1. The National Opioid Epidemic The Scope of the Problem and Treatment for Teens and Young Adults
Steven C. Matson, MD
Chief, Division of Adolescent Medicine
Nationwide Children’s Hospital

2. DISCLOSURE
The speaker and members of the planning committee do not have a conflict of interest in this topic.
There is no commercial support for this program.

3. Outline What is Addiction? Drugs that teens are using
Epidemiology of opioid abuse
General evaluation/treatment of opioid use disorder
Medication assisted treatment
Outcomes of treatment

5. Brain (Neurobiological)
“Drug Abuse is a
Chronic, Relapsing
Brain (Neurobiological)
Disease”

6. DA Concentration (% Baseline)
In Search of the Dopamine High
Food
Sex
200
200
150
150
DA Concentration (% Baseline)
% of Basal DA Output
100
100
Empty 50
Natural rewards stimulate dopamine neurotransmission. Eating something that you enjoy or being stimulated sexually can cause dopamine levels to increase. In these graphs, dopamine is being measured inside the brains of animals. Its increase is shown in response to food or sex cues. This basic mechanism of controlled dopamine release and reuptake has been carefully shaped and calibrated by evolution to reward normal activities critical for our survival.
Box Feeding
Female Present 1 2 3 4 5 6 7 8 60
120
180
Sample
Number
Time (min)
Adapted from: Di Chiara, Neuroscience, 1999; Fiorino and Phillips, J Neuroscience, 1997. 6

7. Drugs of Abuse Increase
Dopamine Levels
Di Chiara and Imperato, Proc. Natl. Acad. Sci. USA,Vol. 85, pp , July 1988,Neurobiology.

8. Drug Use Changes the Brain Weakens the Brain Dopamine System

9. Dopamine D2 Receptors are Lower in Addiction

10. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.

11. The Three Stages of the Addiction Cycle Brain Regions Associated
with Them

12. Definition of Addiction American Society of Addiction Medicine
A primary, chronic disease of brain:
Reward
Motivation
Memory and related circuitry.
Dysfunction leads to pathological pursuit of reward or relief by substance use and other behaviors.

13. Definition of Addiction American Society of Addiction Medicine
Like other chronic diseases, addiction often involves cycles of: Relapse and Remission
Without treatment addiction is progressive and can result in: Disability or Death

14. Addiction is a Developmental Disease That Starts in Adolescence

15. 90% of Those Hooked on Alcohol, Tobacco, or Drugs Started Using Them Before Age 18
25% of Americans who began using any addictive substance before age 18 are addicted.
Only 4% of Americans who started using an addictive substance when they were 21 or older are addicted.

16. Trends in Lifetime Prevalence of Use of Various Drugs in Grade 12 2015

17. % of Ohio Students Who Used Cigarettes or Marijuana During The Past Month 2003‐2013

18. Changes in US High School Tobacco Use 2011 to 2015
Percent Using

19. 12th Grade Substance Use Ohio 2013
2013 Ohio Youth Risk Behavior Survey (YRBS)

20. Overdose Death Rates In US Counties

21. Deaths per 100,000 Population 4 8 12 16 20 4
2003
2014
CDC/NCHS Nation al Vital Statistics System

22. U.S. Opioid Overdose Deaths 2014

23. 2014 Opioid Overdose Death Rates per 100,000 Population (Age-Adjusted)
West Virginia 31.6
Ohio
Kentucky

24. All Opioid Overdose Deaths 1999-2014
2,590 in 2015

25. Overdose Deaths by Drug Type 2014
Location
Natural and Semisynthetic Opioids (e.g. oxycodone, hydrocodone)
Synthetic Opioids, other than Methadone (e.g. fentanyl, tramadol)
Methadone
Heroin
Total Opioid Overdose Deaths
Kentucky
344
179 59
228 (31%)
729
Ohio
618
590
107
1208 (57%)
2106
West Virginia
363
122 35
163 (29%)
554

26. Ohio Overdose Deaths
Unintentional drug overdoses caused the deaths of 3,050 Ohio residents in 2015
Highest number on record, compared to 2,531 in 2014.
The number of overdose deaths increased 20.5% from 2014 to 2015
Fentanyl-related overdose deaths in Ohio more than doubled from 503 in 2014 to 1,155 in 2015

27. Fentanyl-Related Drug Overdoses, Ohio, 2012-15

28. Relative Potency Morphine Heroin: 3 times stronger
Fentanyl 80 times stronger
Carfentanyl 10,000 times stronger

29. Number of Opioid Doses Dispensed to Ohio Patients 2011-2015

30. Neonatal Abstinence Syndrome (NAS) Incidence Rates 25 States, 2012–2013

31. Neonatal Abstinence Syndrome Ohio 2004-2014
Babies with NAS
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014

32. Recognizing Possible Drug Abuse
Change in appearance
New friends, secretive about the new peers
Loss of interest in old hobbies/sports
Lying about new interests and activities
Demanding more privacy; locking doors; avoiding eye contact; sneaking around
Money/valuables missing from home

33. Matching Significant Drug Abuse to Level of Treatment
All patients require a full substance abuse assessment
The assessment drives the level of care
Alcohol
Marijuana
Best treatment for an patient with severe opioid use disorder:
Residential placement
Intensive counseling with Medication Assisted Treatment (MAT)

34. Progression of Use
END
Begin

35. Treatments for Opioid Use Disorder Non-Pharmacologic
Residential Treatment
Intensive Outpatient Programs
12-Step Fellowships
Individual/Group/ Family Therapy
Therapeutic community

36. Treatments for Opioid Use Disorder Pharmacologic Withdrawal/Maintenance
Replacement therapy (MAT)
Methadone
Buprenorphine/Naloxone
Withdrawal based treatment
Supervised withdrawal (Comfort meds, Methadone, Buprenorphine)
Opiate antagonism
Naltrexone (PO/IM)

37. Why Choose Medication Assisted Treatment (MAT)?
Relapse without MAT is high
Opiate addiction has high cue response
Exposure to opiates can rekindle addiction
Cravings and preoccupation with use limit ability to develop coping skills
MAT Without Psychosocial Treatment is
Unlikely to Yield Good Results

38. Buprenorphine Treatment Goals
Suppress withdrawal
Block or decrease euphoric affect of illicit opiates
Minimize/eliminate craving for opioids
Decrease overdose/death
Eliminate IV use/Risk HCV, HBV,HIV
Improve function in all spheres of life

39. Benefits of Office Based Treatment
Confidential, safe, effective in a doctor’s office
Fits lifestyle:
No daily clinic visits
Stay local
Avoid costly residential treatment
Allows for parental involvement
Quickly improves functional status:
School
Work
Family and Other Activities

40. Dopamine-Addiction-Withdrawal
1. Opioids bind to mu receptors, dopamine released, causing pleasurable feelings to be produced.
2. As opioids leave the receptors, pleasurable feelings fade and withdrawal symptoms (and possibly cravings) begin.
3. Opioids continue leaving mu receptors
until the person is in withdrawal.

41. Buprenorphine Treatment
Buprenorphine attaches to the empty opioid receptors, suppressing withdrawal symptoms and cravings and producing a limited euphoria or "high “
5. Buprenorphine attaches firmly to the receptors. At adequate maintenance doses, it fills most receptors and blocks other opioids from attaching.

42. What is the Medication?
Buprenorphine
Naloxone

43. Buprenorphine FormulationsX

44. Generic Buprenorphine
Longer acting forms coming

45. Integrating Substance Use Disorder Services and Mainstream Health Care
Substance use, mental/medical disorders often interconnected
Integrated services can be:
Cost-effective
Reduce intake/treatment wait times for those wanting help
Integration can lead to improved health outcomes through better care coordination.

46. Medical Provider – Initial Visit
Complete Substance Abuse Assessment
Physical exam
Injection track marks
Murmur of endocarditis
Abscesses
Skin excoriations due to “picking”
Hepatomegaly
Signs of withdrawal

47. Medical Provider – Initial Visit Initial Laboratory Testing
Screening for STI
Gonorrhea, Chlamydia, HIV, RPR
Hepatitis Panel
Hep A IgM, IgG
Hep B core antibody, surface antibody, surface antigen
Hep C antibody, quantitative Hep C PCR
If liver enlarged LFTs

48. Medical Provider – Initial Visit
Review Urine Drug Screen
Any presumptive positives are sent for MS/GC confirmation
Review Prescription Monitoring Program (PMP) Report
Required in Ohio to Document at Each Visit)

49. Medical Provider – Initial Visit
Induction/Detoxification onto to BUP/NAL
Determine last opioid use
Most opioids clear system in hrs
Can start BUP/NAL hrs after last use
Methadone has longer half life and initiation of BUP/NAL is delayed until it clears the system

50. Medical Provider – Initial Visit
Common induction dose is 16-4 mg daily
8-2mg sublingual film BID
Can prescribe medications to help transition
Ondansetron for nausea
Clonidine for anxiety/withdrawal
Trazodone mg PO QHS for insomnia
Imodium for diarrhea

51. Medical Provider – Initial Visit
Home “lock down” – allow only school, work, rehab attendance
Confiscate phone, delete contacts
Explain proper medication technique
Trusted adult hold BUP/NAL and give 1 film at a time to patient – observe each dose
Keep BUP/NAL in lock box
Save all empty film wrappers to return to clinic
Warn that lost/stolen doses will not be replaced

52. Medical Provider Follow Up Visit
Initially follow up every 7-10 days
Visits Q 2 weeks for the first 2-3 months
Once consistently attending treatment maintaining abstinence, visits every 3 weeks
Finally, transition to monthly visits

53. Medical Provider Follow Up Visit Mental Health Assessment
After 3-6 weeks of sobriety
Mental health disorder vs. depression and anxiety associated with drug use
Treating depression, anxiety, insomnia helps maintain abstinence
ADD

54. Medical Provider Long Term Care Plan to have on lowest dose possible to maintain sobriety
Once stable for months consider taper
Decrease by mg BUP/NAL as tolerated
Wean to mg daily or every other day, then off – usually by 2-3 years
Some patients may a need consistent dose for years/life to maintain sobriety

55. The Brain Takes Time to Heal
1 MONTH
OF SOBRIETY
12 MONTHS
OF SOBRIETY
NORMAL

56. Medical Provider Long Term Care
Stop taper if feeling vulnerable
Increase if necessary in times of stress
No rush to wean off !
Continue follow-up if off MAT

58. Tips to Improve Outcomes
Welcome patients
Minimal requirements to start
Truthfulness over perfection
Motivational interviewing
Contingency management
Decreasing BUP dose for chronic relapses or failure to engage in behavioral therapy
Incentive programs
Integrated care

59.  Second Visit
 4 months
 6 months
 1 year

60. Alternatives to SL Buprenorphine
Methadone
Vivitrol® (Naltrexone)
Probuphine
Depot-Buprenorphine

61. Emergency Overdose Protection