Editor's note: integration of pharmacotherapy and psychosocial treatment in opiate-addicted youth.
Keywords--addiction, adolescents, MDFT, pharmacotherapy, prescription drugs, Suboxone[R]
Misuse of prescription drugs, particularly opiates, and particularly by adolescents, is a growing problem in the United States. Recent advances in addiction treatment include the development of opiate antagonists and a growing recognition of the need for ongoing monitoring. However, use of these antagonists for adolescents has been limited and deserves additional study and careful implementation.
A recent study of use of Schedule II drugs in California worker's compensation cases determined that the majority of prescription opiates are prescribed by a small percentage of physicians (Swedlow, Ireland & Johnson 2011), who can be identified through reviews of monitoring programs and prescription records. Providing basic education and training to all clinicians regarding appropriate pain management prescribing practices, while focusing corrective efforts on those who misprescribe, would be a cost effective means of addressing this problem.
The nonmedical use of prescription drugs is a growing problem among young people. In 2008, 4.7% of high school seniors used Oxycoutin nonmedically and 9.7% used Vicodin (DuPont 2010). Nonmedical use of a prescription psychoactive drug before the age of 15 is a red flag for involvement in the illicit poly-drug culture, a factor for early onset addiction in adolescence, and is associated with the greatest rates of morbidity and mortality.
Abuse of prescription drugs, particularly prescription opioids, is the nation's fastest growing drug problem. The proportion of these drugs seen in all substance treatment programs rose over 400% from 1998 to 2008 and continues to rise through 2010 (DuPont 2010). This dramatic rise in the number of patients admitted for addiction rose in all segments of the population regardless of age, gender, education level, and/or employment status, but was particularly pronounced in the younger population. Drug overdose deaths now exceed highway fatalities as the leading cause of death in adolescents, and in 2006, drug overdose deaths reached a high of over 38,000 (DuPont, 2010).
In 2008, adolescents constituted approximately a quarter million drug-related emergency room hospital visits and adolescent admissions related to opioid addiction increased from 16% in 1998 to well over 20% in 2008 (ASAM 2010). The number of U.S. emergency room department visits involving nonmedical use of narcotic pain relievers more than doubled from 2004 to 2008; the two most reported narcotic pain relievers were oxycodone (152% increase) and hydrocodone (123% increase), followed by methadone (73% increase) (CESAR 2010).
Recently, federal agents and local police made headlines when they raided several "pill mills" in southern Florida, a state whose oxycodone prescriptions vastly outstrip those of all other states combined (Leinwand, 2011). I had been speaking in nearby Ft. Lauderdale only the week before and spoke with a father whose son had overdosed on Oxycontin. The man was gathering support for a protest rally/picket at an alleged pain clinic, demonstrating the power of parents in attempting to reduce the availability of powerful narcotics. Diversion of opioid prescriptions for nonmedical use is a pervasive--and expensive-defrauding of legitimate health care delivery in some areas.
The surge in prescription drug abuse in young people has also contributed to a rise in drugged driving accidents. The vast majority of young people who misuse prescription opioid analgesics for nonmedical reasons do not have legitimate prescriptions and mix them with illicit drugs, greatly contributing to the increase in drugged driving accidents (DuPont 2010). However, one of the major issues complicating law enforcement's task in dealing with drugged driving is that unlike alcohol, there is no agreed-upon level of drugs in the blood for prescription opioids that is validated to impair driving. Many people who take these medications take them legitimately and appropriately for medical conditions, including pain. Further complicating the issue is the fact that mixing prescription psychoactive drugs with alcohol or illicit drugs greatly increases the risk of accidents. The balance between drivers who legitimately take their medications and drivers who are impaired by these drugs is a very difficult judgement that confronts traffic safety officials.
Treatment admissions for prescription opioids continue to soar. At Newport Academy in Orange, California, a majority of the admissions in both the male and female programs have abused prescription drugs as part of their overall polydrug abuse pattern and require treatment adapted to longer-term recovery. A continuing care model adapted to adolescent habilitation, rather than adult rehabilitation, is crucial for treatment success in youth (Birmingham & Sheehy 1984; Morrison 1990). Teenagers need to learn and practice what are to them new patterns of sobriety, rather than relearning the abandoned, disused and/or forgotten life lessons that most adults acquire.
The use of Multidimensional Family Therapy (MDFT), as developed by Howard A. Liddle (1985), has been shown to offer longer-lasting benefits over cognitive behavioral therapy (CBT) in adolescents (Liddle et al. 2008). Although MDFT has been used primarily as a cost effective outpatient therapy, Newport Academy has incorporated its interventions into an adolescent residential treatment facility (Smith et al. 2011).
MEDICATION ASSISTED TREATMENT
There are very few trials of medication-assisted addiction treatment in adolescence and it is clear that new treatment strategies need to be explored for opiate-addicted adolescents to improve outcomes for this growing cohort. The use of Suboxone[R] (a combination of buprenorphine and naloxone) in the treatment of relapsing opiate-addicted adolescents and extended continuing care models with gender-specific components are areas that need to be considered. Clinical experience has shown that opiatedependent adolescents with comorbid psychiatric disorders can have better treatment outcome when buprenorphine maintenance is combined with appropriate long-term psychotropic medications (Woody 2008).
Buprenorphine-naloxone is an approved medication for persons age 16 and over. However, clinicians have had little evidence-based research on its use in adolescents and young adults. Only short term medication and counseling for young people are commonly used, based on the expectation that their addiction has had a shorter duration than that of an adult counterpart (Whitten 2010). A study by Woody (2008) indicates that the risk of relapse alter detox and the potential benefit of extended buprenorphinenaloxone therapy are similar in both youth and adult patients.
Opioid addicted youth benefit from extended opioid maintenance therapy. Researchers compared a group of 15 to 21 year olds who received drug counseling and either two weeks or 12 weeks of outpatient therapy with buprenorphine-naloxone (Suboxone[R]). At the one year follow-up, subjects who had received longer treatment reported less use of a wide range of drugs than the group who received only counseling and a two-week detoxification regimen (see Table 1) (Whitten 2010; Woody 2008).
In addition, buprenorphine may play a role in reducing the spread of HIV through needle sharing and unprotected sexual activity, which are major risk factors for addicted adolescents. Herbeck and colleagues (2010) report a substantial decrease in both IV drug use and high-risk sexual behavior in a study of 166 buprenorphine-treated individuals.
Since addiction is a chronic disease associated with significant adverse social and psychiatric complications, with relapse often leading to substantial increased mortality and morbidity, the trend in treatment for patients who relapse alter a detox drug-free residential stay is medication-assisted treatment (Rieckmann, Kovas & Rutkowski 2010). For opiate-addicted patients the predominant medication plan used in the U.S. is methadone maintenance, a highly regulated late-stage intervention for adult chronic opiate abusers. Regulatory and clinical contraindications have precluded earlier intervention with opiate-addicted adolescents. Since the passage of DATA 2000, which allowed trained addiction medicine physicians to prescribe Suboxone as a Schedule III drug to addicts in a medical setting, Suboxone can be used for interventions at earlier stages of addiction as well as for opiate-addicted adolescents who have relapsed.
Suboxone is formulated to discourage intravenous administration and has less abuse potential then buprenorphine alone, therefore reducing its attraction for diversion. This is a significant problem with methadone, as evidenced by the increasing number of methadone overdose deaths. Further, since Suboxone is a Schedule III drug, pharmacotherapy from a physician's office makes buprenorphine treatment more acceptable for some opiate-dependent individuals who are not appropriate for traditional opiate maintenance clinics, which are dominated by adult patients with late stage addiction (Herbeck et al. 2010).
Other formulations of buprenorphine can also help reduce overdose and relapse for medication-noncompliant patients (Ling 2010). Vivitrol [R], an injected long-acting naltrexone (an opioid receptor antagonist), should also be considered for adolescents who have been discharged from primary treatment to prevent overdose and relapse. Vivitrol's most successful clinical experience has been with opioid-addicted health professionals and there is very little treatment research on its use by adolescents, despite the increase in patients who have relapsed alter traditional psychosocial treatment (Paul Earley, personal communication 2010).
Methadone maintenance and drug-free therapeutic communities are both effective, established treatment modalities, but are rarely combined. Opiate addicts on methadone who could benefit from a therapeutic community rarely apply, even if it would enhance their recovery. Even if they do apply, few residential treatment centers will accept them (Bonetta 2010).
Ideological conflicts are a major barrier to integrating mixed modality treatment, as traditional therapeutic communities require abstinence from all psychoactive drugs, including medications. However, Sorensen and his UCSF colleagues, in a NIDA-funded study conducted at Walden House in San Francisco, found methadone patients fare as well as drug-free patients in a large therapeutic community setting (Bonetta 2010; Sorensen et al. 2009). From a clinical perspective, the patients that I have referred to San Francisco's Walden House, who have a history of heroin addiction and are now abusing cocaine while in methadone treatment, have done much better in terms of recovery than if they had remained in a program providing only methadone maintenance or a therapeutic community.
Unfortunately, neither of these modalities accepts adolescent opiate addicts under the age of 18. Recent advances in adult opiate treatment have not been translated into adolescent addiction treatment, despite the fact that peak incidence for the early onset of addiction is between the ages of 15 and 21 (NIDA 1997).
As described by Rawson (2010) and his UCLA substance abuse research group, the current addiction treatment field is resistant to change and innovation in treatment methodology. Improving the quality of care for substance-misusing individuals needs to be a national health policy priority in this era of healthcare reform and parity (Roy & Miller 2010). With the growing medicalization of addiction treatment, the addiction field is under pressure for higher accountability, more efficient use of treatment resources, better delivery of quality services and the production of more positive client outcomes.
My personal clinical experience is that many adolescents and young adults who become addicted to opiates initiated their use with prescribed pain medications, usually for skeletal-muscular, e.g. athletic, injuries. This would indicate that appropriate prescribing guidelines need to be employed for this age group as well as older adults.
As described by McCance-Katz (2010), there is in fact limited evidence of the efficacy of opioids in the treatment of chronic nonmalignant pain, and in particular the use of high doses of opioid medication for pain (Balantyne & Mao 2003). Lack of a satisfactory response to opioid therapy may be due to tolerance and the development of hyperanalgesics induced by the opioids, which can be associated with rebound pain or opioid withdrawal symptoms masquerading as unrelieved chronic pain. Dr. McCance-Katz (2010) has outlined practices that can be used to avoid misuse of prescription opioids. These include (1) evaluation of the medical condition with documented review of the risks and benefits of opioid therapy, (2) urine toxicology screening, to monitor compliance with the medication, including detection of illicit substances, which can be a predictor of misuse of opioid medication, (3) registering with the CURES system (California's monitoring program) and (4) the use of pain management treatment agreements. Table 2 lists some behaviors that might help in the identification of prescription opioid abusers.
If a patient treated for opioid therapy for chronic pain becomes addicted to opioid medications, there are several treatment options available, including referral to a substance abuse program that can provide medical withdrawal, referral to methadone maintenance or a trial of buprenorphine treatment (Wesson & Smith 2010). Further, as emphasized by O'Connor (2010) medical education and training needs a greater focus on the diagnosis and treatment of addiction, including specific reference to the abuse and diversion of controlled prescription drugs. Physicians in mainstream medicine must become more part of the solution by following pain management guidelines than part of the problem of the growing epidemic of adolescent opioid addiction. Regulatory bodies must play a greater role in monitoring physician's prescribing patterns to identify those who prescribe inappropriately, whether from lack of information, manipulation by patients, or personal gain (Wesson & Smith 1990).
There is a great need for integration of pharmacotherapy and psychosocial recovery with improved application to the adolescent, particularly as it relates to early onset opioid addiction. In the pharmacotherapy area, the possibility of trials of buprenorphine for young people who have relapsed alter conventional treatment needs to be considered. In the psychosocial realm, greater emphasis needs to be placed on Multidimensional Family Therapy (MDFT) and gender specific treatment (Sherman 2011) in order to increase the scope and efficacy of adolescent addiction treatment.
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David E. Smith, M.D., FASAM (a)
(a) Principal, David E. Smith, MD & Associates, San Francisco; Chair, Addiction Medicine, Newport Academy, Orange CA; Member, Advisory Board, Dominion Diagnostics, North Kingstown, RI. Please address correspondence and reprint requests to David E. Smith, M.D., David E. Smith, MD & Associates, 856 Stanyan Street, San Francisco, CA 94117.
TABLE 1 Longer Medication Regimen Leads to Better Results (from Whitten 2010) Percent of Percent of Detoxification Extended-Therapy Patients Patients Dropped Out of Therapy 79% 30% Abused an Opioid During the Past 55% 38% Week Abused Marijuana During the Past 26% 16% Week Abused Cocaine During the Past 12% 2% Week Injected a Drug During the Past 33% 16% Week TABLE 2 Identification of Prescription Opioid Abusers (from McCance-Katz 2010) Deterioration in home/work Prescription forgery performance Resistance to changes in therapy Abuse of other substances Use of drug by injection or nasal Frequent emergency department route visits Early refills Unauthorized dose increases Lost/stolen prescriptions Nonmedical use Doctor shopping Refusal to provide urine drug screen or see a specialist
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|Author:||Smith, David E.|
|Publication:||Journal of Psychoactive Drugs|
|Date:||Sep 1, 2011|
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