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
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.
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.
Do They Know We Can Help? Michelle Lipinski, M Ed April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate
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
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
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
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
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
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
Substance Use Among High School Drop-‐ outs Past Month Substance Use among 12th Grade Aged Youths, by Dropout Status: 2002 to 2010
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
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
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
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
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).
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).
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
icanhelp Essen+al Components Follow-‐Up Awareness Help-Seeking Link to Resources Identi9ication Engagement Strengthen Build Resources 26
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
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
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.
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
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
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
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
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
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
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
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
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.
IntegraUng Relapse PrevenUon Pharmacotherapy into Treatment of Opioid Dependence for Youth
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?”)
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
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
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
Journal of theAmericanMedicalAssociation, 2008
CTN Youth Buprenorphine Study Opioid Posi+ve Urines: 12 weeks Bup vs Detox (Woody et al, JAMA 2008)
Percent of confirmed opioid-free weeks (cumulative) Krupitsky et al. Lancet. 2011
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
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
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
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
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
Medica+ons, mischief, and monkey business • Diversion • Non-‐compliance • Inconsistency • Other substances
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
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
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
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
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
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
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”
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
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
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
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%
Addi+onal Factors Medica+on vs. No Medica+on Cross-‐sec+onal reten+on at 26 weeks 50% Medication No40% Medication30%20%10%0%
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.
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.
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
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
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
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
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
Pharmacological Treatment • Ques+on: – Which is becer -‐ medica+ons or counseling? • Answer: – Yes
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)