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TAMBURELLO ET AL.
(Borodovsky et al., 2018), though its prescription in juvenile
residential facilities is uncommon. Even in the community,
evidence-based treatment with MOUD for
adolescents is rare. Alinsky et al. (2020) found that in people
13 to 22 years old, fewer than 2% received MOUD
after an overdose in the community.
For nontolerant youths, fatal respiratory depression
from buprenorphine has been reported (Post et al.,
2018). Nevertheless, the American Academy of Pediatrics
has indicated that there are no age-specific safety
reasons barring the use of buprenorphine for the treatment
of OUD (American Academy of Pediatrics Committee
on Substance Use and Prevention, 2016).
A meta-analysis including adolescents as young as 15
found that buprenorphine in daily doses ranging from 6
to 32mg (with a median dose of 12 mg/day) was well tolerated.
Benefits included reduced opioid use and fewer
risky behaviors (Borodovsky et al., 2018).
As in adults (Weiss & Rao, 2017), the longer the youth
remains in treatment with buprenorphine, the better the
outcome (Borodovsky et al., 2018). Thus, with appropriate
selection and informed consent, induction during
placement or during community treatment in the juvenile
justice system is a unique opportunity.
Methadone has not been FDA approved for use in adolescents
(Borodovsky et al., 2018), and regulatory restrictions
make it impractical for most juvenile justice
systems. Administrators may see noncontrolled antagonist
medications for OUD as preferable treatment options.
Long-acting injectable naltrexone may also be
effective for OUD but has even less research available
for adolescents than buprenorphine.
New-Onset Psychosis
Justice-involved youth may present with a first break of
schizophrenia. Childhood-onset psychosis is rare, though
schizophrenia may be in a prodromal phase in late childhood
or early adolescence, and over a third of cases of
first-onset psychosis patients had a month or more of untreated
psychosis during a period of incarceration (Ramsay
Wan et al., 2014). A diagnosis of a psychotic disorder
in a juvenile justice facility predicts recidivism, but treatment
with antipsychotic medication correlates with more
time in the community (Kasinathan, 2015). Thus, an arrest
may be a critical opportunity to interrupt or delay
the progression of a serious mental illness with lifelong
implications.
On the other hand, juvenile justice facilities have come
under scrutiny in recent years for the inappropriate prescription
of antipsychotic medication for behavioral control
(Norton, 2012). In a study in a state juvenile facility
of an internal practice guideline that promoted biopsychosocial
approaches over off-label prescribing, this
had the effect of reducing the cost (and by extension
the amount) of antipsychotic medications provided to
justice-involved youth, without an increase in aggressive
behavior (Lee et al., 2016).
Psychotic symptoms in youth have a broad differential,
including ASD and other child and adolescent psychiatric
disorders. It is critically important to first rule out the use
of substances, including cannabinoids, synthetic cannabinoids,
bath salts, and other illicit drugs. Psychosis is a
rare side effect of prescribed stimulants, more often
seen with mixed amphetamine salts than methylphenidate
(Moran et al., 2019).
Second-generation antipsychotic medications are considered
first-line treatment when indicated. Several are
FDAapproved for use in adolescents, including risperidone,
aripiprazole, olanzapine, quetiapine, paliperidone, lurasidone,
asenapine, and brexpiprazole (Ash & Nelson, 2019;
Texas Health and Human Services Commission, 2019;
U.S. Food & Drug Administration, 2021). Off-label use
should be avoided, informed consent should be thorough,
and the psychiatrist should carefully monitor for and manage
adverse effects. These medications should be stopped
when risks exceed benefits, though psychiatrists should proceed
with great caution in this regard in the context ofa confident
diagnosis of a primary psychotic disorder.
Conclusion
Mental health and substance-related disorders are significant
public health problems affecting youths across a
continuum of justice settings ranging from outpatient
and clinic-based care to detention and secure housing
to residential facilities. These individuals have high
levels of premorbid exposure to adverse childhood and
life experiences. They present with a wide range of
symptoms-from insomnia or depression to selfinjurious,
assaultive, and other disruptive behaviors.
Timely mental health assessment and further psychiatric
consultation, when indicated, is recommended.
Psychotropic medications are commonly used in this patient
population but should be used in a safe and appropriate
manner, and only as part ofa comprehensive individualized
treatment plan that incorporates multidisciplinary, culturally
competent, family-based, trauma-informed care. Combining
psychotropic medication treatment, when clinically
indicated, with evidence-based psychotherapies has the potential
to significantly enhance mental health and wellbeing;
reduce reoffending, morbidity, and mortality; and
impact the long-term trajectory of these at-risk youth and
their families.
The complex nature of these systems highlights the
need for training resources to better address the needs of
this often-underserved group. More research is needed in
psychopharmacology for youth with justice involvement
to bridge the gap between clinical needs and the available
data.
Journal of Correctional Health Care - April 2023

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