My Kid Is Using What? Treatment for Opioid Dependence in Youth

Marc Fishman MD Marc Fishman MD Johns Hopkins University Dept of PsychiatryJohns Hopkins University Dept of Psychiatry

Mountain Manor Treatment Center, Baltimore MDMountain Manor Treatment Center, Baltimore MD

MADC

5/12/11

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?”)

Case (1) 16 F injection heroin and depression• Initial tx suboxone, oral NTX, ineffective 2º non-

adherence despite close parental monitoring, even went as far as liquid

• Received 8 doses XR-NTX, substantial improvement (despite sporadic lapses)

• Extreme conflict with mother, moved in with heroin-using boyfriend

• Insisted on stopping XR-NTX 2º injection site pain• 5 d oral NTX then immediate relapse and dropout

Non-Medical Prescription Opioid UseNon-Medical Prescription Opioid Use

MTF: Annual Use Prevalence 12th Graders

Per

cent

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

Past-Month Non-Medical Users of Past-Month Non-Medical Users of Prescription OpioidsPrescription Opioids, , by Age: 2002-2007by Age: 2002-2007

Per

cent

The NSDUH report February 2009

National Center for Injury Prevention and Control (NCIPC) Data on OD Deaths

http://www.cdc.gov/nchs/data/databriefs/db22.htm - Sept 2009

NumberNumber of Admissions (12-20y) by State: of Admissions (12-20y) by State: Primary Problem with Primary Problem with Any OpioidAny Opioid

Alabama

Alaska

GeorgiaMississippi

New York

WestVirginia

Virgin Islands

8NORTH DAKOTA

14HAWAII

15WYOMING

16

NEBRASKA

18SOUTH DAKOTA

21PUERTO RICO

31IDAHO

34IOWA

45KANSAS

46NEW MEXICO

68MONTANA

93OKLAHOMA

96ARKANSAS

107

SOUTH CAROLINA

112NEW HAMPSHIRE

119NEVADA

122RHODE ISLAND

123COLORADO

136

ARIZONA

136TENNESSEE

143DELAWARE

159NORTH CAROLINA

174

INDIANA

185

LOUISIANA

214

VIRGINIA

235WISCONSIN

245UTAH

251MISSOURI

258VERMONT

279WASHINGTON

287KENTUCKY

309OREGON

379MINNESOTA

401FLORIDA

431TEXAS

443MAINE

500ILLINOIS

681OHIO

1079MICHIGAN

1122

CONNECTICUT

1160MARYLAND

1373CALIFORNIA

1487NEW JERSEY

1720

PENNSYLVANIA

2112MASSACHUSETTS

Q1: 8 to 93.75

Q2: 94 to 179.5

Q3: 180 to 423.5

Q4: 424 to 2907

Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present

Percent of Primary Problem withPercent of Primary Problem with Any Opioid Any Opioid of All Admissionsof All Admissions (12-20y)(12-20y)

Alabama

Alaska

Georgia

Hawaii

Massachusetts

Mississippi

South Dakota

West Virginia

Virgin Islands

0.6%IOWA1.2%

NEBRASKA

1.2%KANSAS

1.4%WYOMING

1.4%NORTH DAKOTA

1.6%COLORADO

1.8%

SOUTH CAROLINA

2.3%IDAHO

3.4%FLORIDA

3.4%WASHINGTON

3.7%OREGON

4.0%

ARIZONA

4.2%CALIFORNIA

4.3%MONTANA

4.4%MISSOURI

4.5%

VIRGINIA

4.5%INDIANA

4.6%MINNESOTA

4.6%OKLAHOMA

4.7%TEXAS 5.3%

LOUISIANA

5.4%

ARKANSAS

5.5%OHIO5.7%

ILLINOIS

6.3%NEVADA

6.8%NEW MEXICO

8.3%TENNESSEE

8.8%WISCONSIN

10.6%UTAH

10.7%

RHODE ISLAND

10.8%NEW YORK

11.8%MARYLAND

12.1%KENTUCKY

12.3%NORTH CAROLINA

13.0%PUERTO RICO

13.1%NEW HAMPSHIRE

13.4%MICHIGAN

14.3%VERMONT

16.7%DELAWARE

16.7%PENNSYLVANIA

21.6%NEW JERSEY

24.4%MAINE

33.0%CONNECTICUT

Q1: 0.6% to 3.4%

Q2: 3.5% to 5.2%

Q3: 5.3% to 11.9%

Q4: 12.0% to 40.4%

Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present

Fortuna, R. J. et al. Pediatrics 2010;126:1108-1116

Percentage of visits during which controlled medications were prescribed to adolescents (A) and young adults (B) from 1994 to 2007 in the NAMCS and the NHAMCS

Adolescent opioid usersprevious clinical experience

• Higher severity and worse outcomes than non opioid using counterparts

• High rates of AMA from residential• Alarmingly low rates of continuing care in

outpatient• Relapse and drop out as the rule

Elements of treatment model

• Longitudinal engagement and management– We don’t have a cure - this is not new news

• More effective counseling techniques

• Anti-addiction pharmacotherapy

• Co-occurring (dual diagnosis) treatment

• Refinements in program design– Longer term maintenance and monitoring

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 after 4-10 weeks:

1234• Sometimes prescriptions left for counselor to

distribute• Infrequently – med distribution up to daily, +/-

monitored self-administration

XR-NTX InductionMethod

• Residential detox using bupe taper

• 7 day abstinence by confinement

• NTX induction with 4 d oral dose titration

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

• Outpatient maintenance

Cumulative retention over 26 weeks by medication

* = p < 0.01 compared to no medication

2.5

Opioid-free weeks over 26 weeks by medication

Combining urine and self report

* = p < 0.01 compared to no medication

Why XR-NTX?

• Failure of other treatments

• History of poor treatment engagement and adherence

• Problems with acceptability of agonist pharmacotherapies

• Patient and family preference

• More tools in the toolbox

Why buprenorphine?

• Failure of other treatments

• Growing positive reputation of bupe

• Patient preference, esp if previous experience

• Anxiety about NTX, or poor tolerance

• More tools in the toolbox

Implementation Issues

Barriers

• Attitudes, misunderstanding and stigma

• Adherence

• Monitoring and supervision

• Goals of treatment re other substances

Implementation Issues

• Insurance coverage for medication• Insurance coverage for inpatient induction -

length of stay• Difficulties of outpatient induction• Insurance coverage for outpatient induction -

staff time• Coordination of medical component• Medication choice: NTX vs bupe vs nothing• Transformation of treatment culture

Medications, mischief, and monkey business

• Diversion

• Non-compliance

• Inconsistency

• Other substances

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”

• More flexible approaches favor contemplation stage, allow gradual engagement and incremental success, lead to broader inclusion, increased atmosphere of “gas ‘n go”

• Finding a balance with motivational incentive approach with access to medication as the contingency

A sprint or a marathon?

Early: I’m a heroin 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)

Pharmacological Treatment

• Question:– Which is better - medications or

counseling?

• Answer:– Yes

We’ve come a long way

Next steps

• 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• Longer term outcomes