In an age of opioid use disorders and more than 70 overdose deaths a day in the United States, adolescents are usually not given the treatment that is recommended for adults: maintenance with an agonist medication (buprenorphine or methadone). Since methadone is only dispensed in opioid treatment programs (OTPs) and most states require patients to have been dependent on opioids for at least a year, buprenorphine, which is approved for ages 16 or older, is an obvious choice. We have written about this for several years, but for a variety of reasons, buprenorphine maintenance for adolescents can be viewed as more of an innovation than a practice.
Why is this? Partly because few randomized controlled trials have been conducted using buprenorphine on young subjects, explained Lisa M. Marsch, Ph.D., lead author of a recent study comparing a 28- with a 56-day taper of buprenorphine with teens and young adults (see p. tk).
“It’s tough to get young people” to participate in treatment studies, mainly because they don’t want to tell their parents, Marsch, who is the director of the Center for Technology and Behavioral Health at Dartmouth, told us last week. Even though physicians don’t have to get parental permission to treat young people, most institutional review boards (IRBs), including Marsch’s for this study, require it. “We went to the IRB at one point to ask if we could set up a system of third parties, for kids who couldn’t access a parent,” said Marsch. The IRB considered the treatment “experimental,” and that’s why parental consent was required.
In fact, the clinical trials for buprenorphine were conducted in people 18 and over. “I don’t think there was a single trial that included anyone under 18,” said Marsch. Physicians can treat younger people off-label, but in a research protocol, the rules are different. This summer, the American Academy of Pediatrics urged its members to treat patients with buprenorphine (see ADAW, Aug. 29).
Another reason that it’s difficult to find adolescents for buprenorphine research is that many of these patients are court-mandated to treatment, and this makes them ineligible for research.
Five years ago, the landmark study showing that buprenorphine only works if people stay on it was published in the Archives of General Psychiatry (see ADAW, Nov. 14, 2011). The study, led by Roger D. Weiss, M.D., found that the relapse rate for the 30-day taper-to-detoxification was 93.4 percent, and 91.4 percent eight weeks after three months of treatment followed by a taper-to-detoxification.
There have been two studies proving the effectiveness of buprenorphine in adolescents: one by Marsch 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 six months with a taper, and those teens who tapered relapsed, showing that maintenance is essential.
Tapers don’t work. Yet Marsch, who is one of the few researchers to study both methadone and buprenorphine treatment for adolescents, is still looking at tapers.
“Why start with tapers when the data are so clear?” she asked rhetorically. And she added that the same rate of relapse likely takes place when young people taper off buprenorphine.
Stigma, patient choice
But people — providers, parents, physicians — are resistant. Standard treatment for adolescents is detoxification, or a brief period of maintenance and a taper, and rehabilitation. “If you talk to people in adolescent addiction treatment programs, medication is still not a part of standard treatment,” she said.
And there’s reason to be cautious in many people’s minds, said Marsch, who is a National Institute on Drug Abuse researcher. “There’s still a lot that’s unknown about the adolescent brain,” she said.
Finally, there’s the issue of patient choice — which, when examined, turns out to be a reflection of stigma, of wanting to put drug issues in the past. “We were compelled to start where we did because a lot of young people were coming to us not wanting maintenance,” said Marsch. One was a star soccer player in high school. “She wanted to go to college, to be an athlete in college, and she said, ‘This has to be a mistake of my past. I don’t want any more involvement in this,’” recalled Marsch. “The kids didn’t want to define themselves by drug use.”
Young people may have had a shorter duration of opioid use than adults, Marsch added. “Could it be that there is a subset of young people who could have a taper and move on?” she asked.
Marsch realizes addiction is a chronic disease. “People’s bodies and brains are wired to eat, drink, procreate and nurture their young,” she said. “Drugs take over the system of self-preservation, they take over the control system.” It’s not a virus in which “you feel bad and you get over it.”
But how long medication should last will not be a one-size-fits-all solution, said March. “Is it for six months? Is it for a year? I don’t think those are the right questions,” she said. “You have to match best practices to patient need.” For some people, medication would be needed for their lifetimes. “We don’t have all the data to answer these questions,” said Marsch.
Also see our Nov. 24, 2014, article on buprenorphine maintenance for adolescents: http://www.alcoholismdrugabuseweekly.com/article-detail/for-teens-with-opioid-use-disorders-buprenorphine-maintenance-better-than-detox.aspx.
Buprenorphine maintenance — long-term treatment — is still shunned when it comes to adolescents.