Treatment options for_juveniles_final

558 views

Published on

Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Treatment Options for Juveniles
presentation by Michelle Lipinski and Dr. Marc Fishman.

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
558
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
28
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Treatment options for_juveniles_final

  1. 1. Treatment  Op+ons  for  Juveniles   Michelle  Lipinski,  MeD   Principal,  Northshore  Recovery  High   School,  and  Principal/Founder,  icanhelp   Program   Dr.  Marc  Fishman,  MD   Medical  Director,  Maryland  Treatment   Centers,  and  Assistant  Professor,  John   Hopkins  University  Department  of   Psychiarty    
  2. 2. Learning  Objec+ves  1.  Define  dependency  and  depriva+on.  2.  Iden+fy  states  of  the  World  of  Abnormal   Rearing  (WAR)  cycle.  3.  Explain  clinical  interven+ons  to  break  the   cycle  of  addic+on.  4.  Plan  how  to  collaborate  with  law   enforcement  and  the  medical  community  to   bring  support  to  juveniles.  
  3. 3. Disclosure  Statement  •  Michelle  Lipinski  has  no  financial  rela+onships   with  proprietary  en++es  that  produce  health   care  goods  and  services.    •  Dr.  Marc  Fishman  has  no  financial   rela+onships  with  proprietary  en++es  that   produce  health  care  goods  and  services.    
  4. 4. Do  They  Know  We  Can  Help?   Michelle  Lipinski,  M  Ed   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  5. 5. The  Adolescent  Brain  Back  of  brain  matures  before  to  the  front  of  the  brain     sensory  and  physical  ac+vi+es  favored  over  complex,   cogni+ve-­‐demanding  ac+vi+es     propensity  toward  risky,  impulsive  behaviors     •  group  sengs  may  promote  risk  taking     poor  planning  and  judgment     ac+vi+es  with  high  excitement  and  low  effort  are  preferred     poor  modula+on  of  emo+ons  (hot  emo+ons  more  common   than  cold  emo+ons)     heightened  interest  in  novel  s+muli  
  6. 6. Adolescent  Brain  Development,     Decision-­‐Making,  and  Risk   We  begin  with  these  basic  facts:   •  The  adolescent  brain  is  not  developed  as  fully   as  the  adult  brain  –  impulse  behaviors  are  less   controlled.   •  Immaturity  of  cogni+ve  processing  may  lead  to  risky   decisions.   •  The  presence  of  peers  influences  decision-­‐making.   •  Strong  emo+ons  may  override  ra+onal  decision-­‐making.   •  Risk-­‐taking  may  facilitate  adolescent  transi+ons.   The  above  are  true  for  all  adolescents  –  but  are  o`en   magnified  for  adolescents  with  learning  disabili+es.  Source:  Reviewed  in:  Dahl,  RE  (2004)  Ann.  N.Y.  Acad.  Sci.  1021:  1-­‐22  
  7. 7. Psychosocial  Impact  on  Adolescents  with   LD   The  normal  psychosocial  pressures  that  adolescents   face  are  magnified  for  those  with  learning   disabili+es:   •  Peer  culture  and  pressure  –  social  clusters   •  Isola+on   •  Intolerance   •  Low  self-­‐esteem   •  Hormones   •  Environmental  differences  –  home  life,  trauma,   social  connectedness,  etc.  Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  
  8. 8. Low  Self-­‐Esteem   •  Low  self-­‐esteem  is  considered  by  many  researchers  to   be  one  of  the  leading  influencers  for  substance  use   and  misuse  among  adolescents.   •  Adolescents  who  have  a  nega+ve  self-­‐image  and  feel   that  they  are  incompetent  are  more  vulnerable  to   peer  pressure  and  more  prone  to  turn  to  alcohol  and   drugs  for  comfort  and  acceptance.   •  Adolescents  with  learning  disabili+es  are  par+cularly   suscep+ble  to  low  self-­‐esteem  and  its  nega+ve   consequences.  Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  
  9. 9. Social-­‐Connectedness   •  Adolescents  with  learning  disabili+es  o`en   experience  difficulty  and  frustra+on  dealing  with   others.   •  They  are  less  likely  to  be  involved  in  extracurricular   ac+vi+es.   •  According  to  the  2011  NSDUH,  youths  that   reported  par+cipa+ng  in  1  or  fewer  ac+vi+es  also   reported  higher  use  of  illicit  drugs    (15.7%  vs   9.4%),  high  use  of  marijuana  (13.3%  vs.  7.3%),   were  almost  twice  as  likely  to  smoke  cigareces   (15.4%  vs.  6.7%)  and  reported  more  binge  use  of   alcohol  (10.9%  vs.  7.1%).  Source:  2011  NSDUH  
  10. 10. Academic  Difficulty  or  Failure   •  Youth  with  learning  disabili+es  have  a  higher   incidence  of  academic  difficul+es,  which  also   make  them  more  vulnerable  to  substance  use   and  abuse.   •  According  to  the  2011  NSDUH,  youth  who   reported  geng  a  “D”  or  lower  the  last  reported   grading  period  when  compared  to  students  who   received  higher  grades  were  3  +mes  more  likely   to  use  illicit  drugs  (27.1%  vs.  9.5%),  use  marijuana   (22.4%  vs.  7.5%),  smoke  cigareces  (25.2%  vs.   7.0%)  and  binge  drink  (16.8%  vs.  7.2%).  Source:  2011  NSDUH  
  11. 11. Substance  Use  Among  High  School  Drop-­‐ outs  Past  Month  Substance  Use  among  12th  Grade  Aged  Youths,  by  Dropout  Status:  2002  to  2010  
  12. 12. Overlap  of  Substance  Abuse  Risk  Factors   and  LD  CharacterisUcs   SUD  Risk  Factors   LD  CharacterisUcs   Low  self-­‐esteem   Low  self-­‐esteem   Academic  failure   Academic  Failure   Depression   Depression   Desire  for  acceptance   Peer  rejec+on  Source:  Substance  abuse  and  learning  disabili+es:  peas  in  a  pod  or  apples  and  oranges?  (September  2000),  retrieved  from  hcp://www.casacolumbia.org  
  13. 13. ADHD  &  Substance  Abuse     Acen+on  deficit  hyperac+vity  disorder  (ADHD)  has  a   prevalence  of  3–9%  in  the  general  childhood  popula+on  and   1–5%  in  the  general  adult  popula+on.     ADHD  affects  between  11  and  35%  of  “substance-­‐abusing”   adults,  o`en+mes  complica+ng  treatment  response.  ¹     Childhood  onset  ADHD  has  not  only  been  associated  with  an   increased  risk  of  substance  abuse,  but  has  also  been  linked  to   behaviors  that  are  indica+ve  of  more  severe  pacerns  of   substance  use,  such  as  earlier  onset,  longer  substance  use   careers,  poorer  treatment  reten+on,  and  higher  relapse  rates.²Source:¹  hcp://informahealthcare.com/doi/abs/10.1080/10826080500294858;  ²Biederman  et  al,  1995;  Wilens,  2006;  Sullivan  &  Rudnik-­‐Levin,  2001,  as  cited  in  Torok,  et  al.  (2012)  Acen+on  deficit  disorder  and  severity  of  substance  use:  the  role  of  comorbid  psychopathology.  Psychology  of  Addic+ve  Behaviors,  Vol.  26,  No.  4,  974-­‐979  
  14. 14. Perceived  Risk  
  15. 15. What  are  our  children  using  to  get   high?  
  16. 16. Youth  do  not  realize,  We  Can  Help   Them    We  are  not  reaching  our  youth  who  need  help      The  youth  do  not  know  they  have  a  problem  
  17. 17. Our  Words,  Our  Ac+ons,  Our   Compassion  “Too often we underestimate the power of a touch, asmile, a kind word, a listening ear, an honestcompliment, or the smallest act of caring, all of whichhave the potential to turn a life around.”  ― Leo Buscaglia 22  
  18. 18. Where  does  it  begin?  •  More  than  half  of  new  illicit  drug  users  begin   with  marijuana.  Next  most  common  are   prescrip+on  pain  relievers,  followed  by   inhalants  (which  is  most  common  among   younger  teens).  
  19. 19. Just  Weed  •  AXer  alcohol,  marijuana  has  the  highest  rate   of  dependence  or  abuse  among  all  drugs.  In   2011,  4.2  million  Americans  met  clinical   criteria  for  dependence  or  abuse  of  marijuana   in  the  past  year—more  than  twice  the  number   for  dependence/abuse  of  prescrip+on  pain   relievers  (1.8  million)  and  four  +mes  the   number  for  dependence/abuse  of  cocaine   (821,000).  
  20. 20. Crea+ng  a  Bridge  to  Services  The  icanhelp  program  builds  help-­‐seeking  and  early  engagement  by  establishing  “safe”  places  for  adolescents  to  develop  a  trus+ng  rapport  with  adults  in  the  community   25  
  21. 21. icanhelp  Essen+al  Components   Follow-­‐Up Awareness Help-­Seeking Link  to   Resources Identi9ication Engagement Strengthen    Build   Resources 26  
  22. 22. Build  Awareness  of  the  icanhelp   Program   Let  youth  and  young  adults   Awareness know  who  to  contact  related  to   the  icanhelp  program   •  icanhelp  logos   •  icanhelp  posters  Iden+fy  icanhelp  Representa+ves   •  icanhelp  presenta+ons  using  icanhelp  Logos  •  The  presence  of  the  icanhelp   logo  signals  that  this  is  a  safe   person  •  Logos  are  reserved  for  people   who  have  been  trained  and  are   members  of  the  icanhelp  team   27  
  23. 23. icanhelp  Posters:  Facilita+ng  the   Conversa+on   If you’re thinking these thoughts... If you’re thinking these thoughts... you may need help. you may need help. Look for the I CAN HELP sticker Look for the I CAN HELP sticker to find a safe person to talk to. to find a safe person to talk to. www.icanhelp.me www.icanhelp.me 28  biopsychosocial  issues   addic+ve  behavior  and  issues  
  24. 24. Support  Youth  So  They  Seek  Help   Youth  are  more  likely  to  seek  help   if…   •  The  adults  around  them  have   posi+ve  atudes  about  help   seeking   Help-­Seeking •  They  think  adults  will  respond   •  They  are  willing  to  overcome  Youth  are  more  likely  to  seek  help  from  informal  supports  such  as   peer  secrecy  requests  (help-­‐friends,  family  or  mentors  rather   seeking  for  friend)  than  professionals.   •  They  think  exis+ng  resources  When  they  seek  professional  help,   can  help  them  they  usually  go  to  someone  familiar   •  They  are  engaged  in  school  such  as  primary  care,  school  nurse  or   29  counselor.  
  25. 25. Why  Target  Adolescents?  •  Mental  health  and  substance  use  problems  o`en  start  in  adolescents   –  About  half  the  adults  with  mental  health  problems  report  experiencing  their  first  episode   during  adolescence  •  Adolescents  do  not  know  that  they  have  a  mental  health/  substance  use  problem   –  There  are  so  many  changes  taking  place  it  is  hard  for  the  youth  and  caregivers  to  know   that  there  is  a  problem  •  Youth  do  not  know  the  route  to  safe  and  suppor+ve  care   –  S+gma  and  lacking  of  knowing  how  to  get  care  leaves  youth  to  their  own  methods   Identi9ication
  26. 26. Being  a  Person  Who  Youth  Go  To  For   Help:  Communica+on  Style  •  Start  where  the  student  is  at   •  Frame  ques+ons  in  a  nonjudgmental   way  •  Building  an  alliance  with  youth  so   they  feel  safe  and  welcome   •  Strength-­‐based  vs.  puni+ve  approach  •  Youth  need  encouragement,   •  Including  the  student  in  decisions,   valida+on  and  support  for   encourage  open  and  honest   expressing  their  opinions   bidirec+onal  discussions     •  Empower  the  student  to  take   responsibility  for  seeking  solu+ons,   and  build  incrementally  on  small   successes   Engagement 31  
  27. 27. Find    Build  Resources  •  In  a  crisis  or  urgent  situa+on,  you  want  to   have  resources  readily  available  •  Develop  a  community  resource  guide  •  Make  the  guide  as  comprehensive  as   possible  –  divide  and  conquer  –  complete   it  as  a  team   Strengthen    Build   Resources 32  
  28. 28. Supports  within  Schools  •  Special  educa+on  •  Social  worker,  psychologist  •  Resource  officer  •  Crisis  response  team  •  Guidance  department  •  Nurse/health  center  •  Administra+on   Strengthen    Build  •  Truancy  official   Resources •  ASOST  supports   •  GSA   •  Alateen   33  
  29. 29. Supports  within  Communi+es  •  Treatment  providers  for  mental  health     addic+ve  disorders   •  Recovery  supports   •  Self-­‐help  groups  •  Parent  supports/groups  •  Primary  Care/ER/Healthcare  •  Drug  free  communi+es  •  Reproduc+ve  health   Strengthen    Build  •  Economic  supports/food  banks   Resources •  GED/educa+on  supports  •  Social  services   •  DCF:  when  to  file  a  51A   •  DMH   •  Workforce  investment  board  •  Courts/juvenile  jus+ce/family  services   •  When  to  file  a  CHINS/CP   34  
  30. 30. Supports  Online  •  Resource  database   •  hcp://icanhelp.me  •  Community     •  hcp://icanhelp.me/community/   •  Wiki   •  Blog   •  and  more  •  Training  Portal   Strengthen    Build  •  Facebook   Resources •  hcp://www.facebook.com/icanhelp.me  •  Future  services   •  icanhelp  newslecer    mailing  list   •  Expanded  search  op+ons  for  resource   database   35  
  31. 31. Contribute  to  Online  Resources   Let  others   benefit  from   your  effort.   •  Share  your   resource  guide   •  Load  the  contact   informa+on  into   the  online   icanhelp  resource   database   36  
  32. 32. Follow  Up:     Why  Services  Don’t  Always  Work   Follow-­‐Up •  Youth  or  family  not  always  ready  to   receive  services,  personal  factors   related  to  mental  and  cogni+ve   func+oning  of  individual  or  family  •  No  service  available  within  a   reasonable  distance,  dropped  services  •  Prac+cal  factors  such  as  insurance,   cost,  transport,  child  care,  eligibility   rules  or  program  scheduling  •  Cultural  factors  such  as  language,   ci+zenship  and  status  •  Nega+ve  experience/bad  rapport  with   provider  •  S+gma  and  labeling  •  Lack  of  cultural  competency   37  
  33. 33. SOAP   •  A  two  week  intensive  a`er-­‐school   program  designed  to  meet  the   specific  needs  of  teens  and  young   adults.  SOAP  provides  a  safe  place  for   teens  and  young  adults  to  spend  their   a`er  school  hours  where  they  can   learn  and  develop  skills  to  support   recovery  from  substance  use   disorders.  
  34. 34. SOAP  Class  Rooms  
  35. 35. SOAP  Ac+vity  Room  
  36. 36. SOAP  Music  Room  
  37. 37. icanhelp.me
  38. 38. IntegraUng  Relapse  PrevenUon  Pharmacotherapy  into  Treatment  of  Opioid   Dependence  for  Youth  
  39. 39. What  should  we  do  with  this  case?  •  17  M  •  Onset  prescrip+on  opioids  15,  progressing  to  daily  use   with  withdrawal  within  8  months  •  Onset  nasal  heroin  16,  injec+on  heroin  6  months  later  •  3  episodes  residen+al  tx,  2  AMA,  1  completed  •  Suboxone  treatment  (monthly  supply  Rx  x  4),  took   erra+cally,  sold  half  •  Presents  in  crisis  seeking  detox  (“Can  I  be  out  of  here   by  Friday?”)  
  40. 40. Past Year Use Prevalence: 8th and 12th Graders (MTF) 1.8   1.6   8th  Graders   12th  Graders   1.4   1.2  Percent   1   0.8   0.6   0.4   0.2   0   91   92   93   94   95   96   97   98   99   00   01   02   03   04   05   06   07   08   09   hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    
  41. 41. MTF:  Annual  Use  Prevalence  12th  Graders   10   12th  Graders   8  Percent   6   4   2   0   91   92   93   94   95   96   97   98   99   00   01   02   03   04   05   06   07   08   09   hcp://www.monitoringthefuture.org/pubs/monographs/overview2009.pdf    
  42. 42. 6%   12  to  17y   18  to  25y    26y       5%   4%  Percent   3%   2%   1%   0%   2002   2003   2004   2005   2006   2007   The    NSDUH  report  February  2009  
  43. 43. Conceptual  underpinnings  •  Use  as  many  effec+ve  tools  as  are  available  •  One  size  does  not  fit  all:  as  many  doors  as  possible  •  A  full  con+nuum  of  care:  mul+ple  services  with  flexible   responses  •  Ins+tu+onal  affilia+on  and  longitudinal  care  promotes   engagement  •  Expecta+on  of  relapsing/reming  course  •  Expecta+on  of  variable  and  shi`ing  treatment  readiness  •  Recovery  as  a  gradual  process,  not  an  overnight  event  -­‐-­‐   expecta+on  of  incremental  progress  
  44. 44. Elements  of  treatment  model  •  Emphasis  on  ongoing  engagement  from  detox  to  next  levels   of  care  (the  revolving  door  should  lead  somewhere)  •  Specialty  care  •  Longitudinal  follow-­‐up  and  management  •  Integra+on  of  relapse  preven+on  medica+on  as  standard  of   care   –  Buprenorphine   –  Extended  release  naltrexone  •  Co-­‐occurring  (dual  diagnosis)  treatment  
  45. 45. 100 90 Full Agonist 80 (Methadone Heroin, oxycodone)Intrinsic Activity 70 60 Partial Agonist 50 (Buprenorphine) 40 30 20 10 Antagonist (Naloxone) 0 -9 -8 -7 -6 -5 -4 Log Dose of Medication
  46. 46. Journal of theAmericanMedicalAssociation, 2008
  47. 47. CTN  Youth  Buprenorphine  Study    Opioid  Posi+ve  Urines:  12  weeks  Bup  vs  Detox     (Woody et al, JAMA 2008)
  48. 48. Percent of confirmed opioid-free weeks (cumulative) Krupitsky et al. Lancet. 2011
  49. 49. Buprenorphine  induc+on  method  •  Residen+al  detox  using  bupe  taper  •  Interrup+on  of  taper,  switch  to  steady  dose,  or  •  Comple+on  of  taper,  later  resume  bupe    •  Alterna+ve  induc+on  as  outpa+ent  (minority)  •  Outpa+ent  maintenance  
  50. 50. Buprenorphine  maintenance  •  Start  weekly  prescrip+on  supply  •  Expecta+on  of  counseling  acendance  •  Frequent  urine  monitoring  •  Increase  dura+on  of  Rx  dura+on  over  +me,  used  as   con+ngency  management  •  Op+onal  tools  for  med  supervision   –  Prescrip+ons  le`  for  counselor  to  distribute   –  Monitored  distribu+on  and/or  administra+on  by   families     –  Direct  med  administra+on  up  to  daily  
  51. 51. XR-­‐NTX  Induc+on  •  Residen+al  detox  using  bupe  taper  •  7  day  abs+nence  by  confinement  •  NTX  induc+on  with  4  d  oral  dose  +tra+on   –  6.26,  12.5,  25,  50  mg  (liquid)  •  1st  dose  injectable  XR-­‐NTX  prior  to   residen+al  discharge  •  Outpa+ent  maintenance  
  52. 52. XR-­‐NTX  Maintenance  •  Monthly  injec+ons  •  Expecta+on  of  counseling  acendance  •  Asser+ve  dosing  reminders  
  53. 53. Why  XR-­‐NTX  MAR?  •  Failure  of  other  treatments  •  Pa+ent  preference  •  Family  preference  •  History  of  poor  treatment  engagement  and   adherence  •  Problems  with  acceptability  of  agonist   pharmacotherapies  •  More  tools  in  the  toolbox  
  54. 54. Why  buprenorphine  MAR?  •  Pa+ent  preference,  esp  if  previous   experience  •  Failure  of  other  treatments  •  Intrinsically  reinforcing  •  Growing  posi+ve  reputa+on  of  bupe  •  Anxiety  about  NTX,  or  poor  tolerance  •  More  tools  in  the  toolbox  
  55. 55. Medica+ons,  mischief,  and  monkey   business  •  Diversion  •  Non-­‐compliance  •  Inconsistency  •  Other  substances  
  56. 56. Case  •  18  F  injec+on  heroin,  mul+ple  failed  treatments  •  Inpa+ent  treatment,  recovery  house,  con+nua+on  suboxone  •  Made  connec+on  to  NA  for  the  first  +me  •  Abs+nent  x  6  months  •  Told  at  NA  mee+ng  “not  really  clean”    stopped  Rx  •  Relapse    •  6  months  later  back  on  suboxone    •  New  stance  towards  Rx  “don’t  ask,  don’t  tell”    •  2  years  abs+nence  
  57. 57. Case  •  18  F  onset  injec+on  heroin  16,  occasional  street  suboxone  •  Outpa+ent  suboxone  maintenance  but  would  take  it  only   intermicently  when  heroin  unavailable  •  Clarified  goal:  not  ready  to  quit,  suboxone  stopped  but  MET   con+nued  •  2  months  later  Rx  restarted  under  mother’s  supervision  with   new  commitment  -­‐-­‐  6  months  abs+nence  
  58. 58. Bricany  •  15  yo  WF  •  1  yr  hx  prescrip+on  opioids,  recent  progression   to  injec+on  heroin,  parents  didn’t  know  extent   of  dependence,  shocked  to  discover  a  needle  •  Parents  compelled  by  idea  of  xr-­‐ntx  
  59. 59. Jennifer  •  17  yo  from  the  suburbs,  injec+on  heroin  x  2  years,  2nd   episode  detox  •  Uses  street  bupe  intermicently  •  Strong  parental  and  juvenile  jus+ce  pressures,   ambivalent  about  quing  •  “If  I  wake  up    there  is  heroin    suboxone  on  the  table  -­‐-­‐   I’ll  use  heroin  every  +me”  •  Agrees  to  trial  of  xr-­‐ntx  
  60. 60. Machew  •  19  M,  3  yr  hx  injec+on  heroin  •  4  previous  episodes  detox,  2  previous   episodes  of  failure  with  bupe  outpt  treatment  •  Wants  to  try  bupe  again  •  Parents  make  xr-­‐ntx  a  condi+on  of  returning   home  
  61. 61. Greg  •  16  M  prescrip+on  opioid  dependence  •  Residen+al  detox,  XR-­‐NTX  induc+on  •  Abs+nent  x  3  months  •  Family  vaca+on,  out  of  town,  dose  #4  delayed  •  While  at  beach  started  deliberate  plan  to  use,  diver+ng  few   dollars  at  a  +me  to  prevent  detec+on  •  On  return,  told  parents  he  was  headed  to  treatment,  went  to   get  drugs  instead,  missed  XR-­‐NTX  •  Relapse  x  3  weeks  •  Brief  residen+al  detox  •  Restart  XR-­‐NTX  with  new  level  of  parental  involvement  
  62. 62. Features  of  youth  treatment  •  Family  leverage  •  Pushback  against  sense  of  parental   dependence  and  restric+on  •  Salience  of  burdens  of  treatment  •  Prominence  of  co-­‐morbidity  •  Family  mobiliza+on  –  “Medicine  may    help   with  the  receptors,  you  s+ll  have  to  parent   your  difficult  teenager”  
  63. 63. Challenges  •  Atudes,  misunderstanding  and  s+gma  •  Adherence  •  Monitoring  and  supervision  •  Range  of  op+ons  may  be  limited   –  Limited  treatment  capacity   –  Limited  insurance  coverage   –  Limited  availability  of  inpa+ent  •  Clock  is  +cking  in  inpa+ent  seng  •  Tensions  in  involving  family,  esp  older  youth  
  64. 64. Challenges  •  Goals  of  treatment  re  other  substances  •  Diversion  of  bupe  •  Need  for  more  intensive  management  op+ons   with  bupe  •  Limited  (and  false)  info  about  xr-­‐ntx  
  65. 65. Youth  opioid  treatment  chart  review  •  Retrospec+ve  review  of  133  pa+ents  entering   outpa+ent  youth  opioid  track  at  Mountain   Manor  in  Bal+more  •  4/07  –  1/10  •  Intake  to  26  weeks  •  All  the  usual  limita+ons  of  messy  clinical   charts  
  66. 66. Youth  opioid  treatment  chart  review   Pa+ent  characteris+cs  Age, mean 18.2 years (range 14-21)Gender, male 53%Race, caucasian 94%Duration of opioid use 2.8 yearsRate of heroin use 80%Rate of injection use 61%In school 23%Current psych Rx 38%Justice system involvement 68%
  67. 67. Youth  opioid  treatment  chart  review   Medica+on  treatment  Treated with:Any medication 61% Buprenorphine 39% Extended release naltrexone 19% Oral naltrexone 3%No medication 39%
  68. 68. Cumula+ve  reten+on  over  26  weeks     by  medica+on  26  24   subsequent    cumula+ve  reten+on  22   1st  episode  reten+on  20   subsequent    cumula+ve  reten+on   *   *  18   *   15.8   15.9  16   15.3  14   4.9   5.5   5.4  12   10.3  10   8   2.5   6   11   10.3   9.9   4   7.8   2   0   Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on   *  =  p    0.01  compared  to  no  medica+on  
  69. 69. Reten+on  by  medica+on   *   *   *  
  70. 70. Opioid-­‐free  weeks  over  26  weeks    by  medica+on   Combining  urine  and  self  report   Opioid  free  weeks,  during  intake  to  week  26,  n  =  133  26  24  22  20  18  16  14   *   *   *  12  10   8   6   13.7   11.5   10.6   4   7   2   0   Any  medica+on   XR-­‐NTX   Buprenorphine   No  medica+on   *  =  p    0.01  compared  to  no  medica+on  
  71. 71. Cumula+ve  reten+on  Propor+ons   1  0.9   Meds  0.8   No  meds  0.7  0.6  0.5  0.4  0.3  0.2  0.1   0   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26  
  72. 72. Cumula+ve  Opioid  Nega+ve  Urines   Opioid Negative Urines 100% 90% 80% XR-NTX Buprenorphine% of Patients 70% No Meds 60% 50% 40% 30% 20% 10% 0% Wks 1-4 Wks 5-8 Wks 9-12 Wks 13-16 Wks 17-20 Wks 21-24 Weeks of Treatment
  73. 73. Addi+onal  Factors   Medica+on  vs.  No  Medica+on   Cross-­‐sec+onal  reten+on  at  26  weeks  50% Medication No40% Medication30%20%10%0%
  74. 74. Conclusions  (I)  • Treatment  with  relapse  preven+on  medica+ons(XR-­‐ NTX  and  buprenorphine)  for  youth  with  opioid   dependence  is  well  tolerated  and  well  accepted  by   pa+ents  and  families,  and  can  be  prac+cally   implemented  as  a  standard  treatment  in  a  community   treatment  program.    • Medica+ons  are  easily  integrated  with  counseling  as   part  of  a  comprehensive  treatment  approach  • Use  of  medica+ons  for  relapse  preven+on  is  associated   with  increased  reten+on  and  treatment  u+liza+on,  and   decreased  drug  use.  
  75. 75. Conclusions  (II)  • Not  surprisingly,  medica+on  compliance  seems  to  be   related  to  effec+veness.  •   Although  pa+ents  dri`  in  and  out  of  treatment,  there   are  substan+al  rates  of  return  to  treatment  following   dropout,  and  re-­‐cessa+on  of  drug  use  following  lapse/ relapse.    • Our  experience  suggests  the  benefits  of  a  more   longitudinal  medical  management  model  of  care  as   compared  to  a  more  tradi+onal  model  of  discrete   episodes  of  care.    
  76. 76. Next  steps  -­‐  clinical  •  Improved  family  involvement  •  How  to  manage  medica+on  discon+nua+on  •  Longer-­‐term  engagement  strategies  •  More  opera+onaliza+on  of  stepped  care      •  Broader  coverage  and  reimbursement,  including  XR-­‐NTX  •  Differen+al  strategies  for  pa+ents  in  early  stages  of  change  in   rela+on  to  other  substances  
  77. 77. Next  steps  –     Research  agenda  from  the  field  •  Longer  term  outcomes?  •  Appropriate  dura+on  of  treatment?  •  Different  medica+on  discon+nua+on  strategies?  •  Bupe  vs  XR-­‐NTX?  •  Post-­‐relapse  strategies  –  s+ck  or  switch?  •  Outpa+ent  vs  inpa+ent  induc+on  •  Dosing  of  counseling  
  78. 78. Case  (1)    16  F  injec+on  heroin  and  depression  •  Ini+al  Rx  oral  NTX,  ineffec+ve  2º  non-­‐adherence  despite  close   parental  monitoring,  even  went  as  far  as  liquid  •  Received  8  doses  XR-­‐NTX,  substan+al  improvement  (despite   sporadic  lapses)  •  Extreme  conflict  with  mother,  moved  in  with  heroin-­‐using   boyfriend  •  Insisted  on  stopping  XR-­‐NTX  2º  injec+on  site  pain  •  5  d  oral  NTX  then  immediate  relapse  and  dropout  
  79. 79. CASE  (2)  •  1  yr  later  (now  18)  presented  back  to  us  a`er  stabilized  on   methadone  1  month,  re-­‐ini+ated  psychotherapy  and  Rx  for   depression  •   A`er  4  months  abs+nent  on  methadone,  switched  to  bupe  •  Erra+c  course  over  4  months  with  sporadic  medica+on  non-­‐ compliance  and  lapses  leading  to  progressive  full  relapse  •  Work  with  family  to  arrange  inpa+ent  treatment  and  detox   with  plan  for  switch  back  to  NTX  •  Surrep++ous  use  of  bupe  and  cheeking  of  NTX  at  residen+al   program  •  Precipitated  withdrawal  when  given  NTX  
  80. 80. Case  (3)  •  Course  of  XR-­‐NTX  for  6  months  •  Half  way  house  and  strong  engagement  in  12  step  fellowship  •  Titra+on  of  an+-­‐depressant  with  gradual  remission  of   depression  and  anxiety  •  Switch  to  oral  naltrexone  for  2  months,  but  “+red  of  meds”  •  Oral  naltrexone  back-­‐up  as  needed  but  rarely  used  •  24  months  sober  •  Working,  pregnancy,  living  with  baby’s  father,  recurrence  of   depression,  break-­‐up,  living  independently  
  81. 81. Pharmacological  Treatment  •  Ques+on:   –  Which  is  becer  -­‐  medica+ons  or  counseling?  •  Answer:   –  Yes  
  82. 82. A  sprint  or  a  marathon?  Early:  I  agree  I  was  out  of  control  with  the  dope,  but   I  can  s+ll  use  a  licle  oxy  on  the  weekends.  Middle:  I’m  a  heroin  addict,  not  an  alcoholic.  I  just   need  to  stop  using  heroin.  A  few  beers  is  fine.  Later:  When  I  get  drunk,  I  end  up  using  heroin  again.   Maybe  I  need  to  stop  drinking  too.  But  taking  a   licle  xanax  when  I’m  stressed  is  no  big  deal.                                                                (sigh)  
  83. 83. Hypothe+cal  Miracle  Cures  

×