SEATTLE — Seventeen-year-old Maddy thought she understood what it meant to be invisible.
Editor’s note: This story contains detailed descriptions of drug use and overdose.
She had, after all, concealed the horrors of her fentanyl addiction for more than a year and a half.
In withdrawal, she’d retreat to her bedroom, sweating, vomiting or struggling to control leg tremors. Away from her mom’s gaze, she’d hide in her family’s backyard shed to use.
When she finally tried to get help, her young age made her invisible to the treatment system, too.
After Maddy told her mom, Sabrina, about her addiction, they packed 10 days’ worth of Maddy’s clothes and drove to the nearest pediatric hospital. Sabrina assumed Seattle Children’s doctors would recognize how urgently her daughter needed care. That Maddy would be admitted for inpatient treatment, get a detox bed or at least a referral to rehab.
Instead, her medical records show, a doctor there gave Maddy a prescription for three days’ worth of the addiction medication buprenorphine, the overdose-reversal drug Narcan and a suggestion to call the state’s recovery hotline. After about an hour and a half, the hospital sent them home.
“We expected that she would go into treatment immediately,” said Sabrina, Maddy’s mom. (The Seattle Times is identifying the family by their first names to protect Maddy’s future education and job prospects.) “No one really wants to help parents help their kids. I was absolutely appalled.”
Teenhood offers a finite but critical window to treat addiction. It’s a period when youth are beginning to solidify routines that could follow them for decades. Nearly 75% of adults admitted to addiction treatment started using before their 18th birthdays.
75% of people who need addiction care started using as teens
A vast majority of adults who were admitted to substance use treatment started using before their 18th birthdays, according to a 2014 report from the federal Substance Abuse and Mental Health Services Administration.
Despite this fact, the medical community and government officials have for decades failed to include youth in the most significant policies affecting their access to care, The Seattle Times has found.
Those oversights have magnified the consequences of addiction in the age of fentanyl — a drug 50 times more powerful than heroin whose fatal dose is as small as a dozen grains of salt. Since 2019, youth opioid-related deaths in Washington have more than tripled. Emergency responses for kids suspected of overdosing on opioids, state Department of Health data shows, have quadrupled.
Suspected overdoses steadily climb among youth
Nationwide, opioid overdose deaths are finally decreasing after a decadelong surge. But Washington is still reporting stubborn increases. Total deaths here jumped 20% in the past year.
When Washington teens like Maddy try to escape these statistics, they’re at a stark disadvantage: They face layers and layers of medical barriers that adults don’t.
Had Maddy been 18, she might have qualified for one of 132 or so adult detox beds that existed in King County when she was seeking care. No such beds exist here for kids her age. She could have also found a doctor trained in addiction medicine, someone who could clearly explain what to expect when taking buprenorphine. As a kid, though, she had little chance. Not a single Washington physician among the state’s 66 members of the American Society of Addiction Medicine lists pediatrics as their specialty.
Drug use and poisonings are “now the third leading cause of death of children in the U.S.,” said Dr. Scott Hadland, chief of adolescent and young adult medicine at Mass General for Children and Harvard Medical School. “Yet when it comes to [drug use], we are caught flat-footed.”
Far fewer detox beds for youth than for adults
Medically supervised withdrawal, or detox, facilities offer a place to support people in withdrawal from opioids, which can lead to severe physical symptoms including vomiting, nausea and diarrhea. As of August 2024, only 11 youth detox beds existed statewide, Washington State Department of Health data shows. King County alone has about 80 detox beds for adults.
Washington State Department of Health and Seattle Times reporting (Fiona Martin / The Seattle Times)
Nationwide, fewer than half of pediatricians are comfortable treating youth addicted to opioids. An estimated 5.5% had ever prescribed lifesaving medications like buprenorphine, the standard of care and only medication approved for opioid use disorder in teens.
The western side of the U.S. is even less likely than other regions to offer buprenorphine. Maddy’s family didn’t know this, but they were lucky she received a prescription. In Washington, the most recent data shows, fewer than 10% of youth facilities offer this medication, though there are indications that access is increasing.
Addiction-treatment medication is hard for teens to get
The addiction medication buprenorphine is the only drug approved for opioid use disorder in teens — but access is much harder for youth than for adults. In Washington, nearly 30% of adult facilities offer addiction medication, while fewer than 10% of youth facilities do.
“The only thing that we know we need to do is buprenorphine, and sites already aren’t doing that,” said Dr. Caroline Raymond-King, a health equity researcher and resident physician at Yale University. “Some of the stuff we’re doing is just frankly kind of ridiculous. And we’re not doing enough of the very limited stuff we know that we should.”
Teens can struggle to recover because of a stark mismatch between how they envision treatment and what their doctors actually provide.
In these moments of desperation, families like Maddy’s are disappointed to find out residential or inpatient care is rarely affordable or available. Hospitals need a special license to admit youth for inpatient addiction treatment, and none of the state’s children’s hospitals have one; only one hospital statewide, Fairfax Behavioral Health in Kirkland, has such a license to treat adults.
At home, the 17-year-old had only a handful of buprenorphine strips and a stack of discharge paperwork.
“Before beginning Buprenorphine, you want to feel very sick from withdrawal symptoms,” the paperwork instructed. “The worse you feel when you begin the medication, the better the medication will work.”
Wait 12 hours after you’ve last used fentanyl before starting the medication.
Cut the first dose in half, place it under your tongue.
Keep it there for 15 minutes.
“Feeling better? Good, the medicine is working.”
With constant aches, nausea, vomiting and diarrhea, Maddy couldn’t make it through five hours, let alone 12.
A box of medication alone couldn’t keep her from using.
“Skyrocketed my addiction”
Maddy was in middle school when she first felt the emptiness of depression.
The summer she turned 15, friends offered her Xanax. She liked how the drug melted her anxious thoughts. She knew little about drug dependence and assumed she had a superpower: that she’d never become addicted.
“I was like, ‘Oh my God, I can just get high without any problems,’” she said.
Soon she was spending most days after school smoking pot at a nearby park. When her parents divorced, she moved with her dad to a small town on the western edge of the Cascades. She was suddenly two hours north, away from her mom and all her friends. Then, the pandemic hit.
Maddy’s sense of her place in the world was largely erased. Self-medicating seemed like a rational response to her pain.
One day during lockdown, she stole a few pills of prescription Vicodin from a relative’s medicine cabinet. Months later, when she moved back to Seattle and lost access to the prescription opioids, she quickly became addicted to a more dangerous substitute: fentanyl.
Isolation, she said, “skyrocketed my addiction.”
A vast majority of people in addiction started using as teens. The prevailing narrative about teen drug use, however, has been one of resilience. Just as teens grow out of other youthful patterns, most youth who experiment with substances, decades of research shows, never become addicted.
What’s more: Addiction treatment has only recently become part of the traditional medical system for adults, a change that hasn’t yet extended to pediatric training or treatment for youth.
As a result, the medical establishment largely overlooks youth addiction as an issue significant enough to warrant extensive training in medical schools, specialized protocols in emergency departments or a commitment to youth-specific research.
“When I was in medical school, I got no training on opioid addiction. When I was in residency, no training on opioid addiction. When I was in fellowship, no training on opioid addiction,” said Hadland, who completed his training in the late 2000s and early 2010s, during the second wave of the opioid crisis. “There’s just a gap at every single step of the way.”
Kids addicted to drugs have historically looked to psychosocial interventions, like counseling, 12-step programs and rehab. Today, when many families think of treatment, they imagine these kinds of settings.
Rehab gives youth respite from their regular lives, distance from drug suppliers and a window into what recovery can look like. There’s a place for rehab, especially for youth who don’t have family support or have relapsed several times, physicians interviewed for this story agreed.
But when it comes to opioids, only medications reduce overdoses and drug-related deaths. They’re so essential that the American Academy of Pediatrics considers these medicines as the first-line treatment for youth.
Despite this, pediatricians rarely diagnose or prescribe medicine to kids addicted to opioids. Only a quarter have experience ever diagnosing a teen with opioid use disorder, according to a recent survey of 474 pediatricians conducted by Hadland and his colleagues.
Maddy told her pediatrician about her drug use in February 2022, even before she told her mom. She imagined she’d at least get medicine that could help her safely stop using. But the physician didn’t offer “any medication,” Maddy said.
“When she’s asking questions like, ‘Are you doing drugs? Do you have an addiction problem?’… I feel like she should have some knowledge of what to do if someone says ‘yes,’” Maddy said.
“I was going in there trying to get advice, tips, information, medication, a treatment plan. That just wasn’t on her radar.”
Nowhere to go
After Maddy decided to tell her mom about her addiction — and their frustrating visit to Seattle Children’s — Sabrina quickly found Maddy an appointment through an outpatient addiction treatment program at Harborview Medical Center.
Maddy was again instructed to take buprenorphine and visit twice weekly for check-ins.
But she struggled to follow her provider’s instructions. Every time she tried to stop using fentanyl, excruciating withdrawals set in. She’d use again to cope. Then, reminding herself she wanted to quit, she’d take buprenorphine.
It was a pernicious cycle. The combination of the two, Maddy quickly found out, can trigger a supercharged wave of the horrible symptoms that kept her using fentanyl in the first place — a phenomenon called “precipitated withdrawals.” She eventually stopped taking the buprenorphine.
It’s “especially hard for teens … to wake up every day and make the choice to take a medicine instead of using when they have cravings,” said Dr. Chris Buresh, an emergency medicine physician at Harborview Medical Center and Seattle Children’s.
Compared with adults, teens are more impulsive. “That ability to project into the future what’s going to happen as a result of that choice … The parts of their brain that do that are a couple of years from showing up,” Buresh said.
After failing regular drug tests, Maddy eventually left the Harborview program.
Frustrated and scared, Sabrina started calling medically supervised withdrawal, or detox, facilities.
But no facility in their county was licensed to treat teens. When Maddy sought care in 2022, only 14 youth detox beds existed statewide; state health department data shows only 11 exist today. “There just straight up wasn’t really anywhere,” Maddy said.
Physicians say the absence of youth detox beds is largely by design.
Washington and many other states rely on guidelines from the American Society of Addiction Medicine to decide what substance use services to pay for, which in turn determines the kinds of beds available.
ASAM acknowledges the deadliness of the opioid epidemic among teens. But it stops short of suggesting a need for youth-specific detox facilities. Instead, it recommends that adult facilities work to better serve youth; the organization is working on new guidelines but hasn’t yet released details. Only three Washington facilities have the extra license required to offer youth detox.
Without detox options, hospitals are usually parents’ first stop.
But as Maddy experienced, hospitals often aren’t equipped to handle kids coming off opioids. Families report driving to rural parts of Washington to hole up with their teen in a hotel as they detox without medical supervision. When the vomiting, nausea and cravings set in, at least they’re miles away from dealers.
Sabrina considered sending Maddy to an out-of-state facility. She learned about “travel buddy” companies she could hire to help Maddy safely use fentanyl on a plane or train so she’d still test positive by the time she arrived. But it took several months — until after Maddy turned 18 — before she could get her daughter into any detox program. Even then, Maddy was only allowed to stay for five days of treatment.
Maddy begged the facility — unsuccessfully — for a longer stay.
The day she discharged, she relapsed.
“Died today”
One day, Maddy took the bus just 10 minutes from her West Seattle home to a park where she was able to buy fentanyl pills almost immediately.
Maddy and several other teens interviewed for this story were quick to point out how easy it is to buy illicit drugs in Seattle.
Dealers deliver fentanyl pills directly to teenagers’ homes. Some teens say they’ve purchased substances on their school grounds and used in high school bathroom stalls. There are no statistics on how often Washington teens use fentanyl at school. But schools statewide reported using Narcan to reverse overdoses 45 times in 2023, up from two times in 2021.
Deaths are going up, too. In 2022, the most recent year with finalized statewide data, 38 Washington kids under 18 died from an opioid overdose — up from 12 kids five years ago; preliminary health department data shows 37 kids died last year.
On average, more than three Washingtonians under age 25 died each week in 2023.
“The fentanyl crisis isn’t showing [the public] pictures of dead young people in the morgue. Right? Because we don’t want to see that,” said Johnny Ohta, a substance use disorder professional at Ryther, a Seattle treatment center with a long history of serving the region’s most vulnerable children.
“But there’s dead young people in our county morgue right now. That died today.”
Of 10 young Washingtonians in recovery who were interviewed for this story, seven said they’ve lost a friend or relative to a drug overdose.
Opioid overdoses killed 3 young people a week on average last year in Washington
In January, Maddy learned an ex-boyfriend was dead from drugs.
More than a year had passed since Maddy’s short stay at detox. She eventually got into a rehab facility in Orange County, Calif. But by that point, she’d gone years without the treatment she needed to head off serious addiction.
After two stints of treatment, she moved back to Seattle. Here, she struggled to find recovery support, like Narcotics Anonymous meetings that cater to young people. Sober living homes were outside her family’s budget. And open use is everywhere in Seattle — at bus stops, the park, downtown.
Always minutes away from Maddy’s reach.
In the dark
On a West Seattle street just after 6:20 p.m. in February, Sabrina races home from work in the dark.
Inside their two-bedroom rental, Sabrina peels from room to room.
Maddy had been sober for 136 days. But she was teetering. And now she wasn’t answering her phone.
She opens Maddy’s bedroom door and finds her nodded out. “Maddy!” she yells, then asks her to hand over any drugs in the house. Sabrina calls a friend for advice. Minutes pass before she realizes Maddy has disappeared.
Her mind flashes to the small red and white shed out back, where she knew Maddy had previously used in secret.
She races through the grass.
Inside, Sabrina finds her daughter, slumped in a chair with a straw in her mouth.
She can’t hear a pulse. So she calls 911 and runs back to the house to grab the overdose reversal drug Narcan. She sprays it up Maddy’s nose and starts CPR.
“Push! Push! Push! Push!” the dispatcher coaches Sabrina over the phone.
A minute later, the dispatcher marks in his notes, Maddy is no longer breathing. And she’s turning blue.
Three minutes pass.
A fire crew is two blocks away.
But Sabrina is sure Maddy’s gone.
“Not OK”
Maddy wakes to flashing lights.
“Mom, mom, what’s happening?” Sabrina remembers her daughter saying.
Then: “I’m not OK. I’m not OK. I’m not OK.”
An ambulance brings Maddy to Harborview Medical Center in Seattle. Sabrina is so shaken that she waits an hour before following in her car. She finds Maddy on a bed in the ER hallway.
About three hours after her overdose, doctors send Maddy home with Narcan but without a treatment plan.
“I got there, and they were like, ‘Well, she’ll be ready to go [home] soon,’ “ Sabrina remembers.
“I was like, what the [expletive] are you talking about?”
Less than one-third of kids and young adults, research shows, receive any follow-up substance use care after an opioid overdose. Only one in 54 are prescribed gold-standard medications.
The reality of youth fentanyl use forces tough questions about how to help kids recover within a system that wasn’t built for them.
In Maddy’s case, access to buprenorphine wasn’t enough. Detox wasn’t available. Rehab came too late.
Several physicians interviewed for this article say the suddenness and scale of the youth fentanyl crisis caught them by surprise. Without an overhaul in physician training, better access to medication and a course correction in how care is delivered, experts and families say, there’s no end in sight.
Youth emergency department visits for opioid overdoses triple
The picture of youth drug addiction “has fundamentally changed,” said Dr. Sarah Bagley, associate professor of medicine and pediatrics at Chobanian & Avedisian School of Medicine and Boston Medical Center. But, “the way pediatricians talk about it, the way we talk about it in the schools or drug education curriculum, hasn’t.”
Bagley has noticed another challenge, too. Among the teens she treats, some say fentanyl’s effects are more effective at relieving their pandemic-era mental health challenges compared to anything else they’ve tried.
That was one of the biggest reasons Maddy struggled to quit. It wasn’t until years after her first hit that she felt a life of sobriety would be better than a life in use.
Nearly dying from an overdose, Maddy says, “just shows the reality of how bad it can get.”
At home in July, small yellow flowers peek out from knee-high grass in Maddy and Sabrina’s backyard.
Sabrina lets months go by without mowing; she can hardly bear going near the backyard shed.
Maddy, who is now 20, went briefly to a sober living facility in California. When she got back, she and her mom adopted two kittens. Motivation to care for others, and for herself, Maddy says.
She’s finally getting comfortable with the idea of getting a job, of having money in her pocket. And she dreams of going to cosmetology school. Maybe, she says, she’ll become a substance use counselor.
On her wrist, she wears a beaded bracelet marked with the date “1/27/2024” — a reminder of the day her ex-boyfriend died, and five days before her most recent overdose.
The word “sick” is tattooed in green on the top of her left hand.
Someday soon, she says, she plans to get it removed.
Hannah Furfaro reported this story while participating in an Association of Health Care Journalists fellowship, which is supported by the Commonwealth Fund.
