Pubdate: Tue, 10 Apr 2018
Source: Philadelphia Daily News (PA)
Copyright: 2018 Philadelphia Newspapers Inc.
Author: Rita Giordano, Staff Writer



"By the time I was 17, 18," Nelson Abbott said, "I graduated to

He tried to stop many times, both by going cold-turkey and tapering
off the drugs, but he hated the withdrawal pains and he wasn't really
ready to quit. Therapy didn't work out, either. But then his best
friend overdosed and died. When Abbott's parents checked him into the
Caron Treatment Center in Berks County, he didn't fight.

But he was surprised. At Caron, he was started on monthly shots of
naltrexone, a drug for people dependent on opioids or alcohol that
cuts cravings, while also blocking how these substances affect the
brain. With this extra help, Abbott found he could focus on his recovery.

"I wasn't sitting there thinking about getting high all the time,"
said Abbott, now 23. "I was able to clear my brain and do some work."

Medication-assisted treatment (MAT) includes medicine such as
naltrexone or methadone as an adjunct to therapy, which might include
counseling and 12-step programs. It is not a new concept by any means.
It's been around long enough to be shown in numerous studies to be a
far more reliable route to recovery than therapy or medication alone.
But with fatal opioid overdoses hitting historic levels, MAT is
getting more attention - even for teens and young adults.

For people age 24 and under, opioid overdoses increased more than 540
percent from 1999 to 2016, according to data from the U.S. Centers for
Disease Control and Prevention. Overall, opioid use disorder in this
age group, especially those age 18 to 24, has skyrocketed.

Yet for a variety of reasons, MAT is not reaching many of the young
people who might benefit from it.

'I was going to die'

Some people don't think you're really in recovery if you're taking a

Nick Gettel's opioid use put him in inpatient drug treatment at Caron
at age 19. He stayed drug-free for six years. But depression and
anxiety led him to relapse. He found the second time getting clean
much harder.

"I wanted to get sober more than anything in the world, but I just
could not get my feet back underneath me," said Gettel, who lives
outside Reading.

He'd always been against MAT; like others in 12-step programs, he
didn't regard it as really being sober. But after an overdose landed
him in the hospital, a doctor he trusted suggested

"I reached a point where I was willing to try anything. I figured,
what the hell, I was going to die. I might as well give it a try."

Deni Carise is chief scientific officer for Recovery Centers of
America, which recently opened a young-adult program on its Devon
campus. In the past, she said, it usually took people years of drug
use to develop a serious addiction.

"It was really unusual to see someone coming to treatment who said, 'I
just started doing drugs six months ago. I'm addicted to heroin.' That
was rare. Now it's not," Carise said.

Despite the evidence supporting MAT as a proven way to help prevent
relapse, it remains controversial, especially for younger people.

It rubs some people the wrong way to treat an opioid addiction with
another opioid such as buprenorphine, the only MAT drug that has been
approved for teens younger than 18. MAT opioids, too, can be abused,
and even if used properly, they may need to be continued

Access is another factor. Buprenorphine requires a special
certification to prescribe, and only a limited number of doctors have

Confronted with rising youth opioid use, the American Academy of
Pediatrics urged its members nearly two years ago to consider MAT for
their adolescent and young adult patients and to get the training to
prescribe buprenorphine.

But change has been slow. Nationally, only about 1 percent of
pediatricians can prescribe buprenorphine, and uptake among doctors
who treat adults isn't much higher.

One national study by researchers from Boston Medical Center and the
medical schools of Boston University and Harvard found that only about
a quarter of commercially insured youths with opioid use disorder were
prescribed naltrexone (which is not an opioid) or buprenorphine within
six months of diagnosis.

George Woody, a Penn psychiatry professor, found young opioid users
who detoxed and then were given buprenorphine and counseling for 12
weeks were more likely to refrain from illicit drug use and stuck with
therapy longer than patients who had counseling alone after detox.
Other studies have produced similar findings.

"If a kid has diabetes, you don't withhold diabetes medications and
rely on exercise and diet," Woody said. "I think the same thing
applies to opioids."

Nick Gettel taking his meds at his Berks County home.

'A chaotic population'

But the medicines aren't cures. Patients of any age need to work on
recovery every day, which for many can mean learning an entirely new
way of life. They most likely will be advised to regularly attend
12-step program meetings, follow the guidance of a counselor or
12-step sponsor, and possibly even develop a whole new sober social
circle. That can be especially difficult for young people. Even
without substance abuse issues, teens and young adults may still be
developing impulse control, and may rebel against any kind of
authority. Young opioid users often have other mental-health issues,
and many abuse other substances, as well.

"They are a chaotic population," said Marc Fishman, an assistant
professor of psychiatry at Johns Hopkins University School of Medicine
and medical director of the Maryland Treatment Centers and Mountain
Manor Treatment in Baltimore. "They [think they] are invincible.
They're not well-engaged in treatment of any kind."

Fishman said he believes all opioid use disorder patients, regardless
of age, should be on a MAT protocol for relapse prevention. He said 80
percent of his patients use MAT. But even with medication, only about
half of opioid users in recovery stick with their treatment after six
months, research indicates, and the rate is even less for young patients.

Yet that looks good compared with how patients do without the
medication, he said. Overall, their relapse rate 30 days after detox
is 80 to 90 percent.

Terri Randall, a Children's Hospital of Philadelphia psychiatrist,
strives to get families involved in the treatment process. She has
used MAT with "a handful" of her teenage patients.

A strong commitment is required for this treatment. Buprenorphine, in
the forms it is usually prescribed, carries a lower risk of abuse, and
skipping a dose does not send patients into withdrawal but it is meant
to be taken as directed. Randall said she insists her MAT patients
"come to their appointments, use the medication as prescribed - not
lose it or run out early - and be involved in treatment." Many teens
and their families find it hard to meet those requirements, she said.
Plenty of kids have trouble following rules, and addiction does
nothing to improve that.

At Gaudenzia, a large regional treatment program, naltrexone is used
often with young adults. But president and CEO Michael Harle said MAT
hasn't been tested enough to be used with adolescents. He is worried
that the push for more MAT may be an attempt to find a quick solution
to a complex disease, one in which most doctors have little training.

"I'm not all excited about the pediatricians being able to get us out
of this problem when they shouldn't have been giving OxyContin to a
17-year-old in the first place," said Harle, who is not a physician,
but has been in the drug-treatment industry for 45 years.

There are shortages of all kinds of drug treatment, especially for
adolescents, and primary-care doctors - even the ones knowledgeable
about addiction - don't have the time to provide all the services
themselves, Harle said.

Joseph Garbely, Caron's medical director, said his facility isn't
using MAT for adolescents because "we're not seeing heroin addicts at
that age."

Regardless of the patient's age, "I always say MAT does not stand for
medication as treatment," he said. "You have to have treatment for the
medication to assist."

But Garbely said his goal is for all Caron's adult patients with
opioid use disorder to be on MAT; about 62 percent, including young
adults, are on the protocol now, he said.

"Heroin or a substance like fentanyl calls their name very loudly,"
Garbely said. "The brain needs time to reset and allow natural rewards
to reward that person again. We've got to get them to that point."

Nick Gettel, now 27, is still reclaiming his life. MAT and a 12-step
program are helping. An avid fisherman, he's working as an outfitter
and thinking about going back to college.

To other young people struggling with opioids, he says keep an open
mind. "I would like to be part of the changing narrative around MAT,"
Gettel said. "I think it will save lives."

Nick Gettel says he thinks that medication-assisted treatment will
save lives.

Which medicines are used in MAT?

Medication-assisted treatment, or MAT, has been shown in studies to
give the best chance for lasting recovery from addiction. Three main
types of medicines may be used; in all cases, experts agree that
counseling to help address the psychosocial issues of addiction is
essential, as well.

Naltrexone is an opioid antagonist, meaning that it is not an opioid,
but it blocks receptors in the brain that are responsible for the
euphoric and pain-relieving effects of opioid drugs. It also curbs
opioid cravings, and is sometimes prescribed for people with
alcoholism. If it is taken by people who still have opioids in their
system, it will result in immediate and painful withdrawal. It is
often prescribed as Vivitrol, the brand name of an extended-release
formulation. Administered by monthly injection, Vivitrol is often
viewed as preferable to the daily pill, which requires more patient
compliance. Naltrexone has FDA approval for patients 18 and older. The
average retail price of Vivitrol is about $1,670 a dose, according to The average retail price of 30 pills is $111.

Methadone is a medically administered opioid that has been used for
decades to help people stay out of active heroin addiction. Considered
an opioid agonist - meaning it acts on the brain's opioid receptors
like any other opioid drug - it prevents excruciating withdrawal
symptoms without the euphoric effects of stronger opioids when taken
as directed. Highly regulated, it requires daily visits to a
methadone-dispensing clinic, some of which also offer on-site drug
counseling. Methadone is generally limited to ages 18 and up, but
exceptions can be made for younger teenagers who have relapsed twice
in one year and who have obtained parental permission. The average
retail price is about $53 for 120 pills.

Buprenorphine is considered a partial agonist, that works similarly to
methadone as a replacement medication. Also like methadone, it is an
opioid and can be abused. The brand name Suboxone includes both
buprenorphine and naloxone, the rescue medicine that revives people
experiencing an overdose. Added to buprenorphine, naloxone makes
abusing the medication more difficult. Buprenorphine is sometimes used
in the opioid detox process - the first few days of withdrawal - as
well as maintenance. It is approved by the FDA for patients 16 or
older. It is most commonly prescribed as a daily medication by doctors
with special certification. An extended-release form has also gotten
FDA approval. The average retail of the generic form of Suboxone is
about $131 for 14 tablets.
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MAP posted-by: Matt