Pharmacologically assisted treatment of opioid-dependent youth

Patient and provider medication preferences affect treatment outcomes among adolescents and young adults with opioid use disorder

BACKGROUND

The opioid epidemic in the United States has not spared youth or young adults, as evidenced by a six-fold increase in opioid use disorder (OUD) diagnoses in the last two decades. Given this dramatic rise, a call for greater uptake and accessibility of medications for opioid use disorder (MOUDs) among youth and young adults has ensued, resulting in an increasing number of MOUD treatment pathways for this vulnerable population.

METHODS

This secondary data analysis seeks to characterize patient and provider preferences for MOUD treatment pathways, and test for associations between baseline MOUD treatment preferences and opioid use and treatment adherence outcomes. Participants included 288 youth and young adults (age 15-21 years), recruited from a residential treatment program in Maryland. The study assessed patient preferences at baseline (n = 253) and provider preferences at patient treatment discharge (n = 224). Mixed-effects negative binomial regression models were conducted for opioid use outcomes, and logistic regressions were conducted for treatment adherence outcomes.

RESULTS

Results indicate that congruence of treatment with patients' (Incidence Rate Ratio [IRR] = 0.65) and providers' (IRR = 0.66) preferences was significantly associated with reduced self-reported days of opioid use in the past 90 days, but only for patients receiving extended-release naltrexone (XR-NTX). Results also indicated that patients were less likely to switch medication treatment pathways (e.g., from XR-NTX to buprenorphine, or vice versa) during follow-up if they received their preferred treatment at baseline, a finding which held true for both XR-NTX (Odds Ratio [OR] = 0.32) and buprenorphine (OR = 0.22).

CONCLUSIONS

Receipt of MOUD congruent with patient and provider preferences was associated with reduced opioid use and greater treatment adherence in this sample of youth and young adults with OUD.

Analysis of rising cases of adolescent opioid use presentations to the emergency department and their management

OBJECTIVE

We sought to answer the question of how adolescents (ages 12-17 years old) with opioid-related presentations are currently managed in the ED. The two main outcomes were the proportion of visits where naloxone and buprenorphine were both used and prescribed, and the rate of revisits to the emergency department in the six months following ED presentation.

METHODS

This was a multi-center retrospective cross-sectional study. We studied patients presenting to the ED who were 12-17 years old with an opioid-related presentation.

RESULTS

Two-hundred and thirty-one patients were identified out of 571 encounters screened. Of these presentations, 77/231 (33%) were girls and 154/231 (67%) were boys. The majority of patients were Latino (64%; n=147); 26% were white (n=59), 6% were middle eastern or Arab (14), and 4% were black (10). Incidence of opioid use disorder per 100,000 presentations increased by 2800% from 2014 to 2022 (21/100,000 +/- 10 [2014] to 600/100,000 +/- 50 [2022]). A plurality of cases was related to opioid withdrawal (42%; 97). On discharge from the ED, 29% of patients received naloxone. For patients in withdrawal, 4% received a prescription for buprenorphine. Twenty-nine percent of patients had a return to the ED in the six months following initial visit.

CONCLUSIONS

Adolescent opioid-related presentations to the ED are rapidly increasing. Increasing ED presentations, compounded by a high 6-month revisit rate, pose a management challenge amid limited outpatient resources for this population. Opioid agonist therapy and naloxone are not routinely provided. Increasing the use of both are two ways to improve the quality of care for this population.

Buprenorphine and its formulations: a comprehensive review

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

Treatment approaches and outcome trajectories for youth with high-risk opioid use: A narrative review

AIM

First use of opioids often happens in adolescence and an increasing number of opioid overdoses are being reported among youth. The purpose of this narrative review was to present the treatment approaches for youth with high-risk opioid use, determine whether the literature supports the use of opioid agonist treatment among youth and identify evidence for better treatment outcomes in the younger population.

METHODS

A search of the literature on PubMed using MeSH terms specific to youth, opioid use and treatment approaches generated 1436 references. Following a screening process, 137 papers were found to be relevant to the treatment of high-risk opioid use among youth. After full-text review, 19 eligible studies were included: four randomized controlled trials, nine observational studies and six reviews.

RESULTS

Research for the different treatment options among youth is limited. The available evidence shows better outcomes in terms of retention in care and cost-effectiveness for opioid agonist treatment than abstinence-based comparisons. Integrating psychosocial interventions into the continuum of care for youth can be an effective way of addressing comorbid psychiatric conditions and emotional drivers of substance use, leading to improved treatment trajectories.

CONCLUSIONS

From the limited findings, there is no evidence to deny youth with high-risk opioid use the same treatment options available to adults. A combination of pharmacological and youth-specific psychosocial interventions is required to maximize retention and survival. There is an urgent need for more research to inform clinical strategies toward appropriate treatment goals for such vulnerable individuals.

Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses

Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.

Extended-release naltrexone for youth with opioid use disorder

BACKGROUND

Few published research studies have examined the effectiveness of extended-release naltrexone (XR-NTX) for the treatment of opioid use disorder (OUD) among adolescents and young adults.

METHODS

This two-group randomized controlled trial recruited 288 youth, ages 15-21, with moderate/severe OUD from a residential addiction treatment program in Baltimore, Maryland. The study randomized the youth within the first week of treatment entry to receive either XR-NTX or treatment-as-usual (TAU; either buprenorphine maintenance treatment or treatment without OUD medication following medically managed withdrawal) prior to discharge, with continued treatment in the community for 6 months. However, due to various reasons spanning patients' and caregivers' preferences and constraints, considerable participant nonadherence to randomized condition occurred (i.e., only 30% of the participants randomized to XR-NTX received an initial injection, while 27% of participants randomized to TAU received an XR-NTX injection at treatment discharge, instead of their assigned treatment). The study used generalized linear mixed modeling (GLiMM) to examine self-reported 90-day opioid, cocaine, marijuana, and alcohol use as well as DSM-5 OUD criteria on "intention-to-treat" (as randomized), "as-received" (XR-NTX vs. not XR-NTX), and "as-medicated" (XR-NTX vs. buprenorphine vs. no medication) bases.

RESULTS

The condition x time interactions in the intention-to-treat analyses failed to reach significance for past-90-day self-reported use of illicit opioids, cocaine, marijuana, or alcohol, or in meeting DSM-5 OUD criteria at 3 or 6 months [all ps > 0.05]. However, these findings are of limited interpretive value due to participant nonadherence to their randomized condition. When the study analyzed results by the treatment received at discharge, the "as-received" group x time interaction for illicit opioid use was significant [p = .003], with the XR-NTX group reporting less opioid use in the past 90 days at 3 and 6 months. Participants who received their first XR-NTX dose at inpatient discharge (n = 82) received, on average, 1.3 subsequent injections in the community over the 6-month study follow-up period. Only 2 of the 82 study participants received XR-NTX continuously through the 6-month postdischarge follow-up period. Twelve serious adverse events (SAEs) occurred during the study, but the study determined that only 1 was possibly study related (hepatitis C/elevated liver function test results).

CONCLUSION

None of the condition x time interactions in the intention-to-treat analyses reached significance. Participants' nonadherence may have contributed to the failure to reject the null hypothesis. Irrespective of randomized condition, participants who received XR-NTX for OUD demonstrated low retention in treatment, receiving an average of only 1.3 subsequent injections, yet reported less opioid use at follow-up than participants who did not received XR-NTX. Treatment programs should consider XR-NTX as a treatment option for youth motivated to receive it. Future research should focus on building developmentally informed strategies to improve uptake of and adherence to relapse prevention medication in this population.

Buprenorphine Treatment for Adolescents and Young Adults With Opioid Use Disorders: A Narrative Review

: In the past decade, a new cohort of adolescents and young adults with opioid use disorders (OUD) has emerged. While medications and psychosocial treatments are available, few adolescents and young adults with OUD can access and remain in treatment. Effective, practical, and scalable treatment paradigms for this young population are needed. Buprenorphine is a medication with unique pharmacological and regulatory characteristics that make it a promising component of adolescent and young adult OUD treatment models. Three randomized controlled trials and multiple observational studies have evaluated the use of buprenorphine to treat this population. However, data from these studies have not been consolidated into an up-to-date summary that may be useful to clinicians. The objective of this narrative review is to inform clinical practice by summarizing results of primary and secondary analyses from randomized controlled clinical trials and observational studies that have evaluated the use of buprenorphine to treat adolescents and young adults with OUD. Based on results from these studies, we encourage the conceptualization of OUD among youth as a chronic medical condition requiring a long-term management strategy. This includes treatment with buprenorphine in conjunction with medication-prescribing protocols that do not necessarily require daily clinic attendance for observed medication adherence. However, more study of treatment delivery models, addressing such issues as medication adherence and intensity requirements, is needed to determine practices that optimize outcomes for youth.

Age related medication for addiction treatment (MAT) use for opioid use disorder among Medicaid-insured patients in New York

BACKGROUND

Medication for addiction treatment (MAT) has received much attention in recent years for treating individuals with opioid use disorders (OUD). However, these medications have been significantly underused among particular subgroups. In this paper, we describe the age distribution of treatment episodes for substance use disorder among Medicaid beneficiaries in New York and corresponding MAT use.

METHODS

Using New York Medicaid claims, we identified individuals with OUD that received treatment for substance use disorder in 2015. The type of substance use treatment is the primary outcome measure, which includes methadone, buprenorphine, naltrexone or other non-medication treatment.

RESULTS

A total of 88,637 individuals were diagnosed with OUD and received treatment for substance use disorder and 56,926 individuals received some type of MAT in 2015, with 40.2% receiving methadone, 21.9% receiving buprenorphine and 2.2% receiving naltrexone while 21.9% received non-medication based treatment. Young adults (ages 18-29) were a large proportion (25%) of individuals in treatment for OUD yet were the least likely to receive MAT. Relative to young adults, 30-39 year olds (adjusted odds ratio [AOR] = 1.62, 95% CI = 1.56-1.68), 40-49 year olds (AOR = 1.90, 95% CI = 1.82-1.99), 50-59 year olds (AOR = 2.65, 95% CI = 2.52-2.78), and 60-64 year olds (AOR = 5.03, 95% CI = 4.62-5.48) were more likely to receive MAT.

CONCLUSIONS

These preliminary findings highlight high numbers of young adults in treatment for OUD and low rates of MAT, which is not consistent with treatment guidelines. Significant differences exist in the type of medication prescribed across age. More attention is needed to address the treatment needs among individuals of different age, notably young adults.

Medication-assisted treatment for youth with opioid use disorder: Current dilemmas and remaining questions

The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth (adolescents and young adults age 15-25) in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with opioid use disorder, and there is an urgent need to expand evidence-based care for treatment of opioid use disorder among this population. Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. In this article, we outline the current dilemmas and questions regarding the use of medication-assisted treatment among youth with opioid use disorder and propose some potential solutions based on the current evidence.

Home-based delivery of XR-NTX in youth with opioid addiction

Early experience with relapse prevention medications in the treatment of opioid addiction in youth has been positive, but barriers to effectiveness and broader adoption have included problems with adherence and retention, and lack of evidence or consensus about implementation. In particular there is relatively little known about either the effectiveness of extended release naltrexone (XR-NTX) in youth, or optimal models of care for its delivery. The purpose of this study is to report on a pilot initiative to improve the effectiveness of XR-NTX by delivering doses at home with assertive outreach to patients enrolled in a community treatment outpatient program. This is a naturalistic case series based on retrospective chart abstractions of 14 young adults (mean age=20.5), who enrolled in the pilot program, and in particular, the 9 who received home-based doses of XR-NTX. They are compared to a historical group of patients (n=21) prior to the pilot, who were referred to receive standard clinic-based doses of XR-NTX. Home-based administration was viewed favorably by patients and families. Although the small sample size is not amenable to statistical analysis, patients in the home based group, compared to the historical clinic-based group, received a greater number of doses overall and over 16 weeks of treatment, had longer retention, and attended similar numbers of clinic-based counseling sessions. These preliminary findings suggest that home-based delivery of XR-NTX and assertive outreach are feasible and promising in this critical target population, may compare favorably to clinic-based treatment as usual, and should be explored further in more rigorous evaluations.

Still "at risk": An examination of how street-involved young people understand, experience, and engage with "harm reduction" in Vancouver's inner city

BACKGROUND

Vancouver is an international leader in implementing interventions to reduce harms related to drug use. However, street-involved young people who use drugs continue to be vulnerable to overdose death, hepatitis C (HCV) infection, and high rates of syringe sharing. To better understand this in the context of the intensive public health response, we examined how young people, who are involved in the 'street drug scene', understood, experienced and engaged with harm reduction.

METHODS

Twelve semi-structured interviews were conducted in 2013 with 13 young people (ages 17-28) recruited from the At-Risk Youth Study, a prospective cohort of street-involved and drug-using young people. These interviews were embedded within a larger, eight-year program of ethnographic research and explored participants' understandings of harm reduction, their use of specific services, and their ideas about improving their day-to-day lives. Interviews were transcribed verbatim and a thematic analysis was performed.

RESULTS

Young peoples' ideas about harm reduction were diverse and expansive. They articulated the limitations of existing programs, indicating that while they are positioned to reduce the risk of HIV and HCV transmission, they offer little meaningful support to improve young peoples' broader life chances. Young people described strategies to mitigate risk and harm in their own lives, including transitioning to drugs deemed less harmful and attempting to gain access to drug treatment. Finally, young people indicated that spatial considerations (e.g., distance from Vancouver's Downtown Eastside) strongly determined access to services.

CONCLUSIONS

In Vancouver, a large, well established harm reduction infrastructure seeks to reduce HIV and HCV transmission among street-involved young people. However, young peoples' multiple understandings, experiences and engagements with harm reduction in this setting illustrate the limitations of the existing infrastructure in improving their broader life chances.

Prevention, early intervention, harm reduction, and treatment of substance use in young people

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision-which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Relapse prevention medications in community treatment for young adults with opioid addiction

BACKGROUND

Despite the well-known effectiveness and widespread use of relapse prevention medications such as extended release naltrexone (XR-NTX) and buprenorphine for opioid addiction in adults, less is known about their use in younger populations.

METHODS

This was a naturalistic study using retrospective chart review of N = 56 serial admissions into a specialty community treatment program that featured the use of relapse prevention medications for young adults (19-26 years old) with opioid use disorders. Treatment outcomes over 24 weeks included retention and weekly opioid-negative urine tests.

RESULTS

Patients were of mean age 23.1, 70% male, 86% Caucasian, 82% with history of injection heroin use, and treated with either buprenorphine (77%) or XR-NTX (23%). The mean number of XR-NTX doses received was 4.1. Retention was approximately 65% at 12 weeks and 40% at 24 weeks, and rates of opioid-negative urine were 50% at 12 weeks and 39% at 24 weeks, with missing samples imputed as positive. There were no statistically significant differences in retention (t = 1.87, P = .06) or in rates of weekly opioid-negative urine tests (t = 1.96, P = .06) between medication groups, over the course of 24 weeks. The XR-NTX group had higher rates of weekly negative urine drug tests for other nonopioid substances (t = 2.83, P < .05) compared with the buprenorphine group. Males were retained in treatment longer and had higher rates of opioid-negative weeks compared with females.

CONCLUSIONS

These results suggest that relapse prevention medications including both buprenorphine and XR-NTX can be effectively incorporated into standard community treatment for opioid addiction in young adults with good results. Specialty programming focused on opioid addiction in young adults may provide a promising model for further treatment development.

Inability to access addiction treatment predicts injection initiation among street-involved youth in a Canadian setting

Background

Preventing injection drug use among vulnerable youth is critical for reducing serious drug-related harms. Addiction treatment is one evidence-based intervention to decrease problematic substance use; however, youth frequently report being unable to access treatment services and the impact of this on drug use trajectories remains largely unexplored. This study examines the relationship between being unable to access addiction treatment and injection initiation among street-involved youth.

Methods

Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth aged 14–26 who use illicit drugs, from September 2005 to May 2014. An extended Cox model with time-dependent variables was used to identify factors independently associated with injection initiation.

Results

Among 462 participants who were injection naïve at baseline, 97 (21 %) initiated injection drug use over study follow-up and 129 (28 %) reported trying but being unable to access addiction treatment in the previous 6 months at some point during the study period. The most frequently reported reason for being unable to access treatment was being put on a wait list. In a multivariable Cox regression analysis, being unable to access addiction treatment remained independently associated with a more rapid rate of injection initiation (Adjusted Hazard Ratio =2.02; 95 % Confidence Interval: 1.12–3.62), after adjusting for potential confounders.

Conclusion

Inability to access addiction treatment was common among our sample and associated with injection initiation. Findings highlight the need for easily accessible, evidence-based addiction treatment for high-risk youth as a means to prevent injection initiation and subsequent serious drug-related harms.