Adolescents with opioid use disorders, in most places, do not get buprenorphine — they get detoxification, and then drug-free treatment. But experts tell ADAW that just as with adults, and perhaps even more so, maintenance treatment with an agonist such as buprenorphine is less likely to lead to relapse. The problem is that in many parts of the country, there are no pediatricians who are familiar with buprenorphine, much less licensed to dispense it. And while buprenorphine is commonly used as a detoxification adjunct, it should be used for maintenance, to help the adolescent get stable, according to John R. Knight, M.D., director of the Center for Adolescent Substance Abuse Research at Boston Children’s Hospital.
“I work with someone who is a bereaved mom, whose daughter detoxed on buprenorphine, went to a halfway house and had a fatal overdose her first night there,” Knight told ADAW. Indeed, newspaper article after newspaper article details the tragedies of young people who cycle in and out of rehabs, their parents taking out second mortgages to pay for them, only to relapse and, in many cases, to die from an overdose. Oddly missing from these stories is any indication that the families had ever been offered, much less tried, buprenorphine.
“For adults, maintenance is the standard of care, and it should be for adolescents,” Knight said. “People need to get on maintenance, and not be tapered down.” Knight, one of the first pediatricians to have a buprenorphine license, said that adolescents can be maintained on very low doses of buprenorphine. A taper isn’t even considered at Children’s until the adolescent has been stable — defined by having no positive drug tests — for at least a year, said Knight. There are about 40 adolescents in the buprenorphine program, which is outpatient, at a time. Their parents attend groups, as do the teens, and there is regular drug testing.
“We need more research on what long-term effect there may be on the adolescent’s still-developing brain,” said Knight, noting that critical growth in both structure and function occur until the mid-20s. “But there’s one thing for sure,” he said. “Whatever buprenorphine’s effects are on the developing brain, they’re far less than the effects of continuing use of heroin.”
As the rates of dependence on prescription opioids and heroin among youth remain high and alarming, expanding effective treatment models for opioid-dependent youth is a public health priority, said Lisa A. Marsch, Ph.D., director of the Center for Technology and Behavioral Health at Dartmouth Psychiatric Research Center, author of one of the only two clinical trials of buprenorphine on adolescents. “A growing research base and clinical experience underscores the important role that buprenorphine can play as part of treatment for opioid dependence among adolescents and young adults.” Marsch’s research, funded by the National Institute on Drug Abuse (NIDA), “has shown that this medication is safe and effective to use with youth as part of a multicomponent treatment model,” she told ADAW. “Although the optimal length of medication administration for youth is not yet known, our work is increasingly showing better outcomes with a period of maintenance on the medication as opposed to brief detoxifications, after which time relapse rates to opioid use are high.”
Teens at Hazelden
Hazelden was one of the first treatment programs to break away from the drug-free dogma and offer buprenorphine, mainly because patients who were discharged from drug-free treatment were overdosing when they got home (see ADAW, Nov. 12, 2012).
Now, under the direction of Joseph Lee, M.D., youth continuum medical director at the Hazelden Betty Ford Foundation, adolescents are getting buprenorphine as part of comprehensive treatment.
“A lot of families are forced to choose between buprenorphine-naloxone office treatment with very little else in the way of psychotherapy and community support, or they go to the other extreme and use a psychotherapy community approach without any medication,” Lee told ADAW. “Those of us on the front lines don’t have the luxury of using rigid ideologies, so we decided to change our protocol.”
When Hazelden started using buprenorphine, recalled Lee, “people said, ‘Finally Hazelden is coming on board’ — we wanted to offer the best of both worlds.”
To be on buprenorphine, adolescents have to be at least 16, and their opioid addiction “has to be a real deal,” based on either severity or duration, said Lee. The family is educated about different options; Hazelden also has a Vivitrol track. “Sometimes, for clinical reasons, we may ask that they consider one track over another,” said Lee. “If they go the buprenorphine route, we ask that they stay in our system.”
Some parents initially are resistant to buprenorphine, but “when they understand the stakes,” they accept that it is science-based and safe, he said. Ironically, some of the adolescents themselves have a stigma about buprenorphine, said Lee. “I make a point to let them know that my job is to keep these teens alive — I don’t sugarcoat the realities,” said Lee.
Maintenance “means different things to different people,” said Lee. “My philosophy is that as long as they need to take it, they take it.” Many teens don’t want to stay on it, he said. “You can imagine if you’re 17 years old, looking down the barrel of how long am I going to take this — they have the feeling of invincibility,” he said. “So we just let them know that for now, they need it.”
Maintenance at Children’s
In many parts of the country, pediatricians and other primary care doctors may assume that detoxification in the local hospital followed by drug-free rehab is the best treatment for teens. But once the teen has been through detoxification, that basically rules out any treatment with buprenorphine, because it has to be given while the patient is in withdrawal, said Knight. At Children’s, all buprenorphine inductions are done on Mondays, so patients are instructed “to stop using no later than Sunday morning,” said Knight.
Unfortunately, the way Children’s uses buprenorphine — as a maintenance, not a detoxification, medication — makes it an “outlier” among adolescent providers, said Knight.
Ultimately, however, most adolescents are highly motivated to get off of buprenorphine, he said, echoing Lee’s experience. “We do a very slow taper, and if cravings return, we stop the taper,” said Knight. For some patients, the taper stops at a very low dose — as low as 2 milligrams a day. “Until they get older and can learn through cognitive behavioral therapy how to handle cravings, buprenorphine is a valuable asset in the tool kit,” he said.
Knight noted that the clinical trial conducted by George Woody, M.D. and colleagues, which was a “remarkable service” to the field, lasted only six months, after which the participants were tapered. He cautioned that only six months of buprenorphine with a taper would most likely be followed by “a lot of relapses, some of which will manifest as fatal overdoses.” In fact, the NIDA POATs trial with adults found relapse rates of greater than 90 percent (see ADAW, Nov. 14, 2011).
More research needed
There is a reluctance on the part of family members to start an adolescent on a controlled substance, said Bob Lubran, director of the Division of Pharmacologic Therapies in the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), which administers the licensing program for physicians who prescribe and dispense buprenorphine. In addition, there’s a shortage of physicians who can prescribe buprenorphine, Lubran said, noting that there’s a shortage in general of physicians who are interested in treating addiction. “We don’t have the numbers on how many pediatricians” can prescribe it, he said, “but we know there are relatively few.”
“There’s an urgent need for further trials comparing maintenance treatment with psychosocial treatment,” said Lubran. “These studies should have a long follow-up period — and that’s a matter for NIDA.”
It’s unclear whether NIDA is planning to do anything more with buprenorphine and adolescents. NIDA was one of the first places we contacted, but they were unable to provide anyone to be interviewed, instead referring us to David Fiellin, M.D., at Yale, who conducted the initial trials on buprenorphine for adults. He referred us to Knight. NIDA funded the only two studies on buprenorphine among adolescents, but they are both old: one by Woody in 2008 (see ADAW, Nov. 10, 2008), and the other by Marsch in 2005 (see ADAW, Oct. 10, 2005). Both showed buprenorphine was effective. Woody told us it was very difficult to recruit subjects, as those under 18 had to get parental consent; most didn’t want to tell their parents.
Still, more studies are essential, said Lubran. “I think there’s the reluctance of a clinician to start a young adolescent on a maintenance therapy, because you’re exposing somebody to a drug for which there are no long-term studies for adolescents,” he told ADAW. “I heard this years ago with methadone — there’s a tendency to be concerned about the consequences of long-term therapy for an adolescent,” he said. “I would venture that the same is true of buprenorphine.” However, he stressed that untreated opioid addiction leads to a high risk for overdose, hepatitis and HIV.
Lubran’s agency has been aggressively promoting buprenorphine, to the extent of lifting the 100-patient cap. But when it comes to adolescents, “the current state of the art is detox to drug-free,” he said. “We would argue for more research to help guide clinical practice.”
Knight knows that a study will have to be done on adolescents showing the effects of buprenorphine. “My sense is we’re not going to find much, once that study gets done,” he said. In the meantime, “buprenorphine can save young lives,” he said.
Other resources include http://pcssmat.org/wp-content/uploads/2014/03/PCSS-MATGuidanceTreatmentofOpioidDependantAdolescent-buprenorphine.SubramaniamLevy1.pdf.
Buprenorphine maintenance treatment has not been studied in adolescents, but whatever the risks, they are not as great as those from untreated opioid addiction, experts say.