Opioid Use by Adolescents

2015

Screening for alcohol abuse and illicit drug use needs to be a standard procedure in any practice that cares for adolescents and young adults. Recent national surveys indicate that prescription pain relievers have replaced marijuana as the most common entry drugs for adolescents beginning to experiment with drugs. In this chapter, we review appropriate screening tools and management approaches for use in this population. We cover standard treatment options with a focus on the treatment of adolescents dependent on heroin or opioid pharmaceuticals and the promising role of buprenorphine in the treatment of this high-risk population.

A case is presented at the end of this chapter, including related questions for additional consideration.

Epidemiology

Opioid abuse among adolescents is a growing problem in the United States. According to data from the National Institute on Drug Abuse’s Monitoring the Future study, use of “narcotics other than heroin” has doubled among high school students since the year 2000, with marked increases in the use of long-acting oxycodone tablets and hydrocodone-acetaminophen combination tablets. In 2007, the annual prevalence for oxycodone and hydrocodone use reached its highest level since these data have been collected, with 1.8%, 3.9%, and 5.2% of eighth, tenth, and twelfth graders, respectively, reporting oxycodone use in the past year and 2.7%, 7.2%, and 9.6% of them, respectively, reporting hydrocodone use in the past year (). Past-year heroin use without a needle also increased among high school seniors, rising from 0.6% in 2006 to 1.0% in 2007. Survey results also indicate an increased perception of availability, decreased social disapproval, and a decreased perception of risk associated with using opioids; all of these factors suggest that opioid misuse continues to be on the rise. These reports likely underestimate actual prevalence because data are collected only from teenagers in school on the day of the survey; teens with high rates of absenteeism and those who drop out of school are an even higher-risk group. Teenagers may not fully appreciate the risks of misusing prescription opioids because these drugs are legal and easily accessible (). Many adolescents who misuse opioids to get high may quickly become addicted and transition to heroin use when they can no longer afford the street price of opioid medications. A decrease in the price of heroin has increased accessibility to teens, and an increase in purity has allowed for nonintravenous administration, which has made the drug more attractive to adolescents. As a result, use of heroin by adolescents has increased substantially and is currently at its highest level since the heroin epidemic of the 1960s. Heroin-related emergency department visits among youths ages 12–17 underwent a fourfold increase between 1991 and 1996 (), and approximately 27% of those reporting first-time heroin use in the year 2000 were under age 18. Although all adolescents are at risk, heroin use is more common among teens with early-onset substance use or those who have developed polysubstance dependence. Boys account for 53%–68% of users and approximately 80%–97% of users are white. Intravenous use accounts for 45%–57% of all heroin use by adolescents, which raises a significant public health concern due to an increased risk of contracting and spreading HIV infection, hepatitis, and other infectious diseases.

Risk and Protective Factors

Individual, peer, family, and community factors all impact the likelihood of drug use and the likelihood of progressing to substance use disorders. Healthy parental attitudes and role modeling decrease the likelihood that teens will try drugs or affiliate with peers who use drugs. Conversely, conflicted parent-child relationships, parental ineffectiveness, insufficient parental monitoring, inconsistent discipline, deprived so-cioeconomic status, and parental alcohol or drug use have all been robustly correlated with adolescent opioid use. Lower levels of parental education are also correlated with heroin use by teens, with rates highest among those whose parents did not complete grade school.

Early-onset substance use predicts a rapid progression to substance use disorders. Early use of nicotine and alcohol increases the risk of developing substance use disorders later in life, including cannabis, stimulant, opioid, and/or alcohol dependence (). Teens diagnosed with substance dependence are also more likely than their peers to continue substance use into adulthood ().

Legal problems and co-occurring childhood psychopathology are also risk factors for progression from opioid use to opioid disorders, especially among adolescent females. The most frequently identified antecedent psychiatric disorders include behavioral disorders (conduct disorder, attention-deficit/hyper-activity disorder [ADHD]), mood disorders, anxiety disorders, and learning disabilities.

Substance Use and Co-Occurring Disorders

Substance use disorders frequently co-occur with other mental health disorders, and opioid dependence is no exception. The most common comorbidities include mood and anxiety disorders, conduct disorder, oppositional defiant disorder, and ADHD. Adolescents with substance use disorders are also more likely to have been victims of physical or sexual abuse than their peers.

Substances of abuse can induce, mimic, or exacerbate underlying mental illness. Opioid-dependent adolescents with comorbid mental health disorders are more likely to require inpatient hospitalization, are less likely to be compliant with medications, are more likely to drop out of treatment, and are at higher risk of relapse. Despite these poor outcomes, simultaneous treatment of the co-occurring mental health disorder helps to alleviate the substance use. Therefore, all adolescents with opioid dependence should be evaluated for co-occurring mental health disorders and should be treated for both disorders simultaneously.

Screening and Assessment

Screening for drug use, including opioids, should occur as part of routine adolescent medical care. Screening is a two-step process — it begins with opening questions about drug use, such as: “During the past 12 months (or since your last appointment), did you drink any alcohol (more than a few sips)? Smoke any marijuana? Use anything else to get high? By ‘anything else’ I mean illegal drugs, over-the-counter and prescription drugs, and things that you sniff or huff ” (). Since 2007, more teens have reported drug initiation with opioid pharmaceuticals than any other class of drugs, including marijuana, making opioids a new gateway drug. Because of this phenomenon, it is important to specifically mention opioids in the opening questions ().

Teens who answer yes to one or more of the opening questions should be further screened with a standardized, developmentally appropriate tool that can distinguish low- versus high-risk substance use. Work by Wilson et al. has demonstrated that even experienced clinicians significantly underestimate substance use disorders when relying on clinical impressions alone. Several screening tools are available, including the CRAFFT questionnaire (with CRAFFT being a mnemonic for six key terms within the questions: car, relax, alone, forget, family or friends, trouble), which has been extensively validated and is recommended by the American Academy of Pediatrics. Every adolescent should receive a brief intervention appropriate to their level of use based on screening results. Readers are referred to the review article “Screening, Brief Intervention, and Referral to Treatment for Adolescents” for a general approach to office-based screening and intervention.

Beyond screening, substance use should be considered in the differential diagnosis of any teen who presents with new-onset behavioral, emotional, or school problems, or when an adult suspects substance use because a teen has appeared intoxicated or has been in possession of drugs or paraphernalia. Recognition of the physical and behavioral manifestations of common drugs of abuse can aid in focusing screening questions, testing, and prompt intervention. Physician and family understanding of risk and protective factors may be the single most important element for identifying at-risk youths and intervening early.

Adolescents who report any use of opioids (other than as prescribed by a physician) should receive further assessment to determine the motivation and pattern of use, associated problems, attempts at quitting, and previous treatment in order to determine the stage of use and whether a substance use disorder is present. Opioid use occurs on a continuum from misuse to dependence as described below. Treatment strategies are most effective when targeted to the stage of use.

Opioid misuse is characterized by oral use of opioids without a prescription exclusively for pain relief. Because of the highly addictive nature of opioids, teens using these medications without medical supervision may develop opioid addiction.

Problematic opioid use is defined by the occurrence of a single adverse consequence as a result of use, use for reasons other than relief of pain (e.g., to become intoxicated), or use by any route other than oral (e.g., insufflated or injected). Substance-related problems may include decreased school performance, suspensions, relationship problems with parents or peers, motor vehicle accidents, injuries, emergency department visits, physical or sexual assaults, and legal problems. These may be accompanied by significant changes in dress, behavior, and peer group.

Opioid abuse refers to continued opioid use in the context of significant problems or impairment in functioning. It is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association 2000) as a maladaptive pattern of use that causes impairment in social or school functioning, recurrent physical risk or legal problems, and continued use despite harm occurring over a 12-month period, with no diagnosis of dependence.

Opioid dependence or addiction refers to loss of control over drug use and is characterized by a maladaptive pattern of compulsive opioid use, preoccupation, and associated negative consequences. Tolerance and withdrawal are nearly universal. Clinical manifestations typically include continual use of substances when available, solitary use, disrupted family relationships, and loss of outside supports. Formal diagnostic criteria are specified in DSM-IV-TR.

If a teen denies drug use in the context of substantial evidence to the contrary, the clinician should conduct a confidential interview and ask for an explanation of the reported observations (e.g., “Why is your mother so worried that you are using drugs?” or “Why were you carrying pills in your pocket-book?”). Urine drug testing for opioids may also be a useful part of an assessment, but the procedure has significant limitations. A drug test may be negative in the context of drug use if the window of detection (<72 hours for most opioid preparations) is missed, or if a specimen is adulterated or substituted. Although most standard urine drug screens include an opiate panel that detects morphine and codeine, synthetic opioids are not always detected by these screens, and tests for those substances must be ordered separately. Conversely, false-positive screening results may occur due to medications or foods cross-reacting with an opiate screening panel; thus all positive results should be confirmed with a definitive test such as gas chromatography-mass spectrometry. Drug testing cannot differentiate use of a medication as prescribed from misuse. Furthermore, a single positive confirmed test result is neither necessary nor sufficient to make the diagnosis of an opioid use disorder. Despite these limitations, a positive test result for opioids in the context of clinical suspicion of drug use may be a useful way to start an honest conversation with an adolescent.

A physical examination including assessment of a full set of vital signs should be performed as part of a complete assessment for an opioid use disorder. Signs of acute intoxication or chronic opioid use are rare in adolescents but should be noted if present. Patients who present in opioid withdrawal may benefit from inpatient detoxification for symptomatic relief.

Opioid Use by Adolescents: Prevention and Pharmacotherapy

Behavioral Treatments

Drug addiction is a complex illness that can impact every aspect of an adolescent’s functioning. Because of the pervasive consequences of drug addiction, comprehensive treatment involves behavioral therapy in addition to medication. Options for behavioral therapy range from office-based management to hospitalization. The clinician performing an assessment should explore the patient’s readiness for treatment (Drug Strategies 2003), withdrawal risk, medical complications, psychiatric comorbidities, and home environment in an attempt to determine the least restrictive treatment setting.

Manual-driven protocols for psychotherapeutic treatment exist in the form of individual, group, and family therapy. These protocols often implement skills-based approaches via cognitive-behavioral therapy, which can be delivered at various levels of care (in outpatient settings, inpatient settings, or residential treatment programs). Long-term treatments may be provided in outpatient settings, but some patients require greater supervision in settings such as long-term residential facilities in order to achieve and maintain abstinence.

The American Academy of Child and Adolescent Psychiatry () has developed a list of principles for adolescent treatment (Recommendations for the assessment and care of adolescents with substance use disorders). Below is a brief description of typical levels of care at which treatment can be rendered.

TABLE Recommendations for the assessment and care of adolescents with substance use disorders (SUDs)

  1. 1. The clinician should observe an appropriate level of confidentiality for the adolescent during the assessment and treatment.
  2. 2. The mental health assessment of older children and adolescents requires screening questions about the use of alcohol and other substances of abuse.
  3. 3. If the screening raises concerns about substance use, the clinician should conduct a more formal evaluation to determine the quantity and frequency of use and consequences of use for each substance used and whether the youth meets criteria for SUD(s).
  4. 4. Toxicology, through the collection of bodily fluids or specimens, should be a routine part of the formal evaluation and ongoing assessment of substance use both during and after treatment.
  5. 5. Adolescents with SUDs should receive specific treatment for their substance use.
  6. 6. Adolescents with SUDs should be treated in the least restrictive setting that is safe and effective.
  7. 7. Family therapy or significant family/parental involvement in treatment should be a component of treatment of SUDs.
  8. 8. Treatment programs and interventions should develop procedures to minimize treatment dropout and to maximize motivation, compliance, and treatment completion.
  9. 9. Medication can be used when indicated for the management of craving and withdrawal and for aversion therapy.
  10. 10. Treatment should encourage and develop peer support, especially regarding the nonuse of substances.
  11. 11. Twelve-step approaches may be used as a basis for treatment. Attendance at Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups is an adjunct to professional treatment of SUDs and should be encouraged.
  12. 12. Programs/interventions should attempt to provide comprehensive services in other domains (e.g., vocational, recreational, medical, family, and legal).
  13. 13. Adolescents with SUDs should receive thorough evaluation for comorbid psychiatric disorders.
  14. 14. Comorbid conditions should be appropriately treated.
  15. 15. Programs and interventions should provide or arrange for posttreatment aftercare.

Outpatient Care

Outpatient care is the mainstay of substance abuse treatment for adolescents who are medically and behaviorally stable, and may consist of individual, group, or family therapy alone or in combination. A variety of psychosocial therapies have been demonstrated to be effective in the treatment of substance use disorders (). Outpatient care varies in intensity. Day treatment or intensive outpatient programs and partial hospitalization programs are highly structured programs that meet for several hours each day for several weeks and generally combine both individual and group treatment. These programs are usually recommended for adolescents who are transitioning from inpatient care back into the community, or for those who are in the early stages of the recovery process. Office-based management refers to less intensive treatment with patients receiving individual and/or group therapy in sessions range from several times per week to several times per month.

Psychiatric Hospitalization

Psychiatric hospitalization may be warranted for adolescents with unstable co-occurring mental illness. Adolescents should receive a full range of services including assessment and consultation, psychopharmacology, family therapy, and recommendations/referrals for aftercare in an inpatient psychiatric treatment facility (). Once medically stable, an adolescent may be a candidate for a less restrictive acute residential treatment (ART) program as an alternative to prolonged inpatient hospitalization. Based on a multimodal approach and therapeutic milieu model, ART programs work closely with parents and teens to build and strengthen interpersonal relationships, learn more about themselves through group therapy and classroom experience, and reinforce emerging healthy alternative behaviors for managing feelings and impulsive behaviors and avoiding substance use. Further evaluation to address specific concerns such as childhood trauma, eating disorders, learning disabilities, and school conflict can be coordinated as necessary. The goal of an ART program is to promote transition from the therapeutic milieu back to the community.

Long-Term Residential Programs

Long-term residential programs provide services over an average period of 3–12 months, and offer a variety of daily therapeutic sessions including individual, group, and family therapy as well as psychoeducation and psychopharmacology. They can accommodate adolescents with both psychiatric and substance use disorders who have been unable to stop using opioids and/or who have other self-injurious behaviors. Locked facilities are available for youths at risk of running away.

Therapeutic Communities

Therapeutic communities are drug-free residential settings that provide treatment for adolescents with addictions and behavioral disorders who have failed to respond to less intensive treatments and are unable to live at home. Adolescents treated in therapeutic community programs are more likely than those in outpatient programs to have prior substance abuse treatment experience and criminal justice histories, and are likely to have experienced more severe consequences. These closely supervised programs are typically longer than residential programs (12–24 months) and use a hierarchical model that reflects increased levels of personal and social responsibility that are acquired as progress is made through the various levels of treatment (). Therapeutic communities differ from other treatment approaches mainly through their use of community and peer interactions as a means of learning and assimilating new attitudes, perceptions, and behaviors previously associated with drug use. However, modifications may be required to accommodate adolescent developmental differences, such as including on-site schooling and family support services.

Conclusion

Adolescence is a time of physical, emotional, and psychological maturation, and experimentation with risky behaviors is common. Use of opioids by adolescents is on the rise, as is opioid dependence. Physicians should screen all adolescents for opioid use, and make an appropriate level of intervention whenever use is identified. Adolescents who have used opioids but are not opioid dependent may benefit from relatively brief office-based interventions. Adolescents who are opioid dependent should have a thorough assessment before beginning treatment. Although promising treatment interventions are emerging, additional research is needed to evaluate behavioral and pharmacological treatment options. This research will help identify how to best minimize opioid withdrawal symptoms and promote treatment retention and long-term opioid abstinence in the context of the maturing adolescent brain. Few medication studies have included adolescents, but accumulating evidence suggests that buprenorphine can be effective in reducing relapse rates with adolescent populations by stabilizing neurochemistry, ameliorating withdrawal, and curbing cravings.

Clinical Pearls

  • • Since 2000, illicit use of prescription opioids has more than doubled in adolescents. Increased perception of availability, decreased social disapproval, and decreased perception of risk of using opioids are all factors suggesting that opioid misuse continues to be on the rise.
  • • Since 2007, more teens have reported drug initiation with opioid pharmaceuticals than with any other class of drugs, including marijuana, making opioids a new gateway drug. Screening for drug use including opioids should occur as part of routine adolescent medical care.
  • • Several screening questionnaires for adolescent substance abuse are available, including the CRAFFT questionnaire. Every adolescent should receive a brief intervention appropriate to his or her level of use based on screening results.
  • • Pain medication can be safe for use even in adolescents with substance use disorders, and pain should not be left untreated because of a history of substance abuse or dependence. However, in these situations clinicians should require increased supervision and monitoring to avoid misuse.
  • • No single approach is suitable for all individuals; treatment should be comprehensive and tailored to particular needs. In most cases, treatment should include opioid agonist therapy in conjunction with evidence-based behavioral therapies. All patients should be screened for co-occurring psychiatric symptoms, and comorbidities should be treated simultaneously.
  • • Few medication studies have included adolescents, but accumulating evidence suggests that buprenorphine can be effective in reducing relapse rates with adolescent populations by stabilizing neurochemistry, ameliorating withdrawal, and curbing cravings.
  • • Comprehensive treatment should incorporate behavioral therapy in addition to medication in settings ranging from office-based management to the hospital level of care.
  • • Substances of abuse can induce, mimic, co-occur with, and/or exacerbate underlying mental illness; therefore, all adolescents with opioid dependence should be evaluated for co-occurring mental health disorders and be treated for both disorders simultaneously.

 

“Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence”