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My Kid Is Using What? Treatment for Opioid Dependence in Youth Marc Fishman MD Johns Hopkins University Dept of Psychiatry Mountain 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 nonadherence 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 Use Percent MTF: Annual Use Prevalence 12th Graders http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf Percent Past-Month Non-Medical Users of Prescription Opioids, by Age: 2002-2007 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 Number of Admissions (12-20y) by State: Primary Problem with Any Opioid NEW HAMPSHIRE 279 WASHINGTON 68 MONTANA 8 NORTH DAKOTA 309 OREGON 15 WYOMING 119 NEVADA 18 SOUTH DAKOTA 16 NEBRASKA 245 UTAH 136 ARIZONA 443 MAINE 258 VERMONT 379 MINNESOTA 2112 MASSACHUSETTS 31 IDAHO 1373 CALIFORNIA 112 123 COLORADO 235 WISCONSIN 34 IOWA 500 ILLINOIS 45 KANSAS 93 OKLAHOMA 46 NEW MEXICO New York 1079 MICHIGAN 251 MISSOURI 96 ARKANSAS 174 INDIANA 1720 PENNSYLVANIA 681 OHIO 1122 CONNECTICUT 1487 NEW JERSEY West Virginia 287 KENTUCKY 136 TENNESSEE 122 RHODE ISLAND 143 DELAWARE 214 VIRGINIA 159 NORTH CAROLINA 1160 MARYLAND SOUTH CAROLINA Q1: 8 to 93.75 107 Mississippi Alabama 431 TEXAS Georgia Q2: 94 to 179.5 185 LOUISIANA Q3: 180 to 423.5 Alaska 401 FLORIDA Q4: 424 to 2907 14 HAWAII Virgin Islands Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present 21 PUERTO RICO Percent of Primary Problem with Any Opioid of All Admissions (12-20y) NEW HAMPSHIRE 3.4% WASHINGTON 4.3% MONTANA 3.7% OREGON Massachusetts 6.3% NEVADA 10.6% UTAH 4.0% ARIZONA 24.4% MAINE 14.3% VERMONT 4.6% MINNESOTA 2.3% IDAHO 1.4% WYOMING 4.2% CALIFORNIA 1.4% NORTH DAKOTA 13.1% South Dakota 6.8% NEW MEXICO 10.8% NEW YORK 13.4% MICHIGAN 1.2% NEBRASKA 1.6% COLORADO 8.8% WISCONSIN 1.2% KANSAS 4.6% OKLAHOMA 5.7% ILLINOIS 4.5% INDIANA 4.4% MISSOURI 5.5% OHIO 12.1% KENTUCKY 8.3% TENNESSEE 5.4% ARKANSAS Mississippi Alabama 4.7% TEXAS 16.7% PENNSYLVANIA 0.6% IOWA 10.7% RHODE ISLAND 33.0% 21.6% CONNECTICUT NEW JERSEY West Virginia 4.5% VIRGINIA 12.3% NORTH CAROLINA 16.7% DELAWARE 11.8% MARYLAND SOUTH CAROLINA 1.8% Georgia Q1: 0.6% to 3.4% Q2: 3.5% to 5.2% 5.3% LOUISIANA Q3: 5.3% to 11.9% Alaska 3.4% FLORIDA Q4: 12.0% to 40.4% Hawaii Virgin Islands Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present 13.0% PUERTO RICO 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 Fortuna, R. J. et al. Pediatrics 2010;126:11081116 Adolescent opioid users previous 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 Induction Method • 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 2.5 * = p < 0.01 compared to no medication 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 XRNTX • Differential strategies for patients in early stages of change in relation to other substances • Longer term outcomes