Treatment of Youth Opioid Addiction: Approaches to a Modern Epidemic. What should we do with this case? Heroin Addiction History

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1 Treatment of Youth Opioid Addiction: Approaches to a Modern Epidemic What should we do with this 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? ) MTF: Annual Use Prevalence 12th Graders Percent Percent Past Year Use Prevalence: 8th and 12th Graders (MTF) Percent Heroin Addiction History The NSDUH report February 2009 Hser, Y.-I. et al. Arch Gen Psychiatry 2001;58:

2 The current opioid epidemic Treatment: Conceptual underpinnings Use as many effective tools as are available One size does not fit all: as many doors as possible A full continuum of care: multiple services with flexible responses Institutional affiliation and longitudinal care promotes engagement Expectation of relapsing/remitting course Expectation of variable and shifting treatment readiness Recovery as a gradual process, not an overnight event -- expectation of incremental progress Elements of treatment model Emphasis on ongoing engagement from detox to next levels of care (the revolving door should lead somewhere) Specialty care Longitudinal follow-up and management Integration of relapse prevention medication as standard of care Buprenorphine Extended release naltrexone Co-occurring (dual diagnosis) treatment Journal of the American Medical Association, 2008 CTN Youth Buprenorphine Study Opioid Positive Urines: 12 weeks Bup vs Detox (Woody et al, JAMA 2008) 2

3 Buprenorphine induction method 20 youth received xr-ntx 16 initiated OP treatment 10 retained at 4 months 9 good outcome 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 of Rx duration over time, used as contingency management Optional tools for med supervision Prescriptions left for counselor to distribute Monitored distribution and/or administration by families Direct med administration up to daily XR-NTX Induction Residential detox using bupe taper 7 day abstinence by confinement NTX induction with 4 d oral dose titration 6.26, 12.5, 25, 50 mg (liquid) 1st dose injectable XR-NTX prior to residential discharge Outpatient maintenance XR-NTX Maintenance Monthly injections Expectation of counseling attendance Assertive dosing reminders Choice of medication: Bupe vs XR-NTX Patient preference Family preference Failure of other treatments, try something new Side effects, anxious anticipation Long acting duration of xr-ntx for poor treatment engagement and adherence Bupe intrinsically reinforcing More familiarity with bupe, pos and neg reputation Problems with acceptability of agonist pharmacotherapies More tools in the toolbox 3

4 If only it were that easy Features of youth treatment Family leverage Pushback against sense of parental dependence and restriction Salience of burdens of treatment Prominence of co-morbidity Family mobilization Medicine may help with the receptors, you still have to parent your difficult teenager Challenges Attitudes, misunderstanding and stigma Adherence Monitoring and supervision Range of options may be limited Limited treatment capacity Limited insurance coverage Limited availability of inpatient Clock is ticking in inpatient setting Tensions in involving family, esp older youth Maintaining credibility in the real world: Medications, mischief, and monkey business Side effects Diversion Non-compliance Inconsistency Other substances Cumula&ve reten&on over 26 weeks by medica&on Reten&on by medica&on * * * 2.5 * = p < 0.01 compared to no medication 4

5 Opioid- free weeks over 26 weeks by medica&on Combining urine and self report Additional Factors Medication vs. No Medication Cross-sectional retention at 26 weeks * = p < 0.01 compared to no medication What is the necessary continuum of care? Inpatient detox and crisis intervention, with medication induction Emphasis on ongoing linkage from detox to next levels of care (the revolving door should lead somewhere) Outpatient counseling, group and individual Outpatient medication treatment Recovery housing Flexible movement up and down levels of care Benefits of medication Reduced craving Blockade of drug effect in event of lapse Interruption of cycle of use, reward, withdrawal Concrete delivery More tools Availability for counseling Benefits of counseling Enhancement of motivation Rehearsal of skills Creation of positive peer recovery culture Reinforcement of pro-social alternatives to drug use More tools Improved adherence to medication What is the main ingredient? Question: Is it medication-assisted treatment, or counseling-assisted medication Answer: Yes 5

6 Relapse prevention Rx delivery Toolbox for individualized treatment Frequent monitoring for response Monitoring for and attention to other substances Use of medication as contingency Limitations on Rx supply as needed Supervised Rx administration as needed Treatment integration: Strong collaborations among disciplines Preventing diversion Start with small supplies Limit dose to 24 mg, usually lower UDS for bupe Daily administration if needed Management of lost medication / Rx Prepare for discrepancy and stigma How to talk to family How to talk to others in the 12 step fellowship How to shop for meetings and sponsors Don t ask, don t tell? What are the gaps in our treatment system? Not enough treatment providers Not enough treatment slots Not enough youth-specific treatment Not enough adoption of relapse prevention medication Not enough continuity of care Not enough flexibility Meet the patients where they are? I agree I m using too much heroin. Can you help me cut down, how about weekends only Sure I ll come to group occasionally when I can make it I agree I ve been using too much heroin but cocaine is not a big problem for me Why can t I take xanax for my anxiety. Nothing else works I d like a year s supply of suboxone please 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, but leaves many behind More flexible approaches favor contemplation stage, allow gradual engagement and incremental success, broader inclusion, increased atmosphere of gas n go but captures many in contemplative stage Finding a balance using motivational incentive approach with treatment outcome as the contingency target and access to medication as the incentive, possibly with stagewise groupings 6

7 A sprint or a marathon? Early: I agree I was out of control with the dope, but I can still use a little oxy on the weekends. Middle: I m an opioid 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) Conclusions (I) Treatment with relapse prevention medications(xr-ntx and buprenorphine) for youth with opioid dependence is well tolerated and well accepted by patients and families, and can be practically implemented as a standard treatment in a community treatment program. Medications are easily integrated with counseling as part of a comprehensive treatment approach Use of medications for relapse prevention is associated with increased retention and treatment utilization, and decreased drug use. Conclusions (II) Not surprisingly, medication compliance seems to be related to effectiveness. Although patients drift in and out of treatment, there are substantial rates of return to treatment following dropout, and re-cessation of drug use following lapse/relapse. Our experience suggests the benefits of a more longitudinal medical management model of care as compared to a more traditional model of discrete episodes of care. Next steps - clinical 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 Next steps Research agenda from the field Longer term outcomes? Appropriate duration of treatment? Different medication discontinuation strategies? Bupe vs XR-NTX? Post-relapse strategies stick or switch? Outpatient vs inpatient induction Dosing of counseling At a crossroads An exciting time with an explosion of new tools But an alarmingly poor level of dissemination and adoption We have an obligation to do better 7

8 We ve come a long way But we have a long way to go. What can you do? Develop relationships with a local network of treatment providers Develop resource maps Target local resource gaps Give providers feedback and constructive criticism Develop family and peer advocacy networks to educate and assist with navigating the system Hypothetical Miracle Cures 8