Breaking through the fog of opioid addiction

Treatment options

In 2016, the American Academy of Pediatrics issued a new policy statement, “Medication-Assisted Treatment for Adolescents with Opioid Disorders,” which recommends that pediatricians consider offering medication-assisted treatments to their adolescent and young adult patients with opioid use disorders or refer them to other providers who can. Ideally, pediatricians should refer patients to clinicians who have expertise in treating substance abuse disorders in adolescents, typically psychiatrists.

Psychiatrists “tend to have quite a bit of experience with addiction, but they can be very hard to find,” Dr. Hulvershorn said. “Sometimes, it’s a mental health center provider who treats adults with addiction. Addiction is a different beast in kids, but that might be the next best thing.”

Three medicines indicated for treating severe opioid disorder include buprenorphine (the “gold standard,” Dr. Matson said), methadone, and naltrexone, which is Dr. Hulvershorn’s typical drug of choice, “because it’s not a drug of abuse. It’s an opioid antagonist, so it blocks the euphoria that you might get when you are using a drug of abuse such as an opioid.”

Even though pediatricians have access to an American Academy of Pediatrics–endorsed buprenorphine waiver course, not all clinicians feel comfortable adding medication-assisted treatment to patients.

“It might mean that you partner with a substance use provider who can do more comprehensive services but not the prescribing,” Dr. Hulvershorn said. “You certainly don’t want to treat these kids in a vacuum by yourself, because it’s very complicated to treat them.”

Still, the office-based practice of prescribing opioid withdrawal medication “is a very successful approach and a reasonable alternative to other approaches that have been used historically, like methadone maintenance programs,” noted Dr. Potenza, emphasizing that physicians have to understand how to help patients with addiction.

Physicians interviewed for this story underscored the importance of a comprehensive approach that includes behavioral treatment, medication, and support from family and friends.

“A lot of kids who get into these problems come from families that don’t have many resources,” Dr. Matson said, noting that, often, it is a generational problem, in which grandparents and parents are drug users. “But, for kids who take a wrong path, encouraging words really can come true. It’s really a matter of how many people you have cheerleading for you and keeping an eye on you.”

When Dr. Matson’s clinic began treating patients with opioid use disorders 8 years ago, only about 25% of adolescents returned for a second visit, and the rate of abstinence at 1 year was only 9%. The clinic has undertake a large quality improvement project to improve that percentage. “We learned to not scare people right away with a bunch of assignments they have to get done but to just welcome them in, get them started on the medication, and give them positive messages. For short-term remission at 3 months, we’re at 50%-60%, which is pretty good. It’s probably as good as any adult program. I think we’re at 35%-40% remission at 1 year for people first time in recovery,” he said.

Where to go from here

Reflecting on what he’d like opioid use disorder treatment to look like 5 or 10 years down the road, Dr. Matson emphasized the prominent role that pediatricians can play.

“We’re really the ones that could make a difference if we can try to intervene,” he said. “I’m not sure I can prove it, but my pipe dream is, the earlier that we catch people and the less time they’ve been using drugs, it’s got to be easier to stop it then, than if they’ve been using for 5 or 10 years.”

That’s the kind of hope Dr. Hulvershorn holds for the17-year-old patient she’s treating who suffers from depression and PTSD.

“She has decided that it’s important for her to come clean,” said Dr. Hulvershorn, who added that the patient has received mental health and trauma counseling. “Part of our treatment program involves helping patients reorganize their life so that activities they’re involved with are not drug-related. That involves finding new friends and new activities, which can take some time. She is really committed to graduating from high school now that she’s clean. She’s really made a 180.”

Dr. Potenza disclosed having been a consultant to Jazz Pharmaceuticals and Opiant Pharmaceuticals. Dr. Matson and Dr. Hulvershorn reported having no relevant financial disclosures.

Role of a pediatrician’s support is vital

The way Deepa R. Camenga, MD, sees it, pediatricians play a vital role in not only counseling adolescents struggling with opioid use disorders but in helping to prevent it in the first place.