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Pain Medicine and Adolescents: Special Considerations
Sharon Levy, MD, MPH Assistant Professor of Pediatrics
Boston Children’s Hospital
Harvard Medical School Director, Adolescent Substance Abuse Program Division of Developmental Behavioral Pediatrics
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Disclosures
• I, Sharon Levy, have no relevant financial or commercial relationships to disclose.
• Funding for this initiative was made possible (in part) by
Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) and Providers’ Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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Learning outcomes
• Understand the neurobiology of opioids action on the brain
• Discuss appropriate use of medication assisted therapy for opioid use disorders
• Identify the role of parents and medical providers in prevention of opioid addiction
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Opiates
Opioids
Oxycodone 20 mg
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Opioid Pharamocology
• Mimic endorphins
• Bind to mu-opioid receptors
• Well-being, satisfaction, pleasure
Opioid µ-receptor and agonist
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Limbic
System
Spinal Cord
Brain Stem
Prefrontal
Cortex
PREFRONTAL CORTEX: Executive Functions LIMBIC SYSTEM: Pleasure, reward BRAIN STEM: Respiration SPINAL CORD: Analgesia
Opioid Neurobiology
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Civil War VIETNAM WAR
METHADONE HARRISON DRUG ACT
“PAIN” AS THE 5th VITAL SIGN
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Increase in Opiate Rx, 1991-2013
Volkow ND. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Natl. Inst. Drug Abus. 2014. Available at:
http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse.
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No
. of
Rx’
s (m
illio
ns)
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Source: Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2011
0123456789
101112131415
Perc
en
tag
eRates of opioid misuse by 12th graders
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• Misuse/Non-medical use
• Substance Use Disorder
• Addiction
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11.1% of 12th graders have misused opioids in their lifetime. There are two main reasons for misuse
• Self-medication for pain
• “Recreationally” (for
euphoria)
Misuse: Self-Medication
National Survey on Drug Use and Health (NSDUH) 2012; Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2013; Cranford JA, Boyd, C., Addict. Behav. 2013 McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior
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11.1% of 12th graders have misused opioids in their lifetime. There are two main reasons for misuse
• Self-medication for pain
• “Recreationally” (for euphoria)
National Survey on Drug Use and Health (NSDUH) 2012; Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2013; Cranford JA, Boyd, C., Addict. Behav. 2013 McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior
Misuse: Recreation
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Source: Allyn, Bacon, 2001. http://www.studyblue.com/notes/note/n/nervous-synapses--signaling-chpt-4849/deck/6399759
Impact on Brain Development
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motivation emotion
Cerebellum Amygdala
Nucleus Accumbens
Prefrontal cortex
Planning, Organizing, Impulse control
Physical coordination, Sensory processing
Slide adapted from Ken Winters, PhD.
Toddler milestones:
balance, walking,
coordination
Preschool milestones:
emotional regulation School age
milestones:
achievement
Adolescent
milestones: impulse
control
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Source: Galvan A, Hare AT, Parra, CE, Penn J, Voss H, Glover G, Casey BJ, Earlier Development of the Accumbens Relative to Orbitofrontal
Cortex Might Underlie Risk-Taking Behavior in Adolescents. Journal of Neuroscience, 2006,26(25):6885–6892
Children ages 7-11 Teens ages 13-17 Adults ages 23-29
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Addiction: A chronic,
relapsing medical
condition resulting from
neurological changes in
the brain’s reward
system leading to
compulsive use of a
substance
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Heroin
• Very rapid delivery of morphine to
the central nervous system
• Potent and relatively inexpensive
• Snorting or smoking as practical
alternatives to injecting
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Heroin Epidemiology
Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Applied Studies. Substance Use Treatment Need among Adolescents: 2003-2004. National Survey on Drug Use and Health (NSDUH) 2011.
0
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2002 2006 2008 2009 2010 2011
Am
eri
can
s A
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icte
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Pharmacologic Non-pharmacologic
Detox
methadone, buprenorphine, clonidine, “comfort meds”
Outpatient individual or group
Antagonist therapy
Naltrexone PO or IM Intensive outpatient/partial
Agonist therapy
Methadone, buprenorphine
Acute or Long Term Residential
Sober home/half-way house
Treatment for Opioid Use Disorder
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Detoxification
Adult studies have recurrently found high relapse rates after detoxification without subsequent treatment. An NIH consensus statement regarding treatment of opioid dependent adults indicated detoxification alone is insufficient treatment.
Woody, GE., et al. Extended vs. Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted Youth. JAMA 300(17) :2003-2011, 2008.
National Institute of Health Consensus Development Conference Statement, 1997.
Kosten TR, Schottenfeld R, Ziedonis D, Falcioni J. Buprenorphine versus methadone maintenance for opioid dependence. Journal of Nervous and Mental Disease 1993;181(6):358-64.; Mattick et al., Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients., Addiction, 2003 Apr;98(4):441-52.; Gowing, L., Buprenorphine for the management of opioid withdrawal., Cochrane Database Syst Rev. 2000;(3):CD002025.
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Medication Assisted Treatment
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Agonist Therapy: Buprenorphine
• Partial agonists form an imperfect fit
• less reinforcing and less commonly abused than full agonists.
• The potential for misuse is not zero
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Drug Abuse Treatment Act of 2000
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• MAT is first line therapy for patients with
opioid use disorders.
• Expanding access to MAT is a top priority.
2014 Buprenorphine Summit Report of Proceedings
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AMA Opioid Task Force
5 goals of the task force:
• Increase physicians’ registration and use of effective PDMPs
• Enhance physicians’ education on effective, evidence-based prescribing
• Reduce the stigma of pain and promote comprehensive assessment and treatment
• Reduce the stigma of substance use disorder and enhance access to treatment
• Expand access to naloxone in the community and through co-prescribing
http://www.ama-assn.org/ama/pub/advocacy/topics/preventing-opioid-abuse/opioid-abuse-task-force.page?
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• buprenorphine vs. clonidine for 28-day detox • Randomized controlled trial; double-blind, double-
dummy design • Participants 13-18 years old, N=36 • All participants received counseling in addition to meds
– Individual and family therapy – Contingency Management – Outreach component
Marsch, L.A., et al. Archives of General Psychiatry 62(10):1157-1164, 2005.
Study design
Research Trials with Adolescents Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial
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64 72
61
32 39
5 0
10
20
30
40
50
60
70
80
opiate - urine Retained in treatment Cont.pharm treatment
Pe
rce
nt
(%)
BuprenorphineGroup
Clonidine Group
Marsch, L.A., et al. Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial. Archives of General Psychiatry 62(10):1157-
1164, 2005.
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–Participants 15-21 years old, N=152
–Randomly assigned to 1 of 2 groups:
•2-week detox
•12-week treatment
–All participants received group and individual counseling
Study design
Research Trials with Adolescents Extended vs. Short-term Buprenorphine-Naloxone for Treatment of
Opioid-Addicted Youth: A Randomized Trial
Woody, GE., et al. JAMA 300(17) :2003-11, 2008
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• Fewer Opioid positive urine screens in
12-week-treatment group
• Higher retention rates in 12-week-
treatment group
Summary of Findings
Research Trials with Adolescents Extended vs. Short-term Buprenorphine-Naloxone for Treatment of
Opioid-Addicted Youth: A Randomized Trial
Woody, GE., et al. JAMA 300(17) :2003-11, 2008
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• Block euphoric effect
• Suppress cravings
• Monthly injectable dosing can help with compliance
• Patients who used naltrexone had less
opioid use, better treatment retention and fewer cravings.
• Efficacy or adverse effects profile in children?
Lobmaier P, Kornor H, Kunoe N, Bjorndal A. Sustained-release naltrexone for opioid dependence. Cochrane database of systematic reviews. 2008(2):CD006140.
Roozen H G, de Waart R, van der Windt D A, van den Brink W, de Jong C A, Kerkhof A J. A systematic review of the effectiveness of naltrexone in the maintenance
treatment of opioid and alcohol dependence. European Neuropsychopharmacology 2006; 16(5): 311-323.
Antagonist Therapy
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Encourage Abstinence
I agree to stop using all drugs.
I understand that it is dangerous to mix buprenorphine with alcohol or other sedatives
I agree to cooperate with urine drug testing whenever requested. PATIENT SIGNATURE AND DATE:
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Monitor
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Psychosocial Support
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Ancillary Treatment
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PCSS Projects
Funding for these initiatives was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) and Providers’ Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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Two Projects. One Mission Helping to end the opioid overdose epidemic.
• PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: Addiction Technology Transfer Center, American Academy of Neurology, American Academy of Pain Medicine, American Academy of Pediatrics, American College of Physicians, American Dental Association, American Medical Association, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society for Pain Management Nursing, International Nurses Society on Addictions, and Southeast Consortium for Substance Abuse Training.
• PCSS-MAT is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society of Addiction Medicine and Association for Medical Education and Research in Substance Abuse.
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PCSS Projects Training Modalities The PCSS Projects offer no-cost training activities with CME to health professionals through the use of:
• Webinars (Live and Archived)
• Online Modules
• Case Vignettes
• One-on-one and Small Group Discussions—coaching for clinical cases
In addition, the projects offer a comprehensive library of resources:
• Clinical Guidances and other educational tools
• Community Resources
• Buprenorphine waiver training via PCSS-MAT
• Listserv - Provides a “Mentor on Call” to answer questions about content presented
through PCSS-MAT and PCSS-O. To join email: [email protected] or [email protected]
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Buprenorphine Waiver Training:
The Half and Half Course – specifically for Pediatricians and Family Physicians in addressing
adolescent specific issues
http://www.cvent.com/d/l4q2mj
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Prevention for Pediatricians
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Changes in Prescribing Controlled Meds to Adolescents, 1994-2007
1. Fortuna RJ, Robbins BW, Caiola E, Joynt M, Halterman JS. Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics. 2010;126(6):1108–16. Available at: http://pediatrics.aappublications.org/content/126/6/1108.short. Accessed August 21, 2014.
1994-95 1996-97 1998-99 2000-01 2002-03 2004-05 2006-07
Pe
rce
nta
ge o
f vi
sits
wit
h
con
tro
lled
me
d R
xed
All controlled medications
Opioid
Sedative-hypnotic
• Stimulant
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National Institute on Drug Abuse (NIDA). (2012). Safe Prescribing for Pain | National Institute on Drug Abuse (NIDA). NIDAMED. Dodds, A. (2008). Pain Management: From Basics to Clinical Practice. Elsevier Health Sciences; Manchikanti, et al.,(2012). American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I and II. Pain Physician
Maximize Non-Opioid Therapy
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Screen before prescribing
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Caution when prescribing opioids
McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior
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Anticipatory guidance
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Alcohol and Marijuana use precede opioid use
Teens that use alcohol or marijuana
• more likely to misuse opioids
• much more likely to misuse opioids for recreational purposes.
Fiellin LE, Tetrault JM, Becker WC, Fiellin DA, Hoff RA.. J. Adolesc. Health. 2013;52(2):158–63. McCabe SE, West BT, Teter CJ, Cranford JA, Ross-Durow PL, Boyd CJ. Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addict Behav. 2012;37(5):651–656.
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Fisher SL, Bucholz KK, Reich W, et al. Teenagers are right--parents do not know much: an analysis of adolescent-parent agreement on reports of adolescent substance use, abuse, and dependence. Alcohol Clin Exp Res. 2006;30(10):1699–1710.
Behavior Child Report Parent Report
Consumed at least 1 drink
54% 30.5%
Have been intoxicated
23.6% 8.1%
Tobacco Use 44% 27%
Marijuana Use 22.9% 13.2%
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Partnership for a Drug-Free America. The Partnership Attitude Tracking Study (PATS): Teens in grades 7 through 12 2005; May 16, 2006
Easy to get from medicine cabinet 62%
Available everywhere 52%
Not illegal 51%
Easy to get through other people’s prescription 50%
Can claim you have a prescription if caught 49%
Cheap 43%
Safer to use than illegal drugs 35%
Less shame attached to using 33%
Easy to purchase over the Internet 32%
Fewer side effects than street drugs 32%
Parents don’t care as much if you get caught 21%
Reasons for Misusing Opioids
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Non-Specific Signs of SUD
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Non-Specific Signs of SUD
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Suggestions for practice
• Opioids are a very good treatment for acute pain AND also very addictive. They have a role but should be used sparingly.
• Pharmacotherapy is an important component of successful treatment of opioid use disorders. Consider offering medication assisted treatment in the primary care setting. Available resources can help to build a successful program.
• Parents and medical professionals are an important line of defense against opioid addiction. Screen to identify and make interventions to prevent or delay substance use.
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Acknowledgements
Teaching Collaborators • Pamela Burke, PhD, RN, FNP, PNP, FSAHM,
FAAN • Linda Malone, DNP, RN, CPNP • Sarah Pitts, MD • Marianne Pugatch, MSW, LICSW • Jennifer Putney, PhD, LICSW Research Collaborators • Elizabeth Harstad, MD, MPH • Lauren Wisk, PhD Clinic Collaborators • Fatma Dedeoglu, MD • Katharine Garvey, MD, MPH • Jen Lightdale, MD, MPH • Paul Rufo, MD, MMSc • Lisa Albers Prock, MD, MPH, FAAP • Paul Hammerness, MD • Andrew MacGinnitie, MD, PhD • Jonathan Gaffin, MD
Research Project Management • Julie Lunstead, MPH, Program Manager • Erin Huang, MPH, Data Manager Adolescent Substance Abuse Program (ASAP) Research Assistants • Dylan Kaye, BA • Jessica Kerr, MPH • Lily Rabinow, MS • Parissa Salimian, BA • Sara Spielman, BS • Meghana Vijaysimha, MPH • Rosemary Ziemnik, BS •
Clinicians • Diana Deister, MD, MS • Leslie Green, MSW, LICSW • Julie Hansen, MSW, LICSW • Shannon Mountain-Ray, MSW, LICSW • Miriam Schizer, MD, MPH • Patricia Schram, MD
Co-principal investigator: Elissa Weitzman, ScD, Msc