Low use of buprenorphine in youth

A recent large-scale analysis from health insurance claims found that under one-quarter of adolescents and young adults with opioid use disorder (OUD) received either buprenorphine or naltrexone (see opioids in youth low use bupren jamapeds2017 in the “chronic pain” folder in the dropbox, or doi:10.1001/jamapediatrics.2017.0745)

Details:

-- retrospective cohort study based on reviewed insurance claims of 9.7 million youth aged 13 to 25; they identified 20,822 with a diagnosis of OUD 2001 to 2014, and matched them with those receiving prescriptions for either buprenorphine or naltrexone within 6 months of the OUD diagnosis. They used the national commercial insurance database Optum, which has inpatient, outpatient, emergency dept and pharmacy claims from large commercial health insurer databases, with members in all 50 states.

-- In those with OUD: 66% male, 82% non-Hispanic white/6% Hispanic/2% non-Hispanic black or Asian, mean age 21 at 1^st diagnosis, 68% urban, neighborhood educational level was rated high 67%/high-middle 20%/low-middle 10%/low 3%, neighborhood poverty level was rated high 6%/high-middle 15%/low-middle 25%/low 54%, region South 42%/Midwest 26%/West 17%/Northeast 15%

-- diagnosis of OUD: 3% age 13 to 15/9% age 16 to 17/35% age 18 to 20/53% age 21 to 25

Results:

-- the rate of OUD diagnoses increased from 0.26/100,000 person-years in 2001 to 1.51/100,000 person-years in 2014, a 6-fold increase

-- overall, 26.8% of the youth were dispensed buprenorphine/naltrexone within 6 months of OUD diagnosis, with 89% being buprenorphine and 11% naltrexone (the relative use of naltrexone has increased in the last 5 years)

-- medication prescriptions increased from 3% in 2002 (year buprenorphine introduced) to 31.8% in 2009, then decreased to 27.5% in 2014;

-- in multivariable analysis (controlling for sex, age at OUD diagnosis, race/ethnicity, geographical region, neighborhood educational level and neighborhood poverty level), adjusted probability of receiving buprenorphine/naltrexone:

    -- age 13 to 15: 1.4%

    -- age 16 to 17: 9.7%

    -- age 18 to 20: 22%

    -- age 21 to 25: 30.5%

        -- the above trend had p<0.001 for the difference

    -- females: 20% vs 24% of males (p<0.001)

    -- 14.8% non-Hispanic black vs 20% Hispanic vs 23.1 % non-Hispanic white (p<0.001)

        ​--so, lower likelihood of treatment in younger people, females, non-Hispanic black or Hispanic youth

Commentary:

-- we are all aware of the huge medical and social issues associated with OUD, including mortality (now surpassing that of motor vehicle accidents), diseases (increases in hepatitis C, HIV), mortality, costs to the system (ER and hospital use) and huge social disruptions

--a prior blog highlighted the tripling of opioid deaths from 1999 to 2014: http://gmodestmedblogs.blogspot.com/2017/01/increasing-deaths-from-opioids_13.html

--and another specifically reported youth substance use and trends in 2013 (http://gmodestmedblogs.blogspot.com/2015/03/substance-use-and-mental-health-in.html  )

-- as noted in the current article, prior studies have found that 2/3 of people in treatment for OUD began drugs before age 25, and 1/3 before age 18, though only 1 in 12 adolescents and young adults are in treatment

-- there have been some important deficiencies in the approach within pediatrics: the American Academy of Pediatrics did not come out with a policy statement recommending the use of pharmacotherapy for OUD until August 2016, though buprenorphine was approved for those >15yo in 2003; and only 1% of the physicians certified to prescribe buprenorphine are pediatricians

-- one striking incongruity is the rather unfortunate situation where clinicians can prescribe opiates without specific training, yet they need formal training to prescribe the safest opiate, buprenorphine, one that has a pretty remarkable track record in helping people with OUD

-- there was an interesting discordance in the above study between the neighborhood educational level, with 87% being high or high-middle, though poverty levels was only 21% in the high or high-middle range. Not sure what to make of that, though it should be noted that these data were from geographical tracks and not granular data from individuals with OUD. Also the race/ethnicity of the patients is based on the neighborhood characteristics and surname analysis, without the actual patients' data

-- this study only looked at young patients using buprenorphine or naltrexone within 6 months of their initial encounter for OUD. There are some unanswered questions (at least to me) which make it hard to put this in perspective: though only 1/4 of the youth were on these meds at 6 months, how many older patients are on the meds within 6 months of diagnosis??? (I certainly see many adults you do not get into treatment for decades, and then do really well....)  It may well be that the youth with OUD are not ready to get off the opiates that soon after starting. It would be interesting to look at the number in treatment after 1 or more years after starting.

--it is a bit unnerving that the total proportion of youth dispensed buprenorphine/naltrexone peaked in 2009 (32%) and has trended a bit down since (to 28%), given the increasing mortality from opiates, despite the increased numbers of insured people under the Affordable Care Act (which unfortunately may change soon)

-- a prior blog reviewed data showing that even appropriate use of prescription opiates in teens is strongly associated with future opioid misuse, even among teens with low pre-opioid likelihood of developing OUD, see http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html   (ie, opioids even given after surgery in younger people seems to create the increased likelihood of OUD later in life)

-- http://gmodestmedblogs.blogspot.com/2017/06/opioidsx3-and-drug-company-shenanigans.html  raises concerns about naltrexone, given the very limited studies on it. The blog also comments on how the drug company is aggressively lobbying congress and specifically the trump administration to promote naltrexone, despite this paucity of scientific evidence (which the drug company seems not to be interested in pursuing)

so,

--this article highlights both this dramatic 6-fold increase in documented OUD in youth over the past 15 years (part of which may be our heightened awareness of the issue, but it is pretty clear that things are a whole lot worse), as well as the fact that such a small percentage of youth are involved in treatment.

-- but, I think part of the issue is national stigmatization of those with OUD, which may be responsible at least in part for requiring clinicians to have special training/licenses to prescribe buprenorphine (as opposed to naltrexone), despite its documented safety and effectiveness. This problem with buprenorphine is likely to be exacerbated by tom price, the head of Dept of Health and Human Services in the US, who is pushing for naltrexone, as noted in above blog. Removing constraints on prescribing buprenorphine would not only further legitimize its use but also make it much more available to patients in need

--and part of the problem is our medical culture, which abetted and fueled the current opioid crisis by pushing more aggressive treatment of pain in the 1990s (and this was fed into/strongly promoted by industry, and specifically Purdue, maker of oxycontin, and pusher of "pain as the fifth vital sign"). Yet now one area of the medical culture has played a role in minimizing aggressive OUD treatment (eg, the Am Acad of Pediatrics, not dealing with OUD for more than a 14 years after buprenoprphine became available despite the well-documented dramatic increases in opioid use in youth and its huge social/medical consequences).