A case of severe opioid and methamphetamine use disorder in a 14 year old.

We present the case of a 14-year-old who established care at our primary care clinic after hospitalization for unintentional fentanyl overdose. They were diagnosed with severe opioid use disorder (OUD) and stimulant use disorder (StUD) and initiated buprenorphine while inpatient. They were then transitioned to the only known outpatient primary care clinic in her county who was actively providing medications for opioid use disorder (MOUD) in adolescents.At the first visit, they reported a history of 20 overdoses, struggling with adherence to buprenorphine and continued opioid cravings. An overdose safety plan was reviewed with them and their parent including providing them naloxone kits, fentanyl test strips, and education handout sheets. Due to their significant overdose history and adherence challenges with sublingual buprenorphine, they were started on long-acting injectable buprenorphine (LAIB) with weekly provider visits and urine toxicology screening. In collaboration with the treatment team, they initiated behavioral treatment with contingency management (CM), with incentives for appointment completion, expected urine results, and successful medication administration. Over the next 19 months, and to date, they have increasingly engaged with care and have remained abstinent. LAIB may be an appealing alternative for adolescents with OUD to improve adherence and reduce risk of recurrent use and overdose. Adjunctive treatment with CM may improve retention in MOUD and have the benefit of treating StUD. There is a need for further research to explore innovative, community-based treatment for youth with OUD.

Neurophysiological correlates of visuo-motor learning through mental and physical practice.

We have previously shown that mental rehearsal can replace up to 75% of physical practice for learning a visuomotor task (Allami, Paulignan, Brovelli, & Boussaoud, (2008). Experimental Brain Research, 184, 105-113). Presumably, mental rehearsal must induce brain changes that facilitate motor learning. We tested this hypothesis by recording scalp electroencephalographic activity (EEG) in two groups of subjects. In one group, subjects executed a reach to grasp task for 240 trials. In the second group, subjects learned the task through a combination of mental rehearsal for the initial 180 trials followed by the execution of 60 trials. Thus, one group physically executed the task for 240 trials, the other only for 60 trials. Amplitudes and latencies of event-related potentials (ERPs) were compared across groups at different stages during learning. We found that ERP activity increases dramatically with training and reaches the same amplitude over the premotor regions in the two groups, despite large differences in physically executed trials. These findings suggest that during mental rehearsal, neuronal changes occur in the motor networks that make physical practice after mental rehearsal more effective in configuring functional networks for skilful behaviour.

Visuo-motor learning with combination of different rates of motor imagery and physical practice.

Sports psychology suggests that mental rehearsal facilitates physical practice in athletes and clinical rehabilitation attempts to use mental rehearsal to restore motor function in hemiplegic patients. Our aim was to examine whether mental rehearsal is equivalent to physical learning, and to determine the optimal proportions of real execution and rehearsal. Subjects were asked to grasp an object and insert it into an adapted slot. One group (G0) practiced the task only by physical execution (240 trials); three groups imagined performing the task in different rates of trials (25%, G25; 50%, G50; 75%, G75), and physically executed movements for the remaining trials; a fourth, control group imagined a visual rotation task in 75% of the trials and then performed the same motor task as the others groups. Movement time (MT) was compared for the first and last physical trials, together with other key trials, across groups. All groups learned, suggesting that mental rehearsal is equivalent to physical motor learning. More importantly, when subjects rehearsed the task for large numbers of trials (G50 and G75), the MT of the first executed trial was significantly shorter than the first executed trial in the physical group (G0), indicating that mental practice is better than no practice at all. Comparison of the first executed trial in G25, G50 and G75 with the corresponding trials in G0 (61, 121 and 181 trials), showed equivalence between mental and physical practice. At the end of training, the performance was much better with high rates of mental practice (G50/G75) compared to physical practice alone (G0), especially when the task was difficult. These findings confirm that mental rehearsal can be beneficial for motor learning and suggest that imagery might be used to supplement or partly replace physical practice in clinical rehabilitation.