Reviewing the latest literature on opioid use among adolescents, pediatric resident Sara Mixter found a slow increase in heroin use by teens over the past two decades, but a dramatic increase – from 4 percent in 1992 to 10 percent in 2010 – in teens using prescription opioids like hydrocodone and oxycodone (Monitoring the Future Study, NIDA). The rise in those addicted, Mixter explained, was due in part to increased availability via opioid prescriptions, which have risen 402 percent from 1997 to 2007 (JAMA 2011;306(20):2258-2259).
“Over half of 12th graders said it’s ‘fairly easy’ or ‘very easy’ to get prescription narcotics,” said Mixter at a recent Hopkins Children’s Grand Rounds. “Only 19 percent of teens who got opioids got them from a drug dealer, with most receiving or buying opioids from friends or family, stealing them or using their own prescriptions.”
The issue is especially important for pediatricians, Mixter noted, because opioid use among adolescents is four times higher than that of adults, and because adolescents may have an increased sensitivity to the “reward” effects of substance abuse and move more rapidly to dependence. Also, there’s significant harm associated with opioid use, including infection with intravenous drug use like HIV and hepatitis, and overdose.
“As we’ve seen the rate of opioid use increase in the community, we’ve also seen an increase in overdoses,” Mixter said. “These are dangerous medications, obviously.”
Methadone and buprenorphine, two forms of opioid replacement therapy (ORT) that use long-acting opioid receptor binders to decrease withdrawal and cravings, have been remarkably successful, Mixter noted. In abstinence-only programs, 70 to 95 percent of patients continue to use drugs compared with 40 to 65 percent of patients receiving ORT (The Cochrane Library 2009, Issue 3).
Another medication, suboxone – a combination of buprenophrine and naloxone – was especially effective in adolescents undergoing detox. In a randomized controlled trial against clonidine, more patients using suboxone completed detox (72 percent) than those using clonidine (29 percent). Also, 61 percent of patients in the suboxone group went on to maintenance therapy, compared with 5 percent in the clonidine group (Arch Gen Psychiatry 2005;62:1165). Another study of adolescents showed significant benefit in using suboxone as a 12-week maintenance therapy, too (JAMA 2008;300(17):2003-2011).
The effectiveness of traditional opioid replacement therapies, however, have been hampered by patients’ lack of adherence to daily dosing requirements. But a newer, 30-day injection formulation of the drug naltrexone – a long-acting antagonist that blocks the euphoric effects of opioids – appears to be getting around the adherence issue. Mixter cited a 19-day case study at Mountain Manor, a Baltimore substance abuse treatment center, that showed good results in keeping patients in therapy and abstinent from drugs (Addiction 2010;105:1669-1676).
“Obviously, there’s a big role for the depot long-acting injection forms of these medications, so patients don’t have to take them every day to maintain sobriety and reduce cravings,” Mixter said. “They are another option in our arsenal for treating adolescents.”
These therapies traditionally have been used in substance abuse centers, Mixter added, but pediatrician can be trained to use them in the primary care environment.