Adoption of medication treatment for adolescent and young adult opioid dependence

Transcription

1 Adoptionofmedicationtreatmentforadolescent andyoungadultopioiddependence 1,2 1 MarcFishman,LawangeenKhan,ShannonGarrett1,LawrenceO Neill1, LaurenHiken1,SyedShah1,AsadBokhari1 1.MountainManorTreatmentCenter BaltimoreMD 2.JohnsHopkinsUniversitySchoolofMedicine,DeptofPsychiatry BaltimoreMD 1

2 Adoption of medication treatment for adolescent and young adult opioid dependence ABSTRACT Background. Opioid dependence in adolescents /young adults is a major public health problem. Emerging evidence suggests that medication treatments are effective in this population. This study aims to describe the implementation of medication treatment for this population in a community treatment program, and examine the association between medication use and treatment retention. Method. Data was abstracted retrospectively from clinical charts of 88 serial patients admitted between 4/08 and 10/09 to the adolescent/ young adult outpatient opioid track at Mountain Manor Treatment Center in Baltimore MD. Results. Patients were 53% male, with mean age 18.3 (range 13 21). The mean retention until 1 st dropout (defined as 2 weeks without any treatment contact) was 8.3 weeks. However return to treatment after dropout was common (42% of patients) with a mean # of interrupted treatment episodes of 2.2 (range 1 9). Cumulative mean treatment retention over all treatment episodes was 14.4 weeks (range 1 53) spanning a mean calendar time duration of 19.9 weeks (range 1 85). 42 patients (48%) were treated with buprenorphine (bup), 15 (17%) were treated with extended release injectable naltrexone (XR NTX), 3 (3%) were treated with oral naltrexone (NTX), and 27 (31%) were treated without medications. Mean cumulative retention by medication class was 17.6 weeks (range 1 43) for bup, 13.2 weeks (range 1 28) for XR NTX, 9.3 weeks (range 1 26) for no medication. Conclusions. Medication treatment for adolescent/ young adult opioid dependence is feasible in a community treatment setting. Treatment engagement followed a pattern of moving in and out of treatment, with substantial rates of return to treatment following dropout. Use of medications for relapse prevention seems to be associated with increased retention in this population in a small, non randomized sample. These very preliminary results suggest the benefits of a more longitudinal medical management model of care as compared to a more traditional model of discrete episodes of care. 2

3 Background Opioid use has risen dramatically among adolescents and young adults. Past year heroin use among 12th graders in the decade from averaged 1%, while past year non medical use of prescription opioids nearly doubled from 4.7% to 9% during the same period. 1 According to the National Survey on Drug Use and Health (NSDUH), nonmedical use of prescription drugs, which includes opiates, was the second most frequently used illicit drug among 12 to 17 year olds (3.3%) following marijuana (6.7%). This age group was second in rates of use only to the age 18 to 25 year group. 2,3 Correspondingly, treatment admissions for opioid use disorders increased 196% between Despite advances in the development of adolescent substance abuse treatments over the past decade, as well as advances in research demonstrating treatment effectiveness, 5 there is relatively little documentation of treatment outcomes among the high severity sub population of adolescent and young adult opioid users. Opioid using adolescents have very high rates of relapse and treatment dropout in outpatient treatment 6 and greater severity and worse post residential treatment outcomes compared to their non opioid using counterparts. 7 The effectiveness of relapse prevention pharmacotherapy for opioid dependence in adults is well documented, and has become the treatment standard of care. Three medications are approved by the FDA for the treatment of opioid dependence in adults the pure agonist methadone, the pure antagonist naltrexone and the partial agonist buprenorphine. However there is very little information about the use and effectiveness of pharmacotherapies for opioid dependence in adolescents and young adults. Methadone has not generally been used for adolescents because of stigma, lack of accessability, and lack of adolescent friendly treatment settings. In a Clinical Trials Network multi site trial (including our center) of adolescents and young adults (mean age =19.2 years), patients randomized to 12 weeks of buprenorphine maintenance had increased retention and decreased opioid positive urines compared to those who received 2 weeks of buprenorphine detoxification only. 9 Naltrexone has recently generated interest as a promising treatment, both as the oral formulation delivered daily under parental supervision, and as the extended release formulation delivered as a monthly injection. 3

4 Methods Clinical Treatment The treatment was conducted at Mountain Manor Treatment Center (MMTC), a community based adolescent substance abuse treatment program in Baltimore MD, which provides both residential and outpatient levels of care. The adolescent residential program is described elsewhere, 7,17 and notably includes medical/nursing staff. The outpatient program includes a Partial Hospital Program (PHP), an Intensive Outpatient Program (IOP), and a mental health clinic for concurrent treatment of comorbid psychiatric disorders. A specialized opioid dependence outpatient track was developed in September 2007 and consists of 1 2 group counseling sessions per week, 1 individual counseling session per week using manual based MET/CBT content, and physician visits typically beginning weekly then tapering to monthly. Specialty Opioid Track/Program Residential (Level III.7) Avg LOS 21 days Crisis intervention Detoxification Role induction Initiation of relapse prevention medication PHP (Level II.5) 5d/week for 1 2 weeks IOP/Outpatient (Level II.1 or I) Opioid groups (CBT) 1 2 evenings/wk Individual counseling 1x/week Physician visits weekly tapering Mental health treatment (on site) as indicated Optional attendance at general adolescent IOP 2 3 evenings/week All patients undergoing residential opioid detoxification were offered a range of alternative treatments including XR NTX, maintenance buprenorphine, oral naltrexone, and counseling treatment without medication support. Selection was based on patient and parent preference, and the clinical recommendation of a physician. Other factors influencing participation and choice of medication included ability to follow up in our outpatient clinic based on geographic distance of residence from the facility, previous experience (including success or failure, 4

5 compliance problems or diversion) with a particular medication (usually buprenorphine, which is more broadly available). Commonly cited reasons for rejecting a particular medication included: stigma against agonists (Bupe), aversion to injection (XR NTX), expense of medication and lack of insurance medication coverage (XR NTX), and lack of insurance coverage for sufficient residential length of stay to initiate treatment (XR NTX). Many patients were also treated with medications for co morbid psychiatric conditions. Buprenorphine (Bupe) Residential detox using bupe Continuation of bupe during detox (or reinstatement of bupe following detox) Weekly prescriptions for bupe as outpatient Gradually increasing prescription interval with progress Naltrexone (NTX) Residential detox using 7d bupe taper 7d period opioid free Oral NTX lead in titration Injectable extended release NTX prior to residential discharge Monthly doses of XR NTX as outpatient (or daily oral NTX with parental supervision) Participants and data collection This is a convenience sample of the 88 patients admitted to the MMTC adolescent/ young adult outpatient opioid program between 4/08 and 10/09. Data was abstracted with identifiable personal information removed from a clinical database used by clinicians to track patient care. Attendance at treatment sessions (PHP, IOP, individual or group counseling, physician visits) between 4/08 and 1/31/10 was recorded. Retention in a treatment episode was measured as weeks until dropout, which was defined as 2 consecutive weeks with no attendance at any treatment session. Attendance at a treatment session subsequent to a dropout was taken to signal the beginning of a new treatment episode. The durations of multiple treatment episodes were added together to give the cumulative treatment retention. Patients were classified in categories according to which medication (or no medication) they were treated with. The 14 patients that switched from one category to another during the course of treatment were classified by the authors (MF and LK) as belonging to the category in which they spent the longest duration of their treatment, or if the durations were roughly equivalent then by the initial category. 5

6 Results Patient characteristics Age Mean 18.3 yrs (range 13 20) Gender 53% male Treated with: Buprenorphine 48% (42) Oral Naltrexone 3% (3) XR Naltrexone 17% (17) No medications 31% (27) Switched 16% (14) Overall retention Mean (range) Retention to 1 st dropout 8.3 weeks (1 25) # of treatment episodes 2.2 (1 9) Cumulative mean retention 14.4 weeks (1 53) Calendar span of all treatment 19.9 weeks (1 85) episodes Retention by medication class Medication class Mean retention to first dropout (range) Mean cumulative retention (range) Mean calendar span all episodes (range) Buprenorphine 9.0 wks (1 32) 17.6 wks (1 43) (1 76) XR Naltrexone 7.8 wks (1 23) 13.2 wks (1 28) (1 43) No medications 7.4 wks (1 25) 9.3 wks (1 26) (1 40) 6

7 Retention by medication class 7

8 Conclusions Medication treatment for adolescent/ young adult opioid dependence is feasible in a community treatment setting. Treatment with both buprenorphine/naloxone and extended release injectable naltrexone was well tolerated and well accepted by patients and their families. The typical course of these patients was one of shifting status, moving in and out of treatment, in and out of remission and lapse/relapse. Treatment engagement followed that pattern of moving in and out of treatment, with substantial rates of return to treatment following dropout. Patient treated with medications had greater retention. Not surprisingly, drop out and relapse seemed related to medication non compliance, and parental involvement seems to be an important ingredient in enhancing compliance. The adoption of medication support as the new standard of care for opioid dependence at the treatment center has been a paradigm shift, and entailed a gradual change within the counseling treatment culture that occurred with training and direct clinical experience. While initially there had been considerable skepticism among counselors about medications used as an replacement for counseling, over time their comments emphasized the apparent utility of medications in increasing retention and making patients more available for counseling than ever before. Practical implementation issues included: the need for onsite physician and nursing staff, which were already available within the residential program and the integrated outpatient psychiatric clinic for co occurring disorders; the need for billing and utilization management infrastructure to support outpatient medical services and medication prescription; integration of the medication component into the existing psychosocial treatment infrastructure, which required the crosstraining of and support from the counselors to monitor and encourage compliance with the dosing schedules. We are finding that although medications for addiction treatment are gradually gaining acceptance, there remains some ongoing resistance to them. For example, many in the 12 Step recovery community continue to have opposition to buprenorphine. Many local half way houses will not accept our patients because of their prohibitions against buprenorphine maintenance therapy. This distinction also had considerable impact for those youth who attempt to engage in the NA fellowship as part of their continuing care. The stigma against maintenance medications persists to some extent even for naltrexone even though it is a pure antagonist, and this unfortunately remains a barrier for broader adoption. For example one patient discontinued medication then dropped out of treatment after 5 months of abstinence on XR NTX when her NA sponsor told she could not take a keychain because she was not really clean. For adolescents and young adult with opioid dependence, relapse prevention medication treatment is feasible and can be practically implemented as a standard 8

9 treatment in a community treatment program. Pharmacotherapies are easily integrated with counseling as part of a comprehensive treatment approach. Use of medications for relapse prevention seems to be associated with increased retention, especially retention with return to treatment after a first episode of care and dropout, in this population in a small, non randomized sample. These very preliminary results suggest the benefits of a more longitudinal medical management model of care as compared to a more traditional model of discrete episodes of care. 9

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