Summary
While opioid dependence in adolescents may represent a narrower population as compared to the categories of mood disorders, ADHD, and anxiety disorders, this is a growing population for which there are no well-established treatments. That the Subutex arm was so robustly more effective across the outcome measures of treatment retention and transition into relapse prevention treatment is extremely encouraging for its use as a primary detoxification drug in adolescent opioid dependence.
Analysis
The use of heroin and prescription narcotics among adolescents is a growing public problem. However, there is little data regarding the safe and effective detoxification of opioids in this population. One major treatment strategy for opioid detoxification includes the use of buprenorphine, a partial opioid agonist providing some opioid effects but with a ceiling effect that enhances safety and avoids an extreme high. Buprenorphine comes in two forms, buprenorphine alone (Subutex, Reckitt Benckiser Pharmaceuticals, Inc.) and buprenorphine with naloxone (Suboxone; the naloxone component, as an opioid antagonist inactivated by oral ingestion but active when injected, helps prevent abuse of the medication through injection). Other detoxification strategies include the use of methadone and clonidine. This study randomized subjects (n=36, mean age 17) to buprenorphine (Subutex) and clonidine detoxification protocols, each arm associated with 3x per week behavioral therapy, performed in an outpatient setting. Doses were variable and based on amount of narcotic use and tolerability. Outcome measures showed a significant difference between the two groups, and markedly favoring the Subutex arm. Treatment retention rates for Subutex were 72% versus 39 % for clonidine. Even more importantly, 61% of Subutex subjects continued relapse prevention treatment with Naltrexone after the acute detoxification phase verus 5% of clonidine subjects. This is likely due to the fact that patient detoxification with Subutex was physically and subjectively better tolerated (also demonstrated in the study), leading to a better perception of the treatment experience as well as the benefit on ongoing treatment after detoxification. Safety and effectiveness studies of buprenorphine have been well established in adults; there is some safety data of buprenorphine in children/adolescents taken for pain studies, but this may be the first randomized, controlled trial comparing different pharmacotherapies for opioid detoxification in adolescents and, by itself, will likely lend support to this treatment regimen. Of course, larger studies are required to confirm these results, and establish safety and efficacy, but these overall findings, nonetheless, would suggest Subutex is a reasonable primary treatment strategy for this population.
