My Kid Is Using What? Treatment for Opioid Dependence in Youth Marc Fishman MD Johns Hopkins...
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My Kid Is Using What? Treatment for Opioid Dependence in Youth
Marc Fishman MD Marc Fishman MD Johns Hopkins University Dept of PsychiatryJohns Hopkins University Dept of Psychiatry
Mountain Manor Treatment Center, Baltimore MDMountain Manor Treatment Center, Baltimore MD
MADC
5/12/11
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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?”)
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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
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Non-Medical Prescription Opioid UseNon-Medical Prescription Opioid Use
MTF: Annual Use Prevalence 12th Graders
Per
cent
http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf
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Past-Month Non-Medical Users of Past-Month Non-Medical Users of Prescription OpioidsPrescription Opioids, , by Age: 2002-2007by Age: 2002-2007
Per
cent
The NSDUH report February 2009
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National Center for Injury Prevention and Control (NCIPC) Data on OD Deaths
http://www.cdc.gov/nchs/data/databriefs/db22.htm - Sept 2009
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NumberNumber of Admissions (12-20y) by State: of Admissions (12-20y) by State: Primary Problem with Primary Problem with Any OpioidAny Opioid
Alabama
Alaska
GeorgiaMississippi
New York
WestVirginia
Virgin Islands
8NORTH DAKOTA
14HAWAII
15WYOMING
16
NEBRASKA
18SOUTH DAKOTA
21PUERTO RICO
31IDAHO
34IOWA
45KANSAS
46NEW MEXICO
68MONTANA
93OKLAHOMA
96ARKANSAS
107
SOUTH CAROLINA
112NEW HAMPSHIRE
119NEVADA
122RHODE ISLAND
123COLORADO
136
ARIZONA
136TENNESSEE
143DELAWARE
159NORTH CAROLINA
174
INDIANA
185
LOUISIANA
214
VIRGINIA
235WISCONSIN
245UTAH
251MISSOURI
258VERMONT
279WASHINGTON
287KENTUCKY
309OREGON
379MINNESOTA
401FLORIDA
431TEXAS
443MAINE
500ILLINOIS
681OHIO
1079MICHIGAN
1122
CONNECTICUT
1160MARYLAND
1373CALIFORNIA
1487NEW JERSEY
1720
PENNSYLVANIA
2112MASSACHUSETTS
Q1: 8 to 93.75
Q2: 94 to 179.5
Q3: 180 to 423.5
Q4: 424 to 2907
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present
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Percent of Primary Problem withPercent of Primary Problem with Any Opioid Any Opioid of All Admissionsof All Admissions (12-20y)(12-20y)
Alabama
Alaska
Georgia
Hawaii
Massachusetts
Mississippi
South Dakota
West Virginia
Virgin Islands
0.6%IOWA1.2%
NEBRASKA
1.2%KANSAS
1.4%WYOMING
1.4%NORTH DAKOTA
1.6%COLORADO
1.8%
SOUTH CAROLINA
2.3%IDAHO
3.4%FLORIDA
3.4%WASHINGTON
3.7%OREGON
4.0%
ARIZONA
4.2%CALIFORNIA
4.3%MONTANA
4.4%MISSOURI
4.5%
VIRGINIA
4.5%INDIANA
4.6%MINNESOTA
4.6%OKLAHOMA
4.7%TEXAS 5.3%
LOUISIANA
5.4%
ARKANSAS
5.5%OHIO5.7%
ILLINOIS
6.3%NEVADA
6.8%NEW MEXICO
8.3%TENNESSEE
8.8%WISCONSIN
10.6%UTAH
10.7%
RHODE ISLAND
10.8%NEW YORK
11.8%MARYLAND
12.1%KENTUCKY
12.3%NORTH CAROLINA
13.0%PUERTO RICO
13.1%NEW HAMPSHIRE
13.4%MICHIGAN
14.3%VERMONT
16.7%DELAWARE
16.7%PENNSYLVANIA
21.6%NEW JERSEY
24.4%MAINE
33.0%CONNECTICUT
Q1: 0.6% to 3.4%
Q2: 3.5% to 5.2%
Q3: 5.3% to 11.9%
Q4: 12.0% to 40.4%
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present
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Fortuna, R. J. et al. Pediatrics 2010;126:1108-1116
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
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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
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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
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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
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Buprenorphine maintenance• Start weekly prescription supply• Expectation of counseling attendance• Frequent urine monitoring• Increase duration after 4-10 weeks:
1234• Sometimes prescriptions left for counselor to
distribute• Infrequently – med distribution up to daily, +/-
monitored self-administration
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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
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Cumulative retention over 26 weeks by medication
* = p < 0.01 compared to no medication
2.5
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Opioid-free weeks over 26 weeks by medication
Combining urine and self report
* = p < 0.01 compared to no medication
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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
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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
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Implementation Issues
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Barriers
• Attitudes, misunderstanding and stigma
• Adherence
• Monitoring and supervision
• Goals of treatment re other substances
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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
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Medications, mischief, and monkey business
• Diversion
• Non-compliance
• Inconsistency
• Other substances
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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
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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)
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Pharmacological Treatment
• Question:– Which is better - medications or
counseling?
• Answer:– Yes
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We’ve come a long way
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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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