Opioid abuse rates have reached epidemic proportions, doubling since the 1990s, and-despite the documented success of medication-assisted therapies in treating opioid addiction-less than half of teens with opioid abuse disorders receive such treatment.
Pediatricians should utilize medication-assisted therapies, such as buprenorphine, for adolescent patients with opioid abuse disorders-and refer those patients elsewhere if they haven’t taken the steps to prescribe such medications, according to a new policy statement from the American Academy of Pediatricians (AAP).
Sharon Levy, MD, MPâH, director of the Adolescent Substance Abuse Program at Boston Children's Hospital and associate professor of pediatrics at Harvard Medical School in Massachusetts, helped craft the new policy statement, which she says addresses not only recommended treatment methods, but also issues with access and support.
“When we talk about problems with access to treatment for teenagers with opioid use disorders, the conversation often centers on the lack of available beds in rehabilitation programs,” Levy says. “This is an important issue that needs to be addressed, but can overshadow the equally important issue that we need to provide much more access to community-based treatment for adolescents.”
As with any treatment plan, Levy says there is benefit to using the least restrictive environment when treating adolescents with opioid use disorders.
“Many teenagers with opioid use disorder are able to remain in school and even participate in hobbies, jobs, or extracurricular activities,” Levy says. “This group needs access to medication-assisted treatment so they can get the treatment they need while continuing with the rest of their lives.”
The position paper outlines the options for medication-assisted therapies, as well as direction on how providers can use them.
“With the new policy statement the AAP is supporting medication-assisted treatment for adolescents with opioid use disorders, and also encouraging pediatricians and other professionals that care for adolescents to become waivered and prescribe medications so that teenagers can access developmentally appropriate treatment within their communities,” Levy says.
The AAP has also created a website for members with an 8-hour buprenorphine waiver course and training materials. The course was sponsored and produced by the American Academy of Addiction Psychiatry and has been endorsed by the AAP.
Opioid abuse has reached epidemic proportions across the country, and effective treatments are available but underused. Less than half of a nationally representative sample of 345 addiction treatment programs reviewed in a recent study offered adolescent and adult patients medication to treat opioid use disorders, according to the AAP’s report, and only 34% of opioid-dependent patients in treatment receive medication compared with 70% of patients with mental health disorders in the same programs. Developmentally appropriate treatment is particularly restricted for adolescents and young adults, notes the AAP, and resources to utilize available therapies and develop new treatments are critical to save the lives of adolescents with opioid addictions.
Prescription pain relief use surged following a directive from the US Department of Health and Human Services in 1992. Nonmedical use of opioid medications in adolescents and young adults aged 12 to 25 years more than doubled between 1991 and 2012, and related disorders including heroin addiction have risen at similar levels, with rates of fatal opioid overdose also doubling in this age group between 2000 and 2013. Other health concerns include consequences of intravenous drug abuse, such as endocarditis, abscesses, and blood-borne disease infection.
Recovery from opioid abuse disorders is attainable, says the AAP, but neurologic changes that affect cravings and behavioral changes brought on by chronic abuse can make it difficult. For teenagers, however, treatment options are scarce, making recovery that much more difficult.
According to the American Society of Addiction Medicine (ASAM), 467,000 adolescents aged 12 to 17 years were nonmedical users of pain relievers in 2014, and another 168,000 were addicted. The rate of adolescents using prescription opioids nearly doubled from 1994 to 2007, and most said they got prescription medications for free from friends and family. Another 28,000 admitted to using heroin-a cheaper, accessible alternative for those addicted to prescription opioids-at some point during the year, and another 18,000 had a heroin use disorder, according to the ASAM.
The2012 National Survey on Drug Use and Health
, compiled by the Substance Abuse and Mental Health Services Administration, found that although opioid use among individuals aged 12 to 25 years increased from 1991 to 2012, 90% of teenagers aged 12 to 17 years with opioid addictions received no treatment at all.
Three medications are currently indicated for treating severe opioid abuse-methadone, naltrexone, and buprenorphine. Methadone is a full opioid agonist with a long half-life that has a history of efficacy in treating opioid abuse, but is largely prohibited in patients aged younger than 18 years.
Naltrexone is an opioid antagonist that blocks the effects of opioids and has little potential for abuse or diversion. It can also be used to treat alcohol cravings, making it useful for patients with dual abuse disorders.
Buprenorphine is a partial opioid agonist that can be given by physicians who complete 8 hours of training and apply for a waiver to prescribe the medication. The US Food and Drug Administration (FDA) in 2002 approved the use of buprenorphine in patients aged 16 years and older, and the AAP cites recent studies showing that adolescents treated with buprenorphine for 2 weeks were more likely to continue treatment than those that received clonidine for the same period. Buprenorphine, like methadone, carries a risk for diversion and abuse, but the AAP says the “addiction potential” is thought to be lower than that of other opioid agonists.
The AAP recommends that resources be made increasingly available to improve access to medication-assisted treatments for opioid-addicted adolescents, and that pediatricians consider offering medication assistance to patients with opioid abuse disorders. If a provider is unable to prescribe these medications, the AAP recommends that they discuss referrals to other providers who can. The AAP also calls for more research on these and other developmentally appropriate treatments for substance abuse in teenagers and young adults, as well as primary and secondary prevention methods.
Until recently, physicians could not treat more than 100 patients at a time with buprenorphine, but the Obama administration increased that limit to 275 patients in July 2016 in an effort to increase access to treatment for opioid addiction. Pharmaceutical companies are also working on developing formulations of buprenorphine that can’t be diverted. In May 2016, the FDA approved an implantable form of the medication-Probuphine-that would provide a constant, low-level dose for up to 6 months.