Treating Opioid Dependence with Buprenorphine: How long should teens and young adults stay in treatment?
Carolyn Schuman, M.D., Medical Director
Reliance Center
Opioid agonist therapy was first developed in the mid-1960s when psychiatrist Marie Nyswander and endocrinologist Vincent Dole demonstrated that methadone, a long acting opioid, resulted in dramatic decreases in withdrawal symptoms, craving, and illicit opioid use in heroin addicts. During two years of follow-up, 90% of patients retained in treatment. 70% of patients in this group became employed, while the remaining 30% showed no evidence of criminal behavior.
Over the next several decades, a growing body of evidence proved that long term treatment was more successful than short term detoxification. The relapse rate after tapering from methadone was approximately 80% at 12 months, and eventually reached more than 90%. Patients in long term therapy did much better – they tended to remain in treatment, and demonstrated greater levels of abstinence from illicit drugs with each successive year in treatment. Opioid dependence became recognized as a chronic disorder which required ongoing treatment. Open ended methadone treatment, without a fixed duration, gained widespread support within the medical community as the preferred therapy for heroin addiction.
Times have changed. In the past ten years two major developments have rocked the addiction treatment world.
First, there have been impressive changes in the types of opioids abused and the ages of the users. Trends over the past ten years showed a decrease in injection heroin use, while the abuse of prescription painkillers skyrocketed. The average age of people who misused prescription opioids was much younger than the average age of injection heroin users.
Second, buprenorphine, a partial opioid agonist, was approved as a second agent for the treatment of opioid dependence. Because of its favorable safety profile, buprenorphine became available for treatment by prescription in a physician’s office.
Researchers began to ask an important question about how long treatment should last in this young group of pill using patients. Could prescription painkiller abusers, who tended to be younger than injection heroin users and had shorter histories of opioid abuse and dependence, successfully undergo a medically supervised withdrawal from opioids and remain drug free after agonist therapy ended? The hope was that these younger patients with shorter addiction histories could move from illicit pill use to prolonged abstinence with the help of a relatively short term buprenorphine taper.
To test this hypothesis, a group of investigators looked at about 150 teen-agers and young adults, ranging in age from 15 to 21. These subjects were randomized to two treatment groups. One group was treated with a two week buprenorphine taper, while the other underwent a three month treatment episode. Individual and group counseling was offered weekly to both groups.
After four and eight weeks, more than half of the subjects randomized to the two week taper had urines that were positive for opioids, while only about a quarter of the patients randomized to the three month treatment had opioids in their urine. This result suggested that patients who continued taking buprenorphine were twice as likely to be free of illegal opioids as patients who discontinued buprenorphine.
But even more significantly, at the end of three months, after both groups had completed their tapers, the rate of relapse was just about identical in the two groups, with about half of all subjects in each group giving opioid positive urines. And further down the line, by 6 to 12 months, the groups continued to look similar, with the rate of relapse ranging from 70% to 80%. Interestingly, this was similar to the rate of relapse that had been observed previously in older injection heroin users.
The conclusions of this study were that younger opioid users with relatively short periods of addiction did well during treatment with buprenorphine. However, when the medication was stopped, these young people acted just like older long term injection heroin users. An accompanying editorial in the Journal of the American Medical Association summarized the study’s conclusions: “The implication is that adolescent opioid-dependent patients, like their adult counterparts, will likely need long-term, rather than short-term, opioid agonist treatment.”
Luckily, times have indeed changed. Today buprenorphine offers a safe, convenient, and confidential treatment option. Because buprenorphine is prescribed in an office based practice, similar to medications for hypertension, high cholesterol, diabetes or asthma, people can continue treatment and avoid relapse to illegal opioids while maintaining a productive and fully functional lifestyle. Over time, working with their physician and their therapist, people can make informed, thoughtful, individualized, and realistic decisions about the duration of their own treatment.
Dole VP, Nyswander ME. “Heroin Addiction – A Metabolic Disease.” Arch Intern Med –Vol 120, July 1967. 19-24.
Fiellin D. “Treatment of Adolescent Opioid Dependence: No Quick Fix.” JAMA.
Vol. 300, No. 17, November 5, 2008. Editorial.
Woody GE, et al. “Extended vs Short-term Buprenorphine-Naloxone for Treatment of Opioid-Addicted Youth.” JAMA. Vol. 300 No. 17, November 5, 2008.
