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Pediatric Drugs

, Volume 15, Issue 6, pp 449–458 | Cite as

Pharmacologically Assisted Treatment of Opioid-Dependent Youth

  • Anna Pecoraro
  • Marc Fishman
  • Michelle Ma
  • Gvantsa Piralishvili
  • George E. WoodyEmail author
Therapy in Practice

Abstract

Opioid misuse, abuse, and dependence are global problems whose patterns vary across cultures. In the USA, the non-medical use of prescription opioids has become particularly serious because of its association with addiction and overdose death. Agonist and antagonist medications have been shown to be effective for opioid-dependent adults, and there is a growing body of data that they are also effective for youth. Here, we summarize evidence that detoxification alone results in high rates of treatment dropout and relapse but that the limited but growing data on the extended use of medication-assisted treatment for opioid-dependent youth have been positive. The implementation of medication-assisted treatment as a standard practice is feasible, easily integrated with counseling or psychotherapy, and has potential to greatly improve outcomes. Although concerns about safety and efficacy with youth require more research, and we do not advocate indefinite maintenance, we suggest that opioid-dependent youth should be considered as candidates for medication-assisted treatment delivered in a comprehensive, developmentally appropriate context, beginning at the first episode of care, with the strength of the recommendation to use medication increasing with each care episode.

Keywords

Heroin Buprenorphine Naltrexone Opioid Dependence Prescription Opioid 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

No funding sources were used to prepare this article, but MF is a member of the Clinical Advisory Board for Orexo, which manufactures a buprenorphine product for which it is seeking FDA approval. MF has an equity interest in a community treatment provider (Maryland Treatment Centers) at which youth opioid treatment is delivered, including medications. GW and AP received salary support from NIDA U10 DA-13043, and GW received salary support from NIDA KO5 DA-17009. GW was the principal investigator of a Clinical Trials Network (CTN) study on buprenorphine among adolescents in which the medication was supplied by Reckitt-Benckiser, and Alkermes has provided XR-NTX for a study in which he is a co-investigator. MF received salary support from NIDA R01 DA02455301, NIDA-VA CS #1030, and NIDA-VA CS #1031. MF participated in a CTN study on buprenorphine among adolescents in which the medication was supplied by Reckitt-Benckiser, and Alkermes has provided XR-NTX for a study in which he is a co-investigator. GP is a co-investigator of a study of Suboxone® and methadone for HIV risk reduction, funded by National Institute on Drug Abuse grants R21-DA-026754, U10 DA-13043, and KO5 DA-17009. Reckitt Benckiser supplied Suboxone® for the trial. MM and AP report no conflicts of interest.

References

  1. 1.
  2. 2.
    Gahr M, Freudenmann RW, Hiemke C, et al. “Krokodil” revival of an old drug with new problems. Subst Use Misuse. 2012;47(7):861–3.PubMedCrossRefGoogle Scholar
  3. 3.
    Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the future: national survey results on drug use, 1975–2010. Bethesda: National Institute on Drug Abuse; 2009.Google Scholar
  4. 4.
    Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the future national survey results on drug use, 1975–2005: vol 1, secondary students (NIH publication no. 06-5883). Bethesda: National Institute on Drug Abuse; 2006.Google Scholar
  5. 5.
    SAMHSA. The NSDUH report: patterns and trends in nonmedical prescription pain reliever use: 2002–2005. Rockville: Substance Abuse and Mental Health Services Administration Office of Applied Studies; 2007.Google Scholar
  6. 6.
    SAMHSA. Results from the 2006 national survey on drug use and health: national findings. Rockville: SAMHSA; 2007.Google Scholar
  7. 7.
    Epstein DH, Phillips KA, Preston KL. Opioids. In: Ruiz P, Strain E, editors. Substance abuse: a comprehensive textbook. Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins Health; 2011. p. 161–90.Google Scholar
  8. 8.
    Hasin D, Nunes E, Meydan J. Comorbidity of alcohol, drug and psychiatric disorders: epidemiology. In: Kranzler HR, Tinsley JA, editors. Dual diagnosis and psychiatric treatment: substance abuse and comorbid disorders. New York: Marcel Dekker Inc.; 2004. p. 1–33.Google Scholar
  9. 9.
    Rodríguez-Llera MC, Domingo-Salvany A, Brugal MT, et al. Psychiatric comorbidity in young heroin users. Drug Alcohol Depend. 2006;84(1):48–55.PubMedCrossRefGoogle Scholar
  10. 10.
    Subramaniam GA, Stitzer MA, Woody GE. Clinical characteristics of treatment seeking adolescents with opioid versus cannabis/alcohol use disorders. Drug Alcohol Depend. 2009;99:141–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Lankenau SE, Teti M, Silva K, et al. Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy. 2012;23(1):37–44 (Epub 2011/06/22).PubMedCrossRefGoogle Scholar
  12. 12.
    Woody GE, Poole SA, Subramaniam G, Dugosh K, Bogenschutz M, Abbott P, et al. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. JAMA. 2008;300(17):2003–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Wu L, Blazer DG, Li T, Woody GW. Treatment use and barriers among adolescents with prescription opioid use disorders: 2005–2008. Addict Behav. 2011;36(12):1233–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Krupitsky E, Zvartau E, Woody G. Use of naltrexone to treat opioid addiction in a country in which methadone and buprenorphine are not available. Curr Psychiatry Rep. 2010;12(5):448–53.PubMedCrossRefGoogle Scholar
  15. 15.
    Krupitsky E, Zvartau E, Blokhina E, et al. Randomized trial of long-acting sustained-release naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence. Arch Gen Psychiatry. 2012;69(9):973–81.PubMedCrossRefGoogle Scholar
  16. 16.
    Pecoraro A, Woody GE. Medication-assisted treatment for opioid dependence: making a difference in prisons. F1000 Med Rep. 2011;3:1.Google Scholar
  17. 17.
    WHO. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: WHO; 2009. http://www.who.int/substanceabuse/publications/opioiddependenceguidelines.pdf.
  18. 18.
    Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2010. Admissions. Rockville: Substance Abuse and Mental Health Services Administration; 2010.Google Scholar
  19. 19.
    Fudala PJ, Woody GE. Recent advances in the treatment of opiate addiction. Curr Psychiatry Rep. 2004;6:339–46.PubMedCrossRefGoogle Scholar
  20. 20.
    Smyth BP, Fagan J, Kernan K. Outcome of heroin-dependent adolescents presenting for opiate substitution treatment. J Subst Abuse Treat. 2012;42(1):35–44.PubMedCrossRefGoogle Scholar
  21. 21.
    Minozzi S, Amato L, Davoli M. Maintenance treatments for opiate dependent adolescents. Cochrane Database Syst Rev. 2009;2:CD007210.Google Scholar
  22. 22.
    Lehmann WX. The use of 1-alpha-acetyl-methadol (LAAM) as compared to methadone in the maintenance and detoxification of young heroin addicts. NIDA Monograph. 1973;8:82–3.Google Scholar
  23. 23.
    Gowling LR, Ali RI. The place of detoxification in treatment of opioid dependence. Curr Opin Psychiatry. 2006;19(3):266–70.CrossRefGoogle Scholar
  24. 24.
    Gandhi DH, Jaffe JH, McNary S, et al. Short-term outcomes after brief ambulatory opioid detoxification with buprenorphine in young heroin users. Addiction. 2003;98(4):453–62.PubMedCrossRefGoogle Scholar
  25. 25.
    Minozzi S, Amato L, Davoli M. Detoxification treatments for opiate dependent adolescents. Cochrane Database Syst Rev. 2009;2:CD006749.Google Scholar
  26. 26.
    Dole VP, Nyswander ME. A medical treatment for diacetylmorphine (heroin) addiction: a clinical trial with methadone hydrochloride. JAMA. 1965;193(8):646–50.PubMedCrossRefGoogle Scholar
  27. 27.
    Amato L, Davoli M, Minozzi S, Ali R, Ferri M. Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database Syst Rev. 2005;(3):CD003409.Google Scholar
  28. 28.
    Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;3:CD002209.Google Scholar
  29. 29.
    Zanis DA, Woody GE. One year mortality rates following methadone treatment discharge. Drug Alcohol Depend. 1998;52(3):257–60.PubMedCrossRefGoogle Scholar
  30. 30.
    Ball JC, Ross A. The effectiveness of methadone maintenance treatment. New York: Springer; 1991.CrossRefGoogle Scholar
  31. 31.
    Metzger DS, Woody GE, McLellan AT, O’Brien CP, Druley P, Navaline H, et al. Human immunodeficiency virus seroconversion among intravenous drug users in and out of treatment: an 18 month prospective follow-up. J Acquir Immune Defic Syndr. 1993;6(9):1049–56.PubMedGoogle Scholar
  32. 32.
    Millman RB, Khuri ET, Nyswander ME. Therapeutic detoxification of adolescent heroin addicts. Ann N Y Acad Sci. 1978;311:153–64.PubMedCrossRefGoogle Scholar
  33. 33.
    Eissenberg T, Greenwald MK, Johnson RE, Liebson IA, Bigelow GE, Stitzer ML. Buprenorphine’s physical dependence potential: antagonist-precipitated withdrawal in humans. J Pharmacol Exp Ther. 1996;276(2):449–59.PubMedGoogle Scholar
  34. 34.
    Eissenberg T, Johnson RE, Bigelow GE, Walsh SL, Liebson IA, Strain EC, et al. Controlled opioid withdrawal evaluation during 72 h dose omission in buprenorphine-maintained patients. Drug Alcohol Depend. 1997;45(1–2):81–91.PubMedCrossRefGoogle Scholar
  35. 35.
    Walsh SL, Eissenberg T. The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend. 2003;70(2 Suppl):S13–27.PubMedCrossRefGoogle Scholar
  36. 36.
    Reckitt Benkiser. Further US RB Pharmaceuticals announcement. 2012 [cited 2012 October 1]. http://www.rb.com/site/RKBR/Templates/MediaInvestorsGeneral2.aspx?pageid=1332&cc=GB.
  37. 37.
    Smyth BP, Fagan J, Kernan K. Outcome of heroin-dependent adolescents presenting for opiate substitution treatment. J Subst Abuse Treatment. 2012;42(1):35–44.CrossRefGoogle Scholar
  38. 38.
    Bell J, Mutch C. Treatment retention in adolescent patients treated with methadone or buprenorphine for opioid dependence: a file review. Drug Alcohol Rev. 2006;25:167–71.PubMedCrossRefGoogle Scholar
  39. 39.
    Sullivan MA, Vosburg SK, Comer SD. Depot naltrexone: antagonism of the reinforcing, subjective, and physiological effects of heroin. Psychopharmacology. 2006;189(1):37–46.PubMedCrossRefGoogle Scholar
  40. 40.
    Kruptisky EM, Burakov AM, Tsoy MV, Egorova VY, Slavina TY, Grinenko AY, et al. Overcoming opioid blockade from depot naltrexone (Prodetoxon®). Addiction. 2007;102(8):1164–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Resnick RB, editor. A practitioner’s experience with naltrexone. In: Proceedings of the 29th annual scientific conference of the American Society of Addiction Medicine; 1998; New OrleansGoogle Scholar
  42. 42.
    Sevarino KA, Kosten TR. Naltrexone for initiation and maintenance of opiate abstinence. In: Dean R, Bilsky EJ, Negus SS, editors. Opiate receptors and antagonists: from bench to clinic. New York: Humana; 2009. p. 227–45.CrossRefGoogle Scholar
  43. 43.
    Krupitsky E, Nunes EV, Ling W, Illeperuma A, Gastfriend DR, Silverman BL. Injectable extended-release naltrexone for opioid dependence: a double-blind. placebo-controlled, multicenter randomised trial. Lancet. 2011;377(9776):1506–13.PubMedCrossRefGoogle Scholar
  44. 44.
    Hulse GK, Morris N, Arnold-Reed D, Tait RJ. Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone. Arch Gen Psychiatry. 2009;66(10):1108–15.PubMedCrossRefGoogle Scholar
  45. 45.
    Hulse GK, Tait RJ. A pilot study to assess the impact of naltrexone implant on accidental opiate overdose in ‘high-risk’ adolescent heroin users. Addict Biol. 2003;8(3):337–42.PubMedCrossRefGoogle Scholar
  46. 46.
    Fishman MJ, Winstanley EL, Curran E, Garrett S, Subramaniam G. Treatment of opioid dependence in adolescents and young adults with extended release naltrexone: preliminary case-series and feasibility. Addiction. 2010;105:1669–76.PubMedCrossRefGoogle Scholar
  47. 47.
    Department of Health. Guidance for the pharmacological management of substance misuse among young people. London: Department of Health; 2009 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_106429.pdf.
  48. 48.
    College of Physicians and Surgeons of Ontario. Methadone maintenance guidelines. Toronto: College of Physicians and Surgeons of Ontario; 2005.Google Scholar
  49. 49.
    College of Physicians and Surgeons of Ontario. Methadone maintenance guidelines. Toronto: College of Physicians and Surgeons of Ontario; 2011 http://www.cpso.on.ca/uploadedFiles/members/MMT-Guidelines.pdf.
  50. 50.
    Code of Federal Regulations, Title 42, section 8. Conditions for distribution and use of methadone products for the treatment of opioid addiction. http://www.dpt.samhsa.gov/regulations/legreg.aspx.
  51. 51.
    Drug Addiction Treatment Act of 2000. Title XXXV, section 3502 of the Children’s Health Act of 2000. AKA PL 106-310. http://buprenorphine.samhsa.gov/fulllaw.html.
  52. 52.
    Rowan A, Fudala P, Mulligan J. The medical management of adolescent heroin dependence. Curr Psychiatry Rep. 2000;2(6):527–30.PubMedCrossRefGoogle Scholar
  53. 53.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington, DC: American Psychiatric Association; 2000.Google Scholar
  54. 54.
    Reckitt-Benkiser. Letter to prescribers of Suboxone® tablets.Google Scholar
  55. 55.
    Saxon AJ, Miotto K. Methadone maintenance. In: Ruiz P, Strain E, editors. Substance abuse: a comprehensive textbook. 5th ed. Philadelphia: Lippincott & Williams Wilkins; 2011. p. 419–36.Google Scholar
  56. 56.
    Methadone hydrochloride Intensol™ (Oral concentrate, USP) prescribing information. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=d0e6a966-179a-45e0-8444-4c1b8523f8d2.
  57. 57.
    Tompkins DA, Strain EC. Buprenorphine in the treatment of opioid dependence. In: Ruiz P, Strain E, editors. Substance abuse: a comprehensive textbook. 5th ed. Philadelphia: Lippincott & Williams Wilkins; 2011. p. 437–56.Google Scholar
  58. 58.
    Suboxone Sublingual Film® prescribing information. http://www.suboxone.com/pdfs/SuboxonePI.pdf.
  59. 59.
    Harrison E, Petrakis I. Naltrexone pharmacotherapy. In: Ruiz P, Strain E, editors. Substance abuse: a comprehensive textbook. 5th ed. Lippincott Williams & Wilkins: Philadelphia; 2011. p. 447–65.Google Scholar
  60. 60.
    Vivitrol® (naltrexone for extended release injectable suspension) prescribing information. http://www.vivitrol.com/Content/pdf/prescribing_info.pdf.

Copyright information

© Springer International Publishing Switzerland 2013

Authors and Affiliations

  • Anna Pecoraro
    • 1
    • 2
  • Marc Fishman
    • 3
    • 4
    • 5
  • Michelle Ma
    • 6
  • Gvantsa Piralishvili
    • 7
  • George E. Woody
    • 1
    • 2
    Email author
  1. 1.Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Delaware Valley Node, Clinical Trials NetworkPhiladelphiaUSA
  3. 3.Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Mountain Manor Treatment CenterBaltimoreUSA
  5. 5.Mid-Atlantic Node, Clinical Trials NetworkBaltimoreUSA
  6. 6.University of Michigan Medical SchoolAnn ArborUSA
  7. 7.International Relations and Projects Management UnitCenter for Mental Health and the Prevention of AddictionTbilisiGeorgia

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