adolescents constitute only a small percentage of treatment seekers in drug dependence treatment settings ( 15 years : 0.4% and 16 - 20 years : 4.6% ) .
community surveys suggest that tobacco , alcohol and cannabis are prevalent substances of abuse among indian adolescents , but opioid use is quite uncommon in this age group ( about 1 in 1000 ) .
heroin use was seen in 3.3% of drug - using adolescents in contact with nehru yuva kendras ( grass - root level voluntary organization for youth ) across the country .
potentially serious complications , e.g. sexual risks , violence and other high risk behaviors are associated with adolescent substance use , which may pose a significant public health issue .
the long - term pharmacotherapies for opioid dependence can be either in the form of an opioid agonist ( e.g. buprenorphine ) or antagonist ( e.g. naltrexone ) therapy .
the use of pharmacotherapies , in conjunction with psychosocial support , is the mainstay of treatment of adult opioid users , but there is only a limited evidence base for their efficacy in adolescents with opioid dependence .
very few reports or studies are available till date on long - term buprenorphine maintenance for adolescent opioid users and only one study has described the use of naltrexone ( antagonist ) in adolescent opioid dependence .
buprenorphine is a partial agonist at mu - opioid receptor , which is used in low to moderate doses to enable the patient to abstain from the use of illicit opioids and prevent craving or withdrawals .
it is available as sublingual ( 2 mg/4 mg ) tablets administered under supervision of staff usually on a daily basis in view of their abuse liability .
a take - home combination of sublingual buprenorphine - naloxone ( 4:1 ) is available which is ineffective by intravenous route , thereby minimizing the risk of abuse .
naltrexone is an opioid receptor antagonist which blocks the effects of opioids and prevents the positive reinforcement associated with the use of opioids .
no prior study or case report from india has described the use of agonist maintenance or antagonist therapy for adolescent opioid users .
we discuss two adolescent patients with opioid ( heroin ) dependence visiting national drug dependence treatment centre ( nddtc ) , all india institute of medical sciences ( aiims ) , new delhi for treatment , who were stablilized on buprenorphine and naltrexone respectively for a substantial period of time .
master a , 15 years old , studied up to 6 std and belonged to a middle socio - economic status joint family living in a small town in the state of uttar pradesh ( 300 km from centre ) .
he presented to adolescent clinic , nddtc , aiims with parents for the first time in january 2009 with chief complaints of the regular use of tobacco ( both smokeless and smoking ) for 8 years , occasional cannabis ( ganja ) use for 3 years and regular heroin ( smack ) use for 3 years .
heroin , the primary drug of use , was initiated at the age of 12 years out of curiosity with some of his friends and later , continued for its pleasurable effects .
there was evidence of tolerance , withdrawals and diminished control over the time and amount of heroin use .
the usual daily dose was 2 - 3 pudias ( worth rs 100 - 150 ) .
as a result of drug use , he started having frequent discord with parents and siblings .
he engaged in stealing and working as an accomplice of pick - pocketers to sustain drug use .
he spent many nights out of his house without informing his whereabouts and experienced a significant decline in physical health and social functioning .
the heroin use continued uninterrupted for 3 years till he presented for treatment on parent 's initiative .
the personal history suggested the presence of conduct symptoms ( truancy , lying , stealing from home ) since childhood prior to onset of drug use .
the complete hemogram , blood sugar , liver and kidney function tests were within normal limits .
patient was hospitalized for management of withdrawals with gradually tapering the dose of low strength buprenorphine ( 0.4 mg s / l tab ; 2 mg / day ) and subsequently , initiated on naltrexone ( 25 mg / day ; dispensed from centre 's pharmacy free of cost ) .
psychosocial interventions aimed at rapport - building , motivation enhancement and psycho education were offered .
however , patient was lost to follow - up after discharge restarting the heroin use and spending time with drug - using peers .
there were two more admissions in ensuing months ( june 2009 and august 2009 ; about 2 weeks each ) which were considered for the purpose of detoxification and reinstatement of naltrexone in view of long distance of travel .
the psychosocial intervention sessions were provided for patient ( to identify high risk situations , relapse prevention , coping skills enhancement , vocational skill building ) .
efforts were also made to engage the family members more actively in treatment process ( and address mother 's overprotective behavior for patient and conflict between parents ) . however , after each of these admissions , there was no follow - up visit in opd and patient resumed the drug use .
however , after the 4th admission ( 2 weeks ; october 2009 ) and subsequent discharge on naltrexone ( 25 mg / day ) , he followed up in out - patient clinic with parents as advised during the ward sessions .
patient continued with the fortnightly follow - up , compliant to medication and maintaining abstinence ( as confirmed by parents and repeated urinalysis ) for a period of 10 months ( oct 2009-aug 2010 ) . throughout this duration
, parents were actively involved in treatment process , supervising the compliance at home and participating in sessions .
patient would intermittently report disinclination to take naltrexone , due to occasional body aches , discomfort and  not feeling fit(protracted withdrawals ) .
eventually , he refused to take naltrexone on his own , relapsed within a few days and was lost to follow up for nearly an year .
he again presented to the out - patient clinic ( in july 2011 ) with the current use of 3 - 4 pudias ( small packets ) smack on a daily basis .
he was not doing any meaningful activity , mostly staying away of home even during nights and engaged in anti - social activities with drug - using peers .
plan for long term management was discussed with patient as well as both parents , during which patient reported disinclination to take naltrexone due to physical discomfort . after a re - assessment
, patient was initiated and stabilized on agonist replacement regimen ( buprenorphine - naloxone combination 4 mg / day ) , which was dispensed biweekly to either of parents .
patient felt comfortable on above medication and completely abstained from street heroin ( confirmed by negative results on urinalysis using thin layer chromatography or rapid cassette tests ) , though occasional cannabis use continued .
he would not go out with drug - using peers and started remaining at home , leading to improvement in his relationships with family .
his father involved him in their small - scale manufacturing unit ( packeted eatables / snacks ) and patient fulfilled various responsibilities , including financial handlings with no complaints .
patient works for nearly 7 - 8 h in a day and spends time with family in evenings .
currently , patient is on the same dose of buprenorphine - naloxone ( 4 mg / day ) for nearly 2 years ( dispensed fortnightly to him / his parents ) , during which he visits the center every month for follow - up continuing till date .
master b , 17 years old , school drop - out after primary class , belonged to nuclear family of lower middle socioeconomic status residing in delhi .
patient had a history of regular tobacco and occasional cannabis ( ganja ) use since 10 years of age , regular inhalant use ( correction fluid- 1bottle / day ) since 11 years of age and heroin use since 16 years of age . at the time of presentation , heroin was the primary drug of use for nearly a year , with a usual dose of 1 - 2 pudias ( small packets ; worth rs 50 - 100 ) per day .
there was significant dysfunction in all the major domains of functioning and patient never tried to abstain ( except for 2 - 3 forced admissions in unauthorized privately run centers lasting few weeks ) . in the psychiatric history ,
at the age of 17 years , patient had a moderate depressive episode lasting 2 weeks and in the ensuing 6 months , there were further four depressive episodes ( each lasting 10 - 20 days ) and two hypo - manic episodes ( 3 - 5 days each ) , all of which had no apparent precipitating factor and remitted spontaneously .
patient was using tobacco and heroin during this period , but no temporal relationship was observed with drug use .
there was a childhood history suggestive of hyperactivity / impulsivity and inattentiveness since 5 - 6 years of age leading to poor academic performance and subsequent drop - out from school .
no treatment was sought and symptoms improved after early adolescence . in addition , there is also a history of conduct symptoms prior to onset of drug use ( truancy , lying to parents , initiating quarrels , physical fights , throwing stones and kicking small animals , running away from home ) .
patient fulfilled the icd-10 diagnostic criteria for tobacco dependence , opioid dependence and bipolar affective disorder - not otherwise specified , and a lifetime diagnosis of volatile solvent dependence and hyperkinetic conduct disorder .
psychosocial treatment sessions focused on enhancing motivation and providing psycho education on various aspects of substance use and psychiatric disorders .
after a detailed assessment , by the third out - patient visit , the patient was started on tab naltrexone ( 50 mg / day ) and tab valproate ( 1 gm / day ) .
patient continued in regular follow up on the above medication for a period of 1 year and 4 months .
the compliance was supervised by mother and he began assisting his father in tailoring in the initial few months .
there were no further mood episodes during this period and patient was largely abstinent from illicit substances , confirmed by repeated cassette tests .
the occasional use of cannabis , however , persisted along with a few behavioral problems .
the psychosocial intervention sessions were delivered at each follow - up and some of the patient 's conflicts with parents were taken up during the sessions .
master a , 15 years old , studied up to 6 std and belonged to a middle socio - economic status joint family living in a small town in the state of uttar pradesh ( 300 km from centre ) .
he presented to adolescent clinic , nddtc , aiims with parents for the first time in january 2009 with chief complaints of the regular use of tobacco ( both smokeless and smoking ) for 8 years , occasional cannabis ( ganja ) use for 3 years and regular heroin ( smack ) use for 3 years .
heroin , the primary drug of use , was initiated at the age of 12 years out of curiosity with some of his friends and later , continued for its pleasurable effects .
there was evidence of tolerance , withdrawals and diminished control over the time and amount of heroin use .
the usual daily dose was 2 - 3 pudias ( worth rs 100 - 150 ) .
as a result of drug use , he started having frequent discord with parents and siblings .
he engaged in stealing and working as an accomplice of pick - pocketers to sustain drug use .
he spent many nights out of his house without informing his whereabouts and experienced a significant decline in physical health and social functioning .
the heroin use continued uninterrupted for 3 years till he presented for treatment on parent 's initiative .
the personal history suggested the presence of conduct symptoms ( truancy , lying , stealing from home ) since childhood prior to onset of drug use .
the complete hemogram , blood sugar , liver and kidney function tests were within normal limits .
patient was hospitalized for management of withdrawals with gradually tapering the dose of low strength buprenorphine ( 0.4 mg s / l tab ; 2 mg / day ) and subsequently , initiated on naltrexone ( 25 mg / day ; dispensed from centre 's pharmacy free of cost ) .
psychosocial interventions aimed at rapport - building , motivation enhancement and psycho education were offered .
however , patient was lost to follow - up after discharge restarting the heroin use and spending time with drug - using peers .
there were two more admissions in ensuing months ( june 2009 and august 2009 ; about 2 weeks each ) which were considered for the purpose of detoxification and reinstatement of naltrexone in view of long distance of travel .
the psychosocial intervention sessions were provided for patient ( to identify high risk situations , relapse prevention , coping skills enhancement , vocational skill building ) .
efforts were also made to engage the family members more actively in treatment process ( and address mother 's overprotective behavior for patient and conflict between parents ) . however , after each of these admissions , there was no follow - up visit in opd and patient resumed the drug use .
however , after the 4th admission ( 2 weeks ; october 2009 ) and subsequent discharge on naltrexone ( 25 mg / day ) , he followed up in out - patient clinic with parents as advised during the ward sessions .
patient continued with the fortnightly follow - up , compliant to medication and maintaining abstinence ( as confirmed by parents and repeated urinalysis ) for a period of 10 months ( oct 2009-aug 2010 ) . throughout this duration
, parents were actively involved in treatment process , supervising the compliance at home and participating in sessions .
patient would intermittently report disinclination to take naltrexone , due to occasional body aches , discomfort and  not feeling fit(protracted withdrawals ) .
eventually , he refused to take naltrexone on his own , relapsed within a few days and was lost to follow up for nearly an year .
he again presented to the out - patient clinic ( in july 2011 ) with the current use of 3 - 4 pudias ( small packets ) smack on a daily basis .
he was not doing any meaningful activity , mostly staying away of home even during nights and engaged in anti - social activities with drug - using peers .
plan for long term management was discussed with patient as well as both parents , during which patient reported disinclination to take naltrexone due to physical discomfort . after a re - assessment
, patient was initiated and stabilized on agonist replacement regimen ( buprenorphine - naloxone combination 4 mg / day ) , which was dispensed biweekly to either of parents .
patient felt comfortable on above medication and completely abstained from street heroin ( confirmed by negative results on urinalysis using thin layer chromatography or rapid cassette tests ) , though occasional cannabis use continued .
he would not go out with drug - using peers and started remaining at home , leading to improvement in his relationships with family .
his father involved him in their small - scale manufacturing unit ( packeted eatables / snacks ) and patient fulfilled various responsibilities , including financial handlings with no complaints .
patient works for nearly 7 - 8 h in a day and spends time with family in evenings .
currently , patient is on the same dose of buprenorphine - naloxone ( 4 mg / day ) for nearly 2 years ( dispensed fortnightly to him / his parents ) , during which he visits the center every month for follow - up continuing till date .
master b , 17 years old , school drop - out after primary class , belonged to nuclear family of lower middle socioeconomic status residing in delhi .
patient had a history of regular tobacco and occasional cannabis ( ganja ) use since 10 years of age , regular inhalant use ( correction fluid- 1bottle / day ) since 11 years of age and heroin use since 16 years of age . at the time of presentation , heroin was the primary drug of use for nearly a year , with a usual dose of 1 - 2 pudias ( small packets ; worth rs 50 - 100 ) per day .
there was significant dysfunction in all the major domains of functioning and patient never tried to abstain ( except for 2 - 3 forced admissions in unauthorized privately run centers lasting few weeks ) . in the psychiatric history , at the age of 17 years
, patient had a moderate depressive episode lasting 2 weeks and in the ensuing 6 months , there were further four depressive episodes ( each lasting 10 - 20 days ) and two hypo - manic episodes ( 3 - 5 days each ) , all of which had no apparent precipitating factor and remitted spontaneously .
patient was using tobacco and heroin during this period , but no temporal relationship was observed with drug use . there was a childhood history suggestive of hyperactivity / impulsivity and inattentiveness since 5 - 6 years of age leading to poor academic performance and subsequent drop - out from school .
no treatment was sought and symptoms improved after early adolescence . in addition , there is also a history of conduct symptoms prior to onset of drug use ( truancy , lying to parents , initiating quarrels , physical fights , throwing stones and kicking small animals , running away from home ) .
patient fulfilled the icd-10 diagnostic criteria for tobacco dependence , opioid dependence and bipolar affective disorder - not otherwise specified , and a lifetime diagnosis of volatile solvent dependence and hyperkinetic conduct disorder .
psychosocial treatment sessions focused on enhancing motivation and providing psycho education on various aspects of substance use and psychiatric disorders . after a detailed assessment , by the third out - patient visit ,
the patient was started on tab naltrexone ( 50 mg / day ) and tab valproate ( 1 gm / day ) .
patient continued in regular follow up on the above medication for a period of 1 year and 4 months .
the compliance was supervised by mother and he began assisting his father in tailoring in the initial few months .
there were no further mood episodes during this period and patient was largely abstinent from illicit substances , confirmed by repeated cassette tests .
the occasional use of cannabis , however , persisted along with a few behavioral problems .
the psychosocial intervention sessions were delivered at each follow - up and some of the patient 's conflicts with parents were taken up during the sessions .
these case descriptions add to the limited literature on long term pharmacological treatment of adolescent patients with opioid dependence .
both the adolescent patients had some common clinical features , e.g. school drop - outs , presence of psychiatric risk factors , very early - onset of first substance use ( 7 and 10 years respectively ) , use of multiple substances , progression from licit to illicit substance , significant dysfunction in various domains and poor motivation at baseline .
these are in accordance to the existing literature on the adolescent - onset substance use disorders .
after initiation of pharmacological treatment in conjunction with psychosocial intervention sessions , both the patients could be retained in long term follow - up ( patient a : 2 years ; patient b : 1.3 years ) , were abstinent from heroin and engaged in meaningful work .
the use of buprenorphine maintenance is quite uncommon among adolescent patients and very few studies have evaluated its efficacy in this age group , which is summarized here .
a multi - site study of opioid - dependent youth ( of which 12 were adolescents ) examined buprenorphine - naloxone treatment vs. standard detoxification , and found significantly better outcomes in drug use and other measures at the end of 12 weeks .
however , the adolescent sub - sample in this study was deemed to be inadequate for a separate analysis .
a file review from an australian treatment setting compared first treatment episode of adolescents on buprenorphine ( n = 25 ) versus methadone ( n = 20 ) , and found that treatment retention was higher in methadone compared to buprenorphine ( mean : 354 days vs. 58 days ) in adolescents .
another us study reported positive experiences of few adolescent patients on buprenorphine in a substance abuse treatment program that also focused on adolescent development .
finally , a cochrane review of various databases ( 1966 - 2008 ) for randomized or controlled trials for effectiveness of any maintenance agent in adolescents , found only two trials ( only one of which involved buprenorphine ) .
the cochrane review was inconclusive and meta - analysis could not be carried out with two heterogeneous trials .
there is often a general policy of dispensing agonist medication only to adult patients due to concerns about starting youth on treatment that is often long - term and reluctance to bring young patients into daily contact with adult patients with extensive addiction histories and antisocial behaviors .
however , a small percentage of adolescents with early - onset of opioid dependence may experience severe dysfunction , engage in high risk and anti - social behaviors and show a poor motivation to quit .
it has been recommended elsewhere too that agonist maintenance may be considered for adolescents who have opioid dependence , age is at least 16 years or above , opioid use 1 year and two documented failed attempts .
so far , only one study is available for naltrexone use in adolescent opioid dependence . in this preliminary
non - controlled , extended - release naltrexone was found to be safe and efficacious in a sample of 16 adolescents and young adults ( mean age : 18.5 years ) . of total , 10 were retained in treatment for at least 4 months and 9 had a good outcome .
in addition , few studies and case reports have evaluated the overall safety of naltrexone for adolescents with alcohol use disorders ( sample age : 16 - 18 years ; dose 50 mg / day ) .
the patients discussed above , naltrexone was initiated after a discussion with patient , parents and a review of existing literature .
naltrexone was tolerated well at the dose of 50 mg / day , with no significant adverse effects .
compared to patient a , patient b had a shorter duration of heroin use and consequently , did not experience any protracted withdrawals , craving or need for an agonist .
it is to be noted that adolescent opioid users frequently have a number of other problems , e.g. the use of drugs by peers , poor family support , living in a locality with easy availability of drugs and underlying psychiatric morbidity , some of which were present in one or both patients .
failure to address those issues will reduce the chance of successful treatment and increase the risk of relapse .
the comorbid bipolar disorder was managed with a mood stabilizer in patient b , with no recurrence during follow - up period .
a good family support was present in both cases , which played a crucial role in ensuring compliance to medication and other treatment aspects .
for example , the take - home doses of buprenorphine - naloxone were dispensed free of cost as a policy , but family members had to travel several hours by train to reach center on a fortnightly basis , thereby investing time and other resources over these years .
in indian context , the active involvement of family in various aspects of treatment process contributes immensely toward improved functioning of the patient .
some drug using adolescents may not have a family or family support , but wherever available , their participation should be actively sought at all treatment steps . to conclude , the case report adds to the limited literature on efficacy of pharmacotherapies for adolescent opioid use .
however , there is a need to conduct systematically planned studies on the adolescent opioid use treatment .
 adolescents constitute only a small percentage of treatment seekers in drug dependence treatment settings . 
 little research evidence is available for pharmacological treatment of adolescent opioid dependence and no prior case report is available from india . 
 we discuss two adolescent patients with opioid ( heroin ) dependence visiting a tertiary care center who have been stabilized on agonist ( sublingual buprenorphine - naloxone ) and antagonist ( oral naltrexone ) respectively for a substantial period of time . 
 a comprehensive management approach , including intensive psychosocial interventions and family involvement , was followed in addition to pharmacotherapies . 
 more research is needed on the efficacy of pharmacological treatment in adolescent opioid users . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
DISCUSSION