Youth opioid addiction, and related harms continue to rise in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with addiction. The time for evidence-based treatment of youth opioid addiction is now.
Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. This post summarises a recent article in the American Journal of Drug and Alcohol Abuse, where we outline the current dilemmas and questions regarding the use of medication-assisted treatment for youth opioid addiction and propose some potential solutions based on the current evidence.
The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth in North America (age 15–25). These growing harms point to an urgent need to expand and scale-up early access to evidence-based treatments for youth opioid addiction. Treatment of youth opioid addiction may be different than treatment of adults because neurodevelopment of brain regions, associated with motivation and impulsivity, happens mainly during adolescence and young adulthood.
Strategies that reduce barriers to treatment commonly experienced by youth and that address clinical care dilemmas when treating youth opioid addiction are urgently needed.
Medications for youth opioid addiction
The American Academy of Paediatrics recently supported buprenorphine/naloxone and methadone for youth opioid addiction. Although research has shown their effectiveness in adults, only a few studies did so among youth.
Based on the strong evidence in the adults and available evidence to date among youth, first-line OAT for youth should be buprenorphine/naloxone, with methadone as an alternative treatment option when buprenorphine/naloxone cannot be used.
Minimum age requirement needs re-evaluation
The literature still disagrees regarding the minimal age requirement to prescribe OAT. For instance, buprenorphine/naloxone is currently approved for opioid addiction at age 16 in the United States and at age 18 in Canada. But the U.S. youth has to fail addiction treatment twice before they can be prescribed methadone under the age of 18. Also, treatment with medications has been prescribed to 10 times more adults than youth although it’s the first line of treatment in many guidelines. This underscores the urgent need to improve medication-assisted treatment access for youth. We still need safety data regarding use of OAT among youth. But the pros are likely to outweigh the cons given the lethality and multiple harms associated with opioid addiction.
Longer tapers are more effective than shorter tapers
How long should be the successful tapers and how to do them effectively? These questions are still unanswered by scientific literature. Studies to date have shown that longer tapers are more effective to reduce opioid use and prevent relapse For this reason, our provincial guidelines in British Columbia, Canada, recommend that tapers for adults, if undertaken, “occur over a minimum 52 weeks duration and with close monitoring during and after the taper given overdose risk is increased.”
Naltrexone injectable versus implantable
Opioid antagonists, such as Naltrexone, have not been evaluated widely among youth. Oral Naltrexone has many problems, such as low compliance, increased risk for relapse and overdose. The researchers should compare methadone or buprenorphine/naloxone with extended-release injectable or implantable naltrexone in youth. This information will help clinicians select the best treatment for youth opioid addiction.
Psychosocial interventions: retention on OAT remains a challenge
Psychosocial interventions are common for treating youth opioid addiction, but are done in a way that is not supported by science. For example, they consist of short-term detox with a referral to individual or group therapy in rehab or outpatient settings. Youth drop out from such treatment frequently. But retention on OAT remains a challenge. For example, one study found that only “56% of youth aged 18–25 years were retained on buprenorphine at 6 months, compared with a 78% of people aged 26 years or more.” OAT seems more efficacious in retaining youth in treatment. Psychosocial intervention is better done in combination with pharmacologic treatment. We need more trials involving youth.
The Prescription Opioid Addiction Treatment Study – POATS
The Prescription Opioid Addiction Treatment Study (POATS) showed that tapering off buprenorphine/naloxone (even after 12 weeks of treatment), was associated with a 90% relapse rate. Ongoing counselling did not make a difference. Based on the adult POATs study, it seems that keeping people on buprenorphine/naloxone is better than tapering them without supports. Psychosocial interventions may help people receiving OAT. Many studies found contingency management helpful. Researchers should do more studies on contigency management.
When in doubt, do not taper
Based on the above, we need more research to better understand optimal treatment approaches for OPIOID ADDICTION in youth. Based on the current evidence, buprenorphine/naloxone appears to be a safe and efficacious option for youth and we propose this should be first-line treatment for OPIOID ADDICTION. More studies comparing OAT and extended-release naltrexone are needed in this population. When treatment is initiated, longer duration (>52 weeks) of OAT is recommended. Decision to taper should be governed by the principle “when in doubt, do not taper” while taking into account the potential risks of relapse and overdose as well as access to chronic relapse prevention care; close monitoring is essential during and after the taper completion. We suggest psychosocial interventions be routinely offered in combination with OAT. Lastly, given the efficacy of OAT, we recommend these medications be provided based on the risk and benefit assessment of each case, regardless of age.
Cited study: Derek C. Chang, Jan Klimas, Evan Wood & Nadia Fairbairn. (In Press) Medication-assisted treatment for youth with opioid use disorder: Current dilemmas and remaining questions. The American Journal of Drug and Alcohol Abuse Vol. 0 , Iss. 0,0
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Barefooted or not, Iceland is a country for adventure seekers. Planning a trip to Iceland? Our narrated itinerary might help you.
Sunday, 31.8. Skógar
Our Gatwick flight was delayed by 90 minutes due to strong winds. We enjoyed our delay though. The best thing about our flight was a prolonged break in the Gatwick, discovery of a public footpath around a small lake with water lilies and harvest of blackberries.
Starved by the flight, we bought super healthy bread with walnuts at the Keflavik airport. Fair car Rental Companypicked us up. Gave us printed maps and weather focused. We opted for a used car with “Scratches and dents all over the place”. We managed to drive the 200km to be in the Skógar hostel just before the bedtime. The hostel was very basic, with dorm rooms only.
Monday, 1.09. Hvoll
Nothing is better than a room on your own, especially after the first night in a super basic hostel. Hiking around the Skogar waterfall wasn’t really great fun. After about 2 hours, we finished the hike, exhausted and wet. The wetness wasn’t obvious until we came down and rested for a while when the high wind started again. The rest of the day, we spent in the Skogar folk museum – a safe haven while the elements had their time outside.
There were so many things in the museum that we wondered whether they know about all of them. You could spend hours learning about Iceland across several themed buildings plus an open air museum. The Vik finished our day with my hot pool treat and a quick stop in the Icewear which proved to be too expensive for our budget. Missing the grocery store just by 20 mins, we went on a scenic journey by the sea, crossing lava fields under the Laki volcanoes.
Tuesday, 2.09. Selfoss
After half an hour driving from the Hvoll hostel to the Skatfafell national park, we headed for the looped walk. The walk was well marked with knee-high yellow-end-painted poles. Also very busy with other hikers, especially at the start and end. The Skatfafellsheiq loop was 15.5 km long and we had about 7 showers on the way, we thought there was no point in taking our raingear off. It took us about 5.5 hours to do the loop walk. At times, we had luck to see bits of the huge Skatfafell glacier pushing its way through the valley. The glacier greeted us with cold wind, the descending side of the walk and mountain Kristínartindar was colder. The trail was rocky at times, especially going down.
On our way to Sellfoss,we stopped to take pictures of the Skatfafell waterfall – foss in Icelandic. We gave a ride to a couple of hikers from France, only to Skogar; happy to see it again in the daylight, we said bye to the youths right in front of the campsite. They told us that they had to stand only 20 mins in the rain and their rides were mostly tourists. But the guy had rides by locals in the past.
Wednesday, 3.09. Golden circle – Geysir, Gullfoss, Pingvellir national park, Borgarnes
Listed in the sub-heading above are the 3 most popular attractions in Iceland.
The underwater tunnel to Borgarnes was surprisingly long. We went all this way to find that all we needed was in the Borgarness– a great hostel, beautiful town with sunset and a hot tub. Was it safe for women? We asked twice, they immediately replied yes, without even thinking about it. A natural reaction. A well hidden secret which we discovered was the 90.50 FM RUV R2 Radio with programmes for all hard rock lovers. The local settlement museum below the restaurant with a gift shop offered 1 hour tours and good insights into early history – the first 60 years and the Icelandic sagas.
Thursday, 4.09 Grundarfjörður
Our car engine oil started to drip. We went into a garage and they called the car rental company to replace our car. The new car arrived very quickly, in about 3.5 hours. We gave a ride to another couple, they were Germans. We learned from them why there were so many German tourists in Iceland; the return flight from Berlin was only 120EUR. “Come back next year!” said the notice on the closed restaurant in Hellisandur. The next seafood place in Ólafsvík was served by very young women. Even staff at the gas station was the same age, we wondered why? The explanation came later in the evening.
Friday, 5.09. Reykjavik
On the way to Reykjavik, we stopped in the Stykkishólmur for a brisk walk around the harbour hills; everything else was closed for season. The farm in Erpsstadir was supposed to be opened from 1pm, but when the farm lady saw us coming, she opened the shop at 12noon. They have woofers through the helpex.net site every year. Their strawberry ice cream tasted like it was made just yesterday. The dirt road to the farm was safe enough for the maximum speed of 80 kph.
In the capital, we saw an exhibition of arctic photography by Rangar Alexonn. It documented a slowly disappearing world of melting glaciers and shrinking communities of Inuit. The Flora café in the Botanic gardens, with their resident cat, is the 2014 best kept secret in the town. In the past, women used to wash the clothes in a nearby hot spring which is commemorated by a volcanic sculpture and information boards.
We couldn’t leave Iceland without Bjork’s early and rare GlingGló (1990) album.
Hope you found this short narration useful. If you’re planning a longer trip to Iceland, check out my friend’s, John Fitzgerald’s blog. It inspired our journey a lot.
|Poetry slam at Accent’s drink-free venue|