According to guidelines from the American Society of Addiction Medicine (ASAM), adolescents age >16 should be offered MAT; the first-line treatment is buprenorphine.40 To avoid risks of abuse and diversion, a combination of buprenorphine/naloxone may be administered.
Maintenance with buprenorphine
In order to prescribe and dispense buprenorphine, clinicians need to obtain a waiver from the Substance Abuse and Mental Health Services Administration. Before initiating buprenorphine, consider the type of opioid the individual used (short- or long-acting), the severity of the OUD, and the last reported use. The 3 phases of buprenorphine treatment are41:
- Induction phase. Buprenorphine can be initiated at 2 to 4 mg/d. Some patients may require up to 8 mg/d on the first day, which can be administered in divided doses.42 Evaluate and monitor patients carefully during the first few hours after the first dose. Patients should be in early withdrawal; otherwise, the buprenorphine might precipitate withdrawal. The induction phase can be completed in 2 to 4 days by titrating the dose so that the signs and symptoms of opioid withdrawal are minimal, and the patient is able to continue treatment. It may be helpful to have the patient’s legal guardian nearby in case the patient does not tolerate the medication or experiences withdrawal. The initial target dose for buprenorphine is approximately 12 to 16 mg/d.
- Stabilization phase. Patients no longer experience withdrawal symptoms and no longer have cravings. This phase can last 6 to 8 weeks. During this phase, patients should be seen weekly and doses should be adjusted if necessary. As a partial mu agonist, buprenorphine does not activate mu receptors fully and reaches a ceiling effect. Hence, doses >24 mg/d have limited added agonist properties.
- Maintenance phase. Because discontinuation of buprenorphine is associated with high relapse rates, patients may need to be maintained long-term on their stabilization dose, and for some patients, the length of time could be indefinite.39 During this phase, patients continue to undergo follow-up, but do so less frequently.
Methadone maintenance is generally not recommended for individuals age <18.
Preventing opioid diversion
Prescription medications that are kept in the home are a substantial source of opioids for adolescents. In 2014, 56% of 12th graders who did not need medications for medical purposes were able to acquire them from their friends or relatives; 36% of 12th graders used their own prescriptions.21 Limiting adolescents’ access to prescription opioids is the first line of prevention. Box 2 describes interventions and strategies to limit adolescents’ access to opioids.
Box 2
Limiting adolescents’ access to opioids
Many adolescents obtain opioids for recreational use from medications that were legitimately prescribed to family or friends. Both clinicians and parents/ guardians can take steps to reduce or prevent this type of diversion
Health care facilities. Regulating the number of pills dispensed to patients is crucial. It is highly recommended to prescribe only the minimal number of opioids necessary. In most cases, 3 to 7 days’ worth of opioids at a time might be sufficient, especially after surgical procedures.
Home. Families can limit adolescents’ access to prescription opioids in the home by keeping all medications in a lock box.
Proper disposal. Various entities offer locations for patients to drop off their unused opioids and other medications for safe disposal. These include police or fire departments and retail pharmacies. The US Drug Enforcement Administration sponsors a National Prescription Drug Take Back Day; see https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html. The FDA also offers information on where and how to dispose of unused medicines at https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines.
CASE CONTINUED
Ms. L is initially prescribed, clonidine, 0.1 mg every 6 hours, to address opioid withdrawal. Clonidine is then tapered and maintained at 0.1 mg twice a day for irritability and impulse control. She is also prescribed sertraline, 100 mg/d, for depression and anxiety, and trazodone, 75 mg as needed at night, to assist with sleep.
Continue to: Following inpatient hospitalization...