September 25, 2019

In working with patients, how do you treat both the addiction and the co-occurring psychiatric disorder?

It is important to treat both the addiction and the co-occurring psychiatric disorder, and to target both of them with evidence-based interventions. In my clinic, the Co-occurring Disorders in Adolescents and Young Adults, or CODA clinic, we follow an evidence-based protocol. We first do a comprehensive diagnostic assessment where we identify substance use, psychiatric, and medical conditions and characterize all of the factors (both positive and negative) that are related to the patient’s presenting problem. Using this information, we develop a personalized treatment plan that targets the substance use disorder and any identified co-occurring psychiatric disorders, along with addressing the individual, family, and community contexts in which the substance use problems developed. We typically provide individual and group therapy and layer on parent training and family-based therapy sessions as needed when we see family discord. When indicated we provide medications to treat both the substance use disorder as well as any co-occurring psychiatric disorders.

Why this co-occurring disorders approach?

The majority of teens and young adults who have an addiction disorder (over 80 percent) also have one or more psychiatric disorders. The most common co-occurring psychiatric disorders include disruptive behavior disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and post-traumatic stress disorder (PTSD). We also see bipolar disorder and psychotic disorders regularly. In individuals with co-occurring disorders, substance use and psychiatric symptoms are tightly coupled and tracked together during treatment. If either one is unaddressed, the persistence of that untreated condition continues to impair school and work functioning, typically resulting in worse outcomes in affected youth.  Because of this, it is important to target both disorders concurrently using evidence-based approaches. This is best done by a team that has specialty training in diagnosing and treating co-occurring disorders in youth. 

What is a good outcome for a young person who has developed an addiction to opioids? 

There are a number of potential health trajectories that youth who develop an opioid use disorder may experience. The most common course following first diagnosis and an initial treatment episode for opioid use disorders is to have a pattern of periods of abstinence followed by lapses or relapses. Other trajectories are also present. For example, some individuals, following treatment, stop using opioids and remain abstinent and functional for the rest of their lives, while others may experience treatment-dependent depression. Even with very aggressive treatment, a subgroup of patients may continue to use opioids and are at very high risk for overdose and death. Medications to treat opioid use disorders are associated with better outcomes and lower risk for opioid-related problems and overdose deaths. Some individuals take medications to maintain abstinence from opioids for short periods of time, while others may need to be on them for an extended period.

How long should someone be on medications to treat opioid addiction?

There is not great data on how long someone should stay on medications to treat opioid use disorders and on who would benefit from short-term versus long-term treatment with these medications. Anecdotally, some adults have been on medications to treat opioid use disorders for 20 to 30 years to treat their cravings. For some, taking them off those medications puts them at risk for relapse. 

What are these medications to treat opioid addiction?

There are currently three kinds of medications approved by the Food and Drug Administration (FDA) to treat opioid use disorders in adults – buprenorphine, methadone, and naltrexone. These medications fall into two categories, agonist medications and antagonist medications based upon whether they activate or block the brain’s opioid system. Buprenorphine is a partial opioid agonist that can be administered either in a dissolving pill under the tongue, an oral tablet, an injection, or an implant. Methadone is a full opioid agonist that is prescribed through highly regulated state-run clinics called methadone maintenance programs where patients come to receive their medication on-site and receive counseling. Individuals who receive methadone from a maintenance program initially come to the clinic daily for their dose. Visits are spaced out over time as individuals sustain abstinence from street opioids and start to function better. Naltrexone is an antagonist medication that blocks the mu-opioid receptor in the brain and reduces both cravings and the “high” that one would get from using heroin or prescription opioids. Naltrexone is available orally and by injection on a monthly basis.

Is there a downside to using medications to treat opioid addiction? 

All medications, including those used to treat opioid use disorders, carry a risk for side effects.  The different medications to treat opioid use disorders have different types of side effects. In my clinic, when I make a recommendation to start a medication to treat opioid use disorder, I spend a lot of time discussing with the patient and their family the potential risks and benefits of starting the medication and weigh these against the potential risks and benefits of receiving behavioral therapy alone. In many cases, the benefits seem to outweigh the risks related to these medications. For example, studies show that medications to treat opioid use disorders, when used in combination with behavioral therapy, decrease opioid use and decrease the risk for opioid overdoses and death in individuals who have moderate to severe opioid use disorders and who experience some physical withdrawal symptoms when they stop using opioids.

Is there a way to predict which patients will benefit the most from medications?

I recommend providing medications for opioid use disorders in conjunction with behavioral therapy for all individuals, both adults and youth, who present with moderate to severe opioid use disorders and who experience physical withdrawal symptoms upon stopping opioids. This is the standard of care as framed by both the American Society of Addiction Medicine and the American Academy of Pediatrics. In addition to severity of opioid addiction and signs of physical withdrawal symptoms, we also look for negative prognostic factors, or characteristics of the patient and the patient’s circumstances, that make that patient more likely to have a bad outcome with behavioral therapy alone. Negative prognostic factors can include history of trauma, injection drug use, presence of other non-opioid drug use or drug use disorders, and presence of co-occurring psychiatric disorders. For patients with multiple negative prognostic factors we generally recommend providing treatment, at least initially, in a higher level of care such as on an inpatient unit or in a residential treatment setting, and then having them step down to outpatient based care. We also tend to be more aggressive in recommending medications to treat their opioid disorder.

Are community pediatricians able to treat youth with opioid addiction?

Community pediatricians play an important role in our continuum of care for youth opioid use disorders. They are on the front lines and are often times the first medical providers to hear about opioid use in youth through parents’ concerns. With proper training community, pediatricians can manage youth at-risk for opioid addiction or youth who are at an early stage of opioid use and who have not progressed to regular opioid use. To safely treat moderate-to-severe opioid use disorders, clinical programs require a high level of training, experience, and staffing and infrastructure support to do urine drug screening and to monitor patients in opioid withdrawal. Given the staffing and resource requirement, few community pediatricians are involved in treating opioid addiction, and those that are, are typically have specialty training in adolescent medicine. The larger role for community pediatricians is screening, identifying youth who are at elevated risk for developing opioid use disorders, and connecting those who need care a higher level of care to substance-use specialty clinics.

How can pediatricians best identify youth who are at-risk for or who have opioid use problems?

Pediatricians should screen for alcohol and other drug use, including opioids, as a part of their annual well-child assessments in all teens. We know from research that “if you don’t ask – you don’t know” with regard to adolescent substance abuse and that pediatricians who use a standardized approach and a validated screening tool to assess for drug use are more likely to identify youth who are experiencing substance use problems in their clinics. An algorithm called SBIRT, or Screening Brief Intervention and Referral to Treatment, has been shown to be effective and is recommended by the American Academy of Pediatrics. Under the algorithm, all adolescent patients are screened with a validated screening instrument (e.g. the CRAFFT) and their scores are used to stratify them into groups – low risk, intermediate risk, and high-risk youth. Youth not using or at low risk of using drugs are provided positive reinforcement and educated about the negative effects of starting drugs. Youth identified as having intermediate risk are given brief motivational interventions by the pediatrician or trained staff person. Youth identified as being at high-risk or having a substance use disorder are referred to an addiction specialist for further assessment and treatment.

Is there still a lot of stigma with addiction?

Sadly, yes.  Even the word “addiction” conveys stigma. A recent research study showed that when clinicians use the term drug addict around their patients that those patients are more likely to drop out of care. There is definitely a truism to that – the use of that word hurts our patients –   it disengages and dehumanizes them. As a society, we have a ways to go to reduce the stigma and to help people understand that addictive disorders are brain diseases and treatable conditions, not moral failings. People who have severe addiction often times engage in bad behaviors to support their drug use, but they are still human beings who deserve our care and respect. It is helpful for people who do not suffer from addictive disorders to learn about the loss of control that addicted individuals experience, especially when they are in the throes of withdrawal and cravings. Many individuals suffering from addictive disorders experience tremendous feelings of shame and guilt about their behaviors and when sober look back and feel horrible about how their drug use and its hold over them has affected their relationships and life.

In your clinic, how do you work with youth who present with substance use problems?

A lot of our work with teens during the early-phase of treatment is around connecting with them, building a trusting relationship, and exploring their motivations for using drugs and alcohol. Do they feel they get any benefit from it? Do they notice negative consequences? We help them explore their ambivalence about the problems they have experienced, and help educate them and their families about the association between the drug use and their mood and anxiety problems. We take a nonjudgmental motivational approach, which is associated with better outcomes. As teens are more engaged and become motivated to change their behaviors, we use more cognitive behavioral approaches. When I teach clinicians how to manage substance use problems, the strong message I communicate is involve parents, involve families. 

What can parents of a young person with a substance use disorder do?

Parents are more important in their teen’s lives than they know. It is important for parents to know that they can have a strong impact on their teen’s behaviors and can impact their teen’s chances for having a good or bad outcome by being present, asking about their teen’s drug use, and modeling good behaviors such as abstinence. Parents should know the signs of drug and alcohol use in teens. It is also helpful for them to know the risk factors for drug and alcohol use, and to address these when their children are young – i.e. before the teenage years. If the child has a mental health problem, getting proper treatment before adolescence can reduce the risk for their young person developing a substance use disorder. Conflict and dysfunction in the family are also associated with a higher risk of alcohol and drug use. Because of this, we do family therapy in our clinic and recommend family therapy interventions for families with younger children to reduce family distress as a substance abuse prevention approach. 

How do you work with parents in the CODA clinic?

Parents of youth who present for substance use disorder treatment experience so much anxiety, distress and guilt. “How could this happen?” they ask. “Is there something I could have done to identify this earlier?” This pattern of parental distress is so common, there is a term for it in family therapy – they call it “parental hell.” In the CODA clinic, we take a family-centric approach.  We spend time with parents and families motivating parents to play an active role in their young person’s recovery; educating parents and families about drug use, treatment, and recovery; and training parents in parenting techniques that may reduce their teen’s drug use. We meet parents where they are at – hear their experience and worries, and help parents translate their distress into energy and motivation towards action steps to support their teen during their treatment. Although teens and young adults are developing their own identity and separating from their family system, what their parents say and do has an impact on them. An important thing that we focus on is helping parents and their teen or young adult to reconnect and rebuild their relationship. We do this because strengthening that relationship is associated with reduction in drug use and better functioning.

In addition to opioids, is marijuana use among young people also a concern?

There is a unique relationship between marijuana and opioid use disorders. For adolescents and young adults, marijuana – more so than alcohol and tobacco – seems to convey higher risk for developing an opioid use disorder. We are not sure why that is, but part of the answer might be related to overlapping neurobiological systems. The part of the brain that marijuana acts on, the endocannabinoid system, overlaps significantly with the brain system that heroin and other opiates act on. A scientific article recently published in the American Journal of Psychiatryfound that the use of marijuana in young adults increased their likelihood of initiating and developing opioid-use disorder three years later, even after controlling for other drug and alcohol use.

So how should pediatricians counsel parents regarding marijuana use by their teens?

With the changing landscape of marijuana, legalization occurring nationally, parents are getting a lot of messaging from the news and popular media about health benefits of marijuana. Because of this, pediatricians need to make an effort to educate themselves about marijuana and its effects on youth so they can provide unbiased scientific evidence to teens and their parents. It is our role as doctors who treat young people to inform youth and their parents that use of marijuana during adolescence is not benign, that it is harmful to the developing brain, and that counter to the popularly held beliefs that it helps with sleep, anxiety and depression, that regular use of marijuana may worsen these conditions in teens. Growing evidence from a number of scientific studies indicate that use of marijuana by teenagers and young adults, especially heavier use, is associated with worse depression and anxiety, and poorer sleep, and that cutting down or stopping marijuana use is associated with a reduction in anxiety and depressive symptoms and improvement in sleep in young people.