Opioid Use in Youth. Amy Yule M.D. March 2,

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1 Opioid Use in Youth Amy Yule M.D. March 2, 2018

2 An opioid is a substance that acts on opioid receptors Beta-endorphin Endogenous opioids Dynorphin Opiates Natural products of the poppy plant Morphine Heroin Synthetic opioids Oxycodone Fentanyl Buprenorphine

3 As prescriptions for opioids increased so did overdose deaths emphasis on pain management in prescription opioids for chronic pain overdose deaths Paulozzi 2011

4 Overdose deaths continue to increase despite increased awareness & resources National Center for Health Statistics, CDC Wonder

5 Overdoses are occurring in youth Youth with SUD presenting for treatment at the MGH Addiction Recovery Management Service 71% 29% Among those with a history of OD: 62% unintentional OD 31% intentional OD 7% unintentional and intentional OD OD No OD Yule, in press

6 Youth access prescription opioids for free Source of Prescription Opioid Misused by 12 th graders in the past year, MTF For free from a friend From a prescription I had Bought from a friend Took from a relative without asking From a drug dealer/stranger Miech 2015

7 Substance use patterns are on a continuum Any non medical use of opioids in an adolescent is cause for concern Limited Use Regular Use Problematic Use Use Disorder

8 Assessment of opioid intoxication & withdrawal Intoxication: Sedation Impaired attention/memory Slurred speech Miosis Withdrawal: Irritability, anxiety, diaphoresis, insomnia, nausea/vomiting, diarrhea, mydriasis Can quantify with the Clinical Opioid Withdrawal Scale (Wesson 2003) DSM

9 Assessment with toxicology testing Type of tests Immunoassay Gas Chromatography Mass Spectrometry What substances are tested? Commonly included opiates : heroin, morphine, codeine Add on: synthetic opioids Hadland 2016

10 Assess for medical co-morbidity Incidence of Hepatitis C contaminated injecting equipment Highest incidence in individuals ages 20 to 29 years Source: CDC, National Notifiable Diseases Surveillance System (NNDSS)

11 Medication for Opioid Use Disorders Antagonist Binds to receptor Does not cause any biological response AND blocks other substances from binding to the receptor Partial Agonist Binds to receptor Causes a partial biological response Full Agonist Binds to receptor Causes a complete biological response

12 Opioid Receptor Antagonist: Naltrexone Extended Release Therapeutic effect: Blocks the euphoric effects of opioids Antagonist: Need to be off opioids for several days before starting the medication to decrease the risk for precipitated opioid withdrawal Medication dose: 380 mg IM Qmonthly SAMHSA 2015

13 Opioid Receptor Antagonist: Naltrexone Extended Release No restrictions around prescribing naltrexone FDA approved for youth >18 years

14 Partial Opioid Receptor Agonist: Buprenorphine/Naloxone Therapeutic effect: Blocks the euphoric effects of opioids Prevents or minimizes withdrawal symptoms Decreases cravings Partial Agonist: To start the medication patients need to be in mild opioid withdrawal Typical dose for stabilization: 8 mg to 16 mg SL daily

15 Partial Opioid Receptor Agonist: Buprenorphine/Naloxone Available in the outpatient setting through providers who are waivered and have a X license FDA: Safe for youth 16 years

16 Research on Buprenorphine/Naloxone in youth Marsch 2005 Randomized controlled trial (RCT) Buprenorphine vs clonidine for detoxification over one month (N=36 adolescents) Indiv on buprenorphine more likely to be retained in treatment, higher % drug tests negative for opioids Woody 2008 RCT Buprenorphine/naloxone for short term opioid detoxification (2 weeks) versus short term maintenance (12 weeks) (N=152 youth) Indiv in short term maintenance had less opioid use, less injecting, more likely to be retained in treatment

17 Research on Buprenorphine/Naloxone in youth Marsch 2016 RCT Buprenorphine taper 28 days vs 56 days (N=53 youth) Indiv with longer taper more likely to be retained in treatment, higher % drug tests negative for opioids

18 Resources for Buprenorphine/Naloxone Providers clinical support system PCSS is a SAMHSA funded organization administered through the American Academy of Addiction Psychiatry Free or low cost trainings Mentorship and training

19 Full Opioid Receptor Agonist: Methadone Therapeutic effect: Blocks the euphoric effects of opioids Prevents or minimizes withdrawal symptoms Decreases cravings Typical dose for stabilization: 60 mg to 120 mg PO daily Risk for overdose when combined with sedatives CSAT 2005

20 Full Opioid Receptor Agonist: Methadone Can only receive methadone in an Opioid Treatment Program Highly structured and supervised Access limited for youth <18 years of age

21 Medication for Opioid Use Disorders Naltrexone Extended Release Buprenorphine/Naloxone Need to be off opioids for a period of time before starting Need to be in opioid withdrawal or off opioids to start Methadone Can start if on opioids

22 Medication for opioid use disorders decreases overdose risk Buprenorphine Methadone Naltrexone ER rate of OD death by 70% when stabilized rate of OD death by 80% when stabilized OD in individuals treated with naltrexone vs control Sordo 2017, Lee 2016

23 Medication to reduce mortality Everyone should have naloxone Naloxone is a short acting opioid receptor antagonist that can reverse an opioid overdose Naloxone kits: IM/SC, IN It is important that people call 911 after administering naloxone SAMHSA 2016

24 Summary Youth have been impacted by the opioid epidemic Decrease opioid overdoses in youth by: Discussing safe medication storage and disposal Using medication to treat youth with opioid use disorders Encourage youth and families to get naloxone