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  1. Snouter Fancier
    [IMGL=white]http://www.drugs-forum.com/photopost/data/687/jmn05055fa.gif?785[/IMGL]Albuquerque—For social workers like Shannon Garrett, MSW, at the Mountain Manor Treatment Center in Baltimore, the greatest challenge in treating young people addicted to prescription opioids may be getting them to therapy in the first place.

    "No treatment tool can work if a patient doesn't show up," said Garrett at the Blending Addiction Science and Practice meeting here in April, organized by the National Institute on Drug Abuse (NIDA).

    Yet medications, such as buprenorphine, can greatly improve patients' adherence to treatment. Garrett, who acknowledged that he was initially skeptical of using prescription drugs to treat patients with these addictions, explained that talk and behavioral therapies can do little to ease the symptoms of withdrawal and strong drug craving that often lead patients to relapse to drug use. But buprenorphine, a partial opioid agonist often paired with naloxone to reduce abuse potential, has been demonstrated in a randomized controlled trial to increase patient retention and improve outcomes (Woody GE et al. JAMA. 2008;300[17]:2003-2011). Now scientists are working to build on this and other emerging evidence to develop therapies targeted to the unique needs of this patient population.

    To encourage clinicians to treat youths with opioid addiction, NIDA released a training DVD, Buprenorphine Treatment for Young Adults, at the meeting. Such treatment tools are essential to help the growing numbers of teens and young adults seeking help for prescription opioid addiction, and to reach the tens of thousands who may go untreated. Geetha Subramaniam, MD, of NIDA's division of clinical neuroscience and behavioral research and a psychiatrist who specializes in treating adolescents with addiction, said that only about 1400 youths aged 12 to 17 years were admitted for treatment of prescription opioid addiction in the United States in 2007, based on data from the Substance Abuse and Mental Health Services Administration's Treatment Episode Data Set. These individuals represent a small fraction of the young people who may be addicted to these drugs, based on the widespread nonmedical use of prescription opioids by this patient population, she said.

    "These patients are going to be coming in your door," said Subramaniam at the meeting. "You must know how to treat them."


    Abuse of powerful prescription analgesics among teens rose substantially between 1992, when 3.3% of 12th graders reported having abused these drugs in the previous year, and 2004, when 9.5% reported such abuse, according to NIDA's 2009 Monitoring the Future Survey, a nationally representative annual survey of nearly 50 000 middle school and high school students. Since 2004, the rate of prescription opioid abuse reported by 12th graders has remained steady, with 1 in 10 students reporting use of these drugs for nonmedical purposes in the past year. Specifically, use of oxycodone (OxyContin) has increased among 12th graders, reaching 4.7% in 2008, and use of acetaminophen and hydrocodone (Vicodin) has remained constant, at about 9.7% in this age group.

    By contrast, heroin use among 12th graders surveyed peaked in 1996 at 1.5% and has since declined to 0.9%. In fact, in 2007, the annual number of youths aged 12 to 17 years admitted to publicly funded addiction treatment centers for prescription opioid dependence exceeded the number being admitted for heroin addiction (about 1000/year), according to an analysis of Treatment Episode Data Set data by Subramaniam.

    While the exact factors driving this trend are unclear, many experts believe that a perception that prescription drugs are safe and the wide availability of prescription opioids are important contributors.

    "Access is a big factor," said Marc J. Fishman, MD, assistant professor of psychiatry at Johns Hopkins University School of Medicine and psychiatrist at Mountain Manor. Fishman explained that as physicians have worked to treat pain more effectively, prescriptions for opioid analgesics have skyrocketed. With these drugs widely available in the community, young people may have easy access to them through family members or friends. Additionally, Fishman noted that these drugs are also being intentionally diverted for abuse by "doctor shoppers" and thieves, and that they are available through offshore Internet pharmacies. Scientists and clinicians at the meeting estimated the street value of a single oxycodone pill to be $25 to $80.

    While abuse of prescription opioid medications has also been documented in older adults, Fishman noted that adolescents and young adults are particularly vulnerable to developing addiction, which may peak in their 20s and 30s. "That age is always at the forefront of drug abuse trends," he said.


    Much of the research on opioid addiction has focused on individuals addicted to heroin, but recent research by Subramaniam and her colleagues has probed the differences between patients using heroin and those abusing prescription opioids.

    In one such study, the scientists compared the characteristics of 41 adolescents (aged 14 to 18 years) who abused prescription opioids and 53 adolescents who reported abusing heroin (Subramaniam GA and Stitzer MA. Drug Alcohol Depend. 2009;101[1-2]:13-19). In both groups, most patients were white and lived in suburban areas; the 2 groups had roughly equal numbers of males and females. However, injection drug use was highly prevalent in the heroin use group (73% in the past 30 days), while none of the prescription opioid users reported injecting drugs; instead, they ingested drugs orally or nasally. Heroin users were also more likely to drop out of school, while prescription opioid abusers were more likely to be suspended.

    Comorbid psychiatric disorders were common in both groups, affecting more than 80% of these individuals. Those in the prescription opioid abuse group were more likely to have attention-deficit/hyperactivity disorder or manic episodes, while those in the heroin abuse group had higher rates of major depressive episodes.

    More than half of the patients in both groups reported also abusing cocaine; however, those in the prescription opioid group were more likely to report using multiple drugs in the past month. Interestingly, 77% of the heroin use group reported that heroin was their drug of first choice, followed by 15% who preferred prescription medication and 8% who preferred cocaine. But in the prescription opioid abuse group, 46% named marijuana as their drug of first choice, followed by 27% who expressed a preference for prescription opioids, 15% for cocaine, 7% for alcohol, and 5% for other drugs.

    In fact, in some patients presenting with problematic drug use, opioid use may not be the most obvious problem, Subramaniam said. "They report lots of marijuana use, but are dependent on opioids," she said.

    Polydrug use also is associated with serious risks. In another study, involving 88 treatment sites, Subramaniam and colleagues compared 475 individuals aged 14 to 21 years who abused heroin or prescription opioids as well as marijuana and alcohol with 475 young people with marijuana or alcohol use problems alone (Subramaniam GA et al. Addiction. 2010;105[4]:686-698). The individuals in the polydrug group had higher rates of psychiatric problems and trauma, greater use of injection drugs and risky sexual behavior, and more physical distress.


    Until recently, there were few data indicating which therapies were most effective for youths with substance abuse disorders, but an emerging body of evidence is providing physicians with more guidance.

    In the Woody et al study published in JAMA, 152 patients aged 15 to 21 years who had opioid use disorders were randomly assigned to 12 weeks of buprenorphine plus naloxone (including a 3-week taper) or 14-day detoxification program with buprenorphine and naloxone. The researchers found that patients in the detoxification group were more likely than the patients receiving extended therapy to have an opioid-positive urine test at week 4 (61% vs 26%) and week 8 (54% vs 23%) but there was not a significant difference at 12 weeks (51% vs 43%). During follow-up at 6, 9, and 12 months, both groups were found to have high rates of positive urine tests, but the extended therapy patients had a lower rate (mean, 48% vs 72% over the 3 time points).

    One question that remains is how long buprenorphine therapy should be continued to achieve the best outcomes in young people with opioid use disorders, said Subramaniam. She noted that data from studies in adults suggest 6 months or more is the most effective. In her practice, Subramaniam said, she begins with 3 months of buprenorphine and then reassesses periodically whether to continue therapy (in some cases as long as 2 to 4 years), with informed consent from the patient that such therapy is experimental.

    "If being on buprenorphine is giving them an opportunity to stay in school, or go back and get their GED, or be employed consistently, that's a good reason to continue," she said.

    In addition to buprenorphine, Fishman and colleagues also treat young patients with opioid addiction with extended-release injectable naltrexone (monthly) and, to a lesser extent, oral naltrexone. An abstract presented at the meeting by the group outlined results of a retrospective study of 88 cases at the Mountain Manor clinic that found that medication use improved treatment retention compared with no medication, although patients in both groups were likely to have periods of relapse followed by return to therapy. The mean cumulative retention rates were 17.6 weeks for patients taking buprenorphine, 13.2 weeks for patients receiving extended-release injectable naltrexone, and 9.3 weeks for no medication.

    "Most of these patients have more than one treatment episode, and we’ve adapted to that," said Fishman.

    Subramaniam also noted in her presentation that methadone, which is available at specific treatment centers, is also a medication option for opioid-addicted youths.

    Fishman recommended that treatment facilities establish programming that specifically targets prescription opioid use disorders, including medication, counseling, educational interventions, and family therapies. He said he and his colleagues have had better patient retention in such a targeted program.

    Patients abusing prescription opioids as well as other drugs also may need additional counseling to address comorbid substance use disorders for which medication may not be available. Garrett, who presented several case studies at the meeting, emphasized the importance of interdisciplinary collaboration and patience in treating young people with opioid use disorders who may have waxing and waning episodes of substance abuse as well as complicating psychosocial issues. He emphasized that treatment should last "as long as it takes."

    Writer: Bridget M. Kuehn
    JAMA. 2010;303(23):2343-2345.
    Source: http://jama.ama-assn.org/cgi/content/full/303/23/2343 [requires subscription or payment]


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