Medication Assisted Treatment For Recovery in the Youth ...



Medication Assisted Treatment for Recovery in the Youth Population

Kay Wanbaugh

Saint Mary’s University of Minnesota

Schools of Graduate & Professional Programs

Capstone Symposium

Literature Review

Rob Koonce

February 18, 2014

Abstract

The hypothesis of this case study is that opioid addicted adolescent clients will be more likely to continue in a chemical dependency treatment milieu when they receive anti-craving medications in conjunction with continued participation in addiction education and support services. The theoretical underpinnings of the study suggest that when clients experience a decrease in cravings and a longer continuum of treatment services, they will be less inclined to relapse. Research has been conducted on the adult population, but study resources are lacking in the adolescent age group. Despite shortcomings in available research data on those ages 14 years through 18 years, the National Institute on Drug Abuse reported the younger age group of the opioid-dependent groups risk of relapse following a successful detoxification is similar to that of adults (Whitten, 2010). The focus of the current project proposes administering anti-craving medications to young clients, then measuring the success of continued involvement in the treatment milieu. The goal of the current study will be (a) to research the effectiveness of anti-craving medications in chemical addiction treatment therapies, which continue engagement for at least 12 months, and (b) to lower the number of overdose deaths from opioid relapse in the adolescent population.

Keywords: addiction, buprenorphine, methadone, maintenance, opioid, treatment, youth

Table of Contents

Abstract………………………………………………………………………………………2

Table of Contents…………………………………………………………………………….3

Introduction………………………………………………………………………………….4

Background………………………………………………………………………………….5

Review of Literature………………………………………………………………………...6

-Review of anti-craving medications………………………………………………..8 -The Challenge of Relapse Potential……………………………………………….11 -Ingredients of Success……………………………………………………………..12

Discussion…………………………………………………………………………………..13

-Adolescent Brain Development……………………………………………………13 -Social Stigma ………………………………………………………………………13 -Additional Challenges……………………………………………………………..14 -Limitations on Research Data……………………………………………………..14

Conclusion………………………………………………………………………………….15

References………………………………………………………………………………….17

Medication Assisted Treatment for Recovery in the Youth Population

Introduction

Current statistics on drug overdose deaths caused by prescription painkillers and heroin are on the rise in the United States. Prescription opioids are now the fastest growing drug that are directly responsible for chemical addiction, and are disproportionately affecting the adolescent age population. Heroin use has risen dramatically due to increased purity, cheaper prices, and the fact it no longer needs to be used intravenously but is widely snorted and smoked (Kleber, 2003). Hazelden, a premier chemical addiction facility in the United States, reported that by 2011, 41% of their adolescent clients came to inpatient treatment for opioid addiction (Seppela, 2013). There has been over a fivefold increase in opioid related overdoses between 1999 and 2006 in youth ages 15 years to 24 years in the United States (Wakeland, Schmidt, Gilson, Haddox, & Webster, 2011).

Current research is showing increased adherence for staying in the recovery support environment when anti-craving medications are given in conjunction with continued chemical addiction therapy and support group attendance. The risk of opioid relapse is highest during the first three to six months following an inpatient treatment program. Anti-craving medication combined with behavioral and psychosocial therapy is associated with better outcome for recovery (Kleber, 2003). Study data is available for the adult population, but is lagging behind in research for the adolescent population.

What affect does anti-craving medication maintenance have on an adolescent client’s ability to adhere to a recovery treatment milieu? To evaluate the effects of anti-craving medication it is necessary to observe clients for an extended period of time following the detoxification process through extended care treatment programs. Clients that continue with therapy, counseling, and support groups for at least 12 months have a better chance of maintaining abstinence in a recovery lifestyle (Burns et al., 2009).

Background

Opioid addiction is considered by many in the medical and mental health industry to be a relapsing brain disease that is chronic in nature (Alford et al., 2011). Millions of Americans suffering from addiction have life consequences that include unemployment, co-occurring mental health diagnosis, time spent in the court system for crimes committed while supporting chemical use, and risky behaviors which are resulting in spreading diseases such as HIV. High numbers of opioid addicts are ending up in correctional institutions. Opioid addiction is creating a tremendous burden on the government and health care system. Multiple disciplines are coming together to make up a collaborative care model for managing opioid and other chemical addictions in an effort to give help to those struggling with addiction (Alford et al., 2011).

There are a number of anti-craving medications that are proving to render successful results. The goal in collaborative care includes keeping a person’s craving for opioids at a minimum. Clients who are prescribed anti-craving medication will be encouraged to continue in chemical addiction treatment and psychosocial therapy to learn how to live a lifestyle of recovery and become healthy productive members of society. Emotional and physical craving for opioids are often stronger than the desire to be healthy and physically comfortable. It is a challenge to convince an opioid dependent client to maintain compliance with taking prescribed anti-craving medication. Without a commitment to take anti-craving medication a client is less likely to maintain continued engagement in addiction education, psychosocial and behavioral therapies, and support group activities. The collaborative model of care aims to engage clients long enough in treatment for them to gain education and establish new healthy support systems (Seppala, 2013).

Opioid dependent clients are often non-compliant with taking medications appropriately. Their inability to commit to an ongoing recovery lifestyle is often due to mental changes that occur in the brain with drug use. Chemical abuse alters memory pathways that are developed in the hippocampus, which is part of the limbic system of the brain. Drugs hijack the reward circuitry and cause dopamine to flood the limbic system (DeChello, 2012). The brain develops tolerance to drugs and the addicted person needs more of the illicit chemical in order to produce a similar euphoria to what had been previously experienced (DeChello, 2012). The altered neuropathway affects decision-making, impulse control, memory, speech, and voluntary movement (Rubia et al., 2000).

In the young adult and adolescent population there are additional concerns about how chemical addiction interrupts the brain development process. The brain is not fully matured until approximately 20 years of age. The frontal lobe, which helps determine risk and stop impulsivity, is the last part of the brain to develop. Heavy chemical use by an adolescent during the critical period of brain development may cause permanent alterations or damage. Mental health implications include poor judgment, preference for risk taking physical activity, impaired memory, impulsive behavior, and diagnosis of depression and anxiety (DeChello, 2012).

Review of Literature

Opioids are now the second most used illicit drug used for non-medical purposes among adolescent between the ages of 12 and 17 years (Fishman, Winstanley, Curran, Garrett, & Subramanian, 2010). Adolescents often try drugs out of curiosity or because they give in to peer pressure. Availability of email, the Internet, and mobile cell phones make drug purchases more easily accessible. Research shows that on average one in every four people who try heroin eventually end up meeting the medical criteria for an opioid dependence diagnosis (Kleber, 2003). The stigma of heroin use is minimized in today’s culture because it no longer is a drug that requires intravenous injection, but delivers the same euphoric sensation by snorting or smoking the substance. Heroin that is available today is virtually uncut and more pure than opioid substances sold in the past. With no way of knowing the strength prior to ingestion, the amount used to reach a euphoric feeling is pushing even the experienced addicts to overdose (McKinney, 2014).

The medical and mental health industries are promoting a collaborative effort, suggesting the administration of anti-craving medications combined with therapy and support group attendance promote a lifestyle of abstinence. Because of the heterogeneity of the opioid using population, it makes sense to utilize a number of resources rather than try to find one gold standard of treatment (Amato, Minozzi, Davoli, & Vecchi, 2011; Whitten, 2010). Anti-craving medication may increase the likelihood of adherence to continued engagement in the treatment milieu post inpatient detoxification, which will enhance the transition to aftercare therapeutic services (Donovan, Knox, Skytta, Blayney, & DiCenzo, 2012). Anti-craving medications should be prescribed to decrease a client’s opioid cravings that lead to chemical relapse. One study showed that along with reduced cravings for opioids clients have increased retention while in the treatment milieu (Seppala, 2013). Without the all-consuming emotional and physical pull of opioid craving, clients will be able to continue in a collaborative treatment protocol and learn skills to live a life in recovery from addiction.

Review of anti-craving medications

Methadone is an oral agonist opioid medication that has been shown to be effective in maintaining patients in treatment and reducing heroin use, but opioid relapse remains an issue (Amato et al., 2011). Major challenges on low dose methadone maintenance include clients who may continue to use heroin, as well as risk for diversion and overdose. Research suggests that 70% of clients relapse within one year after discontinuing maintenance treatment (Zanis, McLellan, Alterman, & Cnaan, 1996). There is a social stigma attached to methadone maintenance and parents are often not willing to allow their children access, preferring abstinence to what might be a lifetime commitment to methadone maintenance.

Buprenorphine/naloxone, also known as Suboxone, is a popular oral medication that is used in the opioid detoxification process. This medication is also becoming popular for reducing opioid craving post detox. Buprenorphine acts on the same neurological receptors as opiates. Buprenorphine, the opioid ingredient in Suboxone, keeps the limbic system of the brain stimulated. Naloxone, the second ingredient in Suboxone, is an opioid antagonistic. If diverted and used intravenously, naloxone may produce severe withdrawal symptoms (National Institute on Drug Abuse, 2006). Bupreorhine/naloxone taken orally as prescribed lacks euphorogenic properties found in methadone and is approved for young adults age 16 and over (Whitten, 2010). Challenges include the requirement of medical personnel for induction and stabilization as the client is monitored for the first seven days with direct observation for signs of euphoria or withdrawal, then follow up appointments at least weekly for the first four to six weeks. Time between medical appointments can eventually lengthen with a client contracting to return to the clinic for random and scheduled urine drug screens (Alford et al., 2011). Another challenge with buprenorphine/naloxone is that clients can choose to discontinue taking this medication, and after three days off the medication may chose to relapse on opioids without experiencing withdrawal symptoms (Fishman et al., 2010). There is also a stigma attached to buprenorphine/naloxone maintenance due to the opioid ingredient. Many halfway houses and extended chemical dependency facilities will not accept a client who is taking the buprenorphine anti-craving maintenance therapy (Fishman et al., 2011).

Oral naltrexone is being described as the ideal anti-craving medication (Kleber, 2003). It is tolerated well with minimal side effects (Feeney, Connor, Young, Tucker, & Czajkowski, 2001). Naltrexone has a long half-life so occasional missed doses are well tolerated. Because this medication does not contain an opioid ingredient it can be discontinued without physical withdrawal symptoms. The challenges with naltrexone include the fact that most addicts are not interested in taking it (Kleber, 2003). Findings from research studies have been difficult to attain due to high drop out rates during treatment and poor compliance with medication administration (Comer et al., 2006). The obstacle of poor compliance is due to the fact a client has the choice to stop taking the medication and to return to opioid use. If a person discontinues oral naltrexone for three to four days and relapses they will get the same euphoric affect from heroin use as they did prior to taking the medication (Comer et al., 2006; Kleber, 2003). Therefore, it is important in the adolescent population that parents contract to supervise medication adherence for oral naltrexone during psychosocial therapy and chemical dependency treatment (Fishman et al., 2010).

Vivitrol is a slow release injectable naltrexone that is administered in a doctor’s office or clinic once per month. Monthly administration takes away the ambivalence of whether clients want to take daily doses of anti-craving medication. By taking away urges of drug craving, clients will be more likely to focus on therapy, recovery education, and support groups (Comer et al., 2006). Challenges include the expense of the medication, averaging $1,200 to $1,500 per injection, and most insurance companies do not endorse administration to clients under the age of 18 years. Also, Vivitrol is non-formulary medication for many payers, which inhibits insurance coverage (Fishman et al., 2010). It is common for clients to test the blockade effect by using large doses of opioids, especially near the end of the 30-day period when naltrexone blood levels are decreasing. Attempting to override the medication threshold runs a risk for a fatal overdose to occur, resulting in respiratory depression or cardiac arrest (Comer et al., 2006; Fishman et al., 2011). Because naltrexone blocks opioid receptors, clients must wear identifying bracelets or necklaces and carry a medical card when taking this medication in case there was a need for emergency surgery, anesthesia, or pain medications. The medical industry would need to administer specific medications to remove the opioid blocking affects from brain receptors before anesthesia or pain medications could have an effect. More research is needed for injectable naltrexone in the adolescent population, as most studies are found in ages 18 years and older.

Gabapentin is an oral medication that has been reported to decrease drug cravings. Other benefits of the medication include effectiveness in reducing anxiety and post acute withdrawal symptoms such as restless legs (Verduin, McKay, & Brady, 2007). Questions remain around the potential for abuse and diversion of this medication. The Food and Drug Administration has classified pregabalin, a chemical compound of gabapentin, as a Schedule V controlled substance (Verduin, McKay, & Brady, 2007). Limited research exists around abuse and anti-craving affects of this medication, or if it aids in promoting therapy and treatment adherence.

The Challenge of Relapse Potential

Relapse is a multifaceted issue and is common among opioid-dependant people. Research shows opioid-dependant adolescents are more likely to drop out of treatment after the detoxification process when compared to non-opioid chemically dependent counterparts (Fishman et al., 2010). There are environmental reasons that contribute to opioid relapse such as the weakening of socio-religious values, peer pressure, easy accessibility of drugs, lack of community recreation centers, failing to continue religious practices, no longer socializing with non-using friends, untreated mental or emotional problems such as anxiety and depression, and lack of family support (Islam, Hashizume, Yamamoto, Alam, & Rabbani, 2012). Extended family support and religious traditions that used to be an essential part of many cultures are deteriorating in contemporary society. Drug dealers often initially offer free drugs to get people physically and emotionally addicted. Environmental influences are a constant threat for relapse. The goal for the collaborative model of care team is to keep a young client in the treatment care system as long as possible, which may increase the chance for a successful recovery.

Due to chemically induced changes in the brain, addicts no longer have positive coping mechanisms to help with emotional disturbances and stress. Sleep patterns are disrupted, which can result in chronic insomnia. Without the aid of anti-craving medications combined with therapies and support groups, young adults often succumb to environmental triggers such as music, smells, and sights. Physical symptoms of craving before relapse have been described as feelings of uneasiness, shivering, and feeling both hot and cold with thorny prickly skin sensations (Islam et al., 2012). Physical and emotional cravings are so strong that an addict only focuses on obtaining opioids for relief from the uncomfortable sensations.

Other danger signs that a person experiences prior to relapse include a loss of motivation for recovery, a feeling of ambivalence, or what is called romancing the drug. Memories of only the euphoria felt with opioid addiction cloud memories, pushing aside the reality of pain and suffering addiction previously caused the person, their family, and society. If a person who has been in recovery for a period of time becomes overconfident, reducing time spent with support groups, they may feel a need to experiment and test their will to see if they can use chemicals socially. Stress and an unbalanced lifestyle, without continued support from groups such as Narcotics Anonymous (NA), may also lead to chemical relapse. A collaborative model of care team that addresses multiple environmental and relapse prevention issues will be more likely to keep a young client in the treatment care system for a longer time period, which may increase the chance for a successful recovery.

Ingredients of Success

The World Health Organization (2009) described drug addiction as a combination of behavioral, cognitive, and physiological factors that require the use of psychoactive medications to interfere with persistent craving and a drug-seeking lifestyle (Amato et al., 2011). Participation in family therapy will help rebuild trust among family members and serve to discourage a return to a lifestyle of addiction (Islam et al., 2012). Along with anti-craving medication maintenance clients should be offered psychiatric care, counseling, therapy, and social work services (Amato et al., 2011). Social services should monitor environmental factors by assuring that clients have clean and sober living arrangements, access to a proper nutritional diet, and are able to find transportation to needed services. Education in self-help skills, relapse prevention education, and participation in groups such as NA support a client in maintaining abstinence from opioids. One study showed clients who have access to support groups such as NA are more likely to maintain abstinence from opioids for at least five years after discharge from a treatment program (Donovan et al., 2010).

Discussion

Adolescent Brain Development

The fact that adolescent brain development is not fully achieved until around the age of 20 years should be taken into consideration when developing a model of collaborative care for recovery from opioid addiction. Normal adolescent behavior includes impulsivity and risk taking because the reasoning parts of the brain, the frontal lobes, are still maturing. Opioid use during the time of brain development has a neurobiological impact that results in arrested emotional and cognitive capabilities (Lingford-Hughes, Welch, Peters, & Nutt, 2012). When choosing which anti-craving medication is most appropriate for the young adult population factors such as possible side effects and ease of diversion, as well as the maturity of the brain, should be taken into consideration.

Anti-craving medications are not to be thought of as a cure for opioid addiction. The goal of keeping opioid cravings to a minimum are to create an opportunity for clients to stay engaged in psychosocial therapy and relapse prevention training that will help decrease the chance for relapse (Kleber, 2003). Caldiero et al. (2006) suggested clients who were prescribed buprenorphine/naloxone during the detoxification process and then continued on a maintenance dose to inhibit opioid craving stayed in the recovery continuum for a longer time period. (Caldiero, Parran, Adelman, & Piche, 2006; Donovan et al., 2012).

Social Stigma

People with opioid addictions endure social stigma from both inside and outside of the recovery community. Stigma against the use of anti-craving medication that results in social rejection is often a trigger for opioid relapse. Many chemical dependency programs have built their curriculum on an abstinence-based platform, leaving no room for acceptance of another model of care. Research that studies success rates for subjects taking anti-craving medications are influenced when extended-care programs and halfway houses deny motivated clients access to their facilities. One study reported initial skepticism among counselors about the use of anti-craving medications being a threat to their counseling careers. Over time it was realized that those clients actually stayed in therapy longer, requiring further counseling sessions (Fishman et al., 2010).

Additional Challenges

Incorporating anti-craving maintenance protocol will require additional resources of medical staff. With buprenorphine/naloxone clinical staff will be involved with prescribing and titrating dosage levels while assessing clients using standardized protocol until a therapeutic blood level is attained (Burns et al., 2009). Clients must be observed to monitor for compliance in taking buprenorphine/naloxone to avoid under or over-medicating and for possible diversion of the medication. Some insurance companies are requiring a certified psych nurse to administer the Vivitrol injectable medication in order to qualify for payer coverage. Most insurance companies are reluctant to cover the high cost of monthly Vivitrol injections Training will be required to provide integration of the medication component into existing psychosocial treatment infrastructure. This will include cross training of counselors and therapists to encourage staff compliance (Fishman et al., 2010).

Limitations on Research Data

Little research was found on the use and effectiveness of anti-craving pharmacotherapy for opioid dependant adolescents and young adults (Fishman et al., 2010). There are limited data results found on client compliance around taking the oral medication naltrexone within rehabilitation programs, or around the impact this medication has on client adherence for longer periods of compliance with addiction therapy (Feeney et al., 2001). Research on oral naltrexone gave weak evidence that subjects actually had personally ingested the medication (Feeney et al., 2001). Studies with adult clients showed those who were started on buprenorphine/naltoxone were more likely to leave their first treatment episode than those started on methadone (Burns et al., 2009). However, methadone is not a medication used with the adolescent population, making buprenorphine/naloxone the better choice for a partial agonist approach for youth.

Research that studied adolescent compliance with staying in treatment while on anti-craving medication had results influenced by whether the young adult was living at an inpatient treatment facility where they could leave against staff advice, or whether they were living in a correctional facility (Burns et al., 2009). Clients who were first treated in a correctional institution had better recorded compliance with treatment stay, but research is lacking as to compliance following release from incarceration. Clients being administered buprenophine/naloxone were more likely to have multiple treatment episodes and often switched medications during the treatment process, which made it difficult to assess study results accurately (Burns et al., 2009).

Conclusion

In sum, research findings suggest prescribing the oral medication buprenophine/naloxone during detoxification protocol, followed by titrating dosage to a therapeutic level that maintained anti-craving status, encouraged continued client engagement in the treatment milieu (Donovan et al., 2012). Treatment services offered should include therapy, chemical addiction education, relapse prevention, and support group engagement for at least a 12-month period. Despite advances in anti-craving medications and chemical dependency treatment for adolescents, there is relatively little research found that explores outcomes of a model of collaboration to serve the high-severity young population of opioid addicts in the United States (Fishman et al., 2010).

Addiction is the result of a combination of social, psychological, and neurological issues that people are exposed to in their lifetime. A combination of therapies, all having the same goals of recovery from chemical addiction, will support creative strategies that include anti-craving medication. Even though diversion of buprenorphine/nalaxone and methadone are a risk, the risk-benefit ratio of reducing personal, social, and community burden shared by both the health care industry and government makes it worth consideration of a collaborative model of care (Cicero, Surratt, & Inciardi, 2007).

The subject of harm reduction and adolescent management of opioid addiction with pharmaceuticals is a politically charge issue (Cicero, Surratt, Inciardi, 2007). There continues to be social stigma attached to the use of pure agonists, such as buprenorphine and methadone, for anti-craving maintenance, especially for young adults (Fishman et al., 2010). Psychosocial therapies combined with anti-craving medication maintenance require further evaluations (Amato et al., 2011). No research articles were found that suggest pharmacological intervention should stand alone without the component of therapy and support. It is suggested that incorporating prescription anti-craving medication protocol combined with multiple disciplines working and communicating together is an essential model of collaboration for the treatment of adolescent opioid addiction (Alford et al., 2011). Further research is needed to determine the most effective anti-craving medications that when combined with chemical addiction education, mental health therapies, and support groups will lower the number of overdose deaths in the adolescent population.

References

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Whitten, L. (2010). Young opioid abusers benefit from extended buprenorphine-naloxone treatment. Retrieved from notes/2010/04/young-opioid-abusers-benefit-extended-buprenorphine-naloxone-treatment

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