Sunday October 23rd 2016

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Prescription opioid addiction, mental health illness and treatment for teens

Are you a parent worried about your child and her exposure to prescription pain killers? You are not alone.

Here, Dr. Lisa Fortuna considers the research on the social and neuro-developmental factors related to teen substance use disorders. Then, she helps translates that into everyday language and practical recommendations. We welcome your questions at the end.

Increasing misuse of opioid prescription drugs and addictions

The misuse of prescription drugs, particularly opioid pain relievers such as hydrocodone and oxycodone, has increased significantly in the U.S. over the past two decades. The public health impact of this trend includes increases in emergency department visits due to misuse or abuse of opioid pain relievers, overdose mortality, and need for substance abuse treatment.

There has been a good deal of concern that misuse of and consequent dependence on opioid drugs by young people has contributed to rising rates of heroin use and injection drug use, particularly among White suburban residents.

Examples of opioid prescription drugs

Examples of opioid prescription drugs which can be misused and lead to addiction include…

Painkillers such as:

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Heroin is also an opioid and is illegal. Additionally, non-medical use of opioid drugs is a common risk factor for the progression to heroin use including by injection (IV).

Opioid drugs sold under brand names include:

In my practice with young people, many have described to me a pattern of starting to take opioid prescription drugs recreationally or to manage emotional problems, which then led them to becoming addicted. After a while they needed to continue to take the drugs in order to not experience withdrawal symptoms, to avoid the intense reemergence of underlying anxiety or depression, and to try to manage the dysphoria (or negative mood) which became part of their addiction.

Sometimes, young people start using these drugs because they are prescribed by physicians after a procedure. Very commonly they find these drugs in the medicine cabinets in their own homes or friends’ homes. There is also a big “street market” for diverted pills (medications prescribed to individuals that end up diverted for illicit sales).

Heroin can become the next problem

Because opioid prescription pills can become a very expensive addiction to maintain, young people can progress to using heroin which tends to be cheaper, helps avoid withdrawal and can offer intensified effects if injected. Those who progress to becoming heroin injectors may continue to use prescription opioids for various reasons, including management of withdrawal symptoms, as a substitute when heroin is not available, or to curb heroin use for other reasons. Combining prescription opioid use with heroin to boost its effect, a practice linked to decreased purity or increased tolerance, produces a significant risk for overdose.

Why do teens abuse these drugs?

1. Access

Many factors influence the risk for substance misuse. Just the fact that these drugs are readily available is a big problem. If the drugs are in our medicine cabinets then young people will have access to them and will experiment with them.

2. Self-medication

Prescription medications may also be used as a means of self-medication. That is, youth with anxiety, traumatic stress, depression, bipolar disorder, or other mental health problems may find that the opioid drug numbs these difficult emotional states. They keep using the drug and find themselves addicted and then there is a shift to needing to take the drug due to physical and psychological dependence.

3. Coexisting mental health problems

We know that in general youth who become addicted to substances have high rates of coexisting mental health problems. This has implications for both mental health services and addiction treatment. Providers treating opioid dependence should be aware of the potential psychiatric co-morbidities associated with this population.

Young people who initiate opioid use as a response to a mental health condition will have different treatment needs than those who initiate opioid use for other reasons (e.g. sensation-seeking). Postraumatic Stress Disorder (PTSD) is a significant risk factor for opioid addictions in both young men and women, suggesting the need for services that address the consequences of traumatic exposure in this population.

Treatment is available!

Although opioid addiction is a major public health problem, treatment for teens lags far behind. The 2012 National Survey on Drug Use and Health found that 90% of drug-addicted youth ages 12-17 get no treatment at all.

Detoxification programs or “detox” is a first step in addressing addiction but it alone is not treatment. Treatment is what comes after.

There are available evidence-based treatments, therapies that have been scientifically validated results for teens. Some interventions help in the early detection of substance use problems and others serve as more intensive treatments that can be used later in the course of an addiction.

Evidence Based Interventions include:

1. Screening, Brief Intervention and Referral to Treatment (SBIRT), a preventative protocol for early detection which primary care providers are increasingly becoming trained in;

2. Motivational Interviewing, a counseling approach that guides individuals to set goals around making changes in their drug use;

3. Screening for mental health condition and treatment of pre-existing depression, anxiety, PTSD and other mental health disorders;

4. Family based interventions like Functional Family Therapy (FFT), which treats teens with addictions in a family setting;

5. Medication assisted treatments for opioid dependence often involves treatment with medication;

  • The maintenance drug (prescribed for long-term and taken on a regular basis) often prescribed for teens is Suboxone, a combination of buprenorphine, an opiate substitute that eliminates craving, and naloxone, which blocks euphoric effects. Studies have shown that ongoing maintenance treatment with Suboxone is more effective than detoxification and abstinence alone (Saleh, 2014; Woody et al., 2008).
  • Another medication called naltrexone is an opioid antagonist (blocks opioids) is also showing evidence in its injectable form as helpful in reducing craving and stabilizing the dysregulation that occurs in the nervous system during addiction.

6. Therapy interventions such as Cognitive Behavioral Therapy, Mindfulness, 12-Step programs designed for teens and other dual diagnosis therapies are important to include in treatment planning. These treatments can gain in effectiveness when used in combination with medications such as Suboxone.

In general, the most effective treatments for teens, help them overcome the psychological and physical dependence they have developed to opioids but also build upon their  individual strengths, help treat any underlying mental health problems and trauma and offer coping skills for better handling stressful circumstances.

Treatment is a long process and the longer youth can continue in treatment the better the outcomes. Despite the risk of lapses and relapses, treatment does work.

We must start understanding teens

Understanding teens is an important part of successfully offering them treatment. Teens with addictions often feel that adults do not understand them. A young woman in recovery shared with me and an audience of physicians at a recent conference “being given options, giving to my community, using my natural strengths, that is what made a difference”.

Reference Sources: For an adolescent and young adult perspective on mental health, drug addictions and treatment approaches visit Youth M.O.V.E. National,
For the latest information on the science of opioid addictions and treatment visit the National Institute for Drug Abuse:
We can start addressing the problem of opioid addiction by reducing the amount of prescriptions in our medicine cabinets and streets, by supporting policies that improve physician education and prescribing practices, by practicing early detection and offering evidence based treatment.
Saleh MI.Modeling longitudinal changes in buprenorphine treatment outcome for opioid dependence.
Pharmacopsychiatry. 2014 Nov;47(7):251-8
Woody GE, Poole SA, Subramaniam G, Dugosh K, Bogenschutz M, Abbott P, Patkar A, Publicker M, McCain K, Potter JS, Forman R, Vetter V, McNicholas L, Blaine J, Lynch KG, Fudala P. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial.
JAMA. 2008 Nov 5;300(17):2003-11

Photo credit: HASTYWORDS

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About Dr. Lisa Fortuna, MD, MPH

Lisa R. Fortuna, MD, is board-certified in child and adolescent psychiatry and in addiction medicine, with over fifteen years of clinical experience with children, adolescents, and families. She is currently faculty at Boston University School of Medicine and medical director of Child and Adolescent Psychiatry at Boston Medical Center. She has published highly cited articles in the areas of post-traumatic stress disorder (PTSD), adolescent substance abuse, and Latino and immigrant mental health. She is the author of (with Zayda Vallejo M. Litt), Treating Co-Occurring PTSD and Addiction: Mindfulness Based Cognitive Therapy for Adolescents with Trauma and Substance Use Disorders (New Harbinger, 2015).

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