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Opioids: addiction is a different beast' in kids: this is the second segment of a two-part series on opioid addiction in adolescent.

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Referring adolescents who struggle to extinguish their craving for opioids is far from an exact science. Ideally, pediatricians should refer patients to clinicians who have expertise in treating substance abuse disorders in adolescents, typically psychiatrists.

Psychiatrists "tend to have quite a bit of experience with addiction, but they can be very hard to find," said Leslie Hulvershorn, MD. "Sometimes, it's a mental health center provider who treats adults with addiction. Addiction is a different beast in kids, bat that might be the next best thing."

Three medicines indicated for treating severe opioid disorder include buprenorphine (the "gold standard," Steven C. Matson, MD, said), methadone, and naltrexone, which is Dr. Hulvershorn's typical drug of choice, "because it's not a drug of abuse. It's an opioid antagonist, so it blocks the euphoria that you might get when you are using a drug of abuse such as an opioid."

Even though pediatricians have access to an American Academy of Pediatrics-endorsed buprenorphine waiver course, not all clinicians feel comfortable adding medication-assisted treatment to patients.

"It might mean that you partner with a substance use provider who can do more comprehensive services but not the prescribing," said Dr. Hulvershorn, a child and adolescent psychiatrist who runs an adolescent addiction treatment outpatient program at Riley Hospital for Children, Indianapolis. "You certainly don't want to treat these kids in a vacuum by yourself, because it's very complicated to treat them." Dr. Hulvershorn also is medical director for the State of Indiana's Division of Mental Health and Addiction, which licenses and certifies all of the opioid treatment programs in the state.

In 2016, the American Academy of Pediatrics issued a new policy statement, "Medication-Assisted Treatment for Adolescents with Opioid Disorders," which recommends that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can.

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Still, the office-based practice of prescribing opioid withdrawal medication "is a very successful approach and a reasonable alternative to other approaches that have been used historically, like methadone maintenance programs," noted Marc N. Potenza, MD, PhD, emphasizing that physicians have to understand how to help patients with addiction. Dr. Potenza is a professor of psychiatry in the Child Study Center at Yale School of Medicine, New Haven, Conn.

Physicians interviewed for this story underscored the importance of a comprehensive approach that includes behavioral treatment, medication, and support from family and friends.

"A lot of kids who get into these problems come from families that don't have many resources," said Dr. Matson, chief of the division of adolescent medicine at Nationwide Children's Hospital, Columbus, Ohio, noting that, often, it is a generational problem, in which grandparents and parents are drug users. "But, for kids who take a wrong path, encouraging words really can come true. It's really a matter of how many people you have cheerleading for you and keeping an eye on you."

When Dr. Matson's clinic began treating patients with opioid use disorders 8 years ago, only about 25% of adolescents returned for a second visit, and the rate of abstinence at 1 year was only 9%. The clinic has undertake a large quality improvement project to improve that percentage. "We learned to not scare people right away with a bunch of assignments they have to get done but to just welcome them in, get them started on the medication, and give them positive messages. For short-term remission at 3 months, we're at 50%-60%, which is pretty good. It's probably as good as any adult program. I think we're at 35%-40% remission at 1 year for people first time in recovery," he said in an interview.

Where to go from here

Reflecting on what he'd like opioid use disorder treatment to look like 5 or 10 years down the road, Dr. Matson emphasized the prominent role that pediatricians can play.

"We're really the ones that could make a difference if we can try to intervene," he said. "I'm not sure I can prove it, but my pipe dream is, the earlier that we catch people and the less time they've been using drugs, it's got to be easier to stop it then, than if they've been using for 5 or 10 years."

That's the kind of hope Dr. Hulvershorn holds for the 17-year-old patient she's treating who suffers from depression and PTSD.

"She has decided that it's important for her to come clean," said Dr. Hulvershorn, who added that the patient has received mental health and trauma counseling. "Part of our treatment program involves helping patients reorganize their life so that activities they're involved with are not drug related. That involves finding new friends and new activities, which can take some time. She is really committed to graduating from high school now that she's clean. She's really made a 180."

Role of a pediatrician's support vital

The way Deepa R. Camenga, MD, sees it, pediatricians play a vital role not only in counseling adolescents struggling with opioid use disorders but in helping to prevent it in the first place.

Prevention starts with advising parents or caregivers to manage any prescription medication that adolescents may receive for medical indications such as wisdom tooth extractions or sports injuries. "There is some risk for misuse or using it inappropriately or recreationally," said Dr. Camenga, a pediatrician at Yale School of Medicine, New Haven, Conn., who is also board certified in addiction medicine. "The parents should be highly involved in the administration of these medications to teenagers."

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Other risk factors for opioid use disorders include alcohol, marijuana, or other recreational drugs use or the presence of undiagnosed or under-treated mental health conditions such as ADHD, anxiety, and depression.

"In the primary care setting, I've seen a real increase in marijuana use over the last 10 years," she said. "Some teens are moving on to opiates, but, luckily, it's still a rarer thing than using marijuana or alcohol. Identifying these conditions is important because, in the act of screening and helping parents and kids link to treatment, pediatricians are preventing drug use."

Other red flags include poor academic performance and a lack of connectedness in the community. "When we are doing the well-child exams, we often ask about the home and school environment," Dr. Camenga said. "Looking for positive healthy activities and attachment is essential. If a kid doesn't have these protective factors, it puts them at higher risk for drug initiation."

Any time an adolescent's drug use is escalating in frequency, leading to parental concern or a decrease in function or problems, consider referring the child to a higher level of treatment with a specialist. "Even among teens with low levels of drug use, there are teens who have many risk factors for escalating to a higher level of use," said Dr. Camenga, who has treated approximately 50 adolescents with opioid use disorders over the past 2 years. "In this case, you may consider referring them earlier rather than later."

Broaching the conversation about referral to a specialist in substance abuse treatment can be tricky. She recommends saying something like, "'They [the substance use treatment providers] are not going to force you to do anything you don't want to do,' because that's a concern for the teens. 'They're going to discuss different options to help you over time, because, physically, it's very difficult to stop on your own.'"

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One young patient with several chronic medical conditions was referred to Dr. Camenga after being hospitalized in a psychiatric facility because she was using heroin and stimulants, which triggered a seizure.

"She came into treatment, and it took about 6 months for stabilization, but now she's doing well," the pediatrician said. "She's been in recovery for 2 years and is not using opioids. She's working, and she's trying to obtain a higher education certificate."

Although the American Academy of Pediatrics published a policy statement recommending that pediatricians consider offering buprenorphine and other medication-assisted treatment options for adolescents coping with opioid use disorder (Pediatrics. 2016 Aug. doi: 10.1542/ peds.2016-1893), Dr. Camenga said that some physicians are reluctant to do so "because there are concerns about exposing the developing brain to another opiate over time, and there are generally few studies that examine the efficacy of buprenorphine in adolescents specifically. However, the adolescents I've had on it do well. I've had several adolescents go through an entire treatment course and into recovery on buprenorphine."

Training options for pediatricians looking to become certified in prescribing buprenorphine for adolescents include an American Academy of Pediatrics-endorsed buprenorphine waiver course.

'At first it may seem overwhelming, but you can make a huge impact by treating two or three people," she said. "When you do the training through Substance Abuse and Mental Health Services Administration-supported programs (including one at www.asam.org), they provide lots of resources for mentorship or support from providers across the nation who work with special populations, including adolescents. Reach out to them. When I was learning, I talked a lot with my colleagues in different states because there are very few people who treat adolescents and who have the comfort in treating children. We're all very supportive of each other and reach out to discuss cases."

Dr. Camenga emphasized that pediatricians play a role in supporting parents and families of adolescents impacted by addiction to opioids.

"It's a rampant disease and we all know someone affected by it," she said. "Even if we feel powerless, perhaps, with this epidemic, we have a unique skill in supporting families. More awareness and less stigmatization, and support of families who are going through this, is important.

"We as a society have stigmatized this disease. I think that inhibits some young people getting treatment earlier rather than later. We also need to focus on prevention," Dr. Camenga emphasized.

Dr. Potenza disclosed having been a consultant to Jazz Pharmaceuticals and Opiant Pharmaceuticals. Dr. Matson and Dr. Hulvershorn reported having no relevant financial disclosures. Dr. Camenga reported having no relevant financial disclosures.

dbrunk@frontlinemedcom.com

Caption: Dr. Leslie Hulvershorn said, "You certainly don't want to treat these kids in a vacuum by yourself."

Caption: Dr. Steven C. Matson said, "Encouraging words really can come true."

Caption: Dr. Deepa R. Camenga said, "We're all very supportive of each other."
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Author:Brunk, Doug
Publication:Pediatric News
Date:Jul 1, 2017
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