Health Resource in Action



OPIOID USE AMONG ADOLESCENTS & YOUNG ADULTS:

Toolkit for Pediatric & Primary Care Providers

June 2019

Attributions:

This guide was developed through a partnership of:

The Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Office of Youth and Young Adult Services

Boston Medical Center, CATALYST Program, Grayken Center for Addiction Medicine

Boston Children’s Hospital, Adolescent Substance Abuse Program

Massachusetts General Hospital, Addiction Recovery Management Service

Written by:

Sarah M. Bagley, MD, MSc, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center

Scott E. Hadland, MD, MPH, MS, Grayken Center for Addiction/ Department of Pediatrics, Boston Medical Center, Boston University School of Medicine

Sharon Levy, MD, MPH, Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital

Samantha F. Schoenberger, BA, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center

Tuhin Roy, MD, Greater Lawrence Family Health Center

Amy M. Yule, MD, Addiction Recovery Management Service, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School

This toolkit has been provided for general primary care and pediatric health information purposes only. The recommendations contained herein do not indicate an exclusive course of action or serve as a standard of medical care. Variations, taking individual circumstances into consideration, may be appropriate. Consideration should also be given to current clinical organizational policies and procedures that may further impact clinical practice within specific settings.

TABLE OF CONTENTS

1 Introduction

3 Problem of Opioid Use among Adolescents and Young Adults

3 Scope of Problem

Trends in Massachusetts

Complications of Use

Polysubstance Use in Adolescence

4 Diagnosis of Opioid Use Disorder (OUD)

5 Treatment for Opioid Use Disorder — Medication for Addiction Treatment (MAT)

Adolescent Access to Care and Pharmacotherapy

7 Guidance for Primary Care and Pediatric Providers

7 Screening

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Related Risk Screening

Pre-Exposure Prophylaxis (PrEP)

7 Special Considerations for MAT in Adolescents and Young Adults Aged 16–25 years

DATA 2000 and CARA 2016

Confidentiality and Consent in Youth Aged 16–17

8 Treatment Protocol

Program Development

Medication Induction and Treatment

Laboratory Tests and Medical Clearance

Toxicology Testing

10 Types of MAT

Buprenorphine

Naltrexone

Choosing a Medication

Duration of Treatment

13 Special Populations

Youth in DCF/DYS Custody

Pregnancy

14 Relapse and Overdose Prevention

Relapse Risks

Overdose Risk

Injection Drug use Harm Reduction

17 Co-occurring Psychiatric Disorders

17 Assessment for Co-occurring Psychiatric Disorders

17 Appropriate Management of Psychiatric Disorders

19 Age-Appropriate Program Development

19 Youth and Family Engagement/ Recovery Supports

Recovery High Schools

Collegiate Recovery Programs

Recovery Housing

20 Anti-Stigma Message

20 Behavioral Health Treatment with MAT

23 Appendices

23 Confidentiality Laws

24 Sample Treatment Documents

27 List of Resources

27 Patient/Family Resource Information

29 References

1This toolkit includes:

• Scope of Problem

• Clinical Guidance for Primary Care and Pediatric Providers

+ Screening, Brief Intervention, and Referral to Treatment

+ Medication Assisted Treatment

+ Special Populations

+ Relapse and Overdose Prevention

+ Co-occurring Psychiatric Disorders

• Age-Appropriate Program Development

• Resources

INTRODUCTION

This toolkit has been developed specifically for pediatric, primary care, and other health professionals treating adolescents and young adults within their medical practice.

The Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Office of Youth and Young Adult Services in partnership with Grayken Center for Addiction at Boston Medical Center, Boston Children’s Hospital, and Massachusetts General Hospital, are pleased to present Opioid Use Among Adolescents and Young Adults: Toolkit for Pediatric and Primary Care Providers.

This toolkit has been developed specifically for pediatric, primary care, and other health professionals treating adolescents and young adults within their medical practice.

The overall aim is to improve clinical care and coordination for adolescents and young adults with opioid use disorders.

This toolkit provides guidance in regard to the medical, psychological, and social needs of adolescents and young adults with opioid use disorders, thereby improving physical and mental health outcomes.

It has been developed to help primary care and pediatric health providers advance the clinical interventions by offering developmentally appropriate screening, treatment engagement, and coordinated care.

A specific focus on evidence-based practices includes Medication Assisted Treatment (MAT) guidance and resources to support these clinical interventions.

PROBLEM OF OPIOID USE AMONG ADOLESCENTS AND YOUNG ADULTS

Scope of Problem

Adolescents and young adults (youth) have been particularly affected by the opioid epidemic.

Between 1999 and 2015, hospitalizations for opioid poisonings nearly doubled for teenagers aged 15–19 and the opioid-related overdose death rate tripled.1,2

Additionally, the rate of opioid use disorder (OUD) diagnosis increased sixfold from 2001 to 2014 among youth (13–25 years old), with a particular increase in diagnosis for young adults aged 21–25 years old.3

With a 72% increase in young adult deaths related to synthetic opioids such as fentanyl between 2014 and 2015, and a 15% increase in heroin-related deaths over that time, it is clear that the epidemic among young people is shifting, and so too must our commitment to response and treatment.1

Adolescence and young adulthood are particularly critical periods for intervention, as substance use can have lifelong effects.

The National Institute on Drug Abuse reports 9 in 10 adults in treatment for substance use disorder first used a substance before age 18.

Two thirds of individuals in opioid treatment reported first opioid use before age 25, while 1 in 3 report first use before age 18.4

Given these striking statistics, primary care and pediatric providers have an essential role to ensure access to timely and evidence-based treatment.

Trends in Massachusetts

The impact of increasing OUD and overdose on youth in Massachusetts is consistent with national trends.

The fastest rate of increase of OUD occurred in 11- to 29-year-old youths from 2013 to 2014.5

The Kaiser Family Foundation reports a fivefold increase in opioid overdose deaths among individuals under age 25 between2012–2015 in the Commonwealth,6 with opioids accounting for nearly a quarter of all deaths for individuals 18–24 years-old.7

Complications of Use

Complications of intravenous drug use include endocarditis, abscesses, and infection with hepatitis C virus and human immunodeficiency virus (HIV) infection,8 all of which contribute significantly to the overall morbidity and mortality.

Youth are especially affected with recent data from the CDC showing that the hepatitis C rate increased fourfold in Americans younger than 30 within the past 10 years,9,10 and after years of decline, decreases in new HIV infections among youth have stalled.11

Polysubstance Use in Adolescence

Adolescents and young adults who misuse prescription opioid medications are also more likely to report use and misuse of other drugs.

One study showed that patients aged 14–26 with two or more substance use disorders were three times more likely to have experienced overdose, compared to those with just a single substance use disorder.12

While most adolescents and young adults do not escalate from sporadic use to substance use disorders, opioid use places these individuals at risk for other serious health and social issues, such as school failure, disengagement from healthy activities, driving under the influence, and contracting an infectious disease through unsafe sex or needle sharing.13

Benzodiazepine use, in particular, can increase an individual’s risk of overdose when used in conjunction with opioids.

This class of medications are strongly associated with adolescent and young adult opioid use, placing

these individuals at a higher risk for overdose.14

Diagnosis of Opioid Use Disorder (OUD)

The 2013 Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) defines an opioid use disorder (OUD) as the repeated occurrence of 2 of the following 11 criteria within a 12-month period.

Tolerance and withdrawal are not sufficient to diagnose an OUD.

Individuals who are prescribed opioids for chronic pain may have physical dependence and withdrawal.

OUD can be classified as mild (2–3 symptoms), moderate (4–5 symptoms), or severe (6 or more symptoms), assessed over the last 12 months.15

These criteria are the same for adolescents and adults.

1. Opioids are taken in larger amounts or over a longer period than was intended.

2. A persistent desire or unsuccessful efforts to cut down or control opioid use.

3. Large amounts of time engaging in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

4. Craving or strong desire to use opioids.

5. Recurrent opioid use resulting in failure to fulfill major role obligations at work, school, or home.

6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.

8. Recurrent opioid use in situations in which it is physically hazardous.

9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.

10. Tolerance, as defined by either:

• A need for markedly increased amounts of opioids to achieve intoxication or desired effect.

• Markedly diminished effect with continued use of the same amount of opioid.

11. Withdrawal, as manifested by either:

• The characteristic opioid withdrawal syndrome.

• The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

SECTION 2. Problem of Opioid Use Among Adolescents and Young Adults

Treatment for Opioid Use Disorder — Medication for Addiction Treatment (MAT)

Medications for addiction treatment (MAT) and behavioral health treatment are effective for OUD, particularly in combination.

There are several behavioral therapies that are evidence based for this age group (see “Behavioral Health Treatment”).

Programs differ in their approaches to integration of behavioral health care in MAT.

Clinicians should encourage behavioral healthcare as an important adjunct to MAT, utilizing motivational interviewing strategies when youth and their family members are resistant to such therapies.

Medications, however, should not be withheld for youth who do not participate in behavioral health treatment.

The American Society of Addiction Medicine published National Practice Guidelines in 2015

advocating for the use of pharmacotherapy in adolescent treatment16 and the American Academy of Pediatrics followed with a policy statement in 2016, arguing for increased access to MAT for adolescents and young adults with OUD.8

Research shows that use of MAT for adolescents and young adults assists in treatment retention, contributes to lower relapse rates, decreases engagement in risky behaviors,17 and increases abstinence.18–20

Among adults, MAT at least doubles the rate of opioid abstinence in randomized-controlled trials compared to no medication.21

MAT improves overall quality of life and reduces overdose risk, a significant contributor to mortality among individuals who use substances.22

The US Food and Drug Administration approves the use of three medications for treatment of OUD: buprenorphine, naltrexone, and methadone.

The general approach to providing buprenorphine and naltrexone in outpatient settings is provided in the following section.

Methadone is an effective treatment; however, if considering it as an option for a young patient, we suggest referring to an addiction specialist.

Individuals under 18 years old are not commonly treated with methadone.

Adolescent Access to Care and Pharmacotherapy

Fewer than 1 in 3 specialty drug treatment programs in the United States offers care to adolescents.3

Youth are not retained in treatment as well as adults, suggesting that young adults who do receive MAT are forced to get it from adult programs that are not structured to meet their developmental needs.23

As diagnoses of OUD increased substantially from 2001–2014, only 1 in 4 eligible youth aged 13–25 years received MAT nationally.3

Furthermore, researchers documented disparities in access and receipt of treatment based on gender, age, and race/ethnicity.

Females were less likely to receive medications than males, with non-Hispanic black and Hispanic youth also less likely to receive medications compared to their Caucasian counterparts.

Of those youth who received medication, buprenorphine was the most common medication used.3

These findings highlight the underutilization in MAT as a treatment modality for this age group, despite strong evidence for its efficacy among adolescent populations.17

GUIDANCE FOR PRIMARY CARE AND PEDIATRIC PROVIDERS

The increasing rate of opioid use disorder (OUD) diagnoses, coupled with the shortage of treatment options for adolescents, strongly support the provision of medication for addiction treatment (MAT) by adolescent providers.

Pediatricians, family physicians, and other physicians who care for young adults are well positioned to offer treatment and services.3,24,25

The following sections serve as a manual for providers in the prescribing of MAT for adolescents and young adults.

Screening

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

The American Academy of Pediatrics supportsthe use of SBIRT in adolescent primary care.

Information about screening in primary care can be found at: pdf/S2BI%20Toolkit.pdf or . gov/nidamed-medical-health-professionals/ screening-tools-resources/screening- tools-for-adolescent-substance-use.

Related Risk Screening

Adolescents and young adults who engage in high-risk behaviors may also be screened for sexually transmitted infections and blood-borne infections such as gonorrhea, chlamydia, syphilis, HIV, as well as hepatitis A, B, and C viruses.26

Positive test results can be addressed with referral to experienced providers and integrated into overall care management planning for youth.

Youth not immune to hepatitis A and B should be offered vaccinations.

Pre-Exposure Prophylaxis (PrEP)

In May 2018, the Food and Drug Administration approved daily oral antiretroviral pre-exposure prophylaxis (PrEP) with Truvada (emtricitabine/ tenofovir disoproxil fumarate) for adolescents under 18 who weigh at least 77 lbs. and are at heightened risk of acquiring HIV infection based on established criteria.

Laws and regulations concerning consent, confidentiality, and parental disclosure differ by jurisdiction.

Additional information about adolescent PrEP use will be incorporated in upcoming CDC guidelines.

This will be available at: guidelines/index.html.

Special Considerations for MAT in Adolescents and Young Adults Aged 16–25 years

DATA 2000 and CARA 2016

In 2000, US Congress passed the Drug

Addiction Treatment Act, known as DATA 2000, which allows physicians to apply for a waiver to prescribe buprenorphine in general medical settings, after an eight hour training course.27

Several organizations, including the American Academy of Pediatrics, have endorsed an adolescent-specific training course for pediatric providers ().

Once waivered, these physicians can prescribe buprenorphine.28

In 2016, the Comprehensive Addiction and Recovery Act (CARA) was signed into law, which extended this waiver to NPs and Pas who have completed 24 hours of training.29

Confidentiality and Consent in Youth Aged 16–17

Protecting confidentiality is critical in OUD treatment and management to support youth engagement in care.

There are several specific laws that govern this subject.

Of note, confidentiality laws do not preclude caregiver involvement.

In general, engagement of caregivers as part of a young person’s treatment plan leads to a higher level of success.

Caregiver involvement

In general, programs should involve parents or other caregivers, henceforth parents, and other

support systems whenever possible.

Parental consent and involvement optimize success and retention in treatment. In many cases, these support systems may already be aware of their child’s opioid use, and the young person may give permission to discuss treatment and progress with parents.30

If a patient is >18 years and wants clinicians to communicate with his or her parents, medical releases of information should be signed with a clear delineation of what information can be shared (e.g. treatment attendance, diagnostic impression, recommendations for treatment, clinical course in treatment, results of toxicology testing).

Medical Care Consent for Minors in Massachusetts

While the age of consent for all medical treatment in Massachusetts is generally 18, minors younger than 18 may consent to a range of services without parental authorization, depending on the circumstances.

Treatment of substance use disorders in minors, including prescribing medications for addiction, is confidential and protected in the Commonwealth of Massachusetts. This means that minors do not need to obtain consent from their parents to receive treatment for OUD.

In the Commonwealth of Massachusetts, a minor 12 years of age or older who is found to be drug dependent by two or more physicians may give their consent to medical care related to the diagnosis or treatment of the dependency.

Consent of parent or legal guardian of the minor is not necessary to authorize treatment.

These provisions do not apply to methadone maintenance therapy.31

Code of Federal Regulations, 42 CFR Part 2

Federal laws and regulations specific to substance use treatment apply, beyond the usual confidentiality regulations with the Health Insurance Portability and Accountability Act (HIPAA).

Specifically, the US Code of Federal Regulations (CFR) restricts disclosure of alcohol and drug treatment records, even for purposes of other medical treatment, or healthcare operations without written consent of the patient.

This applies to all records relating to identity, diagnosis, prognosis, or treatment of any patient in a substance use program.

These restrictions apply to any federally assisted programs, as well as any providers prescribing MAT under a federal DEA license.32

Treatment Protocol

A basic overview and guide is provided within this toolkit.

The protocols below have been adapted from guidance from the Providers Clinical Support System () and Carney, et al.24

Program Development

Practices should establish a clinical model that includes a medical provider who prescribes medication and can monitor treatment, as well as a mental health practitioner who can provide adjunctive behavioral therapy.28

| SECTION 3. Guidance for Primary Care and Pediatric Providers

Medication Induction and Treatment

Prior to starting medication treatment, patients should be assessed for severity of OUD using the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Clinicians should also assess for other substance use and SUD, including alcohol, marijuana, benzodiazepines, and tobacco, and discuss all treatment options available to the patient.

Additionally, practitioners should assess for any co-occurring mental health disorders that should be addressed concurrently in treatment.28

Practices that provide MAT should have specific treatment agreements and consent forms

that are reviewed with a clinician and signed by patients and parents or legal guardians (for patients under 18 who have parental consent for treatment).

A sample treatment agreement is included in Appendix 6.3 of this toolkit.

Treatment agreements outline expectations of the patient and clinician visit adherence, expectations around medications and prescriptions, participation in toxicology testing, and participation in behavioral health counseling.

There are several modalities of behavioral health counseling that are age-appropriate for adolescents and are described in further detail in Section 3 of this toolkit.

This is also an appropriate time to have patients and families sign medical release forms to allow clinicians to communicate with other care providers and trusted adults working with an adolescent, including prior and current clinicians, outside behavioral health providers, school officials, and other trusted adults who may not be legal guardians of the patient but are involved in care planning.

Counseling families and caregivers about medication safety is important at initial and subsequent visits.

This includes: storing medications in a lockbox; observed medication administrations (particularly for adolescents under 18); safety measures to prevent unintentional ingestion by younger children or other members of the household; and overdose prevention and education (including provision of naloxone for overdose reversal).

Notably, the risk of overdose from buprenorphine when taken as directed (while ensuring that young people do not simultaneously use alcohol, benzodiazepines, or other sedatives) is extremely low.

However, younger children, particularly those under the age of six years, remain at risk of overdose on buprenorphine at doses prescribed to treat opioid use disorders in adolescents.33

Laboratory Tests and Medical Clearance

Once a clinician and patient decide to begin MAT, practitioners should conduct baseline laboratory testing, including liver function tests, and screening for human immunodeficiency virus (HIV), syphilis, gonorrhea/chlamydia, and viral hepatitis.

Patients should be up to date on vaccinations, with particular attention to the hepatitis A and B vaccine series.

Biologically female patients should undergo a urine pregnancy test, as pregnancy may change treatment considerations and planning for the patient and clinician (Section “2 Pregnancy” for more information).

Toxicology Testing

Practices differ in their approach to frequency of toxicology testing (most commonly urine or saliva).

In general, frequency of testing should be based on the individual needs of patients.

Fundamentally, the purpose of such tests is to monitor adherence to treatment and provide an opportunity to address other drug use.34

As noted in the prior section, careful attention should be paid to the concurrent use of benzodiazepines, as this can greatly increase the risk of overdose in a patient on an opioid agonist (i.e., buprenorphine or methadone).

Drug panels differ in what drugs they test for and how to interpret results.

Therefore, it is crucial for physicians to be aware of what tests their practice utilizes.

Common urine drug panels include monitoring of opiates, cocaine, amphetamines, benzodiazepines, and barbiturates.

Often an additional order is necessary to test for synthetic opioids such as oxycodone, methadone, buprenorphine, and fentanyl.

Whether clinics test for tetrahydrocannabinol (THC), the active compound in marijuana, differs from site to site.

Clinicians should be mindful that false negatives and positives can occur with toxicology testing and should contact the laboratory that tested the sample with any questions.

For clinicians considering the implementation and schedule of urine drug testing, The American Academy of Pediatrics’ recommendations and Levy and Siqueira (2014) can be valuable resources.35,36

Types of MAT

The basics of buprenorphine and naltrexone are covered below, followed by recommendations for course of treatment.

Buprenorphine

Buprenorphine is a partial agonist of the mu opioid receptor.37

Approval of the use of buprenorphine for adolescents 16 years and older was granted in 2003.3

Buprenorphine is commonly prescribed as a daily medication via sublingual tablets or films. New formulations, such as a monthly injection, and an implant form have also been approved for use in adults.38,39

As of publication of this toolkit, the weekly injection is not yet approved by the FDA.

Future research into the newer injection and implant formulations still needs to be conducted for adolescents and young adults.

Buprenorphine can be prescribed weekly once a patient is stabilized, providing more flexibility in the spacing of clinic visits based on patient response.

Of the three medications, buprenorphine is the best studied among adolescents and young adults.

The extant body of literature suggests that adolescents who remain on buprenorphine for longer periods experience reduced risk of relapse and longer retention in addiction treatment, although the optimal duration of treatment is not known.

One randomized controlled trial demonstrated that adolescents aged 13 to 18 years old who received buprenorphine treatment were more likely to be retained in treatment, have negative urine tests for opiates, and transition to naltrexone, compared to those who received only clonidine for opioid withdrawal symptoms.40

Further research indicates that longer course of treatment for adolescents on buprenorphine leads to lower rates of illicit opioid use.18

Clinical trial data also suggest that remaining on buprenorphine (rather than discontinuing the medication after withdrawal symptoms are addressed) results in improved clinical outcomes.41

Continued buprenorphine adherence over one year is associated with an increase in treatment retention and longer-term abstinence.42

In practice, many adolescents and families request to discontinue buprenorphine once in stable recovery; however, there are not data to support whether or when this is the best approach.

Buprenorphine Training

In accordance with DATA and CARA legislation, buprenorphine requires special training for

prescription.

Waivered providers can prescribe buprenorphine in any pediatric practice.

Once completed, providers can increase the number of patients on buprenorphine in a stepwise fashion in the following way: During the first year after prescription waiver, providers can treat 30 patients at a given time; during the second year, they may prescribe for 100 patients; and during the third year, they may prescribe for 275 patients.

| SECTION 3. Guidance for Primary Care and Pediatric Providers

Buprenorphine Induction and Administration

Online webinars describing different models of buprenorphine induction are available for clinician CME credit.

Up-to-date resources and guidance can be found at: models-of-buprenorphine-induction/. General guidance is provided below.

Patients are generally started on buprenorphine/ naloxone once they present with mild to moderate opioid withdrawal symptoms (as assessed with the Clinical Opioid Withdrawal Scale [COWS].

See Appendix 6.3).

The timing of a patient’s withdrawal will depend on the half-life of the last opioid taken.

Given the variability in half-life for illegally produced fentanyl, patients should be monitored closely and started on buprenorphine/naloxone when they have at least moderate opioid withdrawal symptoms.

Buprenorphine tablets and films are found in two formulations: combined with naloxone, and a monoproduct formulation (i.e., without naloxone).

The combination formulation is designed to prevent misuse because if it is injected, naloxone blocks the opioid receptor, precipitating withdrawal symptoms.37

Generally, pediatric and adolescent providers should prescribe the combined formulation unless it is contraindicated because of an allergy.24

Many clinicians conduct an in-office observed induction for adequate dosing, and parental/family education and monitoring for adverse effects of sedation and drowsiness.

The PCSS MAT Guidance Document for Adolescents and Young Adults notes that treatment dosing ranges from 2–24 mg/day with 59% of patients stabilized on 9–16 mg/ day.43

As in adults, it is optimal to adjust buprenorphine dose until the patient no longer reports withdrawal symptoms or cravings for opioids.30,44

One approach could be an initial dose of 2–4 mg, followed by additional 2 mg dose every 30–60 minutes until a patient’s COWS score is less than 5, or until a max dose of 8 mg has been reached.

Patients can then be sent home with an additional 4 mg to take in the evening, with most individuals maintained on an 8–16 mg daily dose.45

Naltrexone

Naltrexone is an opioid antagonist with high affinity for the opioid receptor.

It prevents opioids from binding to the mu opioid receptor, reducing the risk of overdose and blocking the reinforcing effects of opioid use.

Naltrexone may also reduce cravings for opioids in some patients.

It can be administered in daily oral doses, or more commonly by a monthly injection.

Ongoing clinical trial research is exploring the use of naltrexone home delivery systems, psychosocial treatment, and contingency management in the provision of naltrexone to young adults (see NCT03306368).

No certification must be obtained by providers for prescription of naltrexone; however, at the time of publication it is not FDA approved for patients under 18 years old.

Evidence from adult studies suggests that naltrexone is effective at reducing substance use and may match the clinical success of buprenorphine.46–48

However, trials considering adolescents are lacking.49

Despite this, some evidence supports the offlabel use of naltrexone in adolescents under 18 years old.3,20

In a preliminary case-series with 16 adolescents and young adults with an OUD (mean age 18.5 years), 63% remained in treatment for at least 4 months after beginning a treatment regimen of extended-release naltrexone.

Additionally, 56% had substantially decreased opioid use and improved in at least one psychosocial domain.50

In another observational study, adolescents and young adults who received naltrexone were approximately half as likely to be lost to treatment follow-up compared to youth receiving only behavioral health services for OUD.20

Naltrexone Induction and Administration

The long-acting injectable form of naltrexone is administered once monthly.37

This formulation may encourage treatment engagement in youth; however, it may also prolong periods of non-involvement with medical care and retention rates (compared to buprenorphine).

Given the loss of tolerance with prolonged naltrexone use, patients who miss their monthly injection and relapse on opioids are at an elevated risk of overdose.49

Therefore, clinician judgement should be exercised and individualized to the patient, with regards to a patient’s risk for loss to follow-up.

This can include consideration of the patient’s housing and financial stability, social supports, individual/familial motivation, and likelihood of remaining engaged in treatment.

Suggested schedule for starting naltrexone:

• 3–6 days after most recent use of short-acting opioids, such as heroin, or short-acting prescription opioids (oxycodone, morphine, codeine, hydrocodone, hydromorphone, oxymorphone)

• 7–10 days after most recent use of long-acting opioids, such as methadone, buprenorphine, and long-acting prescription opioids (hydrocodone extended release [ER], morphine ER, oxycodone ER, tramadol ER, oxymorphone ER)24

When initiating treatment with the long-acting injectable form of naltrexone, generally tolerability is first assessed with oral naltrexone.

It is important for providers to educate young people that they are at risk for precipitated opioid withdrawal if naltrexone is taken when opioids are still in their system.

To minimize the risk of precipitated opioid withdrawal the choice of when to start naltrexone should be determined based on the half-life of the opioid that a young person hasbeen using.

Many clinicians initially prescribe several days to one week of oral tablets to monitor tolerability before transitioning to the monthly injection.

Other clinicians provide a single oral dose in an observed clinical setting, and if tolerated by

the patient, provide a long-acting injection approximately two hours later.

Choosing a Medication

There is no definitive algorithm to guide medication choice although there are some general guidelines that providers, patients, and families can follow.

First, providers can give patients and families information about the different medication choices, including how the medication works, the evidence for its use, and potential side effects.

In addition, providers can provide tailored advice based on the individual patient.

Please see the PCSS course, “Choosing a Medication Assisted Treatment”

for more information.

training-courses/introduction-to-medication-assisted- treatment-mat/

Monitoring

While on medication, toxicology tests can be used to ascertain concurrent substance and opioid use, and medication adherence.

If a toxicology screen tests negative for buprenorphine for a patient who is prescribed medication, providers should not immediately assume that the patient is not taking their medication.

Low-dose buprenorphine can be difficult to detect with toxicology testing (particularly through saliva).

| SECTION 3. Guidance for Primary Care and Pediatric Providers

Therefore, clinicians should supplement lab tests with conversations with patients to understand their experience taking MAT and may consider checking metabolites.

These conversations can be an opportunity to discuss risks of ongoing substance use while on buprenorphine, since concurrent alcohol and benzodiazepine use can lead to excessive somnolence, and in high doses, potential overdose.

They can also be a place to discuss desire to switch among forms of MAT if unhappy with one medication.

Duration of Treatment

There is no specific evidence on the optimal duration of treatment for either naltrexone or buprenorphine.

Extant evidence suggests that adolescents and young adults experience more positive outcomes with longer use of medications and engagement in care.18,41

At the same time, prolonged exposure to opioids has a negative impact on the developing brain.

The tradeoff of continuing medication should be made with consideration of severity of substance use disorder and risk of overdose. Shared decision making with the patient, and the parents when possible, should guide treatment.

Length of treatment should be determined based on clinical judgement and progress of patient, in collaboration with family/ support system, if appropriate.

If future tapering is desired, medications should be tapered slowly to avoid withdrawal and return of cravings.30

Once a medication has been discontinued, continuing care, including behavioral health treatment and primary care, is still important.

Special Populations

Adolescents and young adults should have access to evidence-based care, regardless of their involvement in justice and social systems.

Adolescents with chronic pain conditions, currently homeless, LGBTQ-identifying, in government custody, or currently pregnant are all candidates for MAT.

Youth in DCF/DYS Custody

Youth in the care of the Massachusetts Department of Children and Families (DCF) and/or Department of Youth Services (DYS) should still receive care for their opioid use disorder, with decisions made in collaboration with government case workers.

DCF can give consent for a minor to receive medical

treatment.51

However, minors in Massachusetts DO NOT need to have parental or legal guardian consent to agree to treatment for OUD, and adolescents in DCF custody do not require DCF

approval or consent for treatment.31

If a medical provider chooses to treat an adolescent under DCF custody only after obtaining consent from the Department, DCF may consent for the minor, provided that the Department is not consenting to the administration of antipsychotic medication as part of the treatment of substance use disorder.51

DYS policy states that patients should be transitioned to outpatient treatment services if deemed appropriate by medical providers.52

Pregnancy

Opioid use during pregnancy has increased risks, including fetal growth restriction, placental abruption, preterm labor, and possible fetal death.53

Opioid agonist pharmacotherapy during pregnancy has been shown to reduce the risk of obstetrical complications and have better outcomes both for mother and baby.

Babies born to mothers who were treated with methadone or buprenorphine may develop neonatal opioid withdrawal.

Historically, methadone has been the first-line medication choice for treating OUD in pregnant women, but buprenorphine has been shown to be equally safe and effective.53

Increasingly, providers are continuing naltrexone during pregnancy for women stable on the medication prior to pregnancy.

Patients who are pregnant with active OUD or are on MAT should be referred to healthcare professionals experienced in providing prenatal care to patients with OUD and identifying and managing neonatal opioid withdrawal syndrome in infants.

State licensed and/or contracted providers who have relationships with clients that last longer than 30 days are expected to make sure that all clients who are pregnant or parenting an infant have a Plan of Safe Care (POSC).

Other perinatal service providers and healthcare providers are encouraged to screen pregnant and parenting women for substance use and offer either to coordinate a POSC for the client/ patient or refer her to another provider who will coordinate the POSC.

For more information on POSC, go to: .

Relapse and Overdose Prevention

Relapse Risks

Alternating periods of recovery and relapse are common for individuals with OUD.

Patients on MAT who relapse and/or show evidence of use of other illicit substances will need additional support.

Providers may also consider discussing options for more intensive SUD treatment (intensive outpatient program, partial hospital program, residential treatment) if indicated.

It is recommended that healthcare providers continue support from SUD treatment providers for patients on MAT who relapse.

Overdose Risk

Patients develop tolerance to opioids with regular use, requiring larger or more frequent amounts of a substance to continue experiencing reinforcing effects.

When individuals begin MAT after prolonged opioid use, they can lose

tolerance to opioids.

While opioid agonists methadone and buprenorphine maintain activity at the mu opioid receptor, opioid antagonist naltrexone prevents all activity, increasing the loss of tolerance.

If a patient relapses on the same dose they used prior to treatment, they are at an elevated risk of overdose.

Caregiver Education

It is recommended that clinicians educate patients and their families/caregivers about this increased overdose risk.

Specific signs of overdose to review with caregivers include pinpoint pupils, slow or stopped breathing, slow or stopped heartbeat, confusion, slurred speech, and difficulty in arousing patient.54

Several resources exist as educational tools to assist in these conversations, including an Overdose Prevention Toolkit ( product/Opioid-Overdose-Prevention-Toolkit/ SMA18-4742), published by the Substance Abuse and Mental Health Services Administration (SAMHSA) (See Appendix 6.4).

Naloxone Prescription

Naloxone is an FDA-approved antidote to opioid overdose and the fast-acting antagonist of choice to reverse acute opioid toxicity.

It can be administered intramuscularly, subcutaneously, or intravenously.

Naloxone can be prescribed to patients, caregivers, and community members.

Massachusetts pharmacies allow anyone to purchase naltrexone without a prescription.

The proper technique for administration should be reviewed with patients regardless of their MAT status, as well as caregivers.54

Injection Drug Use Harm Reduction

It is recommended that providers educate patients who have progressed to injection drug use on safe injection techniques, including the importance of using new syringes, safer materials (filters, water, tourniquets, acidifier), skin hygiene, safer veins, and syringe disposal.

Syringe exchange programs in Massachusetts provide education and free packs that include materials to support safe injection techniques.

| SECTION 3. Guidance for Primary Care and Pediatric Providers

CO-OCCURRING PSYCHIATRIC DISORDERS

Psychiatric disorders commonly co-occur with substance use disorders in young people.

This is not surprising since psychiatric disorders in childhood, such as Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder/Conduct Disorder, and Depression are associated with an increased risk for developing a substance use disorder.55

One study found 83% of young people with an opioid use disorder had a co-occurring psychiatric disorder that was equivalent to the prevalence of co-occurring psychiatric disorders in young people with an alcohol or cannabis use disorder.44

Opioid use is associated with psychiatric symptoms including depression, thoughts of suicide, and suicide attempts.56

Furthermore, there has been increasing concern that many drug overdose deaths may have been suicides.57

Anxiety is another symptom and disorder that has been specifically linked to opioid use/disorders in young people seeking substance use disorder treatment.58

Assessment for Co-Occurring Psychiatric Disorders

Given the high prevalence of co-occurring psychiatric disorders in young people with opioid use disorders it is important that providers screen and monitor for psychiatric symptoms/ disorders, and assess safety including risk for suicide.

Factors to consider when assessing for a co-occurring psychiatric disorder include the relationship between substance use and psychiatric symptoms, whether or not the psychiatric symptoms/disorder preceded the onset of substance use, and the presence or absence of a family history of psychiatric illness.

Generally, individuals with a co-occurring psychiatric disorder will have experienced psychiatric symptoms in the absence of substance use, the psychiatric disorder preceded the onset of substance use, and/or they have a family history of psychiatric illness.

Appropriate Management of Psychiatric Disorders

Integrated treatment, including therapy and/or medication for both co-occurring disorders is important.

Medication and/or therapy for the co-occurring psychiatric disorder in the absence of substance use disorder treatment will not likely be adequate to stabilize either disorder.

When medications are prescribed for a cooccurring psychiatric disorder, providers need to consider risk associated with continued substance use (continued use of opioids, alcohol, and/or benzodiazepines) while the young person is taking the medication.

Furthermore, while prescription medications with a risk for misuse (e.g. prescription stimulants) are not contraindicated within the context of a substance use disorder, patients should be closely monitored for any signs or symptoms of medication misuse or diversion.

AGE-APPROPRIATE PROGRAM DEVELOPMENT

Adolescents with opioid use disorder (OUD) are developmentally different from older adults, and programs seeking to develop outpatient medication for addiction treatment (MAT) should include evidence-based, age-appropriate counseling and behavioral therapy as adjuncts.59

Additionally, patients of this age group may also have family and other social support that can be an asset to recovery.

Incorporating family — biological or chosen — into treatment is recommended when it is in the best interest of the young person.

Youth and Family Engagement/ Recovery Supports

Recovery High Schools

Massachusetts has public high schools for youth ages 14–21 that provide educational environments suited to support youth recovering from substance use disorder (SUD).

They serve 30–50 students per school and are supported through blended funding from the Commonwealth, local school districts, and educational collaboratives.

The model offers a unique opportunity for students to receive support for their recovery within an academic setting consistent with Massachusetts State Standards.

Students with a diagnosed SUD can attend a recovery high school by choice, as a referral from a student’s sending district is not required.

Independence Academy

Brockton, (508) 510–4091

Liberty Preparatory Academy

Springfield, (413) 750–2484

North Shore Recovery High School

Beverly, (987) 922–3305

Rockdale Recovery High School

Worcester, (508) 854–4939

William J. Ostiguy High School

Boston, (617) 348–6070

Collegiate Recovery Programs

Some colleges and universities may offer collegiate recovery programs (CRP) on campus.

These are supportive environments within the campus culture that reinforce the decision to engage in a lifestyle of recovery from substance use.

They are designed to provide an educational opportunity alongside recovery support to ensure that students do not have to sacrifice one for the other.

More information can be found at:

Recovery Housing

Recovery Home, frequently referred to as a “sober home,” is a broad term describing a substance-free, safe and healthy living environment that promotes recovery from alcohol and other drug use and associated problems.

Residents are expected to abstain from alcohol and illegal drug use. For additional information:

Anti-Stigma Message

Addiction may be the most stigmatized health condition in the United States.60

Person-first language that emphasizes the individual over the health condition and medically accurate terminology helps to reduce stigma.

Several considerations may impact treatment decisions by youth.

Patients may exhibit a hesitancy to initiate medications for opioid use disorder given the negative attitudes expressed by trusted adults (parents, caregivers, state agencies, treatment providers, teachers, etc.) or because they believe these medications will be required for the rest of their lives.

A lack of information regarding the pharmacology of MAT may result in negative sentiments that question whether a patient on medication is “truly sober” or trading one drug for another.20,61

Young adults may get mixed messaging from primary care providers or other trusted adults about the efficacy or use of MAT — a situation compounded by the common separation of addiction treatment and primary care.

It is essential that clinicians provide accurate information to dispel myths that patients may have about starting a medication for their opioid use disorder.

Behavioral Health Treatment with MAT

In general, all adolescents and young adults benefit from developmentally appropriate services tailored to meet their unique social, emotional, cognitive, and physical stages of development.

Adolescents with OUD are developmentally different from older adults, and programs seeking to develop outpatient MAT should include evidence-based, age-appropriate counseling and behavioral therapy as adjuncts.

While medications can help manage cravings and withdrawal symptoms of OUD, counseling helps adolescents and young adults address life domains that may have been impacted by their use and/or address underlining issues or trauma that contributed to their initiation of substance use.

Adolescence and young adulthood are a developmental phase focusing on identity formation and autonomy.

For young people with SUD or OUD this can be especially challenging to navigate when treatment for their disease may mean separating from or reducing interactions with their existing peer group, relying more on parent or guardians instead of separating from them, and possibly not mastering certain developmental tasks that would promote long-term recovery capital such as education, employment, or romantic relationships.

Developmentally appropriate MAT care models must include behavioral health services and be relentless in their efforts to increase engagement and retention in treatment for this population.

Prescribers, clinicians, and support staff should be trained in developmentally appropriate SUD treatment modalities that are rooted in motivational interviewing.

Programs should offer flexible meeting times and days for young people, and whenever possible, flexibility in meeting location for actual counseling sessions.

If possible, programs should utilize contingency management, incentivizing for attendance at sessions in varying denominations and at varying stages of treatment.

Some young people and/or families may be reluctant to engage in behavioral therapy.

It is recommended that providers do not discontinue MAT when a young person is not engaging in behavioral therapy.

Rather, providers may need to continue to provide education on the role of adjunctive behavioral therapy and explore the reasons why a young person and/or family is not following up with this recommendation.

If outpatient MAT programs are not positioned to offer evidence based, developmentally appropriate behavioral health services, they can contract with trained providers in the community such as Adolescent Community Reinforcement Approach (A-CRA) clinicians and agencies.

Provider information may be found at: or 800–327–5050.

| SECTION 5. Age-Appropriate Program Development

Clinical service providers employ evidenced-based practices shown to be effective in engaging with and treating adolescents and young adults with SUD and their families, such as:

Adolescent Community Reinforcement Approach (A-CRA)

A behavioral intervention that seeks to increase family, social, and educational reinforcers

of an adolescent to support recovery ( Research/Treatments/A-CRA)

Multidimensional Family Therapy (MDFT)

Family-centered treatment for youth ()

Multisystemic Therapy (MST)

Intensive family and community-based treatment ()

Adolescent-Focused Family Behavior Therapy (Adolescent FBT)

Includes over a dozen treatments, including treatment planning, behavioral goals, job-skills training, stimulus control ().

Functional Family Therapy (FFT)

An interventional program for families aimed at youth with different behavioral issues, including substance misuse ()

EVIDENCE-BASED TREATMENTS FOR ADOLESCENTS ONLY:

Motivational enhancement therapy combined with cognitive behavioral therapy (MET/CBT)

TREATMENT FOR PARENTS/ CAREGIVERS ONLY:

CRAFT

Community Reinforcement and Family Training

Appendices

APPENDICES

Confidentiality Laws

Clinical documentation and record sharing with referral sources must ensure confidentiality and patient data privacy in compliance with 42 Code of Federal Regulations (CFR) Part 2 and Health Insurance Portability Accountability Act (HIPAA).

This includes providing written policies to ensure confidentiality and information-sharing practices comply with 42 CFR Part 2 and HIPAA.

Commonwealth of Massachusetts |

General Laws

Section 12 E:

Drug dependent minors; consent to medical care; liability for payment; records.

Section 12 FF:

Immunity of person administering naloxone or other opioid antagonist to person experiencing opiate-related overdose.

Sample Treatment Documents

[pic]

[pic]

Sample Treatment Documents

[pic]

List of Resources

Adolescent MAT Dosage Guidance for Buprenorphine:

uploads/2014/03/PCSS-MATGuidance TreatmentofOpioidDependantAdolescent-buprenorphine. SubramaniamLevy1.pdf

Co-Occurring Psychiatric Illnesses and Substance Use in Youth Module:

illness-and-substance-use-in-youth/

Further information on MAT can be found at:

assisted-treatment-mat/

Introduction to MAT:

assisted-treatment-mat/

Naltrexone Step-by-Step Guide:

4e52-bc8b-81f5b5b28cc1

PCSS Module on Models of Buprenorphine Induction:

-induction/

Primer on Antagonist-Based Treatments in Office Setting:

treatment-of-opioid-use-disorder-in-the-office- setting/

Naltrexone Treatment Training for Clinicians:

use-disorder-training-for-clinicians-part-1/

SAMHSA MAT Pocket-Guide:

sma16-4892pg.pdf

SAMHSA TIP 63: Medications for Opioid Use Disorder — Full Document

Medications-for-Opioid-Use-Disorder-Full- Document-Including-Executive-Summaryand- Parts-1-5-/SMA18-5063FULLDOC

SAMHSA TIP 63: Medications for Opioid Use Disorder — Partnering Addiction Treatment Counselors with Clients and Healthcare Professionals (Part 4 of 5):

sma16-4892pg.pdf

SAMHSA Opioid Overdose Prevention Toolkit:

Overdose-Prevention-Toolkit/SMA18-4742

Patient/Family Resource Information

Learn to Cope

A peer-led support network for families dealing with addiction and recovery.

Massachusetts Organization for Addiction Recovery (MOAR)

Recovering individual, families, and friends united as a collective voice to educate the public about the value of recovery from alcohol and other addictions.

Providers Clinical Support System

Patient and Family Frequently Asked Questions and MAT educational materials. | : training-courses/addressing-patient resistance-medication- assisted-treatment/

References

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SA5829 | 10/2019

Commonwealth of Massachusetts department of public health

Boston university school of medicine

Boston children’s hospital until every child is well

Massachusetts general hospital

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