Statewide opioid prescriptions and the prevalence of adolescent opioid misuse in Ohio.

BACKGROUND: Little is known about the relationship between opioid prescribing practices and the prevalence of adolescent opioid misuse. OBJECTIVE: To examine the relationships between both opioid prescriptions filled by adolescents and adults and adolescents seeking treatment for opioid misuse in Ohio. METHODS: Analyses of large statewide databases from 2008 to 2012, including all 88 counties in Ohio. The Ohio Board of Pharmacy provided data regarding prescription opioids filled by adolescents (12-20 years, N = 50,030,820 doses) and adults (>20 years, N = 3,811,288,395 doses) by county of residence. The Ohio Department of Mental Health and Drug Addiction Services provided annual treatment admissions for adolescent opioid misuse by county of residence (N = 6446). RESULTS: Adults filled prescriptions for nearly 100 oral opioid doses per capita annually, while adolescents filled prescriptions for approximately 7 oral opioid doses per capita annually. In Bayesian Poisson modeling examining the effect of annual adult per capita dose on adolescent treatment admissions, adjusted for annual adolescent per capita dose and year, an increase of one in the annual adult per capita opioid dose resulted in an increase of 1.3% (RR = 1.013, 95% HPD CI = [1.008, 1.017]) in the rate of adolescent treatment admissions. This association corresponds to a 99.99% chance that the adolescent treatment rate increases when the annual per capita adult dose is increased by one unit. CONCLUSION: The amount of opioids filled by adults in Ohio, although relatively stable from 2008 to 2012, is approximately 13 times that filled by adolescents and is significantly associated with adolescents seeking treatment for opioid misuse. Efforts to decrease adolescent opioid misuse should also focus on reducing adult opioid prescriptions.

Cutaneous alternariosis in an adolescent patient.

Cutaneous alternariosis is a rare infection typically observed only in immunocompromised adults, but we report here that the infection can occur in apparently healthy adolescents. We saw a clinically healthy adolescent boy who presented with cutaneous alternariosis 6 weeks after suffering a laceration to his right ankle. Treatment with itraconazole resulted in significant improvement after 1 month.

Immunity to Hepatitis B is Undetectable in the Majority of Adolescents and Young Adults Seeking Outpatient Medication Treatment for Opioid Use Disorder.

OBJECTIVE: To assess prevalence and predictors of hepatitis B immune status among adolescents and young adults (AYA) seeking outpatient medication treatment for opioid use disorder (MOUD). STUDY DESIGN: A retrospective medical chart review was conducted of AYA seeking MOUD between January 1, 2013 through December 31, 2015. Inclusion criteria included: diagnosis of opioid use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; received hepatitis serologic testing; and no evidence of prior or current hepatitis B infection. Hepatitis B immunization initiation was defined as a record of at least 1 hepatitis B vaccination; while receipt of at least 3 vaccinations indicated immunization completion. The presence of hepatitis B surface antibody (anti-HBs) was the primary outcome measure. RESULTS: Of the 193 patients that met eligibility criteria, the presence of anti-HBs was evident in 62 (32.1%). Hepatitis B immunization initiation and completion before presenting for MOUD was documented in 102 (52.9%) and 84 (43.5%). In multivariable logistic regression modeling, hepatitis B immunization initiation after infancy was associated with increased odds of having protective anti-HBs relative to immunization series initiation in infancy (OR 8.96, 95% CI 1.57-51.05). Completion of hepatitis B immunization series after infancy as compared to completion in infancy also increased the odds of protective anti-HBs (OR, 6.68, 95% CI 2.10-21.24). CONCLUSIONS: Rates of immunity to hepatitis B were low in AYA seeking MOUD. It is important to immunize patients seeking MOUD for hepatitis B and follow up with checks for seroconversion.

Multifaceted Quality Improvement Initiative Improves Retention in Treatment for Youth with Opioid Use Disorder.

INTRODUCTION: There is a critical need to develop interventions that help adolescents and young adults with opioid use disorders (OUDs) connect with, engage in, and remain consistent with the treatment given that patients who develop long-term OUDs experience long-term medical and mental health sequelae. METHODS: We implemented quality improvement (QI) processes to increase early engagement and 6-month retention within a medication-assisted treatment clinic for youth with OUDs. QI interventions included motivational interviewing (MI) staff training, implementation of reduced initial treatment requirements, reduction of access barriers to treatment, and enhancement of patient treatment motivation. We monitored the impact of the interventions via a p-chart. RESULTS: A statistically significant shift was seen in the 6-month retention rate following both MI staff training and the use of reduced initial treatment requirements. Second visit return rate also experienced a statistically significant shift following transportation support and an incentive program. DISCUSSION: Our data demonstrate that following MI staff training, reduced initial clinic requirements, transportation support, and utilization of an incentive program, the second visit return rate, and 6-month retention rate improved within an outpatient medication-assisted treatment clinic for youth with OUDs.

Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison.

PURPOSE: Rural young adults experience greater unmet need for mental health (MH) and alcohol or drug (AOD) treatment and lower health insurance coverage than urban residents. It is unknown whether Affordable Care Act (ACA) reforms in 2010 (dependent coverage extended to age 26) or 2014 (Medicaid expansion) closed rural/urban gaps in insurance and treatment. The present study compared changes in rates of health insurance, MH treatment, and AOD treatment for rural and urban young adults over a period of ACA reforms. METHODS: Young adult participants (18-25 years) in the National Survey on Drug Use and Health (2008-2014) with past-year psychological distress or AOD abuse were included. Difference-in-differences logistic regression models estimated rural/urban differences in insurance, MH, and AOD treatment pre- versus post-ACA reforms. Analyses adjusted for gender, race, marital status, and health status. RESULTS: Among 39,482 young adults with psychological distress or AOD, adjusted insurance rates increased from 72.0% to 81.9% (2008-2014), but a significant rural/urban difference (5.1%) remained in 2014 (P < .05). Among young adults with psychological distress (n = 23,470), MH treatment rates increased following 2010 reforms from 30.2% to 33.0%, but gains did not continue through 2014. Differences in MH treatment over time did not vary by rural/urban status and there were no significant changes in AOD treatment for either group. CONCLUSIONS: Although rates of insurance increased for all young adults, a significant rural/urban difference persisted in 2014. Meaningful increases in MH and AOD treatment may require targeted efforts to reduce noninsurance barriers to treatment.

Severe Sepsis and Acute Myocardial Dysfunction in an Adolescent with Chlamydia Trachomatis Pelvic Inflammatory Disease: A Case Report.

BACKGROUND: Although generally asymptomatic, severe Chlamydia trachomatis (C. trachomatis) infections have been documented. C. trachomatis has been associated with myocarditis as well as sepsis. CASE: A 19-year-old girl with type 1 diabetes mellitus developed sudden-onset mental status change and shock after resolution of diabetic ketoacidosis. Abdominal and pelvic imaging showed uterine and adnexal inflammation, and pelvic examination confirmed a diagnosis of pelvic inflammatory disease. The patient was intubated, required vasopressor support, and developed severe biventricular myocardial dysfunction. Infectious myocarditis workup was negative. Nucleic acid amplification testing from vaginal discharge was positive for C. trachomatis and Trichomonas vaginalis and negative for Neisseria gonorrhoeae. SUMMARY AND CONCLUSION: C. trachomatis should be considered in the workup of septic shock, particularly in populations at high risk for sexually transmitted infections.

Vulvar Fibroepithelial Polyps in a Female Adolescent: A Case Report.

BACKGROUND: Fibroepithelial polyps (FEPs) are benign tumors, of possibly hormone-dependent nature, found in the vulvovaginal region of women of reproductive age. CASE: A 15-year-old adolescent girl, receiving hormonal contraceptive therapy, who presented with multiple vulvar masses with histopathology consistent with FEP. SUMMARY AND CONCLUSION: The spectrum of the morphology of FEPs might make their diagnosis challenging. We describe a rare presentation of vulvar FEPs in an adolescent girl receiving hormonal contraceptive therapy.

Sexual victimization among African American adolescent females: examination of the reliability and validity of the Sexual Experiences Survey.

Adolescent females are disproportionately represented among reported cases of sexual victimization. Because sexual victimization is associated with an array of negative sequelae (e.g., depression, alcohol abuse), psychometrically sound instruments are urgently needed to assess sexual victimization or coercion. The investigation conducts a preliminary analysis of the reliability and validity of the Sexual Experiences Survey (SES) for a sample drawn from a high-risk population-African American adolescent females. Our analyses indicate good internal consistency for the SES with this sample. Convergent validity is demonstrated. Specifically, scores on the SES are associated with significantly lower levels of self-esteem and mastery, higher levels of depression, lower levels of family cohesion, higher levels of family conflict, and higher levels of using alcohol and being a smoker. Preliminary support for discriminant validity is also obtained. This study is a stepping stone for future investigations into the psychometric evaluation of the SES.

Differences in psychological health and family dysfunction by sexual victimization type in a clinical sample of African American adolescent women.

We examined levels of sexual victimization among a sample of 249 14- to 19-year-old African American adolescent women. Victimization was common: 32.1% reported having been raped, 33.7% had experienced sexual coercion, and 10.8% reported an attempted rape. Only 23.4% had never been victimized. We investigated whether levels of psychological health and family dysfunction varied as a function of the type of sexual victimization. Girls who had been raped had lower levels of self-esteem and mastery and higher levels of depression compared to girls who reported no sexual victimization. Significantly higher levels of family cohesion and significantly lower levels of family support were reported by girls who had been raped versus girls who reported no sexual victimization. These findings are a starting point for future studies by providing evidence that levels of mental health and family dysfunction vary by the type of sexual victimization experienced.

Delayed Ego Strength Development in Opioid Dependent Adolescents and Young Adults.

Objective. To evaluate ego strengths, in the context of Erikson's framework, among adolescents and young adults diagnosed with opioid dependence as compared to non-drug using youth. Methods. Opioid dependent (n = 51) and non-drug using control (n = 31) youth completed the self-administered Psychosocial Inventory of Ego Strengths (PIES). The PIES assesses development in the framework of Erikson's ego strength stages. Multivariate linear regression modeling assessed the independent association of the primary covariate (opioid dependent versus control) as well as potential confounding variables (e.g., psychiatric comorbidities, intelligence) with total PIES score. Results. Mean total PIES score was significantly lower in opioid dependent youth (231.65 ± 30.39 opioid dependent versus 270.67 ± 30.06 control; p < 0.01). Evaluation of the PIES subscores found significant (p < 0.05) delays in all ego strength areas (hope, will, purpose, competence, fidelity, love, care, and wisdom). When adjusting for potential confounders, opioid dependence remained a significant (p < 0.001) independent predictor of total PIES score. Conclusion. Adolescents with opioid dependence demonstrated significant delays in ego strength development. A treatment approach acknowledging this delay may be needed in the counseling and treatment of adolescents with opioid dependence.

A retrospective study of retention of opioid-dependent adolescents and young adults in an outpatient buprenorphine/naloxone clinic.

OBJECTIVES: Opioid abuse and dependence rates continue to rise among U.S. adolescents. Medication-assisted treatment with buprenorphine/naloxone (BUP/NAL) has been shown to be effective up to 12 weeks. Few data are available regarding extended treatment outcomes. The objective of this study was to describe 1-year retention and compliance of a specific pediatric, outpatient BUP/NAL treatment program for opioid-dependent adolescents and young adults. METHODS: Retrospective chart review was conducted of all opioid-dependent adolescents and young adults (N = 103) who sought treatment from January 12, 2010, to January 9, 2011. Participants were classified as prescription opioid-dependent or combined heroin/prescription opioid-dependent. Opioid abstinence and BUP/NAL compliance were assessed by urine drug screen (UDS) at each visit. A Kaplan-Meier curve was fit to describe patients' retention time over 1 year. RESULTS: Mean age was 19.2 ± 1.6 years, 50.5% male, 98.1% white non-Hispanic, and 31.9% prescription opioid-dependent. Overall rates of opioid abstinence and BUP/NAL compliance were high (85.2% and 86.6%, respectively). Seventy-five percent of patients returned for a second visit. Patient retention was 45% at 60 days and 9% at 1 year. Female sex (P < 0.05), negative UDS for opioids (P < 0.001) or tetrahydrocannabinol (P < 0.001), and positive UDS for BUP/NAL (P < 0.001) were associated with longer retention time. CONCLUSIONS: Although patient retention was the largest barrier to success, a subset of opioid-dependent adolescents and young adults achieved long-term sobriety in our specific clinic program with continued outpatient BUP/NAL therapy. Retention correlated with UDS negative for opioids, negative for tetrahydrocannabinol, and positive for BUP/NAL.

Receipt of prescribed controlled substances by adolescents and young adults prior to presenting for opiate dependence treatment.

Purpose. The objective of this study was to document the number of controlled substance prescriptions filled by adolescents and young adult patients in the 2 years prior to presentation for opiate dependence treatment. Methods. Opiate-dependent youth (N = 125) presenting to our Medication-Assisted Treatment for Addiction program from January 1, 2008 to June 30, 2010 were identified via electronic medical record. Subjects were further classified based on their opiate use as dependent to heroin-only, prescription (Rx) opiate-only, or combined heroin + Rx opiate only. The Ohio Automated Rx Reporting System (OARRS) was used to identify each subject's controlled substance prescription history. Negative binomial regression was used to examine the relationships between patient characteristics and the total number of prescriptions filled. Results. Twenty-five percent of subjects had filled ≥6 prescriptions, and 15% had filled ≥11 prescriptions. The mean number of prescriptions filled was 5 (range: 0-59). Thirteen percent had filled ≥6 opiate/narcotic prescriptions, and 8% had filled ≥11 prescriptions. Conclusions. A subset of opiate-dependent youth had filled multiple opiate/narcotic prescriptions providing some evidence that physician-provided prescriptions may be a source of opiate abuse or diversion for a minority of opiate-dependent adolescents and young adults.

Adolescents, IUDs, PID, and Enterococcus: a report of two cases.

BACKGROUND: Intrauterine devices are being used more frequently in adolescents requiring long-term reversible contraception. This population of sexually active adolescents is also at risk for pelvic inflammatory disease (PID). CASES: We report two cases of PID in adolescents with IUDs in place, both of whom had symptom resolution with removal of their IUDs, and in whom both IUDs were culture positive for Enterococcus. SUMMARY AND CONCLUSION: Whether these results indicate vaginal contamination or a causative agent for PID is unclear, but one should consider alternative causes of PID in adolescents with IUDs, particularly in those with prolonged symptoms.

Phthirus pubis as a predictor for chlamydia infections in adolescents.

BACKGROUND: Providers not skilled in the evaluation of sexually transmitted infections (STIs) may treat pubic lice infestation without considering other organisms. This study compared the rate of chlamydia and gonorrhea infections in adolescents with and without pubic lice. GOAL: The goals of the study were to compare the rate of chlamydia and gonorrhea infections between adolescents infested or not infested with pubic lice and to evaluate lice infestation as a predictor for concurrent chlamydia or gonorrhea infection. STUDY DESIGN: A retrospective chart review of sexually active adolescents at a juvenile detention center in the Midwest between July 1998 and June 2000 was conducted. The index group was 62 adolescents with pubic lice screened for concurrent STIs. The control group included 201 randomly selected adolescents without pubic lice who underwent STI screening. RESULTS: In the entire study population (263 subjects), there were 60 cases of chlamydia (23% of all subjects) and 29 cases of gonorrhea (11%). Neisseria gonorrhoeae infection was present in 18% of index subjects and 9% of controls. Chlamydia trachomatis infection was noted in 39% of index subjects and 18% of controls. Pubic lice infestation predicted C trachomatis infection (odds ratio = 3.31). CONCLUSIONS: Pubic lice infestation is predictive of a concurrent C trachomatis infection in this population. Adolescents infested with pubic lice should be screened for other STIs, including chlamydia and gonorrhea.