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
What do dance and science have in common? What makes a successful choreographer or scientist? In this post, I speculate about the bitterness of the academic dance for survival. The academic competition is cruel and uneven. The fittest may not survive, but the bitterest thrive.
Read the full story in my recent post at Academia Obscura http://www.academiaobscura.com/academia-survival-of-the-bitterest/
The medical degree isn’t a vaccine against addiction. “If you don’t drink as much as your GP, you don’t drink too much,” an old saying goes. When it comes to doctors’ own lifestyle habits and patient-related alcohol counselling, the science remains silent.
“I found the workshop really eye opening. It changed my preconceptions of what I thought a ‘drunk Doctor’ would be like; when we were all sat around the table I was wondering to myself when the Doctor would be coming to speak to us and why he wasn’t there already, so I was taken by surprise when it turned out he was sitting right opposite me! I think that shows that this really is an issue that needs to be put in front of medical students as most like me will only have come into contact with alcoholism through seeing patients on wards, or seeing people in the street.”
How to avoid common pitfalls in research supervision?
Figure 2. Epidemiologic triad of a successful PhD
- What supports do you have?
- How they deal with crisis?
- How would you define the plagiarism?
- Overestimating what they know is a common mistake.
- Reliance on email communication is bad.
- The cultural stuff is huge, diversity is always a good thing, but you have to be more tuned in, as a supervisor. Usually the stuff that you don’t see coming creates the most problems.
How to help students through skills-needs analysis and key-skills acquisition for research & professional life?
- Stratified sampling
- Multivariate modelling