Pharmacotherapy in Child and Adolescent Substance Abuse

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• Pharmacotherapy in Child and Adolescent Substance
  Abuse

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Oxycodon Hydrocodon
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• MI and MEH (Motivation Enhancement Therapy)
• CBT
• Contingency Management
• Monitoring and Feedback
• Community Reinforcement Approach
• Family Therapy

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• 2010 250,000 adolescents seeking treatment in
  USA
• 4,800 (2) received pharmacotherapy as core
  intervention

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Medication use in adolescents

• Treatment of comorbidity
• Prevent overdose and toxicity
• Ameliorate withdrawal side effects
• Maintaining abstinence or preventing relapse

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Prevent overdose and toxicity

• Flumazenil
• Naloxone

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Ameliorate withdrawal side effects

• Benzodiazepines
• Clonidine
• Amantadine
• Antidepressants
• Antipsychotic
• Bromocriptine

• Carbamazipine,
• Modafinil
• Pergolide
• Topiramate
• Valproate
• Bupropion

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Ameliorate withdrawal side effects

• Methadone
• Buprenorphine

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Maintaining abstinence or preventing relapse

• Nicotine replacement
• Naltrexone for alcohol use
• Topiramate for alcohol use
• Naltrexone for opiate use
• Methadone maintenance
• Buprenorphine maintenance

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Nicotine replacement

• Most prevalent type of substitution intervention
  for adolescents
• Most effective of the substitution programs
• 12-week optimum
• Combined with behavior therapies

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Topiramate for alcohol

• Fewer drinks per day
• Fewer drinks per drinking day
• Fewer heavy drinking days
• More days abstinent
• Greater reduction in reports of craving

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Naltrexone for opiate use

• Reviews show that oral naltrexone is not superior
  to placebo
• High risk of overdose and toxicity

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• Lehmann WX. The use of 1-alpha-acetyl-methadol
  (LAAM) as compared to methadone in the
  maintenance and detoxification of young heroin
  addicts. NIDA monograph 19738823.
• Woody GE, Poole SA, Subramanian G, Dugosh K,
  Bogenschutz M, Abbott P, et al. Extended vs short
  term buprenorphine-naloxone for treatment of
  opioid addicted youth. a randomised trial. JAMA
  2008300(17)200311

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The Lehmann 1973 study

• Age 14-21 years
• 14 heroin users on LAAM
• 21 heroin users on Methadone
• 16 weeks follow up
• No difference substance abuse or social
  functioning

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The Woody 2008 study
JAMA. 2008300(17)2003-2011
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• 152 opiate dependent individuals
• Age 14-21
• 14-detoxification with buprenorphine
• 12-week maintenance with buprenorphine
• Maximum dose 24 mg/day

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• Weekly individual and group sessions
• Informed consent with quiz for both parents and
  adolescent
• 12-month follow up

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Retention in study
Detoxification group Maintenance group
4 weeks 45 84
8 weeks 27 74
12 weeks 21 70
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Arch Gen Psychiatry. 2005621157-1164
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• 36 opiate dependent adolescents (13-18 years)
• 50 heroin users
• 1/3 injection users
• 28-day intervention
• Clonidine detox
• Buprenorphine tapering

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Retention in treatment
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Helpful or not??

• The Neurochemical explanation?

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• Posternak MA, Solomon DA, Leon AC, Mueller TI,
  Shea MT, Endicott J, Keller MB.(2006). The
  naturalistic course of unipolar major depression
  in the absence of somatic therapy. J Nerv Ment
  Dis. 2006. 194-324-9.
• Part of NIMH Collaborative Study of Depression

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84 No treatment
65 Shift BMD
46 Treated
431 MDD
48 No recovery
318 Recovered
130 recurrence
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Time to recovery 1 month recovery 3 months recovery 6 months recovery 1 year recovery
No treatment 13 weeks 23 52 67 85
Total (n130) 23 weeks 15 38 52 70
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