_-The-Breakthrough-Antipsychotic-That-Could-Change-Everything.jpg?1729528747 "KarXT (Cobenfy)_ The Breakthrough Antipsychotic That Could Change Everything.jpg")
Outpatient Management of Opioid Addiction
Sandra Gomez-Luna, MD
Child, adolescent, and adult psychiatrist in Darien, CT. Medical Director of Parent Child Support Center, a subsidiary of Behavioral Health Care (BHcare)
Dr. Gomez-Luna has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Tell us about your position and what you do.
Dr. Gomez-Luna: I directed a short-term adolescent residential program, where I saw a need for identifying and treating kids’ co-occurring conditions. I did another fellowship in addiction psychiatry, then joined studies at Yale on tobacco use and electronic nicotine devices in adolescents. Now I’m back in a community setting, where I’ve created a community-based addiction program for adolescents called Today’s Choices.
CCPR: Can you describe your typical patients?
Dr. Gomez-Luna: Most of our kids are referred to us after being suspended. We see kids with cannabis, alcohol use, and nicotine disorders, but also opioid use disorders and all the conditions that come along with that, including mood disorders, trauma, and personality disorders.
CCPR: How do you approach opioid use in general child psychiatric practice? It seems almost every kid has access to opioids from somebody’s surgical procedure, and when they can’t find those opioids anymore, heroin’s not hard to track down.
Dr. Gomez-Luna: Absolutely. Wisdom teeth procedures often the open door for that age group (Harbaugh C et al, JAMA 2018;320(5):504–506). Because of the rapid use and the reinforcement aspects of these substances, sometimes it’s a little late when families find out. We try to catch those adolescents in the initial stages of using opioids to slow the process of severe addiction.
CCPR: What’s your general strategy for catching substance use early on?
Dr. Gomez-Luna: We work with schools and primary care offices to identify children at risk for developing rapid addiction. We often get referrals after they are in trouble with schools and coaches, so we reach out a step before that, starting interventions in the community. It’s hard to make a diagnosis because kids don’t talk until they trust people. We want to catch kids when they’re found with marijuana paraphernalia or using nicotine devices. We try to identify that they have tried opioids.
CCPR: What conditions make outpatient treatment of a child’s opioid addiction a reasonable approach?
Dr. Gomez-Luna: It depends on the severity of the problem, the resources they have in the community, family support, and past history—a child who makes poor choices but has a good history of school and social development. For family and community support, we use the Adolescent Community Reinforcement Approach (A-CRA). SAMHSA revised the manual in 2016. We want kids who don’t have severe addiction to opioids to remain in the community, going to school, and doing outside activities (Godley MD et al, Drug Alcohol Depend 2017;174:9–16).
CCPR: What are some of the treatment choices you’ll opt for?
Dr. Gomez-Luna: We’ll prescribe psychotropics, if necessary, and interventions—mostly oriented around cognitive behavioral therapy, but also employing dialectical behavioral therapy, and family and supportive interventions. We also collaborate with community therapists. It’s important to work with adolescents with opioid use disorders who are pre-contemplating coming in. Their families bring them, and we use motivational interviewing (MI). (Editor’s note: For more information on MI, see the QA with Dr. D’Amico on page 7.) We try to get them into a group in their community. For children who have higher symptomatology, we consider a hospital-based or a residential-based treatment.
CCPR: What about detox?
Dr. Gomez-Luna: We don’t like the word “detox.” We say that complete abstinence and recovery is possible and construct a team to support the child’s temporary disconnect from the community, then reintegration when the child is ready. Often, children with substance use disorders feel outcast from their community, so it’s beneficial to facilitate their transition to residential settings. Others want friends and families around, so it’s hard to convince them to stay in residential. The days when detox was the only treatment used are hopefully in the past, but it is necessary sometimes.
CCPR: How do you structure the treatment?
Dr. Gomez-Luna: A-CRA requires individual, family, and community intervention, and a minimum of 2 visits a week. We want the kids to remain in their community, but it comes with a commitment. If you’re driving, you need to drive twice. If you’re taking public transportation, you need to do so twice a week. This is difficult. Families are busy and working, but they need to understand that close monitoring requires more than weekly prescription visits. We are creative, going into communities, providing services to families in their homes. Those who are homeless and living in insecure housing are harder to plan for.
CCPR: Child psychiatrists generally refer a child with an opioid problem to an IOP or a hospital, but what you’re doing is kind of in between. The role of a solo child psychiatrist would include screening, coaxing a teen to tell us what’s going on (or collaborating with teachers, coaches, or somebody whom the child will talk to), and MI. Do we have other roles, for instance medication or therapy, or are we better off referring to a more robust program?
Dr. Gomez-Luna: Yes. Collaborate with schools, with therapists who have time to see the families and the children. Conduct MI so the child is ready for the treatment itself. Office-based treatment for opioid use disorder was conceived for clinicians treating fairly motivated people. You need other psychosocial interventions and work in close collaboration with the therapist, with families and schools as a very close collateral. The problem is that by the time the situation comes to us, we often have no choice but to refer.
CCPR: If we do have those pieces in place, what kinds of treatments or medications are helpful? What would child psychiatrists do to support this plan?
Dr. Gomez-Luna: Everything is extrapolated from the adult population. In Connecticut, the age of consent is 16, which coincides with the age buprenorphine treatment starts. We’re using buprenorphine in children for whom it’s appropriate, and naltrexone as well as psychotropic interventions, such as antidepressants and mood stabilizers. For trauma, we do a mix of treatment for mood, impulsivity, and mood dysregulation. You have to specify in the consent that there is no approval yet for treatment of opioid use disorder in the adolescent population and no safety data, but buprenorphine has been proven to be effective and well tolerated in the adult population (Vicencio-Rosas E et al, J Pain Research 2018;11:549–559). Families have concerns about long-term treatment with partial agonists. I find in my practice that families favor naltrexone when they’re ready for medication, because it is not an agonist or partial-agonist treatment.
CCPR: Once patients are on buprenorphine or Suboxone, what I’m hearing is they don’t get off. It’s like the old methadone clinics.
Dr. Gomez-Luna: Correct. I never prescribe buprenorphine alone, although others do. I use Suboxone (buprenorphine with naloxone). We educate females about trying to avoid pregnancy. This may make the decision easier to be on Suboxone versus just Subutex (buprenorphine). But methadone continues to be the gold standard in treatment of opioid use in pregnant women. Some families decide just to take Narcan (naloxone), and I work with them to be ready for more treatment. It’s all good, because with Narcan, hopefully they can prevent a fatal overdose. Families struggling with suicidal teens can’t predict what will happen, and that is very stressful. There’s so little that these families can control. Narcan might mitigate their fear.
CCPR: So, if I understand you correctly, starting Suboxone is a big move. It’s beginning a medication that has no clear endpoint. If we embark on office treatment of adolescents with opioid disorders, we need to have the other pieces in place before exploring treatment with buprenorphine/naloxone or naltrexone. Also, we should avoid using buprenorphine alone, and educate and provide Narcan to families, yes?
Dr. Gomez-Luna: Yes, that’s right. There is a lot to consider before prescribing Suboxone.
CCPR: What about office drug testing? There was a study a number of years ago that said doing drug tests in your office was no better than asking adolescents about the specifics of their drug use.
Dr. Gomez-Luna: I don’t agree. Point-of-care drug testing is part of our multi-component treatment. It gets tricky, especially for opioids like fentanyl, carfentanyl, other illicitly manufactured opioids, and Kratom, none of which are routinely detected with current immunoassay tests. Sometimes users don’t know their heroin is tainted. So you need confirmation tests, and while you are waiting, use a mix of collateral information and your own understanding of the adolescent’s use. Fentanyl is deadly, and people who use their usual amount of heroin may overdose. You have to understand the nuances of getting urine from an adolescent, especially when you’re a psychiatrist treating trauma. Somebody’s observing, but it’s not always a direct observation.
CCPR: Besides drug testing, what other supervision do you talk with parents about?
Dr. Gomez-Luna: We recommend they try to preserve their child’s functioning in the community. But often, what’s done is undone when teens go to parties or stay overnight somewhere. We focus on reasonable but structured systems, so the adolescent is not immersed in the places and people that promote substance use. Sometimes that means the teen won’t be going out for a while. That’s part of the commitment. Some families stop drinking alcohol if it’s triggering for their kids.
CCPR: What about end points in this approach?
Dr. Gomez-Luna: It all depends on the child and the return to functioning in the community. First comes a phase of safety and medical and psychiatric stabilization. As the child becomes able to function without consistent substance use, we refer the child to a lower level of care. Manualized treatment approaches like A-CRA have a commitment of 3 months, and that’s not enough for the opioid use population. Since adolescents often can’t see themselves 3 years in the future, we say “OK, let’s commit for these 3 months.” Then they do better as they continue to be abstinent from the substance.
CCPR: What’s the long view for these patients?
Dr. Gomez-Luna: Recovery comes at different times. We are very careful about using the word “relapse.” Instead, we say “reuse” or “OK, so you used again.” We look for success everywhere. For example, I had a patient taking benzos and opioids. He was able to get onto Suboxone. For me, that was good enough, because using benzos and opioids is a recipe for a fatal overdose. For most people with addiction, it takes several times for treatment to stick. If you’re establishing a relationship with teens, you become a resource, and they will hopefully reestablish trust in you once they’re ready to attempt treatment again. Psychiatrists need to understand addiction in that sense.
CCPR: They have to be able to tolerate the uncertainties and the fact that some kids don’t make it.
Dr. Gomez-Luna: Yes. The young adult population is at higher risk of developing significant conditions, and for attempting and completing suicide. MI is important, and you need the skills to sit tight when you are under pressure to fix things, having a tolerance for what you can’t completely control. That’s something we teach families. I find it difficult, and I was formally trained in MI to be able to immediately engage adolescents, collaborating with them and helping them to choose their goals. If you get that component, you will be much more adept in providing treatment—not just for opioid use disorders, but all substance use conditions in adolescents.
CCPR: Thank you for your time, Dr. Gomez-Luna.
Child PsychiatryDr. Gomez-Luna: I directed a short-term adolescent residential program, where I saw a need for identifying and treating kids’ co-occurring conditions. I did another fellowship in addiction psychiatry, then joined studies at Yale on tobacco use and electronic nicotine devices in adolescents. Now I’m back in a community setting, where I’ve created a community-based addiction program for adolescents called Today’s Choices.
CCPR: Can you describe your typical patients?
Dr. Gomez-Luna: Most of our kids are referred to us after being suspended. We see kids with cannabis, alcohol use, and nicotine disorders, but also opioid use disorders and all the conditions that come along with that, including mood disorders, trauma, and personality disorders.
CCPR: How do you approach opioid use in general child psychiatric practice? It seems almost every kid has access to opioids from somebody’s surgical procedure, and when they can’t find those opioids anymore, heroin’s not hard to track down.
Dr. Gomez-Luna: Absolutely. Wisdom teeth procedures often the open door for that age group (Harbaugh C et al, JAMA 2018;320(5):504–506). Because of the rapid use and the reinforcement aspects of these substances, sometimes it’s a little late when families find out. We try to catch those adolescents in the initial stages of using opioids to slow the process of severe addiction.
CCPR: What’s your general strategy for catching substance use early on?
Dr. Gomez-Luna: We work with schools and primary care offices to identify children at risk for developing rapid addiction. We often get referrals after they are in trouble with schools and coaches, so we reach out a step before that, starting interventions in the community. It’s hard to make a diagnosis because kids don’t talk until they trust people. We want to catch kids when they’re found with marijuana paraphernalia or using nicotine devices. We try to identify that they have tried opioids.
CCPR: What conditions make outpatient treatment of a child’s opioid addiction a reasonable approach?
Dr. Gomez-Luna: It depends on the severity of the problem, the resources they have in the community, family support, and past history—a child who makes poor choices but has a good history of school and social development. For family and community support, we use the Adolescent Community Reinforcement Approach (A-CRA). SAMHSA revised the manual in 2016. We want kids who don’t have severe addiction to opioids to remain in the community, going to school, and doing outside activities (Godley MD et al, Drug Alcohol Depend 2017;174:9–16).
CCPR: What are some of the treatment choices you’ll opt for?
Dr. Gomez-Luna: We’ll prescribe psychotropics, if necessary, and interventions—mostly oriented around cognitive behavioral therapy, but also employing dialectical behavioral therapy, and family and supportive interventions. We also collaborate with community therapists. It’s important to work with adolescents with opioid use disorders who are pre-contemplating coming in. Their families bring them, and we use motivational interviewing (MI). (Editor’s note: For more information on MI, see the QA with Dr. D’Amico on page 7.) We try to get them into a group in their community. For children who have higher symptomatology, we consider a hospital-based or a residential-based treatment.
CCPR: What about detox?
Dr. Gomez-Luna: We don’t like the word “detox.” We say that complete abstinence and recovery is possible and construct a team to support the child’s temporary disconnect from the community, then reintegration when the child is ready. Often, children with substance use disorders feel outcast from their community, so it’s beneficial to facilitate their transition to residential settings. Others want friends and families around, so it’s hard to convince them to stay in residential. The days when detox was the only treatment used are hopefully in the past, but it is necessary sometimes.
CCPR: How do you structure the treatment?
Dr. Gomez-Luna: A-CRA requires individual, family, and community intervention, and a minimum of 2 visits a week. We want the kids to remain in their community, but it comes with a commitment. If you’re driving, you need to drive twice. If you’re taking public transportation, you need to do so twice a week. This is difficult. Families are busy and working, but they need to understand that close monitoring requires more than weekly prescription visits. We are creative, going into communities, providing services to families in their homes. Those who are homeless and living in insecure housing are harder to plan for.
CCPR: Child psychiatrists generally refer a child with an opioid problem to an IOP or a hospital, but what you’re doing is kind of in between. The role of a solo child psychiatrist would include screening, coaxing a teen to tell us what’s going on (or collaborating with teachers, coaches, or somebody whom the child will talk to), and MI. Do we have other roles, for instance medication or therapy, or are we better off referring to a more robust program?
Dr. Gomez-Luna: Yes. Collaborate with schools, with therapists who have time to see the families and the children. Conduct MI so the child is ready for the treatment itself. Office-based treatment for opioid use disorder was conceived for clinicians treating fairly motivated people. You need other psychosocial interventions and work in close collaboration with the therapist, with families and schools as a very close collateral. The problem is that by the time the situation comes to us, we often have no choice but to refer.
CCPR: If we do have those pieces in place, what kinds of treatments or medications are helpful? What would child psychiatrists do to support this plan?
Dr. Gomez-Luna: Everything is extrapolated from the adult population. In Connecticut, the age of consent is 16, which coincides with the age buprenorphine treatment starts. We’re using buprenorphine in children for whom it’s appropriate, and naltrexone as well as psychotropic interventions, such as antidepressants and mood stabilizers. For trauma, we do a mix of treatment for mood, impulsivity, and mood dysregulation. You have to specify in the consent that there is no approval yet for treatment of opioid use disorder in the adolescent population and no safety data, but buprenorphine has been proven to be effective and well tolerated in the adult population (Vicencio-Rosas E et al, J Pain Research 2018;11:549–559). Families have concerns about long-term treatment with partial agonists. I find in my practice that families favor naltrexone when they’re ready for medication, because it is not an agonist or partial-agonist treatment.
CCPR: Once patients are on buprenorphine or Suboxone, what I’m hearing is they don’t get off. It’s like the old methadone clinics.
Dr. Gomez-Luna: Correct. I never prescribe buprenorphine alone, although others do. I use Suboxone (buprenorphine with naloxone). We educate females about trying to avoid pregnancy. This may make the decision easier to be on Suboxone versus just Subutex (buprenorphine). But methadone continues to be the gold standard in treatment of opioid use in pregnant women. Some families decide just to take Narcan (naloxone), and I work with them to be ready for more treatment. It’s all good, because with Narcan, hopefully they can prevent a fatal overdose. Families struggling with suicidal teens can’t predict what will happen, and that is very stressful. There’s so little that these families can control. Narcan might mitigate their fear.
CCPR: So, if I understand you correctly, starting Suboxone is a big move. It’s beginning a medication that has no clear endpoint. If we embark on office treatment of adolescents with opioid disorders, we need to have the other pieces in place before exploring treatment with buprenorphine/naloxone or naltrexone. Also, we should avoid using buprenorphine alone, and educate and provide Narcan to families, yes?
Dr. Gomez-Luna: Yes, that’s right. There is a lot to consider before prescribing Suboxone.
CCPR: What about office drug testing? There was a study a number of years ago that said doing drug tests in your office was no better than asking adolescents about the specifics of their drug use.
Dr. Gomez-Luna: I don’t agree. Point-of-care drug testing is part of our multi-component treatment. It gets tricky, especially for opioids like fentanyl, carfentanyl, other illicitly manufactured opioids, and Kratom, none of which are routinely detected with current immunoassay tests. Sometimes users don’t know their heroin is tainted. So you need confirmation tests, and while you are waiting, use a mix of collateral information and your own understanding of the adolescent’s use. Fentanyl is deadly, and people who use their usual amount of heroin may overdose. You have to understand the nuances of getting urine from an adolescent, especially when you’re a psychiatrist treating trauma. Somebody’s observing, but it’s not always a direct observation.
CCPR: Besides drug testing, what other supervision do you talk with parents about?
Dr. Gomez-Luna: We recommend they try to preserve their child’s functioning in the community. But often, what’s done is undone when teens go to parties or stay overnight somewhere. We focus on reasonable but structured systems, so the adolescent is not immersed in the places and people that promote substance use. Sometimes that means the teen won’t be going out for a while. That’s part of the commitment. Some families stop drinking alcohol if it’s triggering for their kids.
CCPR: What about end points in this approach?
Dr. Gomez-Luna: It all depends on the child and the return to functioning in the community. First comes a phase of safety and medical and psychiatric stabilization. As the child becomes able to function without consistent substance use, we refer the child to a lower level of care. Manualized treatment approaches like A-CRA have a commitment of 3 months, and that’s not enough for the opioid use population. Since adolescents often can’t see themselves 3 years in the future, we say “OK, let’s commit for these 3 months.” Then they do better as they continue to be abstinent from the substance.
CCPR: What’s the long view for these patients?
Dr. Gomez-Luna: Recovery comes at different times. We are very careful about using the word “relapse.” Instead, we say “reuse” or “OK, so you used again.” We look for success everywhere. For example, I had a patient taking benzos and opioids. He was able to get onto Suboxone. For me, that was good enough, because using benzos and opioids is a recipe for a fatal overdose. For most people with addiction, it takes several times for treatment to stick. If you’re establishing a relationship with teens, you become a resource, and they will hopefully reestablish trust in you once they’re ready to attempt treatment again. Psychiatrists need to understand addiction in that sense.
CCPR: They have to be able to tolerate the uncertainties and the fact that some kids don’t make it.
Dr. Gomez-Luna: Yes. The young adult population is at higher risk of developing significant conditions, and for attempting and completing suicide. MI is important, and you need the skills to sit tight when you are under pressure to fix things, having a tolerance for what you can’t completely control. That’s something we teach families. I find it difficult, and I was formally trained in MI to be able to immediately engage adolescents, collaborating with them and helping them to choose their goals. If you get that component, you will be much more adept in providing treatment—not just for opioid use disorders, but all substance use conditions in adolescents.
CCPR: Thank you for your time, Dr. Gomez-Luna.
Recommended
