April 29, 2013

With anecdotal reports across the country soaring about young people switching from prescription opioid addiction to heroin, ADAW looked into what special treatments are recommended for heroin addiction for people under 25. Experts say that there is no cookie-cutter approach: The treatment must be geared to the individual, just as it is for someone of any age addicted to heroin.

Of the four medications approved for treating opioid addiction — methadone, buprenorphine, naltrexone (oral) and Vivitrol (injectable) — which is best suited for young people?

“The choice of treatment has to be individualized to their risk factors and the overall conditions as they enter treatment,” said Melinda Campopiano, M.D., medical director for the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. But she stressed that medications can’t be the only form of treatment. “The behavioral therapy also needs to be tailored to the individual,” she told ADAW.

Whether the person was using prescription opioids or heroin is not the most important factor in choosing the type of treatment, said Campopiano. “You have to look at how much medical harm they’ve experienced, at the route of administration, and the length of time of the addiction,” she said. “There is no formal guidance” on the best treatment protocol for heroin addiction, regardless of age, she said. “A treatment decision needs to be based on what information is available.”

"It’s a gray area — there’s not much out there in terms of research” on treating young people with heroin addiction, said Philip Herschman, Ph.D., chief clinical officer for CRC Health Group. Nevertheless, Herschman said the same thing that Campopiano did — the characteristics of the user are more important than the age alone. “It’s not a matter of whether they’re using heroin or a prescription opiate — to me, they’re using opiates,” Herschman told ADAW.

Methadone for long-term addiction

That said, however, younger patients are more likely by definition to have had a shorter period of addiction. “Generally, the younger the person, and the shorter the addiction, I might try one kind of treatment,” he said. “The older the patient and the greater the amount of drug use, I might try a different kind.” CRC has opioid treatment programs that provide methadone and buprenorphine treatment, uses buprenorphine and Vivitrol in inpatient and outpatient programs, and provides drug-free treatment, so is not vested in only one type of treatment.

Another issue for Herschman is whether the maintenance medication will be given on an open-ended basis, or for only one year. “If you’re younger and have been addicted for a shorter period of time, and you’re more likely not to need a maintenance drug for the rest of your life, and I’m more likely to start you on a buprenorphine product instead of methadone,” said Herschman. “I can’t point you to any paper, but we’ve seen that the younger addict using for a shorter period of time has a much better chance of getting into that drug-free lifestyle at some point down the road.” For example, a 22 year old who is using Vicodin may need “a couple of years of treatment — one year is the minimum — and then may not need the buprenorphine anymore.”

Even if the young person were using heroin, methadone would not be his first choice, he said. “If it turns out that they fail on the buprenorphine — either they’re not taking it, or they are taking it and it’s not working, then my suggestion would be to try methadone,” he said. There are no FDA-approved medications for heroin addiction in people younger than 18 years of age, said Ivan Montoya, M.D., deputy director of the division of pharmacotherapies and medical consequences of drug abuse at the National Institute on Drug Abuse (NIDA). “So, for them, the only option is counseling,” he told ADAW. “For ages 18 to 25, there are no evidence- based recommendations,” he said. “However, as a clinician, if I have a patient in that age group, I would start with depot naltrexone [Vivitrol], and if he or she does not respond, I would try buprenorphine,” he said. “I’d leave methadone as the last resource.”

However, Montoya said that maintenance with buprenorphine or methadone can help patients, including young patients — even those who plan to go off them eventually. “There is no indication that maintenance is not appropriate for young heroin addicts,” he told ADAW. “In fact, quite the contrary. Research indicates that in some cases maintenance is beneficial, at least to help the patient to get ready for detoxification.”

Herschman speculated that the physiological changes to the brain caused by opioid abuse are less likely to be permanent for people who have abused the drugs for three to four years, compared to someone who has been addicted for decades.

“I don’t think we know what the neurochemistry is, whether it’s reversible or not reversible,” said Campopiano. “But it is true that when you have been misusing a substance — of whatever type — for longer, it is more of a struggle to overcome your use.”

Short-acting opioids

Heroin is notable in that it is short-acting, compared to buprenorphine, methadone and — when properly used and not crushed and snorted — OxyContin. But most prescription opioids are short-acting as well, which is what makes them so highly reinforcing and addictive, said Campopiano. “The short acting supplies a more intense, rapid-onset experience,” she said. “The long acting is slow to work, and doesn’t provide the same euphoria.”

Herschman agreed, noting that anyone who is addicted to opioids — prescription or heroin — is using multiple times a day.

Herschman stressed that the value of the maintenance medications — buprenorphine and methadone — is not that they cure the disease. “The medication stabilizes the patient so that the rest of the treatment can be provided.”

Finally, there is Vivitrol — which unlike buprenorphine and methadone is not an opioid, but rather prevents opioids from having any effect. “I love Vivitrol,” said Herschman. “We’re using it a lot now in our residential setting, and working on some papers with Penn State. What we see in our residential facility is that people get their first injection while they’re in treatment, and the number who complete treatment is up by 50 percent, with the number of AMA discharges down by 60 percent.” Patients don’t, however, start on Vivitrol. Rather, they start on buprenorphine, then taper off it and start on Vivitrol. “When you get to the taper point, that’s the perfect patient for Vivitrol,” he said.

Herschman said CRC is seeing an uptick in heroin use, but not only in the young adult populations. “There’s greater pressure from the Feds on pill mills, and also, it’s gotten to the point where heroin on the street is cheaper than OxyContin on the street. Heroin really is dangerous.” •