Pain Medicine and Adolescents: Special Considerations

Sharon Levy, MD, MPH Assistant Professor of Pediatrics

Boston Children’s Hospital

Harvard Medical School Director, Adolescent Substance Abuse Program Division of Developmental Behavioral Pediatrics

Disclosures

• I, Sharon Levy, have no relevant financial or commercial relationships to disclose.

• Funding for this initiative was made possible (in part) by

Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) and Providers’ Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Learning outcomes

• Understand the neurobiology of opioids action on the brain

• Discuss appropriate use of medication assisted therapy for opioid use disorders

• Identify the role of parents and medical providers in prevention of opioid addiction

Opiates

Opioids

Oxycodone 20 mg

Opioid Pharamocology

• Mimic endorphins

• Bind to mu-opioid receptors

• Well-being, satisfaction, pleasure

Opioid µ-receptor and agonist

Limbic

System

Spinal Cord

Brain Stem

Prefrontal

Cortex

PREFRONTAL CORTEX: Executive Functions LIMBIC SYSTEM: Pleasure, reward BRAIN STEM: Respiration SPINAL CORD: Analgesia

Opioid Neurobiology

Civil War VIETNAM WAR

METHADONE HARRISON DRUG ACT

“PAIN” AS THE 5th VITAL SIGN

Increase in Opiate Rx, 1991-2013

Volkow ND. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Natl. Inst. Drug Abus. 2014. Available at:

http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse.

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Source: Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2011

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eRates of opioid misuse by 12th graders

• Misuse/Non-medical use

• Substance Use Disorder

• Addiction

11.1% of 12th graders have misused opioids in their lifetime. There are two main reasons for misuse

• Self-medication for pain

• “Recreationally” (for

euphoria)

Misuse: Self-Medication

National Survey on Drug Use and Health (NSDUH) 2012; Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2013; Cranford JA, Boyd, C., Addict. Behav. 2013 McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior

11.1% of 12th graders have misused opioids in their lifetime. There are two main reasons for misuse

• Self-medication for pain

• “Recreationally” (for euphoria)

National Survey on Drug Use and Health (NSDUH) 2012; Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2013; Cranford JA, Boyd, C., Addict. Behav. 2013 McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior

Misuse: Recreation

Source: Allyn, Bacon, 2001. http://www.studyblue.com/notes/note/n/nervous-synapses--signaling-chpt-4849/deck/6399759

Impact on Brain Development

motivation emotion

Cerebellum Amygdala

Nucleus Accumbens

Prefrontal cortex

Planning, Organizing, Impulse control

Physical coordination, Sensory processing

Slide adapted from Ken Winters, PhD.

Toddler milestones:

balance, walking,

coordination

Preschool milestones:

emotional regulation School age

milestones:

achievement

Adolescent

milestones: impulse

control

Source: Galvan A, Hare AT, Parra, CE, Penn J, Voss H, Glover G, Casey BJ, Earlier Development of the Accumbens Relative to Orbitofrontal

Cortex Might Underlie Risk-Taking Behavior in Adolescents. Journal of Neuroscience, 2006,26(25):6885–6892

Children ages 7-11 Teens ages 13-17 Adults ages 23-29

Addiction: A chronic,

relapsing medical

condition resulting from

neurological changes in

the brain’s reward

system leading to

compulsive use of a

substance

Heroin

• Very rapid delivery of morphine to

the central nervous system

• Potent and relatively inexpensive

• Snorting or smoking as practical

alternatives to injecting

Heroin Epidemiology

Substance Abuse and Mental Health Services Administration (SAMHSA) Office of Applied Studies. Substance Use Treatment Need among Adolescents: 2003-2004. National Survey on Drug Use and Health (NSDUH) 2011.

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Pharmacologic Non-pharmacologic

Detox

methadone, buprenorphine, clonidine, “comfort meds”

Outpatient individual or group

Antagonist therapy

Naltrexone PO or IM Intensive outpatient/partial

Agonist therapy

Methadone, buprenorphine

Acute or Long Term Residential

Sober home/half-way house

Treatment for Opioid Use Disorder

Detoxification

Adult studies have recurrently found high relapse rates after detoxification without subsequent treatment. An NIH consensus statement regarding treatment of opioid dependent adults indicated detoxification alone is insufficient treatment.

Woody, GE., et al. Extended vs. Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted Youth. JAMA 300(17) :2003-2011, 2008.

National Institute of Health Consensus Development Conference Statement, 1997.

Kosten TR, Schottenfeld R, Ziedonis D, Falcioni J. Buprenorphine versus methadone maintenance for opioid dependence. Journal of Nervous and Mental Disease 1993;181(6):358-64.; Mattick et al., Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients., Addiction, 2003 Apr;98(4):441-52.; Gowing, L., Buprenorphine for the management of opioid withdrawal., Cochrane Database Syst Rev. 2000;(3):CD002025.

Medication Assisted Treatment

Agonist Therapy: Buprenorphine

• Partial agonists form an imperfect fit

• less reinforcing and less commonly abused than full agonists.

• The potential for misuse is not zero

Drug Abuse Treatment Act of 2000

• MAT is first line therapy for patients with

opioid use disorders.

• Expanding access to MAT is a top priority.

2014 Buprenorphine Summit Report of Proceedings

AMA Opioid Task Force

5 goals of the task force:

• Increase physicians’ registration and use of effective PDMPs

• Enhance physicians’ education on effective, evidence-based prescribing

• Reduce the stigma of pain and promote comprehensive assessment and treatment

• Reduce the stigma of substance use disorder and enhance access to treatment

• Expand access to naloxone in the community and through co-prescribing

http://www.ama-assn.org/ama/pub/advocacy/topics/preventing-opioid-abuse/opioid-abuse-task-force.page?

• buprenorphine vs. clonidine for 28-day detox • Randomized controlled trial; double-blind, double-

dummy design • Participants 13-18 years old, N=36 • All participants received counseling in addition to meds

– Individual and family therapy – Contingency Management – Outreach component

Marsch, L.A., et al. Archives of General Psychiatry 62(10):1157-1164, 2005.

Study design

Research Trials with Adolescents Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial

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opiate - urine Retained in treatment Cont.pharm treatment

Pe

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BuprenorphineGroup

Clonidine Group

Marsch, L.A., et al. Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial. Archives of General Psychiatry 62(10):1157-

1164, 2005.

–Participants 15-21 years old, N=152

–Randomly assigned to 1 of 2 groups:

•2-week detox

•12-week treatment

–All participants received group and individual counseling

Study design

Research Trials with Adolescents Extended vs. Short-term Buprenorphine-Naloxone for Treatment of

Opioid-Addicted Youth: A Randomized Trial

Woody, GE., et al. JAMA 300(17) :2003-11, 2008

• Fewer Opioid positive urine screens in

12-week-treatment group

• Higher retention rates in 12-week-

treatment group

Summary of Findings

Research Trials with Adolescents Extended vs. Short-term Buprenorphine-Naloxone for Treatment of

Opioid-Addicted Youth: A Randomized Trial

Woody, GE., et al. JAMA 300(17) :2003-11, 2008

• Block euphoric effect

• Suppress cravings

• Monthly injectable dosing can help with compliance

• Patients who used naltrexone had less

opioid use, better treatment retention and fewer cravings.

• Efficacy or adverse effects profile in children?

Lobmaier P, Kornor H, Kunoe N, Bjorndal A. Sustained-release naltrexone for opioid dependence. Cochrane database of systematic reviews. 2008(2):CD006140.

Roozen H G, de Waart R, van der Windt D A, van den Brink W, de Jong C A, Kerkhof A J. A systematic review of the effectiveness of naltrexone in the maintenance

treatment of opioid and alcohol dependence. European Neuropsychopharmacology 2006; 16(5): 311-323.

Antagonist Therapy

Encourage Abstinence

I agree to stop using all drugs.

I understand that it is dangerous to mix buprenorphine with alcohol or other sedatives

I agree to cooperate with urine drug testing whenever requested. PATIENT SIGNATURE AND DATE:

Monitor

Psychosocial Support

Ancillary Treatment

PCSS Projects

Funding for these initiatives was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) and Providers’ Clinical Support System for Medication Assisted Treatment (grant no. 5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Two Projects. One Mission Helping to end the opioid overdose epidemic.

• PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: Addiction Technology Transfer Center, American Academy of Neurology, American Academy of Pain Medicine, American Academy of Pediatrics, American College of Physicians, American Dental Association, American Medical Association, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society for Pain Management Nursing, International Nurses Society on Addictions, and Southeast Consortium for Substance Abuse Training.

• PCSS-MAT is a collaborative effort led by American Academy of Addiction Psychiatry in partnership with: American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, American Society of Addiction Medicine and Association for Medical Education and Research in Substance Abuse.

PCSS Projects Training Modalities The PCSS Projects offer no-cost training activities with CME to health professionals through the use of:

• Webinars (Live and Archived)

• Online Modules

• Case Vignettes

• One-on-one and Small Group Discussions—coaching for clinical cases

In addition, the projects offer a comprehensive library of resources:

• Clinical Guidances and other educational tools

• Community Resources

• Buprenorphine waiver training via PCSS-MAT

• Listserv - Provides a “Mentor on Call” to answer questions about content presented

through PCSS-MAT and PCSS-O. To join email: pcssmat@aaap.org or pcss-o@aaap.org

Buprenorphine Waiver Training:

The Half and Half Course – specifically for Pediatricians and Family Physicians in addressing

adolescent specific issues

http://www.cvent.com/d/l4q2mj

Prevention for Pediatricians

Changes in Prescribing Controlled Meds to Adolescents, 1994-2007

1. Fortuna RJ, Robbins BW, Caiola E, Joynt M, Halterman JS. Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics. 2010;126(6):1108–16. Available at: http://pediatrics.aappublications.org/content/126/6/1108.short. Accessed August 21, 2014.

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All controlled medications

Opioid

Sedative-hypnotic

• Stimulant

National Institute on Drug Abuse (NIDA). (2012). Safe Prescribing for Pain | National Institute on Drug Abuse (NIDA). NIDAMED. Dodds, A. (2008). Pain Management: From Basics to Clinical Practice. Elsevier Health Sciences; Manchikanti, et al.,(2012). American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I and II. Pain Physician

Maximize Non-Opioid Therapy

Screen before prescribing

Caution when prescribing opioids

McCabe, et al.,(2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behavior

Anticipatory guidance

Alcohol and Marijuana use precede opioid use

Teens that use alcohol or marijuana

• more likely to misuse opioids

• much more likely to misuse opioids for recreational purposes.

Fiellin LE, Tetrault JM, Becker WC, Fiellin DA, Hoff RA.. J. Adolesc. Health. 2013;52(2):158–63. McCabe SE, West BT, Teter CJ, Cranford JA, Ross-Durow PL, Boyd CJ. Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addict Behav. 2012;37(5):651–656.

Fisher SL, Bucholz KK, Reich W, et al. Teenagers are right--parents do not know much: an analysis of adolescent-parent agreement on reports of adolescent substance use, abuse, and dependence. Alcohol Clin Exp Res. 2006;30(10):1699–1710.

Behavior Child Report Parent Report

Consumed at least 1 drink

54% 30.5%

Have been intoxicated

23.6% 8.1%

Tobacco Use 44% 27%

Marijuana Use 22.9% 13.2%

Partnership for a Drug-Free America. The Partnership Attitude Tracking Study (PATS): Teens in grades 7 through 12 2005; May 16, 2006

Easy to get from medicine cabinet 62%

Available everywhere 52%

Not illegal 51%

Easy to get through other people’s prescription 50%

Can claim you have a prescription if caught 49%

Cheap 43%

Safer to use than illegal drugs 35%

Less shame attached to using 33%

Easy to purchase over the Internet 32%

Fewer side effects than street drugs 32%

Parents don’t care as much if you get caught 21%

Reasons for Misusing Opioids

Non-Specific Signs of SUD

Non-Specific Signs of SUD

Suggestions for practice

• Opioids are a very good treatment for acute pain AND also very addictive. They have a role but should be used sparingly.

• Pharmacotherapy is an important component of successful treatment of opioid use disorders. Consider offering medication assisted treatment in the primary care setting. Available resources can help to build a successful program.

• Parents and medical professionals are an important line of defense against opioid addiction. Screen to identify and make interventions to prevent or delay substance use.

Acknowledgements

Teaching Collaborators • Pamela Burke, PhD, RN, FNP, PNP, FSAHM,

FAAN • Linda Malone, DNP, RN, CPNP • Sarah Pitts, MD • Marianne Pugatch, MSW, LICSW • Jennifer Putney, PhD, LICSW Research Collaborators • Elizabeth Harstad, MD, MPH • Lauren Wisk, PhD Clinic Collaborators • Fatma Dedeoglu, MD • Katharine Garvey, MD, MPH • Jen Lightdale, MD, MPH • Paul Rufo, MD, MMSc • Lisa Albers Prock, MD, MPH, FAAP • Paul Hammerness, MD • Andrew MacGinnitie, MD, PhD • Jonathan Gaffin, MD

Research Project Management • Julie Lunstead, MPH, Program Manager • Erin Huang, MPH, Data Manager Adolescent Substance Abuse Program (ASAP) Research Assistants • Dylan Kaye, BA • Jessica Kerr, MPH • Lily Rabinow, MS • Parissa Salimian, BA • Sara Spielman, BS • Meghana Vijaysimha, MPH • Rosemary Ziemnik, BS •

Clinicians • Diana Deister, MD, MS • Leslie Green, MSW, LICSW • Julie Hansen, MSW, LICSW • Shannon Mountain-Ray, MSW, LICSW • Miriam Schizer, MD, MPH • Patricia Schram, MD

Co-principal investigator: Elissa Weitzman, ScD, Msc