Almost two years ago, ADAW reported that most adolescents with opioid use disorders do not get medications that are recommended as the first-line treatment for adults, but rather get detoxification and abstinence-based treatment (see ADAW, Nov. 24, 2014). The result of such treatment was, in many cases, relapse, and, in some, death from overdose. Experts told us that long-term maintenance with buprenorphine, which is approved for ages 16 and up, is far preferable.
However, little has changed, with many young people still getting drug-free treatment, relapsing and overdosing. So last week, the American Academy of Pediatrics (AAP) took the step of urging all its members to get waivered so that they can provide access to buprenorphine for their patients.
In “Medication-Assisted Treatment of Adolescents With Opioid Use Disorders,” published in Pediatrics online August 22, the AAP noted that resources are needed to communicate information about the effective treatments, as well as to develop new treatment especially for this age group. Some adolescents manage to function well despite severe opioid use disorders, but the rate of spontaneous remission is low, according to the AAP.
Methadone is a full opioid agonist with a long half-life that has more than 50 years of demonstrated effectiveness. However, most methadone programs cannot admit patients younger than 18 years. Buprenorphine, a partial opioid agonist, can be prescribed by physicians once they complete 8 hours of training and are given a waiver. Naltrexone, an opioid antagonist, prevents the effects of opioids and is not abusable, but there is no research supporting its efficacy in adolescents. However, it also reduces alcohol cravings, and the injectable extended-release version “may be a good therapeutic option for adolescents and young adults with co-occurring alcohol use disorder, as well as those living in unstable or unsupervised housing,” the AAP said.
There have been two studies proving the effectiveness of buprenorphine in adolescents: one by Lisa A. Marsch, Ph.D., in 2005 (see ADAW, Oct. 10, 2005) and one by George Woody, M.D., in 2008 (see ADAW, Nov. 10, 2008). Woody’s study was for 6 months with a taper, and those teens who tapered relapsed, showing that maintenance is essential. John R. Knight, M.D, director of the Center for Adolescent Substance Abuse Research at Boston Children’s Hospital and one of the first pediatricians to have a buprenorphine license, told us two years ago that maintenance should be the standard of care for adolescents as it is for adults. “People need to get on maintenance, and not be tapered down,” he said. Meanwhile, Woody, whose trial showed that buprenorphine was effective in adolescents but only before they were tapered off it, told us it was difficult to recruit subjects, because those under 18 had to get parental consent, and most didn’t want to tell their parents.
In general, youth have lower treatment retention than adults, and retention is associated with long-term recovery.
Buprenorphine does have the potential for addiction — it is an opioid — but for people who have already become tolerant, this is not the main issue. Maintenance on the medication has been shown to be effective in adults and in adolescents. But “confusion, stigma, and limited resources” restrict access to buprenorphine treatment for both adolescents and adults, said the AAP.
Even addiction treatment programs often do not offer buprenorphine, the AAP noted. “Policies, attitudes, and messages that serve to prevent patients from accessing a medication that can effectively treat a life-threatening condition may be harmful to adolescent health,” the AAP said.
Below are the recommendations from the AAP:
- Opioid addiction is a chronic relapsing neurologic disorder. Although rates of spontaneous recovery are low, outcomes can be improved with medication-assisted treatment. The AAP advocates for increasing resources to improve access to medication-assisted treatment of opioid-addicted adolescents and young adults. This recommendation includes increasing both resources for medication-assisted treatment within primary care and access to developmentally appropriate substance use disorder counseling in community settings. Pediatricians have access to an AAP-endorsed buprenorphine waiver course at http://www.aap.org/mat.
- The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service.
- The AAP supports further research focus on developmentally appropriate treatment of substance use disorders in adolescents and young adults, including primary and secondary prevention, behavioral interventions and medication treatment.
Pediatricians and child psychiatrists
One problem is that pediatricians may be leery of using buprenorphine for their patients. “There is general consensus that medication therapy helps to reduce relapse in patients with opioid use disorder,” Sharon Levy, M.D., lead author of the recommendations, told ADAW. “While there is a smaller evidence base in adolescents, the findings have been consistent with research in adults. With this statement, the American Academy of Pediatrics is supporting greater access to medication therapy in the community. As with any other disorder, youth with opioid use disorders should be treated in the least restrictive setting. Unfortunately, there are too few physicians prescribing medications for patients with opioid use disorders to meet the demand for adults seeking treatment, and the situation is even more dire for adolescents, who should be treated by professionals who are experienced working with this age group. In that regard, this statement is a call to action — for physicians who work with adolescents to become waivered and prescribe and for prescribers to get training in working with this age group.”
“In my area of the country, New England, heroin use among teens appeared to take a significant jump in the mid-’90s,” Stuart Gitlow, M.D., past president of the American Society of Addiction Medicine (ASAM), told ADAW after the AAP recommendations were released. “It was about that time when heroin began to be available in sufficiently pure form that it could be snorted rather than injected. According to my patients, this eliminated what had previously been seen as a barrier to use by younger individuals. From a ‘Do No Harm’ perspective, if a young patient is regularly using narcotics, there is no question in my mind that provision of buprenorphine reduces risk of morbidity and mortality.” Gitlow, who is the American Medical Association delegate from ASAM as well as executive director of the Annenberg Physician Training Program in Addictive Disease and an associate professor at the University of Florida, said that, in fact, not offering treatment does more harm. “Not offering pharmacotherapy to this particular age group leaves those most at risk in grave danger of following the usual disease course,” he said.
“Addictive disease often has its onset when a patient is of the age to be seen by pediatricians and/or child psychiatrists,” added Gitlow. Of all the chronic disease states impacting adults, addictive disease is the one that should be most commonly identified by pediatricians given its incidence and prevalence within the age range of their patients, he said. “It isn’t, of course, and this represents an enormous oversight,” he said. “If the treating clinicians don’t know the disease is there, we can’t hope that they will treat it, whether with medication or not.”
This is why the first step is that pediatricians must screen for addictive disease, said Gitlow. The need for a separate certification requirement to provide buprenorphine is a “continuing barrier,” he said. Like many, he wondered why full-agonist treatment with opioids for pain can be prescribed to many patients with no limit, while buprenorphine treatment for opioid use disorders has caps of 30, 100 and 275 patients per physician, depending on training.
It’s time for pediatricians to be buprenorphine treatment providers, to help their young patients access treatment, says the AAP.