ORLANDO – according to a presentation at the annual meeting of the American Academy of Pediatrics.
Jeff Craven/MDedge News
Dr. Deepa Camenga
“We pediatricians have some unique skills that can really benefit our community of teens,” said Deepa Camenga, MD, of Yale University in New Haven, Conn.
Compared with some other specialists, who may be more reluctant to prescribe buprenorphine, pediatricians are more comfortable and have systems in place to deal with issues surrounding care coordination, adolescent confidentiality, family reassurance, and managing prescriptions for chronic diseases.“We can use those same skills when we’re caring for people with opioid use disorder,” she said.
According to the DSM-5 (Diagnostic and Statistical Manual–5), there are 11 criteria for opioid use disorder based on level of physiological dependence, impaired control, social functioning, and risky use. Meeting two or three criteria constitutes mild substance use disorder, while meeting six or more criteria is associated with severe substance use disorder.
Opioid use disorder in adolescents can be characterized by milder symptoms. Adolescents also tend to be in the early stage of this chronic disease when they seek care for opioid use disorder and need to be informed about the seriousness of the disease, Dr. Camenga noted.
“There is a disconnect about the severity of their illness when they present to me,” she said. “This is a disease that we know is chronic, severe – and without treatment – is progressive. We do know it can progress and get worse, and result in death.”
Treatment options for opioid use disorder in adolescents include behavioral interventions such as residential treatment, intensive outpatient (IOP), and partial hospitalization programs and therapy, as well as pharmacologic interventions like clonidine, buprenorphine, and methadone used for detoxification. Buprenorphine/naloxone has been labeled for use by patients 18 years or older; however, three recent randomized controlled trials have studied the effects of the intervention in 16-year-old and 17-year-old patients. In the trials, there were no serious adverse events reported with support of treatment for a minimum of 12 weeks and “many providers are treating up to a year” based on data from observational studies, Dr. Camenga said. Naltrexone also has been indicated for adolescents with opioid use disorder, with feasibility seen in pilot studies.
If you are interested in providing buprenorphine for patients, you need to apply for a Drug Enforcement Administration X-waiver, have access to their state’s prescription-monitoring program, and have a network of behavioral health providers for therapy and counseling, as well as psychiatrists for evaluation and treatment of other psychiatric disorders. Familiarity with naloxone overdose prevention training also is beneficial.
In addition, you must undergo 8 hours of training and apply for a waiver to prescribe buprenorphine in general medication settings. You can receive ongoing support after training on the AAP and Providers Clinical Support System websites.
Adolescent patients who receive buprenorphine for treatment of opioid use disorder typically undergo induction for 2 days where they are observed by a nurse or provider followed by weekly or biweekly medication-monitoring visits. It is “highly recommended” adolescents take urine drug screens during these visits but the results do not need to be observed. Many patients begin treatment when they are in IOP care, but some patients are not identified until they’ve had more severe consequences of opioid use disorder. Parents are involved in care by providing transportation and picking up and helping to administer medication, but there are confidential portions of the visits with the patient only.
“Parents have to be intimately involved and aware, and that’s an ideal situation,” Dr. Camenga said.
Dr. Camenga reported no relevant conflicts of interest.