In the first two parts of this newsletter series, we reviewed the prevalence, screening and assessment of substance use disorders in Native American youth. In Part 3, we will review treatment for substance use disorders in Native American youth. Keeping in mind the population we are discussing, effective treatment for substance use disorders should ideally include school and community prevention programs, assessment for co-occurring mental health concerns, integration between primary care and behavioral health, and family based intervention with culturally informed treatments. Some therapeutic strategies that can be effective include: Harm Reduction vs. Abstinence, which focuses on patient-centered care that utilizes praise and rewards for desired behavior change (from family and treatment providers). If abstinence is desired, then setting a quit date is helpful. Simple behavior plans based on motivational interviewing can be a good place to start. Teens often benefit from substance use groups that offer support from others in a similar situation. Another outside the box idea is alternative peer groups which leads to having fun with peers without substance use (can be faith or culture-based vs social gatherings). It is imperative to have family involvement because it is much harder to obtain sobriety when family members are using and praise from family for small behavioral change can be motivating. It is important to reduce idle time without overscheduling. This can include active involvement in the community, spiritual activities, and exercise, with a focus on establishing a new identity independent of the substance use. For cannabis use, a harm reduction approach could be to advocate for a teen to delay daily use until adulthood.
Medication assisted treatment (MAT)can sometimes be an ancillary treatment for substance use treatment, in addition to substance recovery therapy. MAT can be considered in the following cases:
· Moderate to severe SUD
· Frequent substance use that leads to risky behaviors and/or interferes with schooling
· Substance use that leads to ER visits and/or hospitalization (for physical or mental health)
· Exacerbation of mood/anxiety symptoms due to substances
· Teens who have been unable to stop using on their own
· Adolescents who are motivated to quit and would like extra medical support/guidance
· Teens whose substance use impedes their ability to engage in and benefit from psychosocial therapies.
While there are several MAT options for adults, many with FDA approval, most MAT options for teens are off-label. Off-label use does not mean that a medication is dangerous for the intended population, but rather than there isn’t as much research about the use of MAT for teens compared to adults. Child and adolescent psychiatry often involves prescribing medications off-label in as safe a manner as possible with informed consent. Naltrexone, acamprosate, and disulfiram are FDA-approved MAT options for adults for alcohol use disorder but would be considered off-label for teens. Buprenorphine, methadone and naltrexone are FDA-approved MAT options for adults for opioid use disorders (OUD) but only buprenorphine is FDA approved for teens ages 16 and older. There are no FDA approved options for cannabis use disorder but n-acetyl cysteine (NAC) and gabapentin are non-FDA approved options for adults and teens. There are no FDA approved options for stimulant (cocaine, methamphetamine) use disorders but bupropion and mirtazapine are non-FDA approved options for adults and teens. Studies show that MAT for adolescents with serious OUDs reduces mortality and is associated with greater retention in care compared with therapy alone. Naloxone, which can rapidly reverse an opioid overdose, also plays an important role in reducing the mortality from OUDs and many middle and high schools are required to have doses of Narcan available and staff members to be trained on how to administer it.
Key takeaways from this series of newsletters includes the importance of screening early and routinely for substance use disorders in Native American adolescents, the importance of assessing for trauma and co-occurring mental health concerns, engaging family and community leads to more effective treatment and reviewing the role that MAT could potentially play in treatment. Please call the Vista Hill Native American SmartCare provider line at 888-987-0960 or refer families to our NASC Family Line at 888-660-6616 for specific case consultation.
Vista Hill Native American SmartCare was renewed by Indian Health Services!
We are excited to announce that NASC is extended for another year through September 2027. NASC is a behavioral health consultation program funded by IHS. We offer our services at no cost to participating organizations and providers. Our goal is to support tribal health organizations in ways that are responsive to the needs of their providers, teams, and communities. Our support includes psychiatric consultation and case discussion for providers, ongoing clinic consultation meetings, behavioral health trainings and education, care coordination, and connections to local behavioral health resources. Please reach out to us at nativeamerican.smartcare@vistahill.org to connect to our services.
AUTHOR:
Charmi Patel Rao MD, DFAACAP
Medical Director, Vista Hill Foundation
Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry