Opioid addiction

Scott E. Hadland, MD, MPH, MS: Teens, Young Adults With Opioid Addiction Need Greater Access to Medication

The opioid crisis has maintained an unrelenting grip on the United States since the late 1990s. The epidemic is now responsible for more than 130 US deaths per day, racking up a total of 42,249 deaths due to overdose in 2016 and 2017 alone.1

Of great concern is the impact of the epidemic borne by adolescents and young adults. Youth can easily come into contact with opioids in their own homes, with prescription bottles supposedly “safely” tucked away in kitchen or bathroom cabinets.

Perhaps even more alarming is that, as prescription opioids become harder to come by due to prescribing crackdowns, adolescents and young adults have an increased risk of encountering heroin or fentanyl as their first opioid.

As opioid use disorder (OUD) is continually diagnosed in youth, increasing their access to medication for OUD is of paramount importance. However, this is not an easy task, said Scott E. Hadland, MD, MPH, MS, pediatrician and addiction specialist at the Grayken Center for Addiction at Boston Medical Center in Massachusetts.

Dr Hadland and his research team recently conducted a study on the effects of timely receipt of buprenorphine, naltrexone, or methadone on retention in care among youth with OUD. For their study, they assessed Medicaid enrollment and complete health insurance claims data from 2.4 million youth aged 13 to 22 years.2

The results of their study showed that youth who received buprenorphine, naltrexone, or methadone were 42%, 46%, and 68% less likely to discontinue treatment, respectively, compared with those who received behavioral treatment only.

However, of the 4837 adolescents and young adults with an OUD diagnosis, only 1 in 21 adolescents and 1 in 4 young adults received OUD medication within 3 months post-diagnosis.

Consultant360 spoke with Dr Hadland about these findings and how they should affect clinical practice going forward.

Consultant360: Are youth more susceptible to the negative effects of opioids compared with adults, or are the effects about the same?

Scott Hadland: We still need to conduct more research in this area. Studies suggest that the young brain continues to develop well into the mid-twenties. Data also suggest that, when young people are exposed to substances including opioids, their brain development can actually be altered by this exposure. However, among older adults whose brains are more fully developed, this is obviously not the case.

C360: Your study found that youth are much less likely to receive a medication for OUD than adults. Why do you think this is?

SH: The answer to this question is complicated. The 3 medications assessed in our study are very difficult to access for everyone in the United States. Buprenorphine can only be prescribed by physicians who undergo an 8-hour course and subsequently apply for a waiver from the Drug Enforcement Agency. However, very few physicians in the United States have undergone this training, and as a result, there are very few people eligible to prescribe these medications.

Methadone is permissible for adolescents under age 18 years, but adolescents are required to demonstrate 2 prior treatment attempts that did not involve medication before they are eligible to receive methadone. Even if they meet this substantial burden, they have to find a methadone treatment program that is willing to accept a young person under age 18 years. In practice, these programs are largely non-existent. So clearly, there are enormous structural barriers that often prevent youth from accessing these medications.

Another complicating factor is that, in my view, the pediatric workforce has fallen behind other specialties in its ability to treat addiction. As a result, there are very few youth-focused providers who feel comfortable treating young people who are struggling with addiction.

Finally, it is clear that there is stigma surrounding the prescription of these medications to young people. Providers are often uncomfortable with the medication or feel as though other non-pharmacologic approaches should be tried first before using a medication. However, our study demonstrates that, by providing medication as early as possible, youth are more strongly retained in treatment vs behavioral treatment alone.

C360: Why do you think that the receipt of medication for OUD was more effective for treatment retention compared with behavioral treatment alone?

SH: We should not be surprised by this. Data show that adults with addiction who receive pharmacotherapy are much more likely to be engaged and retained in treatment, and the data from our study suggest that the same applies for youth with OUD as well. Still, I felt this study was important to conduct because youth are so often denied access to these medications.

C360: How should the findings from your study help change current practice?

SH: When it comes to treating addiction, the clinical guidelines are clear. In 2016, the American Academy of Pediatrics said that these medications should be available to adolescents and young adults with opioid addiction.3 Unfortunately, this clinical practice guideline has not been fully implemented throughout the United States. Although our study demonstrated that medication should be offered as soon as possible in the course of addiction in order to maximize retention in treatment, we found that only 1 in 4 young adults and only 1 in 21 adolescents actually receive these medications.

C360: What are the next steps in your research?

SH: There are a number of health outcomes associated with these medications that we need to better understand among youth. The data unequivocally show that medications are highly effective for adults. Because there are a limited number of similar studies that have not been conducted among youth with OUD, this evidence gap may be holding providers back from offering these medications to young people.

We also need to understand the extent to which medication may help protect young people against overdose and against acquiring hepatitis C virus infection or HIV infection.

Scott E. Hadland, MD, MPH, MS, is a pediatrician and addiction specialist at the Grayken Center for Addiction at Boston Medical Center in Massachusetts.

—Christina Vogt

References:

  1. What is the US opioid epidemic? US Department of Health and Human Services. Page last updated September 2018. https://www.hhs.gov/opioids/about-the-epidemic/index.html. Accessed on September 21, 2018.
  2. Hadland SE, Bagley SM, Rodean J, et al. Receipt of timely addiction treatment and association of early medication treatment with retention in care among youths with opioid use disorder [Published online September 10, 2018]. JAMA Pediatr. doi:10.1001/jamapediatrics.2018.2143
  3. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3). doi:10.1542/peds.2016-1893