Long-Term Agonist and Antagonist Therapy for Adolescent Opioid Dependence: A Description of Two Cases

By Ranjan, Rajeev; Pattanayak, Raman et al. | Indian Journal of Psychological Medicine, October-December 2014 | Go to article overview

Long-Term Agonist and Antagonist Therapy for Adolescent Opioid Dependence: A Description of Two Cases


Ranjan, Rajeev, Pattanayak, Raman, Dhawan, Anju, Indian Journal of Psychological Medicine


Byline: Rajeev. Ranjan, Raman. Pattanayak, Anju. Dhawan

Adolescents constitute only a small percentage of treatment seekers in drug dependence treatment settings. Little research evidence is available for pharmacological treatment of adolescent opioid dependence and no prior case report is available from India. We discuss two adolescent patients with opioid (heroin) dependence visiting a tertiary care center who have been stabilized on agonist (sublingual buprenorphine-naloxone) and antagonist (oral naltrexone) respectively for a substantial period of time. A comprehensive management approach, including intensive psychosocial interventions and family involvement, was followed in addition to pharmacotherapies. More research is needed on the efficacy of pharmacological treatment in adolescent opioid users.

Introduction

Adolescents constitute only a small percentage of treatment seekers in drug dependence treatment settings (≤15 years: 0.4% and 16-20 years: 4.6%). [sup][1] Community surveys [sup][1],[2] suggest that tobacco, alcohol and cannabis are prevalent substances of abuse among Indian adolescents, but opioid use is quite uncommon in this age group (about 1 in 1000). Heroin use was seen in 3.3% of drug-using adolescents in contact with Nehru Yuva Kendras (grass-root level voluntary organization for youth) across the country. [sup][1] Potentially serious complications, e.g. sexual risks, violence and other high risk behaviors are associated with adolescent substance use, which may pose a significant public health issue.

The long-term pharmacotherapies for opioid dependence can be either in the form of an opioid agonist ( e.g. buprenorphine) or antagonist ( e.g. naltrexone) therapy. The use of pharmacotherapies, in conjunction with psychosocial support, is the mainstay of treatment of adult opioid users, [sup][3] but there is only a limited evidence base for their efficacy in adolescents with opioid dependence. Very few reports or studies are available till date on long-term buprenorphine maintenance for adolescent opioid users [sup][4],[5],[6],[7] and only one study has described the use of naltrexone (antagonist) in adolescent opioid dependence. [sup][8]

Buprenorphine is a partial agonist at mu-opioid receptor, which is used in low to moderate doses to enable the patient to abstain from the use of illicit opioids and prevent craving or withdrawals. It is available as sublingual (2 mg/4 mg) tablets administered under supervision of staff usually on a daily basis in view of their abuse liability. A take-home combination of sublingual buprenorphine-naloxone (4:1) is available which is ineffective by intravenous route, thereby minimizing the risk of abuse. Naltrexone is an opioid receptor antagonist which blocks the effects of opioids and prevents the positive reinforcement associated with the use of opioids. It is available in India as an oral tablet (50 mg). [sup][3]

No prior study or case report from India has described the use of agonist maintenance or antagonist therapy for adolescent opioid users. We discuss two adolescent patients with opioid (heroin) dependence visiting National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi for treatment, who were stablilized on Buprenorphine and Naltrexone respectively for a substantial period of time.

Case Reports

Case 1

Master A, 15 years old, studied up to 6 [sup]th std and belonged to a middle socio-economic status joint family living in a small town in the state of Uttar Pradesh (300 km from centre). He presented to Adolescent clinic, NDDTC, AIIMS with parents for the first time in January 2009 with chief complaints of the regular use of tobacco (both smokeless and smoking) for 8 years, occasional cannabis ( ganja ) use for 3 years and regular heroin ( smack ) use for 3 years. Heroin, the primary drug of use, was initiated at the age of 12 years out of curiosity with some of his friends and later, continued for its pleasurable effects. …

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