Transcript My Kids Doing What

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
• 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?”)
Case (1)
16 F injection heroin and depression
• Initial tx suboxone, oral NTX, ineffective 2º nonadherence 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
Non-Medical Prescription Opioid Use
Percent
MTF: Annual Use Prevalence 12th Graders
http://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf
Percent
Past-Month Non-Medical Users of
Prescription Opioids, by Age: 2002-2007
The NSDUH report February 2009
National Center for Injury Prevention and
Control (NCIPC) Data on OD Deaths
http://www.cdc.gov/nchs/data/databriefs/db22.htm - Sept 2009
Number of Admissions (12-20y) by State:
Primary Problem with Any Opioid
NEW HAMPSHIRE
279
WASHINGTON
68
MONTANA
8
NORTH DAKOTA
309
OREGON
15
WYOMING
119
NEVADA
18
SOUTH DAKOTA
16
NEBRASKA
245
UTAH
136
ARIZONA
443
MAINE
258
VERMONT
379
MINNESOTA
2112
MASSACHUSETTS
31
IDAHO
1373
CALIFORNIA
112
123
COLORADO
235
WISCONSIN
34
IOWA
500
ILLINOIS
45
KANSAS
93
OKLAHOMA
46
NEW MEXICO
New York
1079
MICHIGAN
251
MISSOURI
96
ARKANSAS
174
INDIANA
1720
PENNSYLVANIA
681
OHIO
1122
CONNECTICUT
1487
NEW JERSEY
West
Virginia
287
KENTUCKY
136
TENNESSEE
122
RHODE ISLAND
143
DELAWARE
214
VIRGINIA
159
NORTH CAROLINA
1160
MARYLAND
SOUTH
CAROLINA
Q1: 8 to 93.75
107
Mississippi Alabama
431
TEXAS
Georgia
Q2: 94 to 179.5
185
LOUISIANA
Q3: 180 to 423.5
Alaska
401
FLORIDA
Q4: 424 to 2907
14
HAWAII
Virgin Islands
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present
21
PUERTO RICO
Percent of Primary Problem with Any Opioid
of All Admissions (12-20y)
NEW HAMPSHIRE
3.4%
WASHINGTON
4.3%
MONTANA
3.7%
OREGON
Massachusetts
6.3%
NEVADA
10.6%
UTAH
4.0%
ARIZONA
24.4%
MAINE
14.3%
VERMONT
4.6%
MINNESOTA
2.3%
IDAHO
1.4%
WYOMING
4.2%
CALIFORNIA
1.4%
NORTH DAKOTA
13.1%
South Dakota
6.8%
NEW MEXICO
10.8%
NEW YORK
13.4%
MICHIGAN
1.2%
NEBRASKA
1.6%
COLORADO
8.8%
WISCONSIN
1.2%
KANSAS
4.6%
OKLAHOMA
5.7%
ILLINOIS
4.5%
INDIANA
4.4%
MISSOURI
5.5%
OHIO
12.1%
KENTUCKY
8.3%
TENNESSEE
5.4%
ARKANSAS
Mississippi Alabama
4.7%
TEXAS
16.7%
PENNSYLVANIA
0.6%
IOWA
10.7%
RHODE ISLAND
33.0%
21.6% CONNECTICUT
NEW JERSEY
West
Virginia 4.5%
VIRGINIA
12.3%
NORTH CAROLINA
16.7%
DELAWARE
11.8%
MARYLAND
SOUTH
CAROLINA
1.8%
Georgia
Q1: 0.6% to 3.4%
Q2: 3.5% to 5.2%
5.3%
LOUISIANA
Q3: 5.3% to 11.9%
Alaska
3.4%
FLORIDA
Q4: 12.0% to 40.4%
Hawaii
Virgin Islands
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to Present
13.0%
PUERTO RICO
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;126:11081116
Adolescent opioid users
previous 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
Elements of treatment model
• Longitudinal engagement and management
– We don’t have a cure - this is not new news
•
•
•
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More effective counseling techniques
Anti-addiction pharmacotherapy
Co-occurring (dual diagnosis) treatment
Refinements in program design
– Longer term maintenance and monitoring
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
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
XR-NTX Induction
Method
• 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
Cumulative retention over 26 weeks
by medication
2.5
* = p < 0.01 compared to no medication
Opioid-free weeks over 26 weeks
by medication
Combining urine and self report
* = p < 0.01 compared to no medication
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
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
Implementation Issues
Barriers
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•
•
•
Attitudes, misunderstanding and stigma
Adherence
Monitoring and supervision
Goals of treatment re other substances
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
Medications, mischief, and
monkey business
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•
•
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Diversion
Non-compliance
Inconsistency
Other substances
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
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)
Pharmacological Treatment
• Question:
– Which is better - medications or
counseling?
• Answer:
– Yes
We’ve come a long way
Next steps
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•
•
•
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Improved family involvement
How to manage medication discontinuation
Longer-term engagement strategies
More operationalization of stepped care
Broader coverage and reimbursement, including XRNTX
• Differential strategies for patients in early stages of
change in relation to other substances
• Longer term outcomes