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Treatment of Youth Opioid Addiction: Approaches to a

Modern Epidemic

What should we do with this case?

•  17 M •  Onset prescription opioids 15, progressing to

daily use with withdrawal within 8 months •  Onset nasal heroin 16, injection heroin 6

months later •  3 episodes residential tx, 2 AMA, 1 completed •  Suboxone treatment (monthly supply Rx x 4),

took erratically, sold half •  Presents in crisis seeking detox (“Can I be out

of here by Friday?”)

Past Year Use Prevalence: 8th and 12th Graders (MTF)

Perc

ent

http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf

MTF: Annual Use Prevalence 12th Graders

Perc

ent

http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf

Perc

ent

The NSDUH report February 2009

Heroin Addiction History

Hser, Y.-I. et al. Arch Gen Psychiatry 2001;58:503-508.

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The current opioid epidemic

Treatment: Conceptual underpinnings

•  Use as many effective tools as are available •  One size does not fit all: as many doors as

possible •  A full continuum of care: multiple services with

flexible responses •  Institutional affiliation and longitudinal care

promotes engagement •  Expectation of relapsing/remitting course •  Expectation of variable and shifting treatment

readiness •  Recovery as a gradual process, not an overnight

event -- expectation of incremental progress

Elements of treatment model •  Emphasis on ongoing engagement from detox to

next levels of care (the revolving door should lead somewhere)

•  Specialty care •  Longitudinal follow-up and management •  Integration of relapse prevention medication as

standard of care – Buprenorphine – Extended release naltrexone

•  Co-occurring (dual diagnosis) treatment

Journal of the American Medical Association, 2008

CTN Youth Buprenorphine Study Opioid Positive Urines: 12 weeks Bup vs Detox

(Woody et al, JAMA 2008)

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•  20 youth received xr-ntx •  16 initiated OP treatment •  10 retained at 4 months •  9 “good outcome”

Buprenorphine induction method

•  Residential detox using bupe taper •  Interruption of taper, switch to steady

dose, or •  Completion of taper, later resume bupe •  Alternative induction as outpatient

(minority) •  Outpatient maintenance

Buprenorphine maintenance •  Start weekly prescription supply •  Expectation of counseling attendance •  Frequent urine monitoring •  Increase duration of Rx duration over

time, used as contingency management •  Optional tools for med supervision

– Prescriptions left for counselor to distribute – Monitored distribution and/or administration

by families – Direct med administration up to daily

XR-NTX Induction

•  Residential detox using bupe taper •  7 day abstinence by confinement •  NTX induction with 4 d oral dose

titration – 6.26, 12.5, 25, 50 mg (liquid)

•  1st dose injectable XR-NTX prior to residential discharge

•  Outpatient maintenance

XR-NTX Maintenance

•  Monthly injections •  Expectation of counseling attendance •  Assertive dosing reminders

Choice of medication: Bupe vs XR-NTX •  Patient preference •  Family preference •  Failure of other treatments, try something new •  Side effects, anxious anticipation •  Long acting duration of xr-ntx for poor treatment

engagement and adherence •  Bupe intrinsically reinforcing •  More familiarity with bupe, pos and neg reputation •  Problems with acceptability of agonist

pharmacotherapies •  More tools in the toolbox

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If only it were that easy Features of youth treatment

•  Family leverage •  Pushback against sense of parental

dependence and restriction •  Salience of burdens of treatment •  Prominence of co-morbidity •  Family mobilization – “Medicine may

help with the receptors, you still have to parent your difficult teenager”

Challenges •  Attitudes, misunderstanding and stigma •  Adherence •  Monitoring and supervision •  Range of options may be limited

– Limited treatment capacity – Limited insurance coverage – Limited availability of inpatient

•  Clock is ticking in inpatient setting •  Tensions in involving family, esp older

youth

Maintaining credibility in the real world: Medications, mischief, and monkey

business •  Side effects •  Diversion •  Non-compliance •  Inconsistency •  Other substances

Cumula&ve  reten&on  over  26  weeks    by  medica&on  

* = p < 0.01 compared to no medication

2.5

Reten&on  by  medica&on  

* **

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Opioid-­‐free  weeks  over  26  weeks    by  medica&on  

Combining  urine  and  self  report  

* = p < 0.01 compared to no medication

Additional Factors Medication vs. No Medication

Cross-sectional retention at 26 weeks

What is the necessary continuum of care?

•  Inpatient detox and crisis intervention, with medication induction

•  Emphasis on ongoing linkage from detox to next levels of care (the revolving door should lead somewhere)

•  Outpatient counseling, group and individual •  Outpatient medication treatment •  Recovery housing •  Flexible movement up and down levels of

care

Benefits of medication

•  Reduced craving •  Blockade of drug effect in event of lapse •  Interruption of cycle of use, reward, withdrawal •  Concrete delivery •  More tools •  Availability for counseling

Benefits of counseling

•  Enhancement of motivation •  Rehearsal of skills •  Creation of positive peer recovery culture •  Reinforcement of pro-social alternatives to

drug use •  More tools •  Improved adherence to medication

What is the main ingredient?

Question: Is it medication-assisted treatment, or counseling-assisted medication

Answer: Yes

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Relapse prevention Rx delivery Toolbox for individualized treatment •  Frequent monitoring for response •  Monitoring for and attention to other

substances •  Use of medication as contingency •  Limitations on Rx supply as needed •  Supervised Rx administration as needed •  Treatment integration: Strong

collaborations among disciplines

Preventing diversion

•  Start with small supplies •  Limit dose to 24 mg, usually lower •  UDS for bupe •  Daily administration if needed •  Management of “lost” medication / Rx

Prepare for discrepancy and stigma

•  How to talk to family •  How to talk to others in the 12 step

fellowship •  How to shop for meetings and sponsors •  Don’t ask, don’t tell?

What are the gaps in our treatment system?

•  Not enough treatment providers •  Not enough treatment slots •  Not enough youth-specific treatment •  Not enough adoption of relapse

prevention medication •  Not enough continuity of care •  Not enough flexibility

Meet the patients where they are?

•  “I agree I’m using too much heroin. Can you help me cut down, how about weekends only…

•  “Sure I’ll come to group occasionally when I can make it”

•  “I agree I’ve been using too much heroin but cocaine is not a big problem for me”

•  “Why can’t I take xanax for my anxiety. Nothing else works…”

•  “I’d like a year’s supply of suboxone please”

What’s the right balance? •  Stricter, more uniform requirements for continuation

favors action stage, endorses and reinforces success, leads to greater rates of success in those that remain, increased atmosphere of “real recovery,” but leaves many behind

•  More flexible approaches favor contemplation stage, allow gradual engagement and incremental success, broader inclusion, increased atmosphere of “gas ‘n go” but captures many in contemplative stage

•  Finding a balance using motivational incentive approach with treatment outcome as the contingency target and access to medication as the incentive, possibly with stagewise groupings

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A sprint or a marathon?

Early: I agree I was out of control with the dope, but I can still use a little oxy on the weekends.

Middle: I’m an opioid addict, not an alcoholic. I just need to stop using heroin. A few beers is fine.

Later: When I get drunk, I end up using heroin again. Maybe I need to stop drinking too. But taking a little xanax when I’m stressed is no big deal.

(sigh)

Conclusions (I) • Treatment with relapse prevention medications(XR-NTX and buprenorphine) for youth with opioid dependence is well tolerated and well accepted by patients and families, and can be practically implemented as a standard treatment in a community treatment program.

• Medications are easily integrated with counseling as part of a comprehensive treatment approach

• Use of medications for relapse prevention is associated with increased retention and treatment utilization, and decreased drug use.

Conclusions (II)

• Not surprisingly, medication compliance seems to be related to effectiveness.

•  Although patients drift in and out of treatment, there are substantial rates of return to treatment following dropout, and re-cessation of drug use following lapse/relapse.

• Our experience suggests the benefits of a more longitudinal medical management model of care as compared to a more traditional model of discrete episodes of care.

Next steps - clinical

•  Improved family involvement •  How to manage medication discontinuation •  Longer-term engagement strategies •  More operationalization of stepped care •  Broader coverage and reimbursement,

including XR-NTX •  Differential strategies for patients in early

stages of change in relation to other substances

Next steps – Research agenda from the field

•  Longer term outcomes? •  Appropriate duration of treatment? •  Different medication discontinuation strategies? •  Bupe vs XR-NTX? •  Post-relapse strategies – stick or switch? •  Outpatient vs inpatient induction •  Dosing of counseling

At a crossroads

•  An exciting time with an explosion of new tools

•  But an alarmingly poor level of dissemination and adoption

•  We have an obligation to do better

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We’ve come a long way…

But we have a long way to go.

What can you do? •  Develop relationships with a local network of

treatment providers •  Develop resource maps •  Target local resource gaps •  Give providers feedback and constructive

criticism •  Develop family and peer advocacy networks

to educate and assist with navigating the system

Hypothetical Miracle Cures