Opioid Addiction in Youth

Parents who look the other way when their kid is using alcohol or marijuana are blindsided when they discover their young adult is addicted to opioids. Parents, unaware of the trends we’ve been seeing for the last decade, are often shocked to discover the prevalence of opioid addiction in youth. For some young people, opioids are the gateway drug, rather than nicotine, alcohol and marijuana as we’ve seen in the past. For some families, the first hint of drug use has been a fatal or near-fatal opioid overdose. For those kids whose first drugs of abuse are alcohol or marijuana, it’s often a short time until they progress to opioids.

Previously, so-called hard drug use was considered a problem of the inner city. But now, most opioid-addicted youngsters live in suburbs or rural areas, and mostly are non-minority.  The purity and availability of heroin has increased, and now that pain pills are slowly become less available, it’s being by some young adults. Many have the mistaken impression they can’t become addicted if they snort rather than inject heroin.

How young am I talking about? Typically, adolescents are described as 14 or 15 to age 18. However, the human brain continues to develop until around age 24, so people of legal age may still think and act like adolescents. The family milieu also influences maturity level. Some 19 year-olds have been functioning as adults for years, while some 24 year-olds may still be financially and emotionally dependent on their parents.

We don’t have much information to guide treatment for opioid- addicted adolescents. Unfortunately there aren’t many good long-term studies to show us which treatments give the best outcomes for this age group. We do know that rather than looking at a treatment episode as a one-time fix for an acute problem, we need to take a longer view. Opioid addiction behaves more like a chronic disease, and one episode of addiction treatment rarely resolves the problem for life.

At the recent ASAM conference I attended in Atlanta, a two-hour session focused on treating opioid addiction in adolescents. Three doctors at that session spoke about their experience treating this age group for opioid addiction: Marc Fisher MD, Ann Bruner MD, and Sharon Levy MD

These doctors are finding that just like in adults, opioid addiction in adolescents behaves like a chronic disease with relapses and remissions. Parents should be advised to adjust their expectations of what treatment can do for their child. Parents shouldn’t expect one treatment episode to “fix” their child so that they will never have to worry again. Adolescents in opioid addiction treatments have high drop- out rates and high relapse rates, probably due to the opioids particular pharmacology. Many of these kids also have co-existing mental health problems which makes treatment more difficult.

Models of inpatient opioid detoxification followed by outpatient treatments alone show high relapse rates. The doctors presenting at this session reported their outcomes using medications in addition to outpatient counseling programs.

They are using both Suboxone and Vivitrol (naltrexone by monthly injection), and allow patient and family preference to decide which, if any, medication to use. Suboxone is prescribed without a clearly defined stop date; rather, the doctor counsels delaying taper until progress can be made in counseling. Vivitrol similarly has no pre-set stop date.

Suboxone, as an opioid agonist, alleviates physical withdrawal and also blocks euphoria from illicit opioids. However, Vivitrol does not alleviate physical withdrawal and in fact will put an opioid addict into withdrawal if started too soon. For that reason, patients are first started on oral naltrexone tablets and assuming they tolerate the medication well, are then given the injection, which lasts for one month. This opioid blocker prevents euphoria if illicit opioids are used, though it does not reduce opioid cravings.

Compliance was better with Vivitrol than Suboxone. This isn’t surprising, since it’s a once-a month medication. And the more weeks the kids were on Vivitrol, the fewer urine drug screens positive for opioids. With Suboxone, not only were there fewer UDS positive for illicit opioids, but also fewer urine drug screens positive for any illicit drug.

These doctors summarized their experiences by saying that treatment with the medications buprenorphine and naltrexone, in the form of Vivitrol, were well-tolerated, acceptable to patients, and easy to implement. Medications can be easily integrated with counseling as a part of a complete approach to treatment. The use of medication for relapse prevention increased treatment retention. And when kids show up for treatment, they have the opportunity to learn recovery skills.

It’s striking to me that an opioid antagonist is producing as good results as Suboxone. Maybe it’s due to the involvement of the parents of these young people. It’s likely many are financially dependent on their parents, and are therefore more accountable to them. Of course the best thing about Vivitrol is that it doesn’t cause physical dependence, and so can be stopped without difficulty when the patient is ready.

It’s not surprising at all to find Suboxone produces as much benefit in adolescents as it does in adults. The main downside of Suboxone is that it’s difficult to taper, and most patients intend to stop it at some point in their recovery.

During the session, and audience member asked the obvious question: how do we know for sure these medications aren’t going to be harmful in the long run, when used in this young age group? The answer: we don’t know. But we do know what happens to opioid addicts who aren’t treated at all, and to those who drop out of treatment. It isn’t good. With opioid addiction, about half of IV users are dead at 30 years, and the yearly death rate may be as high as 15%. When facing a disease with that mortality, what alternatives do we have? Most doctors think it’s worth taking the risk of possible harm in the future to prevent very bad outcomes now. As we gather more data, hopefully we’ll know more about both the long-term consequences and long-term benefits of medication use.