The Role of Pharmacotherapy in the Treatment of Adolescent Substance Use Disorders

Impact of the COVID-19 Pandemic on Youth Substance Use and Substance-Related Risk Factors and Outcomes: Implications for Prevention, Treatment, and Policy

Youth substance use and substance use disorders (SUD) are major public health issues associated with significant societal cost. The coronavirus SARS-CoV-2 (COVID-19) pandemic and pandemic-related lockdowns, school closures, and social distancing dramatically impacted the daily lives of young people worldwide, resulting in major disruptions to normal developmental trajectories and complex (and at times opposing effects) on different SUD risk and protective factors, which contributed to inconsistent outcomes. During the COVID-19 pandemic, substance use prevalence rates decreased in the general population of US youth, but increased for certain vulnerable subgroups. Additionally, overdose deaths related to fentanyl rose significantly among US youth.

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

"No Excuses Anymore": Substance Use Screening and Treatment for Justice-involved Youth

OBJECTIVE

The aim of this study was to present best practices for substance use disorder (SUD) screening and treatment in the juvenile justice setting.

METHODS

Semistructured qualitative interviews, informed by the Capability-Opportunity-Motivation-Behavior Model, were conducted with medical and behavioral health providers with experience caring for justice-involved youth. Interviews were analyzed using thematic and content analysis to elucidate best practices and identify facilitators and barriers affecting implementation of evidence-based substance use screening and treatment.

RESULTS

We interviewed 14 participants from 12 unique institutions and 9 states. All participants described the populations in their facilities as predominately male and minoritized, with substance use being an exceedingly common problem. Eight main themes emerged from analysis of the barriers and facilitators discussed by participants. These included the importance of (1) ensuring substance use-specific training for all team members, (2) integrating medical and behavioral health care, (3) addressing staff reticence and stigma, (4) building an institutional culture that supports screening and treatment, (5) dedicating adequate resources with respect to time, staffing, and funding, (6) formalizing and standardizing screening and treatment protocols, (7) engaging youth using trauma-informed approaches that emphasize youth strengths and autonomy, and (8) collaborating with multidisciplinary teams and community partners to maximize linkage to follow-up care after release.

CONCLUSIONS

Our findings highlight an urgent need for improved implementation of evidence-based, developmentally appropriate substance use treatment for justice-involved youth. Although the majority of participants screen youth, they described variable implementation of behavioral health interventions and limited provision of on-site withdrawal management and treatment using medications for SUD.

Old Dog, New Tricks: A Review of Identifying and Addressing Youth Cannabis Vaping in the Pediatric Clinical Setting

Cannabis vaping has emerged as a predominant mode of cannabis use among United States (US) adolescents and young adults (AYA) primarily due to the popularity of modifiable designs of vaping devices coupled with changes in cannabis policies and increased availability of cannabinoid products. New methods for cannabis vaping by e-liquid/oil vaping, dry plant vaping, and cannabis concentrate vaping (ie, dabbing) have had high uptake among American youth with unclear long-term health implications. Issues with contamination, mislabeling, and expansion of the vaped cannabis market to include not only delta-9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) but also delta-9-THC analogs (eg, delta-8 and delta-10) sold as hemp-derived "legal highs" further complicated this healthcare space. Recent research suggests that cannabis/THC vaping carries distinct and overlapping risks when compared to cannabis smoking and may be associated with greater risk for acute lung injuries, seizures, and acute psychiatric symptoms. Primary care clinicians providing care for AYA are in an ideal position to identify cannabis misuse and intervene early to address cannabis vaping. To improve public health outcomes, a need exists for pediatric clinicians to be educated about different ways/methods that youth are vaping cannabinoid products and associated risks related to cannabinoid vaping. Further, pediatric clinicians need to be trained how to effectively screen for and discuss cannabis vaping with their youth patients. In the current article, we present a clinically focused review of cannabis vaping among young people with 3 main aims to: (1) identify and describe the cannabis vaping products commonly used by American youth; (2) review the health correlates of youth cannabis vaping; and (3) discuss clinical considerations related to identifying and treating youth who vape cannabis.

Towards an International Consensus on the Prevention, Treatment, and Management of High-Risk Substance Use and Overdose among Youth

Background and Objectives: Now more than ever, there is an obvious need to reduce the overall burden of disease and risk of premature mortality that are associated with mental health and substance use disorders among young people. However, the current state of research and evidence-based clinical care for high-risk substance use among youth is fragmented and scarce. The objective of the study is to establish consensus for the prevention, treatment, and management of high-risk substance use and overdose among youth (10 to 24 years old). Materials and Methods: A modified Delphi technique was used based on the combination of scientific evidence and clinical experience of a group of 31 experts representing 10 countries. A semi-structured questionnaire with five domains (clinical risks, target populations, intervention goals, intervention strategies, and settings/expertise) was shared with the panelists. Based on their responses, statements were developed, which were subsequently revised and finalized through three iterations of feedback. Results: Among the five major domains, 60 statements reached consensus. Importantly, experts agreed that screening in primary care and other clinical settings is recommended for all youth, and that the objectives of treating youth with high-risk substance use are to reduce harm and mortality while promoting resilience and healthy development. For all substance use disorders, evidence-based interventions should be available and should be used according to the needs and preferences of the patient. Involuntary admission was the only topic that did not reach consensus, mainly due to its ethical implications and resulting lack of comparable evidence. Conclusions: High-risk substance use and overdoses among youth have become a major challenge. The system’s response has been insufficient and needs substantial change. Internationally devised consensus statements provide a first step in system improvement and reform.

Therapy Dose Mediates the Relationship Between Buprenorphine/Naloxone and Opioid Treatment Outcomes in Youth Receiving Medication for Opioid Use Disorder Treatment

BACKGROUND

Evidence-based interventions for treating opioid use disorder (OUD) in youth are limited and little is known about specific and general mechanisms of OUD treatments and how they promote abstinence.

METHODS

The present study used data from the NIDA-CTN-0010 trial to evaluate the mediating effects of psychosocial treatment-related variables (therapy dose and therapeutic alliance) on end-of-treatment opioid abstinence in a sample of youth with OUD (n = 152, 40% female, mean age = 19.7 years) randomized to receive either 12-weeks of treatment with Bup/Nal ("Bup-Nal") or up to 2 weeks of Bup/Nal detoxification ("Detox") with both treatment arms receiving weekly individual and group drug counseling ± family therapy.

RESULTS

Participants in the Bup-Nal group attended more therapy sessions (16 vs 6 sessions), had increased therapeutic alliance at week-4, and had less opioid use by week-12 compared to those in the Detox group. In both treatment arms, youth who attended more therapy sessions were less likely to have a week-12 opioid positive urine. In a multiple mediator model, therapy dose mediated the association between treatment arm and opioid abstinence.

CONCLUSIONS

These findings provide preliminary support for a "dose-response" effect of addiction-focused therapy on abstinence in youth OUD. Further, the results identified a mediating effect of therapy dose on the relationship between treatment assignment and opioid treatment outcomes, suggesting that extended Bup-Nal treatment may enhance abstinence, in part, through a mechanism of therapy facilitation, by increasing therapy dose during treatment.

Novel Agents for the Pharmacological Treatment of Alcohol Use Disorder

Alcohol use disorder (AUD) is a highly prevalent but severely under-treated disorder, with only three widely-approved pharmacotherapies. Given that AUD is a very heterogeneous disorder, it is unlikely that one single medication will be effective for all individuals with an AUD. As such, there is a need to develop new, more effective, and diverse pharmacological treatment options for AUD with the hopes of increasing utilization and improving care. In this qualitative literature review, we discuss the efficacy, mechanism of action, and tolerability of approved, repurposed, and novel pharmacotherapies for the treatment of AUD with a clinical perspective. Pharmacotherapies discussed include: disulfiram, acamprosate, naltrexone, nalmefene, topiramate, gabapentin, varenicline, baclofen, sodium oxybate, aripiprazole, ondansetron, mifepristone, ibudilast, suvorexant, prazosin, doxazosin, N-acetylcysteine, GET73, ASP8062, ABT-436, PF-5190457, and cannabidiol. Overall, many repurposed and novel agents discussed in this review demonstrate clinical effectiveness and promise for the future of AUD treatment. Importantly, these medications also offer potential improvements towards the advancement of precision medicine and personalized treatment for the heterogeneous AUD population. However, there remains a great need to improve access to treatment, increase the menu of approved pharmacological treatments, and de-stigmatize and increase treatment-seeking for AUD.

Immune treatments for alcohol use disorder: A translational framework

While the immune system is essential for survival, an excessive or prolonged inflammatory response, such as that resulting from sustained heavy alcohol use, can damage the host and contribute to psychiatric disorders. A growing body of literature indicates that the immune system plays a critical role in the development and maintenance of alcohol use disorder (AUD). As such, there is enthusiasm for treatments that can restore healthy levels of inflammation as a mechanism to reduce drinking and promote recovery. In this qualitative literature review, we provide a conceptual rationale for immune therapies and discuss progress in medications development for AUD focused on the immune system as a treatment target. This review is organized into sections based on primary signaling pathways targeted by the candidate therapies, namely: (a) toll-like receptors, (b) phosphodiesterase inhibitors, (c) peroxisome proliferator-activated receptors, (d) microglia and astrocytes, (e) other immune pharmacotherapies, and (f) behavioral therapies. As relevant within each section, we examine the basic biological mechanisms of each class of therapy and evaluate preclinical research testing the role of the therapy on mitigating alcohol-related behaviors in animal models. To the extent available, translational findings are reviewed with discussion of completed and ongoing randomized clinical trials and their findings to date. An applied and clinically focused approach is taken to identify the potential clinical applications of the various treatments reviewed. We conclude by delineating the most promising candidate treatments and discussing future directions by considering opportunities for immune treatment development and personalized medicine for AUD.

Screening for Unhealthy Drug Use: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

An estimated 12% of adults 18 years or older and 8% of adolescents aged 12 to 17 years report unhealthy use of prescription or illegal drugs in the US.

OBJECTIVE

To update its 2008 recommendation, the USPSTF commissioned reviews of the evidence on screening by asking questions about drug use and interventions for unhealthy drug use in adults and adolescents.

POPULATION

This recommendation statement applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment. This statement applies to settings and populations for which services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

EVIDENCE ASSESSMENT

In adults, the USPSTF concludes with moderate certainty that screening by asking questions about unhealthy drug use has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred. In adolescents, because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for unhealthy drug use are uncertain and that the balance of benefits and harms cannot be determined.

RECOMMENDATION

The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. (I statement).

Management of Opioid Misuse and Opioid Use Disorders Among Youth

In response to the growing impact of the current opioid public health crisis in the United States on adolescents and young adults, pediatricians have an expanding role in identifying opioid use early, preventing escalation of risky use, reducing opioid-related harms, and delivering effective therapies. Research and expert consensus suggest the use of brief interventions focused on reducing risks associated with ongoing opioid use and using motivational interviewing strategies to engage youth in treatment. Because fatal opioid overdose remains a major cause of opioid-related mortality among youth, delivering overdose education as part of any visit in which a youth endorses opioid use is one evidence-based strategy to decrease the burden of opioid-related mortality. For youth that are injecting opioids, safe injection practices and linkage to needle or syringe exchanges should be considered to reduce complications from injection drug use. It is crucial that youth be offered treatment at the time of diagnosis of an opioid use disorder (OUD), including medications, behavioral interventions, and/or referral to mutual support groups. The 2 medications commonly used for office-based OUD treatment in adolescents are extended-release naltrexone (opioid antagonist) and buprenorphine (partial opioid agonist), although there is a significant treatment gap in prescribing these medications to youth, especially adolescents <18 years of age. Addiction is a pediatric disease that pediatricians and adolescent medicine physicians are uniquely poised to manage, given their expertise in longitudinal, preventive, and family- and patient-centered care. Growing evidence supports the need for integration of OUD treatment into primary care.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Substance-Induced Psychosis in Youth

Youth experiencing psychosis also frequently misuse substances, making it clinically challenging to differentiate substance-induced psychosis (SIP) from a primary psychotic disorder (PPD), which has important implications for management and prognosis. This article presents practical considerations related to differentiating SIP from PPD, including information on substances associated with symptoms of psychosis. Recommendations for management of SIP are also reviewed, including screening for and treating comorbid substance use disorders and using evidence-based medication and psychosocial interventions.

Outpatient psychosocial substance use treatments for young people: An overview of reviews

BACKGROUND

Systematic reviews and meta-analyses (reviews) conflict regarding the efficacy and feasibility of substance disorder treatments for young people (YP). This overview of reviews, synthesizes, and methodologically assesses reviews examining substance disorder interventions for YP in outpatient settings.

METHODS

Reviews published between 1990 and March 2018 were searched using EBM Reviews, PsycINFO, Embase, Ovid Medline, and Campbell Collaboration. Reviews investigating efficacy and/or feasibility of YP substance disorder treatments in outpatient settings were included.

FORTY-THREE REVIEWS MET ALL INCLUSION CRITERIA

To appraise methodological biases, 40 reviews were assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2) and 3 were narratively assessed. One reviewer (NS) extracted study data and evaluated all 43 reviews. For inter-rater reliability, 13 (30%) reviews were extracted and appraised in duplicate by a second reviewer (JA, RC or ES). Agreement on AMSTAR2 ratings reached 100%. Agreement was moderate; κ = .52 (p < .05), 95% CI (.20, .84).

RESULTS

All high quality methodological reviews (n = 6) focused on intervention efficacy and none on treatment feasibility. One (n = 1) high quality review reported evidence for an intervention. Multidimensional Family Therapy (MDFT) has possible efficacy in reducing YP substance use when compared to treatment as usual, Cognitive Behavior Therapy, Adolescent Community Reinforcement Approach and Multifamily Educational Therapy.

CONCLUSIONS

Methodological and reporting quality of reviews require improvement. High quality reviews focused on intervention efficacy but treatments commonly lacked evidence. One high quality review found MDFT demonstrated promising outcomes. Reviews examining feasibility of interventions were of low methodological quality.

Prescription Drug Misuse: Sources of Controlled Medications in Adolescents

OBJECTIVE

Adolescent controlled prescription drug misuse (PDM) co-occurs with significant consequences, including lower educational achievement, substance use disorder (SUD) symptoms, and psychopathology. Nonetheless, adolescent PDM sources and the prevalence of other substance use, SUD, and mental health outcomes associated with sources remain poorly understood.

METHOD

Data were from the 2009 to 2014 National Survey on Drug Use and Health, including 103,920 adolescents (12-17 years of age). Six mutually exclusive sources were used: physician source only, theft/fake prescription only, friend/relative for free only, purchases only, other source only, or multiple sources. Analyses occurred separately for prescription opioids, stimulants, and tranquilizer/sedatives. PDM source prevalence across adolescents and by sex and school enrollment/engagement were estimated. Adjusted odds of past-year DSM-IV substance-specific SUD, marijuana use, any SUD, major depressive disorder (MDD), anxiety diagnosis, mental health treatment, and past-month binge drinking were estimated by source.

RESULTS

Friends/relatives, for free, was the most common source (29.0%-33.2%), followed by physician sources for opioids (23.9%), purchases for stimulants (23.5%), and tranquilizer/sedatives (22.7%). Few school enrollment/engagement differences existed, but female adolescents were more likely to use multiple sources. Over 70% of adolescents using multiple sources had a past-year SUD. Multiple sources, purchases, and theft/fake prescription were more strongly associated with other substance use than physician source use, and multiple source use was linked with MDD.

CONCLUSION

Adolescents using multiple sources, purchases and theft/fake prescriptions have elevated rates of other substance use, SUD and MDD and particularly warrant intervention. Also, adolescents with other SUD and MDD should be screened for PDM and misuse sources.

Disulfiram (Tetraethylthiuram Disulfide) in the Treatment of Lyme Disease and Babesiosis: Report of Experience in Three Cases

Three patients, each of whom had required intensive open-ended antimicrobial therapy for control of the symptoms of chronic relapsing neurological Lyme disease and relapsing babesiosis, were able to discontinue treatment and remain clinically well for periods of observation of 6–23 months following the completion of a finite course of treatment solely with disulfiram. One patient relapsed at six months and is being re-treated with disulfiram.

Neurobiology of substance use in adolescents and potential therapeutic effects of exercise for prevention and treatment of substance use disorders

Substance use (e.g., alcohol, marijuana, opioids, cocaine., etc,) use often initiates during adolescence, a critical period of physiological and social development marked by an increase in risk-taking due, in part, to heightened motivation to obtain arousal from rewards. Substance use during adolescence has been associated with a greater risk of substance use disorders (SUD) in adulthood. Although use rates for most substances have remained relatively stable, the frequency of marijuana use and the perception that regular marijuana use is not harmful has increased in adolescents. Furthermore, the nonmedical use of opioids has increased, particularly in the South, Midwest, and rural low-income communities. Substance use in adolescence has been associated with adverse structural and functional brain changes and, may exacerbate the natural "imbalance" between frontal/regulatory and cortical-subcortical circuits, leading to further heightened impulsive and reward-driven behaviors. Exercise increases growth and brain-derived neurotrophic factors that stimulate endogenous dopaminergic systems that, in turn, enhance general plasticity, learning, and memory. Exercise may help to reinforce the "naïve" or underdeveloped connections between neurological reward and regulatory processes in adolescence from the "bottom up" and "offset" reward seeking from substances, while concomitantly improving cardiovascular health, as well as academic and social achievement. In this review, we provide an overview of the current state of substance use in adolescents and rationale for the utilization of exercise, particularly "assisted" exercise, which we have shown increases neural activity in cortical-subcortical regions and may modulate brain dopamine levels during adolescence, a unique window of heightened reward sensitivity and neural plasticity, for the prevention and adjunctive treatment of SUD.

Addressing Adolescents' and Young Adults' Substance Use Disorders

Adolescents and young adults (AYAs) have unique needs and important biopsychosocial differences when compared with older adults who use substances. As their brains continue to develop, youth are especially susceptible to the reinforcing effects of substances in the context of a still-developing capacity for executive control and decision making. In this article, the authors highlight key differences in the neurobiologic, epidemiologic, and relational aspects of substance use found in AYA. They also discuss how best to engage with youth who use substances and how prevention and intervention can be adapted for optimal effectiveness for this distinct and high-risk population.

Psychosocial interventions among children and adolescents

Substance use disorders in children and adolescents are a significant cause of concern as they can have long term implications in practically every sphere. The etiological factors that contribute to substance use disorders are complex and the formulation must amalgamate and synthesize all the different factors including the predisposing, perpetuating, precipitating and protective factors in order to plan management. Interventions must stem from this comprehensive formulation and must be child-focused, multidisciplinary, multisystemic, with strong family participation and community involvement. The treating team must actively collaborate with the young person and help him/her understand the rationale for treatment in order for them to engage in it. Assessment and treatment of comorbidities are an important part of intervention package. Skill training for problem solving, emotional regulation, social skills, and communication are an essential part of the treatment for substance use disorders in adolescents. Relapse prevention strategies, including how to seek help when there is a lapse must be part and parcel of the interventions delivered to the young person. Substance use disorder interventions must be part of a larger plan that addresses other areas of concern in the young person's life. While there are few studies, and so a relatively weak and preliminary evidence base for pharmacotherapeutic interventions, early evidence shows that their combination with psychosocial interventions may have a synergistic effect on substance use reduction. Substance use disorders affect the entire family and the community at large and thus must be treated holistically, but by individualising the treatment to suit the needs of that particular child and family.