Treatment  Op+ons  for  Juveniles  

Michelle  Lipinski,  MeD  Principal,  Northshore  Recovery  High  

School,  and  Principal/Founder,  icanhelp  Program  

Dr.  Marc  Fishman,  MD  Medical  Director,  Maryland  Treatment  Centers,  and  Assistant  Professor,  John  Hopkins  University  Department  of  

Psychiarty    

Learning  Objec+ves  

1.  Define  dependency  and  depriva+on.  2.  Iden+fy  states  of  the  World  of  Abnormal  

Rearing  (WAR)  cycle.  

3.  Explain  clinical  interven+ons  to  break  the  cycle  of  addic+on.  

4.  Plan  how  to  collaborate  with  law  enforcement  and  the  medical  community  to  bring  support  to  juveniles.  

Disclosure  Statement  

•  Michelle  Lipinski  has  no  financial  rela+onships  with  proprietary  en++es  that  produce  health  care  goods  and  services.    

•  Dr.  Marc  Fishman  has  no  financial  rela+onships  with  proprietary  en++es  that  produce  health  care  goods  and  services.    

Do  They  Know  We  Can  Help?  Michelle  Lipinski,  M  Ed  

April  2  –  4,  2013  Omni  Orlando  Resort    

at  ChampionsGate  

Back  of  brain  matures  before  to  the  front  of  the  brain  

  sensory  and  physical  ac+vi+es  favored  over  complex,  cogni+ve-­‐demanding  ac+vi+es  

  propensity  toward  risky,  impulsive  behaviors    

•  group  se\ngs  may  promote  risk  taking    poor  planning  and  judgment  

  ac+vi+es  with  high  excitement  and  low  effort  are  preferred    poor  modula+on  of  emo+ons  (hot  emo+ons  more  common  

than  cold  emo+ons)  

  heightened  interest  in  novel  s+muli  

The  Adolescent  Brain  

Adolescent  Brain  Development,    Decision-­‐Making,  and  Risk  

We  begin  with  these  basic  facts:  •  The  adolescent  brain  is  not  developed  as  fully  as  the  adult  brain  –  impulse  behaviors  are  less  controlled.  •  Immaturity  of  cogni+ve  processing  may  lead  to  risky  

decisions.  

•  The  presence  of  peers  influences  decision-­‐making.  

•  Strong  emo+ons  may  override  ra+onal  decision-­‐making.  •  Risk-­‐taking  may  facilitate  adolescent  transi+ons.  

The  above  are  true  for  all  adolescents  –  but  are  o`en  magnified  for  adolescents  with  learning  disabili+es.  

Source:  Reviewed  in:  Dahl,  RE  (2004)  Ann.  N.Y.  Acad.  Sci.  1021:  1-­‐22  

Psychosocial  Impact  on  Adolescents  with  LD  

The  normal  psychosocial  pressures  that  adolescents  face  are  magnified  for  those  with  learning  disabili+es:  •  Peer  culture  and  pressure  –  social  clusters  •  Isola+on  •  Intolerance  •  Low  self-­‐esteem  •  Hormones  •  Environmental  differences  –  home  life,  trauma,  

social  connectedness,  etc.  

Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  

Low  Self-­‐Esteem  

•  Low  self-­‐esteem  is  considered  by  many  researchers  to  be  one  of  the  leading  influencers  for  substance  use  and  misuse  among  adolescents.  

•  Adolescents  who  have  a  nega+ve  self-­‐image  and  feel  that  they  are  incompetent  are  more  vulnerable  to  peer  pressure  and  more  prone  to  turn  to  alcohol  and  drugs  for  comfort  and  acceptance.  

•  Adolescents  with  learning  disabili+es  are  par+cularly  suscep+ble  to  low  self-­‐esteem  and  its  nega+ve  consequences.  

Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  

Social-­‐Connectedness  

•  Adolescents  with  learning  disabili+es  o`en  experience  difficulty  and  frustra+on  dealing  with  others.  

•  They  are  less  likely  to  be  involved  in  extracurricular  ac+vi+es.  

•  According  to  the  2011  NSDUH,  youths  that  reported  par+cipa+ng  in  1  or  fewer  ac+vi+es  also  reported  higher  use  of  illicit  drugs    (15.7%  vs  9.4%),  high  use  of  marijuana  (13.3%  vs.  7.3%),  were  almost  twice  as  likely  to  smoke  cigareces  (15.4%  vs.  6.7%)  and  reported  more  binge  use  of  alcohol  (10.9%  vs.  7.1%).  

Source:  2011  NSDUH  

Academic  Difficulty  or  Failure  

•  Youth  with  learning  disabili+es  have  a  higher  incidence  of  academic  difficul+es,  which  also  make  them  more  vulnerable  to  substance  use  and  abuse.  

•  According  to  the  2011  NSDUH,  youth  who  reported  ge\ng  a  “D”  or  lower  the  last  reported  grading  period  when  compared  to  students  who  received  higher  grades  were  3  +mes  more  likely  to  use  illicit  drugs  (27.1%  vs.  9.5%),  use  marijuana  (22.4%  vs.  7.5%),  smoke  cigareces  (25.2%  vs.  7.0%)  and  binge  drink  (16.8%  vs.  7.2%).  

Source:  2011  NSDUH  

Substance  Use  Among  High  School  Drop-­‐outs  

Past  Month  Substance  Use  among  12th  Grade  Aged  Youths,  by  Dropout  Status:  2002  to  2010  

Overlap  of  Substance  Abuse  Risk  Factors  and  LD  CharacterisUcs  

SUD  Risk  Factors   LD  CharacterisUcs  

Low  self-­‐esteem   Low  self-­‐esteem  

Academic  failure   Academic  Failure  

Depression   Depression  

Desire  for  acceptance   Peer  rejec+on  

Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  

ADHD  &  Substance  Abuse  

  Acen+on  deficit  hyperac+vity  disorder  (ADHD)  has  a  prevalence  of  3–9%  in  the  general  childhood  popula+on  and  1–5%  in  the  general  adult  popula+on.  

  ADHD  affects  between  11  and  35%  of  “substance-­‐abusing”  adults,  o`en+mes  complica+ng  treatment  response.  ¹  

  Childhood  onset  ADHD  has  not  only  been  associated  with  an  increased  risk  of  substance  abuse,  but  has  also  been  linked  to  behaviors  that  are  indica+ve  of  more  severe  pacerns  of  substance  use,  such  as  earlier  onset,  longer  substance  use  careers,  poorer  treatment  reten+on,  and  higher  relapse  rates.²

Source:¹  hcp://informahealthcare.com/doi/abs/10.1080/10826080500294858;  ²Biederman  et  al,  1995;  Wilens,  2006;  Sullivan  &  Rudnik-­‐Levin,  2001,  as  cited  in  Torok,  et  al.  (2012)  Acen+on  deficit  disorder  and  severity  of  substance  use:  the  role  of  comorbid  psychopathology.  Psychology  of  Addic+ve  Behaviors,  Vol.  26,  No.  4,  974-­‐979  

Perceived  Risk  

What  are  our  children  using  to  get  high?  

Youth  do  not  realize,  We  Can  Help  Them  

  We  are  not  reaching  our  youth  who  need  help    

  The  youth  do  not  know  they  have  a  problem  

Our  Words,  Our  Ac+ons,  Our  Compassion  

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” ���

― Leo Buscaglia

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Where  does  it  begin?  

•  More  than  half  of  new  illicit  drug  users  begin  with  marijuana.  Next  most  common  are  prescrip+on  pain  relievers,  followed  by  inhalants  (which  is  most  common  among  younger  teens).  

Just  Weed  

•  AXer  alcohol,  marijuana  has  the  highest  rate  of  dependence  or  abuse  among  all  drugs.  In  2011,  4.2  million  Americans  met  clinical  criteria  for  dependence  or  abuse  of  marijuana  in  the  past  year—more  than  twice  the  number  for  dependence/abuse  of  prescrip+on  pain  relievers  (1.8  million)  and  four  +mes  the  number  for  dependence/abuse  of  cocaine  (821,000).  

Crea+ng  a  Bridge  to  Services  

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The  icanhelp  program  builds  help-­‐seeking  and  early  engagement  by  establishing  “safe”  places  for  adolescents  to  develop  a  trus+ng  rapport  with  adults  in  the  community  

icanhelp  Essen+al  Components  

26  

Strengthen  &  Build  Resources

Link  to  Resources

Help-­Seeking

Identi9ication

Awareness

Engagement

Follow-­‐Up

Build  Awareness  of  the  icanhelp  Program  

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Awareness Let  youth  and  young  adults  know  who  to  contact  related  to  the  icanhelp  program  •  icanhelp  logos  •  icanhelp  posters  •  icanhelp  presenta+ons  Iden+fy  icanhelp  Representa+ves  

using  icanhelp  Logos  

•  The  presence  of  the  icanhelp  logo  signals  that  this  is  a  safe  person  

•  Logos  are  reserved  for  people  who  have  been  trained  and  are  members  of  the  icanhelp  team  

icanhelp  Posters:  Facilita+ng  the  Conversa+on  

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If you’re thinking these thoughts...you may need help.Look for the I CAN HELP stickerto find a safe person to talk to.www.icanhelp.me

If you’re thinking these thoughts...you may need help.Look for the I CAN HELP stickerto find a safe person to talk to.www.icanhelp.me

biopsychosocial  issues   addic+ve  behavior  and  issues  

Support  Youth  So  They  Seek  Help  

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Help-­Seeking

Youth  are  more  likely  to  seek  help  if…  •  The  adults  around  them  have  

posi+ve  a\tudes  about  help  seeking  

•  They  think  adults  will  respond  •  They  are  willing  to  overcome  

peer  secrecy  requests  (help-­‐seeking  for  friend)  

•  They  think  exis+ng  resources  can  help  them  

•  They  are  engaged  in  school  

Youth  are  more  likely  to  seek  help  from  informal  supports  such  as  friends,  family  or  mentors  rather  than  professionals.  

When  they  seek  professional  help,  they  usually  go  to  someone  familiar  such  as  primary  care,  school  nurse  or  counselor.  

Why  Target  Adolescents?  

•  Mental  health  and  substance  use  problems  o`en  start  in  adolescents  –  About  half  the  adults  with  mental  health  problems  report  experiencing  their  first  episode  

during  adolescence  

•  Adolescents  do  not  know  that  they  have  a  mental  health/  substance  use  problem  –  There  are  so  many  changes  taking  place  it  is  hard  for  the  youth  and  caregivers  to  know  

that  there  is  a  problem  

•  Youth  do  not  know  the  route  to  safe  and  suppor+ve  care  –  S+gma  and  lacking  of  knowing  how  to  get  care  leaves  youth  to  their  own  methods  

Identi9ication

Being  a  Person  Who  Youth  Go  To  For  Help:  Communica+on  Style  

Engagement

•  Frame  ques+ons  in  a  nonjudgmental  way  

•  Strength-­‐based  vs.  puni+ve  approach  

•  Including  the  student  in  decisions,  encourage  open  and  honest  bidirec+onal  discussions    

•  Empower  the  student  to  take  responsibility  for  seeking  solu+ons,  and  build  incrementally  on  small  successes  

31  

•  Start  where  the  student  is  at  •  Building  an  alliance  with  youth  so  

they  feel  safe  and  welcome  

•  Youth  need  encouragement,  valida+on  and  support  for  expressing  their  opinions  

Find  &  Build  Resources  

•  In  a  crisis  or  urgent  situa+on,  you  want  to  have  resources  readily  available  

•  Develop  a  community  resource  guide  

•  Make  the  guide  as  comprehensive  as  possible  –  divide  and  conquer  –  complete  it  as  a  team   Strengthen  &  Build  

Resources

32  

Supports  within  Schools  

•  Special  educa+on  •  Social  worker,  psychologist  •  Resource  officer  •  Crisis  response  team  •  Guidance  department  •  Nurse/health  center  •  Administra+on  •  Truancy  official  •  ASOST  supports  

•  GSA  •  Alateen  

33  

Strengthen  &  Build  Resources

Supports  within  Communi+es  

•  Treatment  providers  for  mental  health  &  addic+ve  disorders  

•  Recovery  supports  •  Self-­‐help  groups  

•  Parent  supports/groups  •  Primary  Care/ER/Healthcare  •  Drug  free  communi+es  •  Reproduc+ve  health  •  Economic  supports/food  banks  •  GED/educa+on  supports  •  Social  services  

•  DCF:  when  to  file  a  51A  •  DMH  •  Workforce  investment  board  

•  Courts/juvenile  jus+ce/family  services  •  When  to  file  a  CHINS/C&P  

34  

Strengthen  &  Build  Resources

Supports  Online  

•  Resource  database  •  hcp://icanhelp.me  

•  Community    •  hcp://icanhelp.me/community/  •  Wiki  •  Blog  •  and  more  

•  Training  Portal  •  Facebook  

•  hcp://www.facebook.com/icanhelp.me  •  Future  services  

•  icanhelp  newslecer  &  mailing  list  •  Expanded  search  op+ons  for  resource  

database  

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Strengthen  &  Build  Resources

Contribute  to  Online  Resources  

Let  others  benefit  from  your  effort.  •  Share  your  

resource  guide  

•  Load  the  contact  informa+on  into  the  online  icanhelp  resource  database  

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Follow  Up:    Why  Services  Don’t  Always  Work  

Follow-­‐Up •  Youth  or  family  not  always  ready  to  

receive  services,  personal  factors  related  to  mental  and  cogni+ve  func+oning  of  individual  or  family  

•  No  service  available  within  a  reasonable  distance,  dropped  services  

•  Prac+cal  factors  such  as  insurance,  cost,  transport,  child  care,  eligibility  rules  or  program  scheduling  

•  Cultural  factors  such  as  language,  ci+zenship  and  status  

•  Nega+ve  experience/bad  rapport  with  provider  

•  S+gma  and  labeling  •  Lack  of  cultural  competency  

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SOAP  

•  A  two  week  intensive  a`er-­‐school  program  designed  to  meet  the  specific  needs  of  teens  and  young  adults.  SOAP  provides  a  safe  place  for  teens  and  young  adults  to  spend  their  a`er  school  hours  where  they  can  learn  and  develop  skills  to  support  recovery  from  substance  use  disorders.  

SOAP  Class  Rooms  

SOAP  Ac+vity  Room  

SOAP  Music  Room  

icanhelp.me

IntegraUng  Relapse  PrevenUon  Pharmacotherapy  into  Treatment  of  Opioid  

Dependence  for  Youth  

What  should  we  do  with  this  case?  

•  17  M  •  Onset  prescrip+on  opioids  15,  progressing  to  daily  use  

with  withdrawal  within  8  months  •  Onset  nasal  heroin  16,  injec+on  heroin  6  months  later  •  3  episodes  residen+al  tx,  2  AMA,  1  completed  

•  Suboxone  treatment  (monthly  supply  Rx  x  4),  took  erra+cally,  sold  half  

•  Presents  in  crisis  seeking  detox  (“Can  I  be  out  of  here  by  Friday?”)  

0  

0.2  

0.4  

0.6  

0.8  

1  

1.2  

1.4  

1.6  

1.8  

'91   '92   '93   '94   '95   '96   '97   '98   '99   '00   '01   '02   '03   '04   '05   06   07   08   09  

8th  Graders   12th  Graders  

Past Year Use Prevalence: 8th and 12th Graders (MTF)

Percen

t  

hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    

0  

2  

4  

6  

8  

10  

'91   '92   '93   '94   '95   '96   '97   '98   '99   '00   '01   '02   '03   '04   '05   06   07   08   09  

12th  Graders  

MTF:  Annual  Use  Prevalence  12th  Graders  

Percen

t  

hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    

0%  

1%  

2%  

3%  

4%  

5%  

6%  

2002   2003   2004   2005   2006   2007  

12  to  17y   18  to  25y    26y  &  >  

Percen

t  

The    NSDUH  report  February  2009  

Conceptual  underpinnings  •  Use  as  many  effec+ve  tools  as  are  available  •  One  size  does  not  fit  all:  as  many  doors  as  possible  •  A  full  con+nuum  of  care:  mul+ple  services  with  flexible  

responses  •  Ins+tu+onal  affilia+on  and  longitudinal  care  promotes  

engagement  •  Expecta+on  of  relapsing/remi\ng  course  •  Expecta+on  of  variable  and  shi`ing  treatment  readiness  •  Recovery  as  a  gradual  process,  not  an  overnight  event  -­‐-­‐  

expecta+on  of  incremental  progress  

Elements  of  treatment  model  

•  Emphasis  on  ongoing  engagement  from  detox  to  next  levels  of  care  (the  revolving  door  should  lead  somewhere)  

•  Specialty  care  •  Longitudinal  follow-­‐up  and  management  •  Integra+on  of  relapse  preven+on  medica+on  as  standard  of  

care  –  Buprenorphine  –  Extended  release  naltrexone  

•  Co-­‐occurring  (dual  diagnosis)  treatment  

Intr

insi

c A

ctiv

ity

0 10 20 30 40 50 60 70 80 90

100

-9 -8 -7 -6 -5 -4

Log Dose of Medication

Full Agonist (Methadone Heroin, oxycodone)

Partial Agonist (Buprenorphine)

Antagonist (Naloxone)

Journal of the American Medical Association, 2008

CTN  Youth  Buprenorphine  Study    Opioid  Posi+ve  Urines:  12  weeks  Bup  vs  Detox    

(Woody et al, JAMA 2008)

Percent of confirmed opioid-free weeks (cumulative)

Krupitsky et al. Lancet. 2011

Buprenorphine  induc+on  method  

•  Residen+al  detox  using  bupe  taper  •  Interrup+on  of  taper,  switch  to  steady  dose,  or  •  Comple+on  of  taper,  later  resume  bupe    

•  Alterna+ve  induc+on  as  outpa+ent  (minority)  

•  Outpa+ent  maintenance  

Buprenorphine  maintenance  •  Start  weekly  prescrip+on  supply  •  Expecta+on  of  counseling  acendance  •  Frequent  urine  monitoring  •  Increase  dura+on  of  Rx  dura+on  over  +me,  used  as  con+ngency  management  

•  Op+onal  tools  for  med  supervision  –  Prescrip+ons  le`  for  counselor  to  distribute  – Monitored  distribu+on  and/or  administra+on  by  families    

–  Direct  med  administra+on  up  to  daily  

XR-­‐NTX  Induc+on  

•  Residen+al  detox  using  bupe  taper  •  7  day  abs+nence  by  confinement  

•  NTX  induc+on  with  4  d  oral  dose  +tra+on  – 6.26,  12.5,  25,  50  mg  (liquid)  

•  1st  dose  injectable  XR-­‐NTX  prior  to  residen+al  discharge  

•  Outpa+ent  maintenance  

XR-­‐NTX  Maintenance  

•  Monthly  injec+ons  •  Expecta+on  of  counseling  acendance  •  Asser+ve  dosing  reminders  

Why  XR-­‐NTX  MAR?  

•  Failure  of  other  treatments  •  Pa+ent  preference  •  Family  preference  

•  History  of  poor  treatment  engagement  and  adherence  

•  Problems  with  acceptability  of  agonist  pharmacotherapies  

•  More  tools  in  the  toolbox  

Why  buprenorphine  MAR?  •  Pa+ent  preference,  esp  if  previous  experience  

•  Failure  of  other  treatments  

•  Intrinsically  reinforcing  •  Growing  posi+ve  reputa+on  of  bupe  •  Anxiety  about  NTX,  or  poor  tolerance  •  More  tools  in  the  toolbox  

Medica+ons,  mischief,  and  monkey  business  

•  Diversion  •  Non-­‐compliance  

•  Inconsistency  •  Other  substances  

Case  

•  18  F  injec+on  heroin,  mul+ple  failed  treatments  •  Inpa+ent  treatment,  recovery  house,  con+nua+on  suboxone  •  Made  connec+on  to  NA  for  the  first  +me  •  Abs+nent  x  6  months  •  Told  at  NA  mee+ng  “not  really  clean”    stopped  Rx  •  Relapse    •  6  months  later  back  on  suboxone    •  New  stance  towards  Rx  “don’t  ask,  don’t  tell”    •  2  years  abs+nence  

Case  

•  18  F  onset  injec+on  heroin  16,  occasional  street  suboxone  •  Outpa+ent  suboxone  maintenance  but  would  take  it  only  

intermicently  when  heroin  unavailable  •  Clarified  goal:  not  ready  to  quit,  suboxone  stopped  but  MET  

con+nued  •  2  months  later  Rx  restarted  under  mother’s  supervision  with  

new  commitment  -­‐-­‐>  6  months  abs+nence  

Bricany  

•  15  yo  WF  •  1  yr  hx  prescrip+on  opioids,  recent  progression  to  injec+on  heroin,  parents  didn’t  know  extent  of  dependence,  shocked  to  discover  a  needle  

•  Parents  compelled  by  idea  of  xr-­‐ntx  

Jennifer  •  17  yo  from  the  suburbs,  injec+on  heroin  x  2  years,  2nd  episode  detox  

•  Uses  street  bupe  intermicently  

•  Strong  parental  and  juvenile  jus+ce  pressures,  ambivalent  about  qui\ng  

•  “If  I  wake  up  &  there  is  heroin  &  suboxone  on  the  table  -­‐-­‐  I’ll  use  heroin  every  +me”  

•  Agrees  to  trial  of  xr-­‐ntx  

Machew  

•  19  M,  3  yr  hx  injec+on  heroin  •  4  previous  episodes  detox,  2  previous  episodes  of  failure  with  bupe  outpt  treatment  

•  Wants  to  try  bupe  again  

•  Parents  make  xr-­‐ntx  a  condi+on  of  returning  home  

Greg  •  16  M  prescrip+on  opioid  dependence  •  Residen+al  detox,  XR-­‐NTX  induc+on  •  Abs+nent  x  3  months  •  Family  vaca+on,  out  of  town,  dose  #4  delayed  •  While  at  beach  started  deliberate  plan  to  use,  diver+ng  few  

dollars  at  a  +me  to  prevent  detec+on  •  On  return,  told  parents  he  was  headed  to  treatment,  went  to  

get  drugs  instead,  missed  XR-­‐NTX  •  Relapse  x  3  weeks  •  Brief  residen+al  detox  •  Restart  XR-­‐NTX  with  new  level  of  parental  involvement  

Features  of  youth  treatment  

•  Family  leverage  •  Pushback  against  sense  of  parental  dependence  and  restric+on  

•  Salience  of  burdens  of  treatment  

•  Prominence  of  co-­‐morbidity  

•  Family  mobiliza+on  –  “Medicine  may    help  with  the  receptors,  you  s+ll  have  to  parent  your  difficult  teenager”  

Challenges  •  A\tudes,  misunderstanding  and  s+gma  •  Adherence  •  Monitoring  and  supervision  •  Range  of  op+ons  may  be  limited  

– Limited  treatment  capacity  – Limited  insurance  coverage  – Limited  availability  of  inpa+ent  

•  Clock  is  +cking  in  inpa+ent  se\ng  •  Tensions  in  involving  family,  esp  older  youth  

Challenges  •  Goals  of  treatment  re  other  substances  •  Diversion  of  bupe  •  Need  for  more  intensive  management  op+ons  with  bupe  

•  Limited  (and  false)  info  about  xr-­‐ntx  

Youth  opioid  treatment  chart  review  

•  Retrospec+ve  review  of  133  pa+ents  entering  outpa+ent  youth  opioid  track  at  Mountain  Manor  in  Bal+more  

•  4/07  –  1/10  •  Intake  to  26  weeks  •  All  the  usual  limita+ons  of  messy  clinical  charts  

Youth  opioid  treatment  chart  review  Pa+ent  characteris+cs  

Age, mean 18.2 years (range 14-21) Gender, male 53% Race, caucasian 94% Duration of opioid use 2.8 years Rate of heroin use 80% Rate of injection use 61% In school 23% Current psych Rx 38% Justice system involvement 68%

Youth  opioid  treatment  chart  review  Medica+on  treatment  

Treated with: Any medication 61% Buprenorphine 39% Extended release naltrexone 19% Oral naltrexone 3% No medication 39%

Cumula+ve  reten+on  over  26  weeks    by  medica+on  

10.3   9.9   11  7.8  

0  2  4  6  8  

10  12  14  16  18  20  22  24  26  

Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on  

subsequent    cumula+ve  reten+on  1st  episode  reten+on  subsequent    cumula+ve  reten+on  

*  *   *  

5.5   5.4  4.9  

15.8  15.3  

15.9  

10.3  

*  =  p  <  0.01  compared  to  no  medica+on  

2.5  

Reten+on  by  medica+on  

*   *  *  

Opioid-­‐free  weeks  over  26  weeks    by  medica+on  

Combining  urine  and  self  report  

11.5  13.7  

10.6  7  

0  2  4  6  8  

10  12  14  16  18  20  22  24  26  

Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on  

Opioid  free  weeks,  during  intake  to  week  26,  n  =  133  

*  *  

*  

*  =  p  <  0.01  compared  to  no  medica+on  

Cumula+ve  reten+on  Propor+ons  

0  

0.1  

0.2  

0.3  

0.4  

0.5  

0.6  

0.7  

0.8  

0.9  

1  

1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26  

Meds  No  meds  

Cumula+ve  Opioid  Nega+ve  Urines  

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wks 1-4 Wks 5-8 Wks 9-12 Wks 13-16 Wks 17-20 Wks 21-24

% o

f Pat

ient

s

Weeks of Treatment

Opioid Negative Urines

XR-NTX

Buprenorphine

No Meds

Addi+onal  Factors  Medica+on  vs.  No  Medica+on  

Cross-­‐sec+onal  reten+on  at  26  weeks  

0%

10%

20%

30%

40%

50% Medication

No Medication

Conclusions  (I)  • Treatment  with  relapse  preven+on  medica+ons(XR-­‐NTX  and  buprenorphine)  for  youth  with  opioid  dependence  is  well  tolerated  and  well  accepted  by  pa+ents  and  families,  and  can  be  prac+cally  implemented  as  a  standard  treatment  in  a  community  treatment  program.    

• Medica+ons  are  easily  integrated  with  counseling  as  part  of  a  comprehensive  treatment  approach  

• Use  of  medica+ons  for  relapse  preven+on  is  associated  with  increased  reten+on  and  treatment  u+liza+on,  and  decreased  drug  use.  

Conclusions  (II)  

• Not  surprisingly,  medica+on  compliance  seems  to  be  related  to  effec+veness.  

•   Although  pa+ents  dri`  in  and  out  of  treatment,  there  are  substan+al  rates  of  return  to  treatment  following  dropout,  and  re-­‐cessa+on  of  drug  use  following  lapse/relapse.    

• Our  experience  suggests  the  benefits  of  a  more  longitudinal  medical  management  model  of  care  as  compared  to  a  more  tradi+onal  model  of  discrete  episodes  of  care.    

Next  steps  -­‐  clinical  

•  Improved  family  involvement  

•  How  to  manage  medica+on  discon+nua+on  •  Longer-­‐term  engagement  strategies  

•  More  opera+onaliza+on  of  stepped  care      •  Broader  coverage  and  reimbursement,  including  XR-­‐NTX  

•  Differen+al  strategies  for  pa+ents  in  early  stages  of  change  in  rela+on  to  other  substances  

Next  steps  –    Research  agenda  from  the  field  

•  Longer  term  outcomes?  

•  Appropriate  dura+on  of  treatment?  •  Different  medica+on  discon+nua+on  strategies?  •  Bupe  vs  XR-­‐NTX?  •  Post-­‐relapse  strategies  –  s+ck  or  switch?  •  Outpa+ent  vs  inpa+ent  induc+on  •  Dosing  of  counseling  

Case  (1)    

16  F  injec+on  heroin  and  depression  

•  Ini+al  Rx  oral  NTX,  ineffec+ve  2º  non-­‐adherence  despite  close  parental  monitoring,  even  went  as  far  as  liquid  

•  Received  8  doses  XR-­‐NTX,  substan+al  improvement  (despite  sporadic  lapses)  

•  Extreme  conflict  with  mother,  moved  in  with  heroin-­‐using  boyfriend  

•  Insisted  on  stopping  XR-­‐NTX  2º  injec+on  site  pain  •  5  d  oral  NTX  then  immediate  relapse  and  dropout  

CASE  (2)  •  1  yr  later  (now  18)  presented  back  to  us  a`er  stabilized  on  

methadone  1  month,  re-­‐ini+ated  psychotherapy  and  Rx  for  depression  

•   A`er  4  months  abs+nent  on  methadone,  switched  to  bupe  

•  Erra+c  course  over  4  months  with  sporadic  medica+on  non-­‐compliance  and  lapses  leading  to  progressive  full  relapse  

•  Work  with  family  to  arrange  inpa+ent  treatment  and  detox  with  plan  for  switch  back  to  NTX  

•  Surrep++ous  use  of  bupe  and  cheeking  of  NTX  at  residen+al  program  

•  Precipitated  withdrawal  when  given  NTX  

Case  (3)  •  Course  of  XR-­‐NTX  for  6  months  •  Half  way  house  and  strong  engagement  in  12  step  fellowship  

•  Titra+on  of  an+-­‐depressant  with  gradual  remission  of  depression  and  anxiety  

•  Switch  to  oral  naltrexone  for  2  months,  but  “+red  of  meds”  

•  Oral  naltrexone  back-­‐up  as  needed  but  rarely  used  

•  24  months  sober  •  Working,  pregnancy,  living  with  baby’s  father,  recurrence  of  

depression,  break-­‐up,  living  independently  

Pharmacological  Treatment  

•  Ques+on:  – Which  is  becer  -­‐  medica+ons  or  counseling?  

•  Answer:  – Yes  

A  sprint  or  a  marathon?  

Early:  I  agree  I  was  out  of  control  with  the  dope,  but  I  can  s+ll  use  a  licle  oxy  on  the  weekends.  

Middle:  I’m  a  heroin  addict,  not  an  alcoholic.  I  just  need  to  stop  using  heroin.  A  few  beers  is  fine.  

Later:  When  I  get  drunk,  I  end  up  using  heroin  again.  Maybe  I  need  to  stop  drinking  too.  But  taking  a  licle  xanax  when  I’m  stressed  is  no  big  deal.  

                                                             (sigh)  

Hypothe+cal  Miracle  Cures