Opioid Agonist Treatment for Teen Addicts Better than Detox and Counseling
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PHILADELPHIA, Nov. 4 -- Young opioid addicts stayed clean longer when they received extended treatment with buprenorphine and naloxone (Suboxone) compared with short-term detoxification followed by counseling, researchers here said.
Relapse rates were more than twice as high in adolescents treated with conventional detox therapy and counseling after four and eight weeks than in youths receiving buprenorphine and naloxone in a randomized trial, reported George E. Woody, M.D., of the University of Pennsylvania, and colleagues in the Nov. 5 issue of the Journal of the American Medical Association.
The medication-treated patients also had better retention in treatment, lower use of non-opioid street drugs, less injecting behavior, and a reduced need for additional treatment. Action Points
- Explain to interested patients that the study found that extended treatment with buprenorphine-naloxone (Suboxone) in teenage opioid addicts was better than conventional detox therapy at preventing relapse.
- Explain that relapse rates in both groups were about the same after medication was stopped.
But at week 12, when tapering of buprenorphine and naloxone in the extended-medication group ended, there was no significant difference between groups.
Subsequent relapse rates for the two treatments were similar in the year-long study.
The researchers concluded that extended buprenorphine and naloxone was more effective than the conventional approach in young addicts, but only while they were receiving the medication.
The year-long study involved 152 patients 15 to 21 years old (mean age 19) who had been using opioids regularly for a mean of 1.5 years.
The buprenorphine-naloxone combination is FDA-approved for addicts 16 and older, but most participants in its clinical studies have had addiction histories of five years or more.
The researchers noted that a two-week detoxification program followed by counseling has been the standard approach for treating young addicts, with opioid agonist therapy usually reserved for treating withdrawal symptoms.
In their study, the control group received buprenorphine and naloxone for two weeks, up to a maximum dose of 14 mg of buprenorphine. This was followed by counseling including one individual and one group session weekly for 12 weeks.
The intervention group received buprenorphine and naloxone up to a maximum of 24 mg of buprenorphine daily for a total of 12 weeks, with tapering started at week nine.
At week four, 26% (95% CI 14% to 38%) of the intervention group and 61% (95% CI 47% to 75%) of the control group had positive urine-test results for opioids, signifying relapse.
A similar difference was seen at week eight.
By week 12, positive urine tests were found in 51% of control patients and 43% of the extended-medication group, which did not differ significantly.
Participants were followed and tested for an additional nine months. Over most of this time, positive urine tests were moderately but not significantly less common in the extended-medication group.
An exception was at the final test, one year after the study began.
Among 91 participants available for testing, only about 40% of the extended-medication group had positive results compared with 75% of the control group. The difference was statistically significant (P not specified), according to the researchers, but its clinical meaning was uncertain.
Other key findings for extended-medication versus control patients included:
- Retention in treatment at 8 weeks: 74% versus 27%
- Recent opioid use at 8 weeks: 19% versus 52%
- Recent cocaine use at 8 weeks: 2% versus 14%
- Recent marijuana use at 8 weeks: 6% versus 19%
- Counseling sessions attended over 12 weeks: mean 11.8 versus 5.1
In an accompanying editorial, David Fiellin, M.D., of Yale University, agreed that the extended-medication approach gave better results than detox plus counseling.
"But only during the period that medication was provided," he added.
"The most important finding of this study is the rate of relapse in both treatment groups following the medication taper," Dr. Fiellin wrote.
"The implication is that adolescent opioid-dependent patients, like their adult counterparts, will likely need long-term, rather than short-term, opioid agonist treatment."
He also pointed out that the study was too small to support meaningful conclusions on the safety of such an approach in young addicts, although no serious adverse events attributed to buprenorphine-naloxone were seen.
Dr. Fiellin suggested that offering naltrexone to patients after the buprenorphine-naloxone taper might have helped forestall relapse and promoted retention in treatment.
In an interview, Dr. Woody agreed, but said compliance with naltrexone -- currently available as a daily oral tablet -- is a major problem.
He said follow-up treatment with naltrexone might be more practical when extended-release versions become available.
The study was funded by the National Institute on Drug Abuse. Reckitt Benckiser provided study medications. Study authors reported relationships with Ortho-McNeil, Purdue Pharma, Schering-Plough, Forest, Lilly, Bristol-Meyers Squibb, GlaxoSmithKline, Reckitt Benckiser, GlaxoSmithKline, Janssen, Jazz Pharmaceuticals Lundbeck, Organon, Pfizer, and Johnson & Johnson.
Dr. Fiellin reported receiving honoraria from medical societies for providing lectures at events that were funded with unrestricted educational grants from Reckitt Benckiser.
By John Gever, Senior Editor, MedPage Today
Published: November 04, 2008
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco .
Primary source: Journal of the American Medical Association
Woody G, et al "Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial" JAMA 2008; 300: 2003-11.
Additional source: Journal of the American Medical Association
Fiellin D "Treatment of adolescent opioid dependence: no quick fix" JAMA 2008; 300: 2057-59.
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