Resolving youth opioid addiction needs evidence-based care
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
Survival of the bitterest: Why dancers are good role models for scientists
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/
Patient-Related Drinking and Alcohol Counselling: Do Doctors Own Lifestyle Habits Matter?
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.
Personal Experience
Surveys of physicians’ attitudes towards drugs or drinking are multitude. They are relatively easy to do – doctors answer them by circling numbers or ticking the boxes in research questionnaires. While sometimes it’s easy to figure out the purpose of the survey and adjust one’s answers accordingly, other times the survey doesn’t give clues about its underlying goals.
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| Photocredit: wisequacks.org |
A Boston surveyasked over a hundred family doctors whether they knew someone (other than a patient) with an alcohol or drug problem. Up to 85% knew someone with these problems and about a third of them said this person was “family, a close friend or themselves.” Compared to the rest of the survey, they were more confident in asking patients about alcohol and advising on low-risk drinking. This positive effect did not translate to the other parts of their job, such as “perceived responsibility, attitudes, professional satisfaction, and practices”, though.
When faced with a “human face” of addiction, some medical doctors change their preconceptions:
“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.”
The Example comments made by students who attended an addictions workshop were taken from http://www.sgul.ac.uk/research/projects/icdp/pdf/smugprojectreport.pdf The doctor was a member of the Sick Doctors Trust http://sick-doctors-trust.co.uk/
The measurement problem
Two measurement problems hinder research on this topic. How to measure doctors’ drinking? How to measure the alcohol treatment they provide to patients with addiction?
Objective measures of alcohol consumption would be best. The measures we normally use are unreliable – Breathalyzers or ETG (Ethyl Glucuronide) tests. Apart from being perhaps somewhat intrusive for docs, they it pick up recent drinking only. Similar to other alcohol research, we would have to rely on what the doctors tell us.
Actual measures of practice are less worrying than objective measures of drinking. Again, measuring success of doctors’ approach by the number of abstaining patients is extremely difficult. Our best shots are proxy measures, such as number of prescribed medications or number of referrals to specialists. Although audits of doctors’ practice have been found to underestimate the actual care delivered by doctors, the Self-reports of practice seem to inflate the figures.
Other lifestyle habits
A previously published blog post and an article in the Irish Psychologist described two studies that illustrated how doctors’ lifestyle habits matter and how their ambivalence can be boosted. Research at the University of Michigan, cardiovascular centre demonstrated how doctors’ confidence in their ability to advise patients on diet and exercise correspond with their own personal health and fitness levels. Maybe lifestyle habits influence health care (in one paper) for a different issue (diet/exercise), but does that relate in some way to alcohol?
Another team supervised by Hettema and Sorensen used Motivational enhancement therapy (MET) to help medical trainees to resolve their ambivalence around managing alcohol and drug problems. They’ve put a group of nine medical residents through a brief MET therapy before they learned more about alcohol consulting and advice-giving. Five weeks later, their consulting and advice-giving went up, but due to the small numbers, the researchers called for caution with interpretation of their results.
No one is immune from addiction. While we know that doctors do get it too, we see little, if any, literature that specifically supports a statistically significant association between physician drinking and physician screening or counselling. In another words, we don’t know whether their own drinking or drug taking influences how they treat addictions. Can you find a paper?
Research Support and Supervisor Development programme: Epidemiologic triad of a successful PhD
The last Friday workshopat University College Dublin addressed a group of twelve supervisors with presentations by an epidemiologist, a physicist, a careers and a graduate studies officer.
How to avoid common pitfalls in research supervision?
Codd, the Epidemiologist told us about the key things we needed to know as supervisors. They were three: administrative, personal and academic matters. Together, they create the host environment part of her Epidemiologic triad of a successful PhD (see figure 1 below).
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Figure 2. Epidemiologic triad of a successful PhD
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Administrative matters. We need to make these students ticking over. Know your school PhD director (she interviews all PhD applicants in some schools). Look for the policies and procedures that relate to PhD. Ask your administrators: “Could we have a workshop for the supervisors in the school – annual PhD supervisors’ workshop?” There are always issues with at least 10% of students. As a relatively new trend in Ireland, the structured PhD helps to pick up and resolve those issues.
Academic matters. What have potatoes and supervisors in common? Think about the annual cycle of potatoes – new potatoes, big thing in Ireland, if you leave them in bright place, they sprout, the old potato shrinks and dies – as the Tuber (see Figure 2). The PhDs are like your offshoots.
Are you competing with your students? The last 6 months of PhD can be especially prone to competition because of the expertise that students learned.
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Personal matters. Be hyper vigilant – watch out for early warning signs of troubles. Some student problems cluster and almost create types of students. Student types MC’s list:
Part-/full time, inter-/national, the endless, the eager beaver, the slow starter, the double jobbing one, the competent, charming disarming, manipulative, diffident/ incommunicado, demanding, insecure, dependent, impossible. Conflicts with supervisors occur and when they do it’s almost always about expectations. Share the burden – please talk with your colleagues about the pleasures and difficulties of supervision.
Dunne, the Physicist, brainstormed with us over a list of questions that we should ask our potential supervisees at interviews:
- 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?
Drs Harkin and Cunninghan explained what PhDs do after graduation and how supervisors can use an underutilised career-planning tool at the University College Dublin.
What do PhDs do after graduation? PhD is not the best option for all who start it. Those who won’t end up in academia need other skills to succeed in the big world. Ancillary activities are important – ask the students to volunteer, or enter competitions.
Which transferable skills will your doctoral students develop? Most graduate students don’t have good writing skills, administration, foreign language, basic computer skills, project management, because their programme doesn’t focus on them. We’re not there yet.
The Research & Professional Development Plan can help. The student should take the ownership of it. Try it yourself: http://www.ucd.ie/graduatestudies/currentstudents/rpdp/
This post offered my views on the fourth meeting of the new Research Support and Supervisor Development programme (RSSDP) at the University College Dublin, Ireland. This programme is targeted at new and experienced faculty who would like to refresh their knowledge in the area. The 5 last-Friday workshops are based on sharing of practices with experienced supervisors and students, case studies, open forum discussions and knowledge sharing with colleagues on policy in the research supervisory field. I covered the previous meetings in the posts about leaders, styles, and recruitment. Watch this space for my observations from these workshops.
Clinical trials are about human dynamics: RCT course in Belfast, May 7-8
As a trialist, the pressure of working on a trial is much bigger than being in a small group educational session. Challenges of implementing a trial are multiple, mainly influenced by the values of outcomes for different people. Whose question is the trial answering? If you’ve ever found yourself puzzled by these issues, you may find some solace in reading my notes from a courseon clinical trials.
7 instructors and 21 participants – all from Northern Ireland (except 2 Dubliners), 2 medics, three 1-st year PhD students and some professors – talked about clinical trials for two days last week at Queens University Belfast. The aim of the course wasn’t to learn everything, but to think laterally about trials. Professor Clarkecovered the basics of starting trials: formulating a clear research question, deciding on comparisons and placebos and dealing with confounding factors. The 7 main ways of dealing with confounding are:
- Matching
- Exclusion
- Stratified sampling
- Standardisation
- Multivariate modelling
- Randomisation
The pleasures and terrors of trial recruitment were described by Dr Maguire. Everybody struggling with meeting the recruitment targets should read the top 10 tipsfor recruiting into trials at the All-Ireland Hub for Trials Methodology Research website. Trialists should plan for what they’re going to do if things don’t go the way they planned. Recruiters can also become tired and it’s good to think ahead about what would possibly prevent them from recruiting. Even small rewards to recruiters, such as cream eggs, can increase their satisfaction. Satisfaction=Retention. Research networks for General Practitioners can facilitate recruitment.
Dr McAneney introduced us to the role of social networks in clinical trials. We are all connected. All the users of Facebook can be linked by 3.74 steps. Networks make the trials work or crash. Networks allow diffusion of innovation. Decisions of participants and researchers are influenced by networks.
Prof McAuleyhelped the participants to write the protocol and funding application for their first trial. Publishing a trial protocol sets the bar pretty high for researchers – transparency and accountability are key. If it’s not possible to publish the protocol in a peer-reviewed journal, then post it online. Every protocol is changed over time and they should be listed on the first page. The CONSORT diagram is an essential part of a protocol. It’s the only slide that’s projected during meetings of grant reviewers.
Dr Shorterand Prof Buntingcontinued with tips for analysing outcomes. The essence of any research is control. Although power calculations for trials seem difficult, they involve only a short sequence of basic steps. Categorical outcomes require more data and more participants than continuous outcomes. Analysis of clinical trials assumes that our participants are all from the same population. The classical assumption of trials analysis was that individual differences do not matter, they were ignored. Another assumption that things are measured perfectly never holds.
Finally, Dr Dunlopfinished the course presentations with ethics and data storage.