Data Scant on Tx for Young Opioid Abusers


BETHESDA, MD. – Very little published evidence exists to back treatments for adolescents with opioid abuse or dependence.

In addition, those adolescents appear to have characteristics that differ from those abusing or dependent on marijuana or alcohol, Dr. Geetha Subramaniam reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Most of the studies on treatments for adolescent opioid users were published in the 1960s and 1970s, and included no randomized trials or control groups (J. Subst. Abuse Treat. 2002;23:231–7), said Dr. Subramaniam of Johns Hopkins University, Baltimore.

Methadone maintenance treatment is known to work for adolescents if it is given for a long enough period of time and in high enough doses. But it is tough for patients under age 18 to qualify for methadone maintenance treatment and to find a provider who is willing to treat them.

Even for adult patients, many physicians are uncomfortable with prescribing methadone because of concerns about addiction.

For adolescents, drug-free treatment in therapeutic communities for up to 6 months is known to be effective. But in many cases, it is not cost effective to place a patient in residential treatment for 6 months, Dr. Subramaniam pointed out.

In a recently published randomized, controlled trial of 36 adolescent opioid users who participated in a 28-day course of detoxification, a significantly greater percentage of patients who received 6–8 mg of buprenorphine remained in treatment (72%) and had a higher percentage of opioid-negative urine samples (64%) than did patients who received 0.1–0.3 mg of clonidine (39% and 32%, respectively) (Arch. Gen. Psychiatry 2005;62:1157–64).

Another trial is enrolling heroin-addicted patients 14–21 years old to compare a 12-week course of buprenorphine and naloxone (the combination is marketed as Suboxone) with a standard 2-week course of Suboxone.

Adult opioid users have had success with psychosocial treatments in outpatient (cognitive-behavioral therapy, contingency management, or self-help groups) or residential settings (therapeutic community). For those patients, methadone maintenance treatment has been shown to reduce opiate use and mortality. But researchers have not conducted any treatment trials comparing psychosocial treatments for opioid users who are adolescents.

The few published U.S. studies of comorbidities in adolescents with opioid use disorders are limited by their focus on heroin or opioid users rather than on those who had progressed to abuse and dependence, Dr. Subramaniam said.

Those studies found that most users were male and white, came from single-family homes, and had psychiatric and legal problems.

The reports showed that most of the adolescents used other drugs, and about half injected drugs.

At Johns Hopkins, Dr. Subramaniam is conducting a study examining the differences between adolescents diagnosed with an opioid use disorder and those diagnosed with a marijuana and/or alcohol use disorder. The diagnosis of a “use disorder” connotes drug abuse or dependence.

Dr. Subramaniam presented results on 40 patients in each group; about 100 patients are expected to be recruited for each arm of the study. The patients are matched for age, gender, inpatient and outpatient status, and cocaine use in the past 30 days.

Whites made up a significantly higher percentage of opioid users (95%) than marijuana/alcohol users (48%). Dropout rates from school were significantly higher in opioid users (70%) than marijuana/alcohol users (33%). The average age of the patients in each group was about 17 years.

Most (65%) of the adolescents with opioid use disorder named heroin, oxycodone, or other opiates as their drug of first choice, but 19% called cocaine their first choice. Most (73%) patients in the comparison group reported marijuana as their drug of first choice, followed by cocaine and then alcohol.

Patients in both groups first began regularly using marijuana (about 14 years) and alcohol (13.2–13.5 years) at a similar average age. But patients with opioid use disorders began regularly using opioids and cocaine at a significantly younger age (15.2 years and 15.7 years, respectively) than patients in the comparison group (16.8 years for both).

“Somehow [patients with opioid use disorder are] gravitating into harder drugs much earlier” than the comparison group, Dr. Subramaniam said. “What facilitates this kind of trajectory, I don't know, but that is an important point for us to think about.”

In the past year, patients with an opioid use disorder had a concomitant cocaine or sedative use disorder in a significantly higher percentage of cases than those with marijuana/alcohol use disorders. Both groups had high, but not significantly different, prevalences of psychiatric diagnoses in the past year.

Opioid users had engaged in behaviors in the past 30 days that put them at risk for HIV at significantly higher rates than patients in the comparison group, including injection drug use (43% vs. 3%) and never using condoms (38% vs. 18%).


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