Maintenance treatments for opiate-dependent adolescents

Review question

We reviewed the evidence about the effect of maintenance treatment either alone or associated with psychosocial intervention compared with no intervention, placebo, other pharmacological intervention, pharmacological detoxification or psychosocial intervention in adolescents (13 to 18 years).

Background

Substance abuse among adolescents (13 to 18 years old) is a serious and growing problem. It is important to identify effective treatments for those who are opioid-dependent. The most common drugs used by young people worldwide are cannabis and inhalants. Psychostimulants (ecstasy and amphetamines), cocaine, LSD, heroin and other opioids are also used. Many adolescents who use heroin start by snorting it but some progress to injection. Heroin is used sporadically by the majority who use it, but it can become an addictive disorder. In adults, pharmacotherapy is a necessary and acceptable part of effective treatment for opioid dependence. Among adolescents, medications have been used infrequently and a choice has to be made between detoxification and maintenance treatment. Among maintenance treatment methadone and buprenorphine are the most frequently used drugs. Methadone needs daily doses, while LAAM (levomethadyl acetate hydrochloride) must be taken every two or three days. LAAM has been withdrawn from the market because of concerns about life-threatening effects on the heart .

Psychosocial interventions are interventions that use psychological or social strategy to achieve a therapeutic benefit in inpatient. The most common used approaches are: Cognitive-behavioural therapy,methods based on the assumption that since substance abuse among adolescents is a learned behaviour it can be unlearned as well; contingency management ,which uses reinforcement and punishment contingencies to enhance motivation: family therapy which is based on the conceptualisation that adolescent substance abuse stem from maladaptive family interactions; drug counselling which includes a strong emphasis on abstinence, assistance with social, family and legal problems. It focuses on behaviours and external events rather than intrapsychic processes; therapeutic community and motivational approach which rather than confront the patient's resistance to abstinence in a direct and sometimes aggressive manner, "rolls with resistance". At he same time, he tries to help the patient develop more self-motivation to stop using via specified techniques

Study characteristics

The review authors searched the literature and identified two controlled trials from the USA that involved 187 heroin addicts, aged 14 to 21 years; the participants were treated as outpatients. One study of 37 participants compared methadone with levo-alpha-acetylmethadol (LAAM) for maintenance treatment. After 16 weeks of maintenance treatment the adolescents were detoxified. The second trial of 150 adolescents compared buprenorphine and naloxone as maintenance treatment for nine weeks followed by tapered doses for up to 12 weeks with buprenorphine detoxification over 14 days.

Key results

In the first trial methadone and LAAM led to similar improvements in social functioning. No side effects were reported.

In the second trial the maintenance treatment seemed to be more effective in retaining patients in treatment but not in reducing the use of drugs of abuse. At one-year follow-up, self reported opioid use was clearly less in the maintenance group and more adolescents were enrolled in other addiction programmes. The most common side effect in both groups was headache. No participants left the study because of side effects.

It is difficult to draw conclusions about the use of maintenance pharmacological interventions from only two trials. Conducting trials with young people may be difficult for both practical and ethical reasons.

Quality of the evidence

This review was limited by the very low number of trials retrieved. The quality of the evidence was very low for the comparison between methadone and LAAM and low for the comparison between buprenorphine detoxification and buprenorphine maintenance. The evidence is current to January 2014.