prevent relapse or overdose.^2,4,5,6

Opioid withdrawal can be characteristically described as a combination of signs and symptoms. These include autonomic symptoms (hypertension, tachycardia, diaphoresis, mydriasis, piloerection, lacrimation, and rhinorrhea), gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal cramping), psychological symptoms (irritability, agitation, anxiety, and insomnia), and behavioral signs (excessive yawning and an intense desire for drugs).⁶ When opioid withdrawal or OUD is suspected, a thorough history and physical examination should include opioid use screening and an assessment to determine the presence of signs and symptoms and the severity of withdrawal.

The Clinical Opiate Withdrawal Scale (COWS), developed in 2003, is an 11-item tool designed for use by a clinician in either an inpatient or outpatient setting to rate opiate withdrawal symptoms and monitor them over time.⁷ The summed score provides guidance as to the severity of withdrawal (mild: 5–12; moderate: 13–24; moderately severe: 25–36; and severe: >36) and helps determine when to initiate treatment. Typically, a score of 5 or greater indicates the presence of withdrawal symptoms that may warrant pharmacological intervention.^7-9

For adolescents experiencing active opioid withdrawal (COWS score ≥ 5), buprenorphine, a partial opioid agonist, is an effective, evidence-based treatment to manage withdrawal symptoms and reduce cravings.⁶ Options include a tablet or sublingual film formulation, and both can contain naloxone, an opioid antagonist, to deter abuse of the product, particularly through non-oral administration. The sublingual buprenorphine/naloxone film (Suboxone^®) offers improved absorption, faster dissolution, and reduced potential for misuse compared to the tablet formulation.¹⁰ It also provides a safe option that can be administered across various care settings or prescribed for at-home treatment initiation.^8,9,11 Studies have shown that adolescents treated with buprenorphine/naloxone have improved retention in treatment and reduced opioid use compared to those receiving non-pharmacologic interventions alone.¹²

Pharmacological treatment should be paired with psychosocial support, including behavioral therapy and family engagement. Adolescents benefit from integrated care models that address underlying mental health conditions and provide continuity of care through outpatient follow-up.¹²

Children’s Mercy provides a clinical pathway available at Opioid Withdrawal Treatment: Buprenorphine/Naloxone (Suboxone). In addition to guidance on the management of opioid withdrawal, the pathway provides patient and family educational materials on how to talk about drug use, important facts about opioid use, and information about naloxone and Suboxone sublingual films.

References:

1. Connolly S, Govoni TD, Jiang X, et al. Characteristics of alcohol, marijuana, and other drug use among persons aged 13–18 years being assessed for substance use disorder treatment — United States, 2014–2022. MMWR Morb Mortal Wkly Rep. 2024;73(5):97-99. doi:10.15585/mmwr.mm7305a1
2. Warren LK, Adams, J, Bobashev G. Trends in opioid misuse among individuals aged 12 to 21 years in the US. JAMA Netw Open. 2023; 6(6):e2316276. doi:10.1001/jamanetworkopen.2023.16276
3. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2024 National Survey on Drug Use and Health (HHS Publication No. PEP25-07-007, NSDUH Series H-60). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Administration. Published July 2025. Accessed October 15, 2025. https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health/national-releases
4. Tanz LJ, Dinwiddie AT, Mattson CL, O’Donnell J, Davis NL. Drug overdose deaths among persons aged 10-19 years – United States, July 2019-December 2021. MMWR Morb Mortal Wkly Rep. 2022;71:1576-1582. doi:10.15585/mmwr.mm7150a2
5. Trope LA, Stemmle M, Chang A, et al. A novel inpatient buprenorphine induction program for adolescents with opioid use disorder. Hosp Pediatr. 2023;13(2):e23-e28. doi:10.1542/hpeds.2022-006864
6. Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. 2020;395(10241):1938-1948. doi:10.1016/S0140-6736(20)30852-7
7. Wesson DR, Ling W. The clinical opiate withdrawal scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. doi:10.1080/02791072.2003.10400007
8. Kumar P, Kaliamurthy S, Thomas J. Initiation of buprenorphine treatment of opioid use disorder in pediatric emergency departments. Pediatrics. August 2024;154(2):e2024066226. doi:10.1542/peds.2024-066226
9. Substance Abuse and Mental Health Services Administration (SAMHSA). Buprenorphine quick start guide. Accessed October 16, 2025. https://www.samhsa.gov/sites/default/files/quick-start-guide.pdf
10. Butler SF, Black RA, Severtson SG, Dart RC, Green JL. Understanding abuse of buprenorphine/naloxone film versus tablet products using data from ASI-MV® substance use disorder treatment centers and RADARS® System Poison Centers. J Subst Abuse Treat. 2018;84:42-49. doi:10.1016/j.jsat.2017.10.010
11. Substance Abuse and Mental Health Services Administration (SAMHSA). Practical tools for prescribing and promoting buprenorphine in primary care settings. SAMHSA Publication No. PEP21-06-01-002. Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services, 2021. Accessed October 16, 2025. https://library.samhsa.gov/sites/default/files/pep21-06-01-002.pdf
12. Cunningham C, Edlund MJ, Fishman M, et al. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med. 2020;14(2S)(suppl 1):1-91. doi:10.1097/ADM.0000000000000633