First there was the bottle of opioid cough medicine he chugged when he was 13 or 14. Then the pills prescribed to his father for chronic pain. A few here and there weren't missed. Soon he was buying his own, but that got expensive for a middle-class boy from outside of Harrisburg. So he found a high that was both cheaper and stronger
"By the time I was 17, 18," Nelson Abbott said, "I graduated to heroin."
He tried to stop many times, both by going cold-turkey and tapering off the drugs, but he hated the withdrawal pains and he wasn't really ready to quit. Therapy didn't work out, either. But then his best friend overdosed and died. When Abbott's parents checked him into the Caron Treatment Center in Berks County, he didn't fight.
But he was surprised. At Caron, he was started on monthly shots of naltrexone, a drug for people dependent on opioids or alcohol that cuts cravings, while also blocking how these substances affect the brain. With this extra help, Abbott found he could focus on his recovery.
"I wasn't sitting there thinking about getting high all the time," said Abbott, now 23. "I was able to clear my brain and do some work."
Medication-assisted treatment (MAT) includes medicine such as naltrexone or methadone as an adjunct to therapy, which might include counseling and 12-step programs. It is not a new concept by any means. It's been around long enough to be shown in numerous studies to be a far more reliable route to recovery than therapy or medication alone. But with fatal opioid overdoses hitting historic levels, MAT is getting more attention – even for teens and young adults.
For people age 24 and under, opioid overdoses increased more than 540 percent from 1999 to 2016, according to data from the U.S. Centers for Disease Control and Prevention. Overall, opioid use disorder in this age group, especially those age 18 to 24, has skyrocketed.
Yet for a variety of reasons, MAT is not reaching many of the young people who might benefit from it.
‘I was going to die’
Some people don't think you're really in recovery if you're taking a drug.
Nick Gettel's opioid use put him in inpatient drug treatment at Caron at age 19. He stayed drug-free for six years. But depression and anxiety led him to relapse. He found the second time getting clean much harder.
"I wanted to get sober more than anything in the world, but I just could not get my feet back underneath me," said Gettel, who lives outside Reading.
He'd always been against MAT; like others in 12-step programs, he didn't regard it as really being sober. But after an overdose landed him in the hospital, a doctor he trusted suggested buprenorphine.
"I reached a point where I was willing to try anything. I figured, what the hell, I was going to die. I might as well give it a try."
Change comes slowly
Deni Carise is chief scientific officer for Recovery Centers of America, which recently opened a young-adult program on its Devon campus. In the past, she said, it usually took people years of drug use to develop a serious addiction.
"It was really unusual to see someone coming to treatment who said, 'I just started doing drugs six months ago. I'm addicted to heroin.' That was rare. Now it's not," Carise said.
Despite the evidence supporting MAT as a proven way to help prevent relapse, it remains controversial, especially for younger people.
It rubs some people the wrong way to treat an opioid addiction with another opioid such as buprenorphine, the only MAT drug that has been approved for teens younger than 18. MAT opioids, too, can be abused, and even if used properly, they may need to be continued indefinitely.
Access is another factor. Buprenorphine requires a special certification to prescribe, and only a limited number of doctors have it.
Confronted with rising youth opioid use, the American Academy of Pediatrics urged its members nearly two years ago to consider MAT for their adolescent and young adult patients and to get the training to prescribe buprenorphine.
But change has been slow. Nationally, only about 1 percent of pediatricians can prescribe buprenorphine, and uptake among doctors who treat adults isn't much higher.
One national study by researchers from Boston Medical Center and the medical schools of Boston University and Harvard found that only about a quarter of commercially insured youths with opioid use disorder were prescribed naltrexone (which is not an opioid) or buprenorphine within six months of diagnosis.
George Woody, a Penn psychiatry professor, found young opioid users who detoxed and then were given buprenorphine and counseling for 12 weeks were more likely to refrain from illicit drug use and stuck with therapy longer than patients who had counseling alone after detox. Other studies have produced similar findings.
"If a kid has diabetes, you don't withhold diabetes medications and rely on exercise and diet," Woody said. "I think the same thing applies to opioids."
‘A chaotic population’
But the medicines aren't cures. Patients of any age need to work on recovery every day, which for many can mean learning an entirely new way of life. They most likely will be advised to regularly attend 12-step program meetings, follow the guidance of a counselor or 12-step sponsor, and possibly even develop a whole new sober social circle. That can be especially difficult for young people. Even without substance abuse issues, teens and young adults may still be developing impulse control, and may rebel against any kind of authority. Young opioid users often have other mental-health issues, and many abuse other substances, as well.
"They are a chaotic population," said Marc Fishman, an assistant professor of psychiatry at Johns Hopkins University School of Medicine and medical director of the Maryland Treatment Centers and Mountain Manor Treatment in Baltimore. "They [think they] are invincible. They're not well-engaged in treatment of any kind."
Fishman said he believes all opioid use disorder patients, regardless of age, should be on a MAT protocol for relapse prevention. He said 80 percent of his patients use MAT. But even with medication, only about half of opioid users in recovery stick with their treatment after six months, research indicates, and the rate is even less for young patients.
Yet that looks good compared with how patients do without the medication, he said. Overall, their relapse rate 30 days after detox is 80 to 90 percent.
‘A handful’ of patients
Terri Randall, a Children's Hospital of Philadelphia psychiatrist, strives to get families involved in the treatment process. She has used MAT with "a handful" of her teenage patients.
A strong commitment is required for this treatment. Buprenorphine, in the forms it is usually prescribed, carries a lower risk of abuse, and skipping a dose does not send patients into withdrawal but it is meant to be taken as directed. Randall said she insists her MAT patients "come to their appointments, use the medication as prescribed – not lose it or run out early – and be involved in treatment." Many teens and their families find it hard to meet those requirements, she said. Plenty of kids have trouble following rules, and addiction does nothing to improve that.
At Gaudenzia, a large regional treatment program, naltrexone is used often with young adults. But president and CEO Michael Harle said MAT hasn't been tested enough to be used with adolescents. He is worried that the push for more MAT may be an attempt to find a quick solution to a complex disease, one in which most doctors have little training.
"I'm not all excited about the pediatricians being able to get us out of this problem when they shouldn't have been giving OxyContin to a 17-year-old in the first place," said Harle, who is not a physician, but has been in the drug-treatment industry for 45 years.
There are shortages of all kinds of drug treatment, especially for adolescents, and primary-care doctors – even the ones knowledgeable about addiction – don't have the time to provide all the services themselves, Harle said.
Joseph Garbely, Caron's medical director, said his facility isn't using MAT for adolescents because "we're not seeing heroin addicts at that age."
Regardless of the patient's age, "I always say MAT does not stand for medication as treatment," he said. "You have to have treatment for the medication to assist."
But Garbely said his goal is for all Caron's adult patients with opioid use disorder to be on MAT; about 62 percent, including young adults, are on the protocol now, he said.
"Heroin or a substance like fentanyl calls their name very loudly," Garbely said. "The brain needs time to reset and allow natural rewards to reward that person again. We've got to get them to that point."
Nick Gettel, now 27, is still reclaiming his life. MAT and a 12-step program are helping. An avid fisherman, he's working as an outfitter and thinking about going back to college.
To other young people struggling with opioids, he says keep an open mind. "I would like to be part of the changing narrative around MAT," Gettel said. "I think it will save lives."
Which medicines are used in MAT?
Medication-assisted treatment, or MAT, has been shown in studies to give the best chance for lasting recovery from addiction. Three main types of medicines may be used; in all cases, experts agree that counseling to help address the psychosocial issues of addiction is essential, as well.
Naltrexone is an opioid antagonist, meaning that it is not an opioid, but it blocks receptors in the brain that are responsible for the euphoric and pain-relieving effects of opioid drugs. It also curbs opioid cravings, and is sometimes prescribed for people with alcoholism. If it is taken by people who still have opioids in their system, it will result in immediate and painful withdrawal. It is often prescribed as Vivitrol, the brand name of an extended-release formulation. Administered by monthly injection, Vivitrol is often viewed as preferable to the daily pill, which requires more patient compliance. Naltrexone has FDA approval for patients 18 and older. The average retail price of Vivitrol is about $1,670 a dose, according to GoodRx.com. The average retail price of 30 pills is $111.
Methadone is a medically administered opioid that has been used for decades to help people stay out of active heroin addiction. Considered an opioid agonist – meaning it acts on the brain's opioid receptors like any other opioid drug — it prevents excruciating withdrawal symptoms without the euphoric effects of stronger opioids when taken as directed. Highly regulated, it requires daily visits to a methadone-dispensing clinic, some of which also offer on-site drug counseling. Methadone is generally limited to ages 18 and up, but exceptions can be made for younger teenagers who have relapsed twice in one year and who have obtained parental permission. The average retail price is about $53 for 120 pills.
Buprenorphine is considered a partial agonist, that works similarly to methadone as a replacement medication. Also like methadone, it is an opioid and can be abused. The brand name Suboxone includes both buprenorphine and naloxone, the rescue medicine that revives people experiencing an overdose. Added to buprenorphine, naloxone makes abusing the medication more difficult. Buprenorphine is sometimes used in the opioid detox process – the first few days of withdrawal – as well as maintenance. It is approved by the FDA for patients 16 or older. It is most commonly prescribed as a daily medication by doctors with special certification. An extended-release form has also gotten FDA approval. The average retail of the generic form of Suboxone is about $131 for 14 tablets.