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My Kid Is Using What? Treatment for Opioid Dependence in Youth

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

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My Kid Is Using What? Treatment for Opioid Dependence in Youth

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  1. 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

  2. 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?”)

  3. Case (1) 16 F injection heroin and depression • Initial tx suboxone, oral NTX, ineffective 2º non-adherence 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

  4. Non-Medical Prescription Opioid Use MTF: Annual Use Prevalence 12th Graders Percent http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf

  5. Past-Month Non-Medical Users of Prescription Opioids, by Age: 2002-2007 Percent The NSDUH report February 2009

  6. National Center for Injury Prevention and Control (NCIPC) Data on OD Deaths http://www.cdc.gov/nchs/data/databriefs/db22.htm - Sept 2009

  7. Numberof Admissions (12-20y) by State: Primary Problem with Any Opioid 112 NEW HAMPSHIRE 279 WASHINGTON 443 68 8 258 MAINE 379 NORTH DAKOTA MONTANA VERMONT MINNESOTA 309 2112 OREGON MASSACHUSETTS 31 18 235 IDAHO New York WISCONSIN SOUTH DAKOTA 122 15 1079 RHODE ISLAND WYOMING MICHIGAN 34 1720 1122 119 16 IOWA PENNSYLVANIA CONNECTICUT NEVADA 681 NEBRASKA 1487 OHIO 500 NEW JERSEY 174 245 ILLINOIS 1373 West INDIANA 123 UTAH CALIFORNIA Virginia 143 214 COLORADO 45 DELAWARE 251 VIRGINIA 287 KANSAS MISSOURI KENTUCKY 1160 159 136 MARYLAND NORTH CAROLINA TENNESSEE 93 136 96 SOUTH CAROLINA 46 OKLAHOMA ARIZONA ARKANSAS NEW MEXICO Q1: 8 to 93.75 107 Alabama Georgia Mississippi Q2: 94 to 179.5 431 185 Q3: 180 to 423.5 TEXAS LOUISIANA Alaska Q4: 424 to 2907 401 FLORIDA 14 HAWAII Virgin Islands Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present 21 PUERTO RICO

  8. Percent of Primary Problem withAny Opioid of All Admissions(12-20y) NEW HAMPSHIRE 13.1% 3.4% WASHINGTON 24.4% 4.3% 14.3% 1.4% MAINE 4.6% MONTANA NORTH DAKOTA VERMONT MINNESOTA 3.7% OREGON 2.3% Massachusetts IDAHO 8.8% 10.8% WISCONSIN South Dakota NEW YORK 10.7% 1.4% 13.4% RHODE ISLAND WYOMING MICHIGAN 16.7% 0.6% 33.0% PENNSYLVANIA 6.3% 1.2% IOWA CONNECTICUT NEVADA 5.5% 21.6% NEBRASKA 5.7% 10.6% OHIO NEW JERSEY 4.5% ILLINOIS UTAH 4.2% INDIANA West 1.6% CALIFORNIA Virginia 16.7% 4.5% COLORADO 1.2% 4.4% DELAWARE VIRGINIA KANSAS 12.1% MISSOURI KENTUCKY 12.3% 11.8% 8.3% NORTH CAROLINA MARYLAND TENNESSEE 4.6% 4.0% 6.8% OKLAHOMA 5.4% SOUTH CAROLINA ARIZONA NEW MEXICO ARKANSAS 1.8% Q1: 0.6% to 3.4% Alabama Georgia Mississippi Q2: 3.5% to 5.2% 4.7% TEXAS 5.3% Q3: 5.3% to 11.9% LOUISIANA Alaska Q4: 12.0% to 40.4% 3.4% FLORIDA Hawaii Virgin Islands Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present 13.0% PUERTO RICO

  9. 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;126:1108-1116

  10. Adolescent opioid usersprevious 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

  11. 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

  12. 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

  13. Buprenorphine maintenance • Start weekly prescription supply • Expectation of counseling attendance • Frequent urine monitoring • Increase duration after 4-10 weeks: 1234 • Sometimes prescriptions left for counselor to distribute • Infrequently – med distribution up to daily, +/- monitored self-administration

  14. XR-NTX InductionMethod • 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

  15. Cumulative retention over 26 weeks by medication 2.5 * = p < 0.01 compared to no medication

  16. Opioid-free weeks over 26 weeks by medicationCombining urine and self report * = p < 0.01 compared to no medication

  17. 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

  18. 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

  19. Implementation Issues

  20. Barriers • Attitudes, misunderstanding and stigma • Adherence • Monitoring and supervision • Goals of treatment re other substances

  21. 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

  22. Medications, mischief, and monkey business • Diversion • Non-compliance • Inconsistency • Other substances

  23. 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

  24. 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)

  25. Pharmacological Treatment • Question: • Which is better - medications or counseling? • Answer: • Yes

  26. We’ve come a long way

  27. Next steps • 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 • Longer term outcomes

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