Neurobiology of Adolescent Substance Use and the Impact of Alcohol on the Adolescent Brain

SHANNON MOUNTAIN-RAY: Hello, and welcome today’s presentation, “Adolescent Substance Use: What’s the Deal?” I’m Shannon Mountain-Ray, Director of Integrated Care for the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. I’m extremely excited to be here today to talk about this very important topic.

This presentation will cover topics such as adolescent brain development and how it creates a special vulnerability for young people to develop substance use disorder. We’ll also talk about the impact of adolescent substance use on physical and mental health and give some important points that you can share with patients and caregivers about those risks.

To give a little bit of background, I come from the Adolescent Substance Use and Addiction Program, which we call ASAP for short. ASAP is a part of the Division of Developmental Medicine at Boston Children’s Hospital. ASAP started as an outpatient treatment program for young people who struggled with substance use. Our outpatient clinic consists of a multidisciplinary team of psychiatrists, developmental behavioral pediatricians, social workers, nurse practitioners, a wide range of administrative and research support. It is a hospital-based program, both at our Boston campus and our Waltham campus, and most recently providing extensive virtual care opportunities.

It is an outpatient treatment program, and it covers the broad range of substance use, from what we say, from experimentation to addiction, so for young people who may have only used substances once or twice, all the way to young people who are using every day over multiple years. Some of the services that are provided are things like comprehensive substance use evaluation, individual and group counseling, medications for substance use disorders, clinical drug testing, psychopharmacology, group therapy, and parent or caregiver guidance.

Our outpatient program has been around since 2000, and we have worked with a number of young people. But what we know is, of the 4.5% of adolescents between the ages of 12 and 17 who are diagnosed with a past year substance use disorder, only about 8.3% of them receive treatment. And so we were thinking, what else can we do? How else can we reach patients who are struggling with substance use?

Thus was born multiple integration efforts. Our primary care substance use integration program is the area that I focus on, and we’ll talk a little bit more about. In addition to that, we have our primary care telephonic consultation and virtual behavioral health treatment program. We provide school-based vaping groups and also have a partnership with our juvenile justice system.

Thinking about integration, we really focus on addiction medicine and primary care. How can we bring those two things together? Primary care tends to be where young people often present with issues related to substance use and behavioral health concerns, so we were thinking, how can we bring our outpatient model into pediatric primary care?

So what we looked at was bringing a clinical social worker with specialty training in substance use evaluation and treatment and having them integrate into the primary care setting as part of the multidisciplinary team. This is an office-based model as well as a virtual model and also provides an outpatient level of care from experimentation to addiction.

Care model focuses on caring for patients in the medical home, providing comprehensive evaluation, working with primary care providers to do things such as provide medications for alcohol, opioid, cannabis, and nicotine use disorders, and the social worker providing psychosocial treatment, including individual and group therapy, parent and caregiver guidance, and also working with the practice to provide referral in case coordination. In addition to the social worker integrating into the primary care practice, we also have support by the Addiction Specialty Program, so all of the ASAP providers provide some level of consultation to primary care providers for any questions or training needs that they may have.

So now, we’re going to switch gears, and we’re going to talk about James. James is a 17-year-old with no past medical or psychiatric history. He comes in for his annual well child visit. He’s a B+ student, and he’s finishing his junior year. He lives with his parents and is an only child. He’s a two-sport athlete.

Upon screen, James– excuse me– reports occasional drinking with friends on weekends but denies ever using illicit substances, and he’s starting to look at colleges. James receives his vaccines, and his PCP congratulates him on his hard work at school and his safe choices about drugs. One week later, James attends an end-of-the-year party with some friends. While driving home, his car jumps the curb, slams head on into a tree, and he’s pronounced dead at the scene. His BAC at autopsy is 0.24.

The reason that we use this as an example is because the primary care provider did a number of really great things. They screened for substance use. They got a sense of what was going on and provided some positive reinforcement about his safe choices around drugs. But there is more that primary care providers can do. In addition to talking about drugs, also screening and discussing alcohol and not only discussing the risks associated with the potential to develop a substance use disorder, but all of the correlates associated with adolescent substance use, many of which we’ll talk about in this presentation.

When we consider the leading causes of mortality amongst ages 10 to 24, we see the top three causes of death are things like unintentional injuries, which include things like motor vehicle accidents, poisonings, drownings, et cetera, with the next two being suicide and homicide. When we think about this in terms of adolescent substance use, we know that substance use in this age group increases the risk for all of those causes of death.

One area that we like to highlight is driving under the influence. Motor vehicle accidents remain the leading cause of death for young people this age. I have a slide here that specifically focuses on marijuana because in our experience, many young people have gotten the message around alcohol and driving and the risks of drinking and driving. Although it’s extremely important to continue to educate young people on the concerns around drinking and driving, it is also very important to specifically address areas such as cannabis use or other drug use while driving.

As you can see from this slide, high school seniors who smoke cannabis are two times more likely to receive a ticket and 65% more likely to get into a car crash than those who don’t smoke. We have often heard from young people who use cannabis and drive that they often feel that they actually drive better when they’re high. They focus more. They feel like they drive slower. But what we know from the research is, that’s not the case. Their reaction and coordination time are quite compromised, and the risk remains very high of an accident or some other negative outcome related to cannabis use and driving.

Some good news. When we look at the numbers and the prevalence of adolescent substance use, we see that adolescent substance use has actually declined in the last year amongst all age groups, high school age groups, so 8th, 10th, and 12th grade. When we dig a little bit deeper into the numbers, it’s important to understand some of the context. This is data that comes from the Monitoring the Future survey. This is a survey done with about 50,000 8th, 10th, and 12th graders every year. They ask a variety of youth risk behavior questions, including questions around substance use.

What we have demonstrated here are the data related to substances used by 12th graders in 2021, and we look at both the lifetime use and the past 30 day use. So when we consider lifetime use, this is the question that’s focused on, in your lifetime, have you ever tried any of these substances? And you can see that about 54.1% of 12th graders report alcohol use in their lifetime, and about 38.6% report cannabis use in their lifetime.

So the reason why we like to highlight this is because often we hear from young people and from parents and caregivers that all kids are using alcohol, every kid uses marijuana. And what we know is, that’s just not true. And when we look at the lifetime numbers, you can see that although adolescent alcohol use is normative by the time– trying alcohol by the time someone’s in 12th grade is normative, it is not normative for young people to be using cannabis by the time they’re in 12th grade.

When we look at other substances, you can see the percentages are much lower in terms of use. Alcohol, nicotine, tobacco, and cannabis are the most widely used substances in this age group by far. So when you’re thinking about screening young people for substance use, one of the things to consider is, what is the substance that they’re using? And if they report things like inhalant use or hallucinogen use or amphetamines or opioid use, they are in a higher risk category than the majority of their peers. So it’s helpful to understand the perspective of that.

Then we look at past 30 day use, and what we can see is, from those lifetime numbers, those numbers get cut in half. So this is asking a question around, in the past 30 days, have you ever used those substances? And we can have a better understanding of regular use patterns when we ask a question about past 30 day use. And you can see, again, those numbers get cut in half, so 54.1% of high school seniors say they’ve tried alcohol, but only 25.8% say they’ve used in the past 30 days.

The same is true for cannabis. 38.6% report lifetime use, and only about 19.5% report past 30 day use. And of course, again, looking at other substances, those numbers also go down significantly. So it’s helpful when you’re thinking about how prevalent is adolescent substance use, and you get reports from young people and parents about what’s happening. You can have a sense of where they fall on the spectrum.

We also know most drug use starts in adolescence, so this demonstrates past year initiates. And as you can see, there’s a significant jump between 12 and 13 and 14 and 15, and then again between 14 and 15 and 16 and 17, with the majority of initiation happening between the ages of 16 and 20. There is a significant decline by the time someone reaches 25, and then again when someone is 26 or older.

Some of the correlates of substance use during adolescence are things like intentional and unintentional injuries, emergency room visits, violence, legal issues, school issues, risky sexual behavior, sexual assaults, et cetera. So again, we worry about things like the development of a substance use disorder, but what we worry almost more about is the other things that can happen. Only about 10% of young people who use substances will go on to develop a substance use disorder, and we are very concerned about that. We’ll talk about why they’re higher risk during the phase of adolescence.

But what we also really want to highlight is, not only are we concerned about the development of a substance use disorder, but all of these other really negative experiences and potential outcomes. Adolescents are developmentally more vulnerable to developing substance use disorders and problems associated with substance use. It has everything to do with brain development.

So here’s a study that was done related to the age at first use and later risk for the development of a substance use disorder. If we look at the blue graph, we can see that young people who try to start drinking alcohol by the time they’re 13 have about a 50% chance of developing an alcohol use disorder. With every year they delay initiation, that risk goes down. So you can see it continues to go down, whereas if they wait to drink alcohol until they’re 21 or older, the risk of developing an alcohol use disorder goes down to about 9%.

The percentages are different with cannabis, but the trend is the same. So the younger you start using, the more likely it is you’ll develop a substance use disorder. So what is going on in that adolescent brain? Why are they more prone to developing substance use disorders or having negative effects related to adolescent substance use?

So one of the things we know is that the brain development continues into about the mid-20s. We used to think it stopped around age 10. That’s mostly because the brain, the size and the weight of the brain is at its maximum at 10 years and continues at that stage throughout life. So prior to the initiation of MRI imaging, we assumed that brain development stopped when the brain stopped growing.

What we now know is actually that adolescence is a critical period in brain development and that the brain continues to develop until the mid-20s. Brain develops from the back to the front, starting with a cere– excuse me– starting with a cerebellum and ending with the prefrontal cortex. The cerebellum is the area of the brain that’s related to things like walking, talking, motor skills, kind of maneuvering through the world in a physical way.

Next area of the brain to develop is this middle part of the brain. And I’m going to be specifically focusing on areas of the brain that are related to substance use, so that’s why we’re focusing on the amygdala. This is an area of the brain that’s related to things like emotional control, pleasure, reward, et cetera. Another area in the middle part of the brain that’s developing– it’s actually fully developed by the time someone reaches adolescence, is also the nucleus accumbens. This is also an area of the brain that’s related to pleasure and reward, and also things like learning and memory.

The final area of the brain to develop is the prefrontal cortex. This is in the front of the brain and is not fully developed until around 24 to 25 years old. And this is the area of the brain that’s really focused on things like executive functioning, impulse control, future-oriented thinking, et cetera.

If we’re looking at this in a little bit of a different way, we look at the limbic system, which includes the hippocampus and the amygdala, and that is fully mature by the time someone reaches adolescent– excuse me– adolescence and highly sensitive. So this is the area of the brain that focuses on things like emotional memory, fear response, pleasure, fight or flight.

And then that nucleus accumbens, also fully developed in adolescence and highly active and related to things like pleasure and reward and plays a major role in the development of substance use disorders. And then, again, that prefrontal cortex, which is not fully developed until late adolescence or early adulthood, and is responsible for all of these very important pieces of impulse control, decision-making, organizing, et cetera.

When we think about this in terms of substance use, I often like to use a car analogy. And think about this middle part of the brain, again, that limbic system that includes the hippocampus and amygdala and also the nucleus accumbens. I like to think about that as the gas pedal of the brain. So this is an area that’s highly sensitive and very responsive to pleasure and reward and fully developed by the time someone reaches adolescence.

And then we look at this other area of the brain, prefrontal cortex, and I like to think of that as the brake pedal of the brain. This is the area that helps us think through the decisions that we make and really kind of helps us to mitigate risk at times. So the tricky part about adolescence is that gas pedal is working very, very well, but the brake pedal isn’t fully developed. Think of the adolescent brain as a sports car. That gas pedal that you step on it just a little bit and it takes you from 0 to 60 very quickly is working very well, but that brake pedal is not.

The other thing that’s happening during adolescent development is extensive neuronal development. So this is a picture of before one reaches a process called blossoming, so all of a sudden in the brain, there is a phase that’s called blossoming where there’s extensive growth in terms of the number of neurons and neural pathways in the brain. About 11 for girls and 12 and 1/2 for boys, this thickening undergoes a process called pruning. So if you think of the neurons as being sort of a wily shrub, and it needs to be pruned down in order to work as efficiently and effectively as it possibly can.

So pruning starts, and in this phase, there’s a process of use it or lose it. So it’s really important for young people to use all the various parts of their brain to have all different kinds of experiences, physical experiences, artistic and creative experiences, intellectual experiences, relationships, social experiences in order to use as much of their brain as possible and really keep what they need. Because if not, the thickening undergoes this pruning, and you lose areas of your brain that you’re not using as well, and substance use can really affect this process.

At the same time, myelination is happening. So myelin sheaths that encase the nerve cells thicken like insulation on a wire to help the cell transmission be faster and more efficient, so lots of really important processes happening. So if we’re going with a car analogy, you might think, during adolescence, the brain is working to become an information superhighway, to be as efficient and as effective as possible.

So what’s also really interesting about where the gas pedal and the brake pedal fall is that we have another part of our brain called the reward pathway. This is an area of our brain that has evolutionary purposes. The reason why we have this area of the brain is really to remind us to do the things we need to do to survive, so things like eating, having sex to procreate, having social connections for protection, things like that. And what happens is, we have those experiences, and it triggers the reward pathway. The reward pathway gives off a very pleasurable experience.

And the idea is, because we’ve had that pleasurable experience, it will motivate us to want to continue to have those kinds of experiences. The interesting part related to substances is that substances hit that very same part of the brain, and so that triggers a pleasurable response. And for some– and we don’t know why some do and some don’t. We have some theories about genetics and other things that contribute to why someone might develop a substance use disorder, but we don’t really know how to predict this. It’s that when substances hit that area of the brain, they have a pleasurable response, and for some, the repetition and the reinforcement of that pleasurable response may lead to compulsive desire for substances. Hence, a substance use disorder.

I’m going to use an example to kind of bring all of this home, and I use cannabis specifically as an example because in our experience, cannabis tends to be the most widely misunderstood substance related to adolescent substance use. So we’ll start with talking about what’s in cannabis. Cannabis contains many cannabinoids, hundreds of cannabinoids. Some we know a little bit about, and some we know nothing about.

So some of the more widely known are things like delta-9-tetrahydrocannabinol, or THC. There’s also delta-8-tetrahydrocannabinol, cannabidiol, which is known as CBD, cannabinol, and some of these other cannabinoids. There is research being done. There will be more hopefully around the effects of these cannabinoids over time and specifically related to adolescent brain development.

What is the active chemical in cannabis? That is delta-9-tetrahydrocannabinol, also known as THC. It is the main active chemical, and cannabis potency depends on how much THC it contains. THC binds– excuse me– to the brain’s own cannabinoid receptor sites, so we’ll talk a little bit about what that means.

In our brains, we have a system called the endocannabinoid system. The primary purpose of this system is regulation. Often, we talk about it in terms of being a volume control. It helps to dial down neuron activity when it’s too strong, and it regulates several important areas, including things like pleasure, mood, pain, appetite, sleep, motivation, focus, memory, and attention. I often say, if you know young people who are using cannabis, you can tell that there’s often disruption in many of these areas. The endocannabinoid system also helps to keep neuron activity in balance, not underactive or overactive.

Your body produces its own cannabinoid chemical called anandamide, and anandamide binds to the cannabinoid receptors in your brain. I like to think of these receptors as cups and that our own endogenous chemicals are supposed to fill those cups and do their job and help to keep us in balance. Why do we have cannabinoid receptors? According to animal studies, they have shown that animals who do not have anandamides tend to experience things like more pain, difficulty controlling their appetite. They may be more anxious and less able to cope with stress.

What’s very interesting is, when you look at anandamide and compare it to THC, they look very similar. So what happens is, when you bring THC into your system, your brain thinks it’s anandamide, and it should go in those cannabinoid receptors. The difference is that when you use ananda– or when your brain produces anandamide, you do get a dopamine release. With cannabis, you get a much bigger dopamine release.

We think about this using a medical frame. We think of anandamide as a scalpel and THC as the hammer. Both dial down neuron activity to change neurotransmitter release, but THC has a much stronger and longer effect than anandamide on the cells. And THC interferes with anandamide function, so it can’t do its job properly.

There are THC binding sites all over the brain. There really isn’t any area of the brain that is untouched. Some of the things that are affected by cannabis are things like movement, sensation, judgment, reward, memory, coordination, and vision. Some of the acute pleasurable effects are things like mild euphoria, visual and auditory enhancements, and increased talking. Some of the adverse effects can be things like decreased coordination and reaction time, difficulty concentrating, and impaired memory and learning.

One of the concerning trends is that the content of THC in cannabis has increased over the years. As you can see when we look at this blue line, you can see between 1995 and 2018 the potency of cannabis products has increased with much higher levels of THC. Sometimes people can overuse or have a toxic level of THC in their brains, and this is when things happen, such as really extreme mood fluctuations, hallucinations, depersonalization, anxiety and panic, paranoia, and vomiting.

Something else to be aware of is cannabis withdrawal. So often working with young people, this is really important to highlight these points in order to help them prepare if they’re going to make any change to their cannabis use. If they are not prepared for this, often these things– they’ll experience these things, and then it will reinforce their desire to continue to use cannabis. So some of the withdrawal symptoms include things like restlessness and anxiety, increase irritability and anger, difficulty sleeping, decreased appetite, and sometimes weight loss.

And again, if you tell a young person, if you’re counseling a young person and they’re talking about making a change, either decreasing or stopping their cannabis use altogether, but often, if you ask young people why they’re using cannabis, they list many of the things on this list. So if they’re not prepared that they might experience this kind of withdrawal, they’re going to experience an increase in their anxiety, an increase in their irritability, much more difficulty falling asleep.

And then they’re going to say, well, see, it is helping me. This is why I’m using it. But what they need to know is, when they experience withdrawal, generally those symptoms are temporary and they dissipate over time. For those that don’t dissipate, we can get a much clearer sense of what the underlying issues are, and we can target the treatment to focus on those areas.

It was a study done in New Zealand that discussed persistent cannabis users showing neuropsychological decline from childhood to midlife. So this was called the Dunedin Study and had over 1,000 participants, which they followed from the age of 13 through 38 years old. At 13, it was prior to any initiation of cannabis use.

What they found was, when they broke it down between participants who had never used cannabis to those who had had three or more years of heavy use, and by heavy use, meaning multiple days over– excuse me– over an extended period of time, three years or more. When they went and they looked at the data related to IQ scores at 38 years old, what they found is those who had never used, their IQ score basically stayed around the same. But those who had three or more years of heavy use, their IQ decreased by almost 7 points.

THC is also known to reduce hippocampal neuron activation. With chronic exposure, neurons are gradually lost due to continual– excuse me– continual suppression. And those that use THC tend to have smaller hippocampuses and poorer memory. Teen working memory is also impacted by cannabis use, as you can see. Teens were asked to perform some level of a memory task. Those who don’t smoke at all did much better than those who use cannabis.

We also have ample research on the long-term effects associated with cannabis use in adolescents, including increased rates of psychosis, depression, anxiety, diminished life satisfaction and achievement, cognitive decline, and the development of substance use disorders. The American Academy of Pediatrics opposes legalization of cannabis because of the potential harms to children and adolescents.

This is just a really to highlight, if we can stop pretending that cannabis is harmless. This is directly sort of focused on adolescent consumption of cannabis and underscoring that with legalization, the misconception that drugs can’t hurt anybody– it can, especially young people. So what we know research tells us is that with legalization, the perception of risk decreases.

And we know this to be true, certainly with opioids. We also know this to be true with cannabis. And so it’s really important to consider that in how we’re talking to parents and young people about cannabis use and about substances in general, that their perception of risk– and we see it in multiple conversations we have with patients and families– that the perception of risk definitely decreases since legalization.

And some important points to take away. The adolescent brain is not fully developed. The reward pathway is highly sensitive during adolescence, and this increases the susceptibility to developing a substance use disorder. Substance use during adolescence– excuse me– substance use during adolescence can change the developing brain, increasing risks for learning, memory, and mental health problems.

Thank you for being with us today, and I hope you take some of this information away and can utilize it with your patients and families.

The Impact of Nicotine and Cannabis on the Adolescent Brain

VIRGINIA SANABIA: And today’s presenter is Dr. Miriam Schizer, Medical Director, Adolescent Abuse– Adolescent Substance Abuse and Addiction Program at Boston Children’s Hospital. Also Assistant Professor of Pediatrics at Harvard Medical School and Diplomate, General Pediatrics and Addiction Medicine.

MIRIAM SCHIZER: All right. Thank you, Virginia. Good morning, everyone, and thank you for spending the first part of your day with me. I really appreciate it.

All right, so the focus of today’s talk is going to be cannabis and nicotine vaping. And I had some fun with the title slide. You’ll notice the products on the left are the old-fashioned version and the products on the right are what a lot of your patients are using these days. So very different look.

The way I’ve organized today’s presentation is we’re going to spend the first half talking about cannabis and the second half talking about nicotine vaping, and we will have a very a short question-and-answer in between talks. So think about your cannabis questions and then we’ll focus on nicotine.

So in terms of what we’re covering today, we’ve got a lot to cover. I’m going to start with each substance looking at the epidemiology and really paying attention to this changing landscape that I alluded to.

I’m going to make sure you leave today understanding the nuts and bolts of how your patients are using cannabis and nicotine in the current year. Certainly we’re going to focus on the adverse health effects of both substances, and then perhaps most importantly, what you can do about it in your primary care setting.

So over the years as I’ve talked to different audiences about cannabis, I often show a map that focuses on this changing phenomenon of where marijuana or cannabis is legal and where it isn’t. I can tell you that at last count, there are 19 states plus the District of Columbia that have legalized the recreational use of marijuana. I remember when this was just beginning in 2012 with Colorado.

And I think the take-home message of this slide is states that are pictured in orange are fully illegal for cannabis use, and you can see, there are only four states at this point. So why am I bringing this up when we’re talking about adolescence? I think the million-dollar question is, as the conversation changes, as people believe that cannabis is a somewhat benign substance, how does this affect our adolescence?

All right. Virginia, I’ll try one more time and then I might pass it off. Let’s see if my computer behaves. So I’ve already talked to you guys about the Monitoring the Future Survey. This, again, is a survey that questions about 50,000 students a year in what they consider a nationally representative sample. Typically they’re questioning eighth, 10th, and 12th graders about their substance use and also their attitudes towards substance use. So this gives us a wealth of data for us to see trends. As I mentioned, we’ve had this study since 1975.

So this graph, you’re looking at 12th graders who’ve been surveyed from 1975 through 2021. Question that they were asked is, do you believe there is, quote, “a great risk of harm,” end quote, associated with cannabis use? This is the curve pictured in blue. And you can see, over the decades, there’s been very significant fluctuation in what percentage of adolescents believes that cannabis use is harmful. And you can see that this percentage has been on the decline, and that’s what we are concerned about.

Then they’re also asked whether they’ve used cannabis in the past month. Remember, they’re considered a current user if they answer yes to that question. And you can see the relationship between these two curves, that as more adolescents believe cannabis is not harmful, they’re more likely to use it, and this is essentially what we’re worried about.

So this brings us to the present showing some recent trends in cannabis use and cannabis vaping. Just to orient you, green is eighth grade, blue is 10th grade, yellow is 12th grade. So if you look at past year marijuana use, I’m going to focus on 2021, looks like about 30% of our 12th graders said they used cannabis in the past year, 17% 10th graders, and a little less than 10% of eighth graders.

Thankfully daily cannabis use is definitely making low numbers as you can see for the middle graph. And then a large part of the story over the last few years has been this vaping phenomenon, and we’re going to talk about this for cannabis as well as for nicotine.

I will mention that there has been a decline from 2020 to 2021 that you can see on the graph. We’re not sure if that’s real. This survey was done in the first half of the year when a lot of kids weren’t in school because of the pandemic, and so access might have been a factor.

All right, now we’re going to focus on nuts and bolts. This is a picture of the cannabis sativa plant. So what’s interesting about cannabis is we know that it contains numerous chemicals which are aptly called cannabinoids. The one that we know the most about is delta-9-tetrahydrocannabinol or THC, which is the primary psychoactive ingredient in cannabis.

What’s also worth pointing out is that there are over 100 compounds in total, and some of these we know very little about. Cannabidiol is known as CBD. I’m going to say a little about that later.

All right, so let’s focus on THC, which, as I mentioned, is the primary psychoactive ingredient in cannabis. We know that it’s fat-soluble, and as such, it readily crosses both the blood-brain barrier and the placenta. This lipophilic quality is important. We know that it accumulates in adipose tissue and this can result in a relatively long elimination half-life. In our next session, we’re going to talk about drug testing, so I’m going to come back to that point.

We know that THC is able to exert its effects by acting on the body’s own endogenous cannabinoid receptors. All right, so how are your patients using cannabis? Generally, the dried buds and the leaves of the plant are smoked. We have this new phenomenon of vaping which we’re going to talk about a lot today.

We have been seeing more edible use. I think as dispensaries become more prevalent, they often sell cannabis in the form of edibles, so we’re seeing more adolescents using it that way. And then you might hear about hash oil or dabbing which is using a very, very potent form of THC.

I always like to do a little show and tell. The picture on the left is it classic joint or marijuana cigarette. The picture in the middle is a blunt which is a hollowed-out cigar in which the tobacco material is replaced with cannabis. The picture on the right is a water pipe or a bong. Before kids were vaping, a lot of parents would bring their children to our program to ace ASAAP having discovered a bong in the child’s bedroom and that’s how they discovered the use. I would hear that story a lot.

So because we’re talking about vaping, I want to make sure everyone has an understanding of how these devices work. In the literature they’re referred to as ENDS or Electronic Nicotine Delivery Systems. And no matter what they look like on the outside, they all have the same internal structure.

These are battery-powered devices. The most important features are there is a cartridge that holds the liquid and this is what is vaporized. And this sits immediately adjacent to a heating element. So when the patient uses the mouthpiece, it triggers the heating element to heat up the liquid and this generates a vapor.

So it’s important to know what liquid the patient is using. This could contain flavored nicotine, unflavored nicotine, cannabis, patients will call this a dab pin. Some of your patients might be vaping just flavoring, but I think that’s fairly uncommon.

All right now, let’s focus on the acute effects of cannabis intoxication. Generally these vary by person and by dose. When you’re thinking about the timing of peak effects, if a patient is smoking or vaping, these usually occur about 30 minutes after they begin using.

As you would expect, if they’re eating an edible, this effect is delayed and can take about one to six hours to achieve the peak effect, and patients get into trouble because of this phenomenon. A lot of times they will, if they’re not used to using edibles, they will keep ingesting it and then they’ll develop a syndrome of severe intoxication when it hits them.

In terms of the physiological effects, we know that cannabis causes increase in heart rate, increase in blood pressure, bronchial relaxation. Patients can have a dry mouth. In fact, I have parents that tell me– they can tell when their child’s used cannabis because the speech is altered because the child’s mouth is so dry. And then the well-known effect of red eyes or a conjunctival injection.

So as you talk to your patients about their cannabis use, it’s important to understand the positive effects so you can have these conversations with them. There’s a wonderful phrase in the literature called a calming euphoria. I think that’s what patients are seeking. Patients will also report a decrease in their anxiety, heightened perception. Generally patients feel more social after using cannabis.

There’s this interesting sensation of time slowing. I’m sure you’re all familiar with the munchie effect or increased appetite, and a subjective decrease in pain.

So certainly it’s important to note the negative effects as well of acute intoxication. Some patients will report paranoia, worsening anxiety, irritability, we know that cannabis affects short-term memory, it affects attention and judgment. You may not know that it also affects coordination and balance. It can cause a distortion in spatial perception. And again, there’s this interesting change in awareness of the passage of time.

It’s important to point out that several of these neurocognitive effects have what we call a hangover effect, so they are present for up to 24 hours after use, possibly even longer. And again, as you think about patients in your practice who are new drivers, these are significant effects.

So part of the story is that marijuana or cannabis has become much more potent over the last few decades. When I use the term potency, I’m referring to the percentage of THC in the cannabis product. And so looking at this graph, if you were to smoke a joint in 1995, the potency would be about 4%. You could see that a joint in 2018 would be about a four-fold increase or 16% potency, and this is deliberate on the part of the cannabis growers.

What’s even more alarming is if you look at cannabis vaping devices, the average potency of these devices can range anywhere from 70% to 90%. I got these images off the internet. You can see this Fruity Pebbles cannabis vaping device. You can speculate who the target audience is of a device like that.

And one thing that’s important to understand about these vaping devices is that they’re much more discreet than combustible cannabis. They don’t generate the same classic odor, and so kids can often use them in plain sight. Looking at this ad on the right, which I covered with a mark, because I’m not advertising cannabis, obviously, but the point is vape cartridges are portable, discreet, and convenient. They don’t smell like Snoop Dogg just walk by, and kids know this.

So as we see this increase in THC content, it’s really significant. We’re much more likely to see adverse effects. This is data showing an increase in emergency department visits for cannabis over the past several years. And by adverse effects, generally these are psychiatric. Patients will go to an ED with severe anxiety, severe panic, paranoia, hallucinations, erratic mood swings, or aggressive behavior. So patients respond differently to these higher potency products.

All right, so back to what THC does. So I mentioned that we have an endogenous cannabinoid system that is present in the brain, and THC is able to exert its effects because of chemical similarities to these endocannabinoids. Anandamide is the one that we know the most about, and that word means bliss. I think it’s based on the Arabic.

So in the spirit of a picture is worth a thousand words, this is the brain in cross-section. Everywhere you see a purple dot is where there is a cannabinoid receptor which binds THC. And so really, the impact of this visual is, wow, there are a lot of purple dots. And you can see, they’re really throughout the brain. What’s interesting is there are no cannabinoid receptors in the brainstem which is why we don’t see respiratory depression or overdose the way we do with opioids.

So there’s been a lot of work trying to understand the purpose and the role of the endocannabinoid system. Generally, its point is to dial down neuron activity and it has effects on a various number of neurotransmitters in the central nervous system. When you compare THC to anandamide, the analogy that I like best is a sledgehammer, THC, versus anandamide. THC has a much stronger effect and a much longer-lasting effect.

And what’s really important to understand is we’re learning that the endocannabinoid system plays an important role in brain development. In fact, these receptors are present in fetal tissue, so this starts very early on. And we believe that this is the essence of why cannabis interferes with brain development, by interfering with the normal functioning of this system.

All right, now we’re going to talk about a few more adverse health effects of cannabis. I would recommend that all of you read an article that was published in the New England Journal of Medicine in 2014– well, it was a few years ago, but it’s still very relevant– discussing the adverse health effects of marijuana use.

And the authors separated the effects into those of short-term use and those of long-term use. So looking at the effects of short-term use, they cited impaired short-term memory, which makes it difficult to learn and to retain information. Think about the developmental task of adolescence, which is to learn. And I will also mention that with these vaping devices, there’s a lot more cannabis use now that’s taking place during the school day.

Cannabis does cause impairment in motor coordination. This has relevance for athletes and drivers. We know that like any other psychoactive substance, cannabis will negatively impact judgment, and this will make adolescents at risk for a host of high-risk behaviors, including sexual behaviors. In high doses, particularly with these potent devices, we also see paranoia and even frank psychosis.

This slide highlights the effects of long term use, and the authors put an asterisk next to those effects that were particularly significant for users who began using in adolescence. And so I’ve gone ahead and drawn a red box around those effects. It’s a myth that cannabis is not addictive, I will tell you that it is. In the literature, the number quoted for all comers 12 and up is that about 10% of users will develop a cannabis addiction.

That number doubles to about 17% if you begin using in adolescence. And certainly, if you have patients who are daily users, the percentage who are addicted or have a severe cannabis use disorder is much, much higher. Cannabis is associated with an alteration in brain development. Also, it’s associated with poor educational outcome. We see this in ASAAP all the time, patients who have a significant decline in their academic performance and possibly don’t even stay in school.

During our last session, we talked about cognitive impairment associated with cannabis use with the study demonstrating the drop in IQ. And sometimes I think in medicine, we don’t focus enough on qualitative factors. And so it has been proven or shown, demonstrated that cannabis users tend to have diminished life satisfaction and achievement over the lifespan, so that is a significant impact as well.

We know that cannabis does increase the risk of psychotic outcomes independently of transient intoxication. We’re particularly worried of patients who might have a genetic predisposition to a psychotic disorder such as schizophrenia.

There’s a lot of studies that are looking at anatomy and functional brain imaging trying to tease out what effect cannabis is having on the brain. This is an important study. The structure that is colored is the corpus callosum, which is the largest white matter tract in the brain, that connects the two hemispheres.

Hopefully you can appreciate on my slide the normal width of the corpus callosum on the slide on the left. This shows substantial narrowing in a daily cannabis user, and this narrowing is similar to what you see in the brain of a patient with schizophrenia. So the thinking is that cannabis over time causes some sort of an effect on the brain that mimics the changes that take place in schizophrenia.

Hopefully many in my audience today have heard of Cannabis Hyperemesis Syndrome, we call the CHS, which we don’t fully understand, but it’s a syndrome in which typically patients who are heavy cannabis users develop a syndrome of intractable vomiting. They’re vomiting multiple times a day. They typically will present to an emergency department at least once. They often get a million-dollar workup, and cannabis use is usually discovered later on in the workup and presents as a diagnosis of exclusion.

I will say that one of the pathognomonic features of this syndrome is patients feel better in the shower. And so if your patient is telling you that they’re vomiting multiple times a day, they’re taking 10 showers a day and they use cannabis, you would be wise to think of this syndrome.

As I mentioned, we in ASAAP are hearing more about edible use over the past few years. I believe that tracks with the increasing number of dispensaries in our area. We know that these can contain high amounts of cannabis or they can be potent, and they’re often in foods that would be attractive to young children and also mentioned to pets. We’ve had a number of families where the pet ends up at the vet severely impaired because of cannabis ingestion.

Colorado did a study early on after they legalized cannabis which showed a significant uptick in calls to the Poison Control Center and ED visits for younger children who had ingested cannabis, and some of these children can become quite ill, even end up in an ICU.

This was a news story about a year ago from one of our local high schools showing that, again, this phenomenon where high school students end up in the hospital after eating edibles, this happens. All right, this card was shared with me a few years ago from someone who had been doing SBIRT in the BMC Emergency Department. I think kids are visual learners, so I really like this card that focuses on cannabis effects on numerous parts of the body.

I will say that we know the most about the effects on brain and mood, but we’re starting to fill in the blanks with other organ systems. As well I’ll mention that over the years, we’ve had a number of boys in our practice with gynecomastia, and there is a literature suggesting that this is linked to cannabis. And so we’ve shared our concern with these patients.

So there is most definitely a syndrome of cannabis withdrawal. This would be particularly relevant for your patients who are heavy users and then stop abruptly. This is described in the DSM-5. The number one symptom is mood. Patients are anxious, they’re irritable, they’re angry. That’s, I’d say, the biggest effect.

The sleep disturbance is also well-described. Patients will have trouble falling and staying asleep. They’ll often have vivid dreams. Patients also report a decrease in appetite which can be associated with weight loss.

Over our sessions, as we talk about withdrawal states, this will be true for nicotine as well, typically when you’re thinking of the withdrawal state, it is the opposite of the intoxication state.

So certainly it’s important to know about the effects of cannabis on driving as you have conversations with your patients. This slide should look familiar, it’s the brain in cross-section, but instead of purple dots, I’m highlighting the functions of the areas of the brain that are most impacted by THC. And obviously, vision, judgment, coordination, movement, these are all central to the act of driving.

There have been a number of studies using driving simulators looking at the effects of acute THC intoxication on driving, and we know that it affects attention, working memory, coordination, reaction time– this is measurable, and visual perception. I learned this only recently that it affects peripheral vision.

And then we’ve talked about this perception of time. And so it affects time distance judgment, which is very important when you’re driving. And I used to say when people would come in person to see these talks, when you’re driving to work, think about how you would drive if you didn’t have good peripheral vision.

Also, keep in mind that if your patients are using cannabis and alcohol together, this can be catastrophic for their driving. For THC, patients can try to compensate with behavioral strategies. On the other hand, if they have alcohol on board, they lose the ability to compensate for their cannabis– the effects of cannabis on their driving, and so they are more impaired. There’s like a synergy. They’re more impaired for the combination than they would be for the amount that they used of either one by itself.

There’s an important study I would encourage you to read that was published from McLean in 2020 which showed that patients with chronic cannabis use showed a degree of driving impairment even when they weren’t acutely intoxicated. So this will definitely fuel your conversations with your patients. Fuel, no pun intended. I thought that was funny.

All right, so as we talk about medical cannabis, if your patient asks you for a medical cannabis card, I would urge you to say no. The way to think about cannabis is there is a lot of work looking at some of these individual cannabinoid compounds, and there’s no question that some of them either have been shown to have therapeutic benefit or will be shown in the years to come, but that wouldn’t be the same as advising a patient to use cannabis.

The analogy that I like to use is we know that antibiotics were first isolated for moldy bread, but you would give the patient the pharmaceutical product, not the parent, not the moldy bread.

Interestingly, if you look at studies of why people are requesting medical cannabis, by far, the most common indications are things like anxiety, insomnia, chronic pain, and depression. And the take-home is we just don’t have an evidence base that medical cannabis is effective. And again, I sound like a broken record, but we know that it causes harms. So it does seem clearly that the risk outweighs the benefit. This slide is just to illustrate that we do not have an evidence base for what people are seeking it for.

There is a short list of FDA-approved medical cannabinoids. It’s good to know about these. And this list may grow over the next few years. In pediatrics, the only FDA-approved cannabinoid is Epidiolex, which is cannabidiol, which was shown very convincingly to have a positive effect on certain rare and intractable forms of pediatric epilepsy. So yes, those are the indications, but not for medical cannabis.

I would encourage you to follow the news and to watch what the cannabis industry is doing. There are some eerie similarities to what the tobacco industry was doing in the last century. If you have time, I would encourage you to read a great article or a great piece, “Big Marijuana– Lessons from Big Tobacco,” that was written by Sharon Levy, who’s our program director, which goes over in detail what these similarities are.

And the punchline is that the tobacco industry achieved the degree of success that it did by changes in product design, marketing, and lobbying, and we’re seeing those same changes or transformations in the new cannabis industry. This is an example of marketing. This is what you might see on the internet. This is an ad for Pure Gold which is 100% potent. Remember, we’re talking about this alarming increase in potency. And this is how it’s advertised.

Because this product is so potent, you don’t need a large amount to get high, so it’s cost-effective I guess is the argument. And it reduces exposure to other toxins. There’s no basis for this claim.

We know that cannabis is being marketed to kids. Recall my Fruity Pebbles vaping device. This isn’t subtle. And if you’re like me, you’ll have a sense of deja vu and remember the Joe Camel debacle in the last century.

So the American Academy of Pediatrics published a policy statement in 2015, another important read that I would encourage you all to look at. There’s also a technical report that was published going over a lot of the details of cannabis use.

And the AAP clearly stated that pediatricians should oppose the legalization of marijuana and that we should support studying the effects of recent laws– remember my map in the beginning of this presentation– so that we can understand the impact of these laws and define best policies to reduce adolescent cannabis use. We have to speak up for adolescents.

All right, so now we’re going to switch gears and think about what you can do in your practice for patients who are using cannabis. These are questions that we looked at last time. So you’ve done your screen, you know that your patient is using cannabis, you want to get more information. And so I won’t go over these because we talked about this last time, but feel free to use this as a cheat sheet as you get more comfortable.

So again, the name of the game is to clear up any misinformation, give your patients advice to quit. If you’re comfortable enough and you’re well-read about the effects of cannabis, then you will know what to say, for an individual patient, and you want to tailor it to what they think is important.

So examples would be teens who use cannabis are more likely to have mental health disorders, including anxiety, depression, suicidal thoughts, and psychotic disorder. We know that cannabis interferes with brain development and is associated with decreasing IQ. Teens who use cannabis are more likely to have school problems and not do as well in their education or career.

So again, I’m a broken record, but you want to advise all patients that abstinence is best. If you can, I would suggest that you recommend that they do an abstinence trial. Now if you think they’re receptive, I would recommend a one-to-three-month trial. The idea is they stop using and then they come back and they tell you what they noticed.

You’ll have patients who are resistant, and again, it’s perfectly acceptable to use a harm reduction approach in this setting. And so examples would be if a patient is using seven days a week, you can try to convince them to stop using during the week to limit their use to the weekends and then come back and talk to you.

I’ve even had patients where the best I can do is, they’re using every day, how about you stop using on Tuesdays and then come back and tell me how it goes? So again, you meet where they’re willing to meet.

All right, so this is another slide that goes over cannabis withdrawal. This is a little more specific in terms of a time frame. It’s very important, if you’re encouraging patients to do an abstinence trial, that you offer them support around the withdrawal symptoms because as we’ll talk about when we talk about opioid use, one of the strongest drivers of returning to use after trying to quit is not feeling well because of the withdrawal, and that happens with cannabis as well.

So very early on, patients feel more anxious, they lose their focus, they’re irritable, and they have trouble sleeping. There are a surprising number of systemic effects as well. Patients will talk about sweating, headache, nausea, vomiting, cravings, decreased appetite as we mentioned. Then over time, the lingering effects are generally the mood effects, anxiety, depression, craving, and sleep disturbance.

So the most important approach is to be proactive, to talk to patients about their withdrawal symptoms, and to brainstorm about ways to support them. So for patients who have significant appetite loss, you can consider an appetite stimulant. Patients with nausea, Zofran or ondansetron is an excellent medication. You can consider giving them a sleep aid if they’re having trouble sleeping. Melatonin is over-the-counter, hydroxyzine can be prescribed.

Patients who are having headaches, you can recommend over-the-counter analgesics. And then patients, particularly if they have pre-existing anxiety, will definitely report worsening anxiety. And so you could consider use of a prescription medication to treat their anxiety. And again, this is short-term use, I would say, on the order of two to four weeks. Certainly you want to avoid anything in the benzodiazepine family or gabapentin because we know these have intrinsic potential for addiction.

I’d encourage you to hold on to this reference. Dr. Diana Deister, who’s our psychiatrist, has given us support over time with what medication she likes for these symptoms. I think her favorites are mirtazapine or buspirone, Buspar, pictured at the top and at the bottom. And these are good choices because they can treat a variety of symptoms of cannabis withdrawal. If you need any support around this, I would encourage you to call our consult line and ask for support around the best use of these medications.

So over the past few years, we have started using an N-acetylcysteine for the treatment of our patients with cannabis use disorder. I will call it NAC, it’s a lot easier to say. And if you haven’t heard of NAC used for this indication, you might be remembering it as a reversal agent for acetaminophen overdose. This is, in fact, the same N-acetylcysteine. And this is generally available over the counter. Think I skipped a slide.

There’s been a lot of research looking at NAC in psychiatry and addiction medicine. It seems to have a very significant effect on substance use. We think that the reason is it has some effect on glutamate modulation in the nucleus accumbens, which I mentioned in our last talk, is part of the reward pathway or the pleasure center of the brain. Certainly when you give NAC to animal models, they have a marked decrease in drug-seeking behavior.

So Gray did the initial studies that he published in 2012, and we’ve been in touch with him on a number of occasions. And he is blessed our treating our patients with NAC. He found that patients who were between the ages of 15 to 21 being treated for cannabis use disorder, they were also getting a behavior intervention.

They were getting contingency management. The patients who received NAC were more likely to have negative urine drug tests for cannabis compared to the patients that were receiving placebo. And so this was enough for us to consider using NAC for this population. I will say that it’s not FDA-approved, but we are very comfortable using it for this indication.

Generally, it’s well-tolerated. Patients might complain about two things– the size of the capsule, which means they’re a little hard to swallow, and they don’t taste or smell very good, but you can get past that by taking them with food. The target dose as reported in the literature is 1,200 milligrams twice a day. These are available in 600-milligram capsules.

Because I’m always worried about side effects, I didn’t mention this, but they’re typically GI. I like to bring patients to the target dose slowly. So an example of a dosing schedule is pictured below where you have from day 1, 600 milligrams in the morning, to day 4, you get them to the target dose. If you have a patient that you know is sensitive to medication, you can make this slower. Generally, the literature supports continuing this for eight weeks. On the other hand, if a patient is doing well, you can continue it for longer.

Often in the Q&A, someone will ask me a question about cannabidiol or CBD, and in fact, we had an email this week from one of our social workers, a patient with suggesting that she switched to CBD in order to stop using THC. I’m going to give you a qualified answer to this.

Interestingly, there was a study published fairly recently that showed that for individuals, wide age range, with severe cannabis use disorder, a four-week trial of CBD, 400 milligrams a day, seemed to be effective in reducing their use.

The caveat is, my take-home is that I do not recommend using CBD for this indication. Patients may bring it up, which is why I wanted to include the slide, because we don’t know the long-term effects of CBD and I’m not comfortable recommending something that has been poorly studied.

Another really important reason not to use it is that these products are generally unregulated. You really don’t know what you’re getting when you purchase CBD. And in fact, we know patients who have been using CBD have THC in their urine drug tests and they swear up and down all they’ve used is CBD and we believe them.

The only caveat is, if you have a patient with a severe cannabis use disorder who is asking if they can use CBD instead, since they’re already using THC, is CBD safer than THC? You can have an individualized conversation with the patient, but I am distinctly not recommending using CBD in this context. I want to make sure I’m clear about that.

So as you’re monitoring these patients, there are a number of tools that you can use. We’re going to talk at our next session about drug testing to monitor levels. All of these patients that we’re talking about today will benefit from counseling, that’s a no-brainer.

And so I would encourage you to partner with a behavioral health clinician in your practice. We also have virtual counseling available through MDCAP which is really wonderful in this setting. I also want to point out that a lot of these adolescents will have co-occurring anxiety or depression and would benefit from psychiatric care.

All right, so we’re going to just mention a few profiles of patients that you will see in your practice if you haven’t already. One example is Jacob who is a 17-year-old junior in high school. This is a fairly typical story. He started using cannabis in ninth grade. At first, his used for sporadic, and then he purchased his own dab pen, which meant that he can use in his bedroom– he could use in plain sight. And since then, he became a daily user.

Jacob does not think his use is a problem. It’s legal, what’s the big deal? All my friends do it. Remember our discussion about stages of change. He would be pre-contemplated. He also has a history of anxiety and believes that cannabis helps him cope. As you discuss with Jacob, he thinks parents are aware of his use, but likely not the full extent.

So this would be a perfect treatment plan for Jacob should you meet Jacob in your practice. You want to recommend abstinence. If he refuses, try to come up with a plan that he will agree to cut back for an abstinence challenge and you’ll support him around any withdrawal symptoms that he develops.

You want to refer him to a therapist to discuss both his anxiety and his cannabis use. I would start Jacob on an N-acetylcysteine, I would start weekly drug testing, and partner with him to see if he can lower his levels. You want to follow up, that’s the most important piece. So I would recommend seeing him monthly to see how he’s doing and also to look at these drug test results. If he allows you to open the door and meet with his parents, that would be helpful as well.

I’m going to share three other patients who are maybe a little more complicated. These are patients that I’ve treated in ASAAP over the years. And I think because we have so much to cover, I’m going to kind of summarize the highlights instead of making it participatory just because we have a lot to cover.

Adam is a 15-year-old high school freshman living in a Boston suburb. He had a diagnosis of generalized anxiety disorder since early elementary school. Adam was– I’m using the past tense because I saw him a couple of years ago. He was a talented musician, but this was not always a good thing because his friend group was older.

Adam started using cannabis sporadically when he was an eighth grader. He quickly escalated to daily use and he preferred smoke cannabis and a dab pen. He had tried other substances, including psilocybin, or mushrooms, and Xanax. His mother was aware of his anxiety and his cannabis use. She brought him to a psychiatrist who prescribed fluoxetine.

I’m sure you’ll meet Adams in your practice who refuse pharmaceutical products because they believe that cannabis is natural and plant-based. They trust cannabis but they don’t trust prescription medication.

There was a complicated backstory for Adam. His parents were divorced and his father had a lengthy history of hospitalizations for bipolar disorder and severe substance use. So this was a complicated kiddo.

And again, in the interest of time, what really jumps out about this case is in order to treat Adam’s cannabis use disorder, you have to find some way in to treat his very real anxiety disorder. And so that was something– he met with a psychiatrist who was willing to try nutritional supplementation and other avenues because of his resistance to pharmaceutical products.

Genetic loading s obviously a big deal for this young man or an important factor. And what I remember most about Adam is mom had a lot of guilt. She had guilt about the divorce, guilt about dad’s poor health and his anxiety, and it was very hard for her to set limits even though he was a relatively young patient for ASAAP. And so in this case, working with mom so that she would set limits was essential.

All right, another patient from ASAAP. Cindy was a junior at boarding school who was referred to us because she got in trouble at her boarding school for using a nicotine vaping device. And so before she could return, she was required to do some sort of treatment, and so she began her ASAAP evaluation.

What was interesting about Cindy is that she was motivated to stop using nicotine, but she also used cannabis regularly and she had no interest in discussing her cannabis use. So again, you can be a different stage of change for a different substance. And you might see patients in your practice who are willing to cut back on one substance but not another.

And so the important point is that the door opens when they’re willing to discuss with you use of one substance. And so we take that, we started treating her for our nicotine use disorder, and then every conversation we had, we were doing some motivational interviewing around her cannabis use.

All right. We’ve seen, unfortunately, too many patients like Luke. Luke was a 15-year-old high school freshman. He was actually living with his grandparents. His biological father died of a heroin overdose when he was a small child and his mother was doing OK, but she was living in a sober house in Connecticut, mostly out of the picture right now.

So Luke had started using cannabis a few times a week. One out of 10, not at all willing to stop using cannabis. His grandparents had set some limits, and so he had cut back, but he was completely pre-contemplative. No use of other substances at this point. Luke had a very significant psychiatric history, including alphabet soup– major depression, generalized anxiety disorder, PTSD– he had had a very turbulent early childhood– and ADHD.

Thankfully there was a community therapist already involved who was interested in doing trauma work when it seemed like Luke was ready. How concerned would you be about Luke? The answer is extremely concerned. This is not a patient with his history who should be using any psychoactive drug. And again, we’ve seen a number of these patients over the years.

So we work very closely with the grandparents trying to set limits around his use, raising this to the level of urgent. And then again, that psychiatric piece would be extremely important in Luke’s treatment, including the trauma piece, which would require skilled care in the community.

All right. So I’m going to stop. Virginia, I don’t know if you can take over or if we want to open it up. We’re going to do a question-and-answer for cannabis, and then we’re going to talk about nicotine. All right, so I’m to–

VIRGINIA SANABIA: Sure. I can take over just in case there’s anything on the chat.

MIRIAM SCHIZER: Or we will ask the group. Does anyone have questions about cannabis? It’s also a good chance to stretch if you want to stretch.

VIRGINIA SANABIA: We have one participant that raised her hand.

MIRIAM SCHIZER: And you can say the question or you can put it in the chat. Personal preference.

VIRGINIA SANABIA: Katherine, you can go ahead and speak.

AUDIENCE: I just have a question about drug testing when the patients aren’t super on board with it. I feel like– I remember learning in medical school or in residency at some point that there is some controversy over forced drug testing or that could actually be pretty detrimental to the therapeutic relationship if there was just disagreement over that.

And so I was wondering what your approach was to– you’d recommended weekly drug testing for some of these kids and I was wondering how you approach that if they weren’t excited or very into that suggestion.

MIRIAM SCHIZER: Yeah. No, thank you, that’s a fantastic question, and I’m going to cover that in a little more detail at our drug testing talk. But it’s actually a hard no, that the American Academy of Pediatrics says it’s a no-no. That’s kind of a silly phrase, but says that we should not get a drug test from an adolescent without his or her consent. Every now and then we’ll get a patient referred to us where a test was done without their knowledge, and that’s a big no-no.

It also puts you in a rabbit hole because if you get a result, how do you talk to the patient about the result when they didn’t know you were testing? And so typically what we do is if parents are involved then there’s some logical consequence, OK, you don’t want a drug test, then we’re not going to let you drive the car because we’re worried that you’re using substances.

So it’s not coercion that’s used, necessarily, and it’s certainly not covert secret drug testing, but it’s more use of logical consequences to give the adolescent a push towards drug testing. Some patients will still say no, I’m not going to do it and then we’re stuck. But it’s, again, using motivational interviewing or more effectively parent consequence so that the patient will cooperate.

I will say, in patients who are using cannabis and the cat’s out of the bag, we know they’re using cannabis, then often they will partner with us so that we can see their levels because we’re not telling them the test has to be negative. We’re just saying, let’s see if you can use less and get lower levels. And sometimes, if they have a competitive nature they will play that game with us. Thank you, excellent question.

All right, anyone else with a cannabis question? If not, we’ll go to nicotine.

VIRGINIA SANABIA: It looks like that’s it. Nothing on a chat.

MIRIAM SCHIZER: All right. Well, if you think of a question, we’ll have a Q&A at the end. So we can certainly talk about cannabis then as well. All right, do I still have control, Virginia?

VIRGINIA SANABIA: Yep. I’m going to hand over control right now.

MIRIAM SCHIZER: All right. And everyone, feel free to stretch. I know 90 minutes is a long time to sit. All right, so now we’re going to switch gears and we’re going to talk about nicotine vaping. All right, so certainly you know that this has reached epidemic proportions. In 2016, the US Surgeon General himself declared vaping a national epidemic among adolescents.

This is data from Monitoring the Future, which you now know well. 2019 appears to be peak use in what we’ve seen with nicotine. Hopefully we won’t see these numbers again. And the rise in nicotine vaping from 2017 to 2019, you can look at the right side of the slide, was the largest increase ever seen in the Monitoring the Future Survey.

So as of 2019, 25% of 12th graders had used nicotine via vaping in the past month, 20% of 10th graders, and 10% of eighth graders. Really just spend a moment wrapping your head around these numbers.

So this is data bringing us to 2021. You can see on the left what daily nicotine vaping looks like. The numbers are possibly lower than what you might expect. And then past month vaping, we have seen a decline since 2019. I’m a little worried that the 2021 numbers aren’t accurate because patients weren’t in school for the full year, and as we know, there’s a lot of vaping that takes place in school. But we’ll see.

There’s also a component of the Monitoring the Future Survey that I haven’t talked to you about which looks at college-age youth and also youth of the same age who aren’t in college, and we’ve seen a very significant increase in vaping in this population as well. You can see in 2021, 25% of young adults not in college and 20% of college students had vaped nicotine in the past month. So certainly as you’re seeing college students home for their physicals, you want to be aware of the widespread nature of this phenomenon.

We get a lot of information from the National Youth Tobacco Survey. This is data from 2021. And the question is, what percentage of high school students are using tobacco products? So that number overall lands at about 25%. And then the punchline of the slide is about 20% are using them– so the biggest number is for e-cigarettes. So tobacco or nicotine use in the year 2022 appears to be in the form of e-cigarettes, and we know this.

So I will tell you that about 85% of adolescents who use e-cigarettes are using flavorings. We know that the industry knows this and they’re targeting their products with flavorings to adolescents and young adults. And then this shows you– again, this is information from the National Youth Tobacco Survey looking at different types of e-cigarettes, and there are a number of different types available.

Really, the important visual is look at how many are using fruit-flavored, mint flavors, candy, dessert, other sweets, or menthol. And the industry knows exactly what they’re doing and they know that this is for the adolescents, not the adults.

So I always like reviewing this information. What are the reasons that teens give for vaping? I think this is an important way to think about it. So 60% said they’re using these devices to experiment, to see what it’s like. Think of how teens love technology. These are these, quote, “cool devices,” end quote.

40% say they use it because it tastes good. Again, this is– if we could ban all devices with flavorings, we would be making a huge step forward because the kids really like the flavorings. 40% say vaping to have a good time with my friends, 40% say to relax or to relieve tension. 30% say they’re using these devices to feel good or get high again. So this slide is also capturing teens who are vaping cannabis.

And then I also want to highlight that 30% said that they’re bored and they have nothing else to do. And so as you follow patients in your practice, as they approach the teen years, it’s really important to make sure that they have ways to fill their time and that they’re structuring their time because we know that idle time or boredom is a huge risk factor for substance use.

The other point I want to make in the patients who are vaping to feel good or get high, it’s surprising that some patients will vape and they don’t know what is in the vaping device that they’re using. That’s something that seems very foreign to us, but if you’re an adolescent, that could be the case. Again, we’re talking about marketing, this is nicotine’s new look. These are images that adolescents are exposed to, the new look of nicotine.

There are a number of different types of e-cigarettes or vaping devices. As you get histories from your patients, I would encourage you to ask them the brand that they’re using, what sort of device just so you could learn what’s out there. We’ve seen a huge rise in recent years in disposable e-cigarettes, e-cigarettes with pre-filled cartridges where you buy the device and then you can refill the cartridge. The JUUL was an example of that.

And then there are boxy types, tanks or mods or pod mods. I don’t fully understand the nuances of all of these devices, but it is good to talk to your patients about what they’re using.

One of the most disturbing aspects of this vaping phenomena is that adults, parents are often not– teachers are often just not familiar with what these devices look like and they are deliberately made to look like other things. And so this is an example of vaping devices that look like a pen and a cell phone. If you saw these in a backpack, you wouldn’t necessarily give it a second thought.

I think this picture bothers me the most for obvious reasons. You can use a vaping device that looks like an asthma inhaler. That just really pushes all my buttons. And then these are advertised on the internet. You can get a vape hoodie, I couldn’t make this up, which is the strings of the sweatshirt are actually occult vaping devices.

So for years we were hearing about the JUUL. In fact JUULing was a verb synonymous with using an electronic cigarette. The way these work is you would buy the device and then there would be cartridges that you could use up, or pods, and then purchase again.

What’s important to know about JUUL pods is they contain an awful lot of nicotine. The amount of nicotine one joule pod is equivalent to 20 cigarettes or a pack of combustible cigarettes. And certainly, these were marketed to kids with youth-friendly flavors. My patients used to tell me about mango, mint, and peach.

So finally, the FDA issued a policy in April of 2020. In this policy, they banned the sale of any ENDS– remember that’s an Electronic Nicotine Delivery System– any ENDS product that contained pods or cartridges with flavors other than tobacco or menthol. They also prohibited the sale of these devices to minors and the sale of any tobacco product to anyone under 21 years of age.

The problem with that ban is that there was a fairly significant loophole that the industry took advantage of, which is the ban was specifically on pods or cartridges that were flavored. And so this led to a surge in these disposable e-cigarette devices because technically they follow the letter of the law because you don’t refill a pod.

And so I’m hearing a lot about puff bars– you’ll see the picture on the left– Which is what a lot of kids are using these days, which are clearly fruit-flavored and attractive for adolescents.

All right, now we’re going to think about both the acute and the long-term health risks of vaping. When you think about the acute harms, we’re primarily discussing injuries or illness associated with inhalation, ingestion, or malfunction of the vaping product. So hopefully everyone in this audience is familiar with EVALI, which is E-cigarette or Vaping Associated Lung Injury. You’ll sometimes see it as just VALI.

And so a typical story of this would be someone who’s previously healthy, has used some sort of a vaping device in the past 90 days. They have definite pulmonary infiltrates on imaging and a workup looking for an infectious etiology is negative. It’s interesting that this was the big story in the fall of 2019 before COVID became the next big story.

So there was a lot in the news, particularly in the fall of 2019 when the news broke about this condition. This was an example of an ABC News story of a teen who was put on life support for vaping. She said, I didn’t think of myself as a smoker. And certainly patients who are vaping nicotine don’t think of themselves as smokers or anything like that. There’s the visual image. I won’t say a word, but I’ll just let that sit with you for a moment.

All right, so the case definition of EVALI, a confirmed case, as I mentioned, is the patient must have a history of vaping in the 90 days prior to presentation. They have definite abnormalities on pulmonary imaging. And then when the initial workup is done, there is no other agent, there’s no infectious agent thought to be causing their symptoms, and similarly, there’s no other plausible diagnosis.

You can have a probable case if criteria 1, 2, and 4 are present. There is an infectious agent identified, but the thinking is, this patient is more ill than they would be just for that agent.

So whenever we meet a new patient when we do part 1 of our evaluation at ASAAP, every patient gets screened for EVALI and we ask a whole checklist of symptoms. As you would expect, respiratory symptoms are prominent. Patients will be reporting chest pain, cough, shortness of breath. I often ask about any change in exercise tolerance that the patient may have noticed over the intervals that they’re vaping.

GI symptoms are surprisingly common. Patients can have nausea, vomiting, diarrhea, or abdominal pain. And constitutional symptoms can also be present, including fever, chills, and weight loss. We’ll have a patient as an example who has a history of an unexplained weight loss, no other symptoms, has been vaping, and we consider that sufficient to refer them to vaping clinic.

Which is a perfect segue. The Pulmonary Division at Boston Children’s did a very quick pivot in the fall of 2019 and they set up a vaping clinic, and they would be happy to see your patients. You can reach them at vaping@childrens.harvard.edu, or there’s a phone number as well if you have any concerns about a patient.

Generally these are in-person evaluations. Patients come in, they get a full set of pulmonary function tests, a chest X-ray, and then an in-person evaluation with the pulmonologist. Even if the pulmonologist does not think this is EVALI, they do a really nice job of discussing the pulmonary harm, the risk factors of what vaping does to the lungs. So if you have any questions, if you’re not sure, you can give them a call or drop them an email.

So again, focusing on acute harms, despite the marketing that vaping is a healthy alternative, we know that there are constituents of e-cigarette vapor that are toxic. As an example, testing has demonstrated several carcinogens present in this vapor, including aldehydes, metals, polycyclic aromatic hydrocarbons. And it’s really interesting, the flavoring that I’m talking to you about, because kids love the flavoring.

I remember the pulmonologists very early on talking about how flavoring was not meant to interface with pulmonary parenchyma. So right away that’s a problem, that people are inhaling these flavorings.

One of the things to know about these e-cigarette devices is that patients can get a higher concentration of nicotine with a vaping– taking a hit, if you will, of a vaping device compared to using a combustible cigarette. And the manufacturers knew this, that’s what they’re going for. And so patients can sometimes develop signs of nicotine toxicity which can include abdominal pain, dizziness, headaches, and decreased concentration.

Kids have a name for this. They talk about feeling nic-sick if they use too much nicotine all at once. And frustratingly, some kids think it’s a badge of honor that they use enough to feel, quote, nic-sick. As I mentioned, some patients are using devices that require you to refill the cartridge.

And so there are these bottles of liquid nicotine that are suddenly floating about. They used to be marketed– they would have apple juice logos or popcorn or things like that. That is no longer happening, but we do know that if liquid nicotine gets into the wrong hands, this is toxic and potentially fatal.

These devices can malfunction and burn. These are actual photos of burns that people have sustained by these devices. I remember that the picture on the right is an adolescent who was driving and had a device on his lap and it malfunctioned.

We’ve had a lot of interest during the COVID-19 pandemic of the interplay between vaping and COVID-19. There is not a lot yet in the literature. There was a study published in 2020 in the Journal of Adolescent Health looking at youth between ages of 13 and 24. What they found was for individuals who are both vaping and smoking, they demonstrated that these individuals were at higher risk of developing symptomatic COVID-19 and also more likely to test positive for COVID-19.

It was less conclusive for just vaping. I think we have more work to do on this. But one thing that I would encourage you to think about is think about how patients share these devices. I’ve had a number of patients who are doing their own harm reduction. They’ve decided not to buy their own device, but they will borrow a friend’s just so they have some access. And think about the sharing of oral and respiratory secretions. It really is an infectious agent’s dream come true.

Now we’re going to focus on the long-term harms. This slide has to do with vaping, so it’s for both nicotine and cannabis use. I like this slide because I really want you to focus on the words at the top of the slide, which is we really don’t know the long-term health risks of vaping. And so you can say to your patients, how do you feel being a guinea pig and seeing what we’re going to a few years down the line?

We’re learning about pulmonary risks, we’re learning about cardiovascular risks, cancer risks. I’m giving a talk at a dental conference this spring and I’ll be discussing some of the oral health risks as well.

So we know that nicotine is extremely addictive. I think it’s important as you’re talking to your patients about nicotine to understand this cycle pictured on this slide. So an individual smokes a cigarette that could easily read “vapes.” Nicotine we know reaches the brain very rapidly. That’s one of the reasons it’s desirable, is that very rapid effect. The smoker feels instant relief, pleasure, whatever they’re going for in the use of the device.

But then what’s important is that nicotine has a fairly short half-life. And so after about 30 minutes, that effect is starting to diminish. And then what takes over is the patient develops withdrawal symptoms. So they go from feeling this nice effect to they don’t feel so good, and then that drives them to use nicotine again. And this is a cycle that repeats for a daily user numerous times throughout the day.

So we know that nicotine works on the reward pathway, which is really the center of the brain for addiction medicine. This is where all substances of abuse work. They lead to an increase in dopamine, which makes the brain want to do it again, and this is the pathway towards addiction. Again, the nucleus accumbens is a really important actor.

So we know that nicotine has adverse effects on the developing adolescent brain. I’ve mentioned how addictive it is, that– you can think of it similar to cocaine and heroin in terms of degree of addictive potential. We know that it produces persistent changes in the brain, and this is another example where a developing brain is more susceptible to harm than someone who’s over 25.

Nicotine has been shown to cause attentional problems, working memory problems in chronic users, and it’s also associated with mood disorder and impulsivity. So again, nicotine use is far from benign.

I think what is– one of the most tragic aspects of this vaping epidemic for my field is that over the last 20 years, we have made a significant dent in the percentage of adolescents who are using combustible cigarettes. Really, a public health success story, if you will. And now there’s a new population of adolescents who might not have used combustible cigarettes who are now attracted to these vaping devices. So those who use only e-cigarettes are potentially– I’m reading the slide– a new group of youth who would not have smoked otherwise.

When these devices were originally introduced, they were marketed as smoking cessation tools. The idea is adult smokers would switch from combustible cigarettes to vaping devices and then they could progressively wean the concentration of nicotine they were using until they were no longer dependent on nicotine.

We do not see that at all with youth. This would never be acceptable as a smoking cessation tool, and in fact, we’re seeing this go in the opposite direction where you start with e-cigarette use and then they transition to combustible cigarettes.

We also know that this population is more likely to be using or to use cannabis in the future, and it’s also associated with the use of alcohol and other drugs. It’s interesting how much controversy there is about the idea of gateway drugs in general. For this audience, I would encourage you to think of nicotine, alcohol, and cannabis all in their own right as a gateway drug.

So it’s important to understand the effects of nicotine versus the physiological effects of withdrawal. So when a patient uses nicotine, they feel alert. This is a short-term stimulant. We know that it reduces appetite. Some people use this as a strategy for losing weight. It causes an increase in blood pressure and heart rate and can cause palpitations.

The withdrawal symptoms have a slightly different flavor, and it’s important to know these symptoms cold when you talk to your patients about their vaping. So classically, patients report headaches, they feel anxious, they’re irritable, they have trouble concentrating, they’re restless, they’re hungry. You can also have physiological symptoms such as tremor, sweating, and dizziness. And remember my summary, that generally the withdrawal state is the opposite of the intoxication state.

One of the things I hear about from kids a lot, the kids particularly who are using multiple times a day, is that when they’re sitting in the classroom, they can’t focus because they’re having nicotine withdrawal and they’re just thinking about going to the bathroom to use a vaping device.

So as I mentioned, withdrawal symptoms show up within hours of the last use. If you stop, quote, cold turkey, generally symptoms will peak in the middle of the first week. That can be the height of this discomfort, and then will linger for about three to four weeks on average.

All right. So, what can you do about it? This is the punchline. At our last session, we talked about the importance of screening your patients for substance use, including nicotine. I really like the construct of the five A’s just to have a gestalt for what you are doing with your patients. You’re asking about their use, your advising them to quit, you’re assessing their readiness to quit– remember, the stages of change. You’re assisting them in whatever quit attempt they’re willing to make. And then can’t say this often enough, you’re arranging to see them in follow-up.

Nicholas Chodi was a fellow with us a few years back. He was fantastic, and he made this his field. And so he’s published very prolifically on the harms of vaping. He went– we lost him, unfortunately. He returned to his native Canada. I’d encourage you to read a position statement that he published in 2021, “Protecting children and adolescents against the risk of vaping.” Just a really nice summary of how to think about vaping in your practice.

These are assessment questions, and I have lifted these from Dr. Chodi’s paper. So again these are guides to what you want to ask your patients about when you’re discussing vaping with them.

So I’d encourage you to get to the products that are out there. So ask them what type and brand of vape they’re using. Are they using a disposable? Are they using refillable cartridges, et cetera. And you can ask them if you’re comfortable how they’re getting these devices. So you want to ask them what they are vaping. Hopefully they will know. I have told you that a small percentage of kids are vaping and they’re not sure what they’re vaping. So are they vaping nicotine, cannabis? Are they using the flavorings?

Some kids are more sophisticated than others and will know the nicotine concentration of the device that they’re using. Other kids will have no idea. They just– it hasn’t registered. You want to understand their history of using. How old were when they started vaping? Why did they start? What are they getting out of it? Why do they continue to vape? And then we’ve talked about the Holy Grail when you’re doing a motivational interviewing type of intervention, you want to understand what negatives they’ve experienced in their history of vaping.

So it’s important to ask them the context. There’s a very important question in the smoking cessation literature, that you want to know how long a patient is awake before they reach for their first cigarette that’s a very strong marker of the severity of their nicotine addiction. So similarly, is this someone who reaches over to their vaping device as soon as they wake up or do they wait a few hours?

You want to understand where they’re vaping. Are they vaping at home or at school or at work? Is this social for them or are they vaping alone? Interesting how things have turned upside-down where kids now are more likely to use substances at school than they are at home. I’ve seen a number of parents over the summer where they said, my child’s doing well this summer, but I’m really anxious that they’re going to go back to using when they get back to school, and this wasn’t the case as strongly five or 10 years ago.

Certainly you want to understand the frequency of their using. You want to be quantitative. How many days a week are they using? How many times a day? I had a patient recently who told me that he took 600 hits a day from his vaping device. I have no idea how he got that number, but certainly he was making a strong statement.

You can get some sense of how long their device lasts. You can ask him in contrast to their friends, do they go through these devices more quickly or more slowly? And again, you’re just trying to get some sort of a quantitative assessment of how much they’re vaping.

So this slide, again, motivational interviewing, looking for any negative consequences or reasons they might have had in the past to quit. So have they ever tried to quit in the past? If they did, how did that go? How long were they able to go without vaping? And then you want to ask them when they stop, what sort of withdrawal symptoms do they experience? How bothersome are those symptoms? And whether they get cravings when they’re not using.

So again, I would encourage you all to be very comfortable with the symptoms of nicotine withdrawal so you can list them for your patient and say, do you get this, do you get that, do you get that?

All right, so strategies for treatment. As I’ve mentioned, all of your patients should hear you say, for the sake of their health, you would recommend that they quit, that they not use at all. And then you want to see if they’re a candidate for nicotine replacement therapy. That’s primarily what we’re talking about today as the number one treatment for patients who are vaping and have motivation to quit.

So you want to ask them, as I mentioned, about cravings and nicotine withdrawal symptoms. If they’re experiencing either, then they are a candidate for NRT or Nicotine Replacement Therapy. Whenever you’re talking to your patients about vaping, you should be screening them for any symptoms of EVALI.

It’s important to note, we looked at the news story of a patient who had a fulminant presentation, but patients can also have subacute presentation. So you really want to screen for GI symptoms, weight loss, and then most importantly, any respiratory symptoms that they’ve noticed.

Always, when you can, connect these patients to counseling. That’s a fantastic intervention for all of these patients, and there are a number of ways to do that. We also give patients quit lines. There are apps that they can use that will support them around their efforts to quit. One of my favorites is called Quit Vaping, it’s downloadable for free, and I’ve had a number of patients who’ve done well with the Quit Vaping app.

So if patients are willing to initiate a trial of nicotine replacement therapy, you want to make sure they understand that this means they’re going to try quitting. They’re not going to continue vaping and wear a nicotine patch. They have to be willing to try a quit attempt. And I often encourage patients to set a quit date, and this is something that should be premeditated so they can really mobilize their resources to do this.

So nicotine replacement therapy is exactly what it sounds like. You are using the full agonist or nicotine to bind to these receptors so that over time, if a patient is ideally using the patch and supplementing with the oral forms of nicotine replacement therapy, they are going to experience a significant reduction in their withdrawal symptoms and also in their cravings.

Another indication, just something to think about is, if you have a patient who’s going to be hospitalized for some length of time and has a history of vaping, if they’re not going to be able– if they’re not going to have access to nicotine in that setting, they would be an excellent candidate for a nicotine patch.

So we’ve gotten– we at ASAAP have gotten very comfortable over the past few years using nicotine replacement therapy. And the idea is, the best way to do it is to use a combination of long-acting nicotine replacement, which is the nicotine patch, and short-acting replacement, which is either the lozenge or the gum.

I’ll mention that these are available over the counter for patients 18 and up. For patients under 18, you’ll want to write a prescription. And I typically will try a prescription even for older patients hoping that insurance will cover at least a portion of the cost. Generally this is safe and well-tolerated, so there’s really not a downside.

All right, so I mentioned my recommendation is to combine the long-acting and the short-acting. So as you give instructions to your patients on how to use the nicotine patch, this slide tells you all of the acceptable locations for where the patient can wear it. We recommend that patients put it on every morning as part of their morning routine. You want to make sure they’re rotating the site, that they’re not just putting it in the same place because that area of skin will get irritated if that’s the case.

Generally, we suggest that patients take it off before they go to sleep. Patients who wear it overnight often report vivid or disturbing dreams. I would say the only exception is, if you have a patient that has such severe nicotine addiction that they are vaping first thing in the morning because they don’t feel well because of their withdrawal, then that patient might benefit from wearing a patch overnight.

This was easier in terms of dosing when we were working with combustible cigarettes. For patients who would smoke over 10 cigarettes a day, which is half a pack, then they would be a candidate for the 21-milligram, which is the highest strength. This is always done as a taper. So I should say it comes in three different strengths, 7, 14, and 21-milligram.

For the heaviest users, they would wear the 21-milligram patch for about six weeks, then they taper down to the 14-milligram patch for two weeks, and then the 7-milligram patch for two more weeks. For patients with fewer cigarettes per day, it would be reasonable to start with a 14-milligram patch as mentioned Below

It is more difficult for sure when patients are vaping. We don’t have this easy conversion or substitution, so you have to use a little bit more of a gestalt. When patients were using the JUUL, that was all that we were seeing for a few years. It was fairly easy because a pod, as I mentioned, is equivalent to a pack of cigarettes. So a patient using a pod a day or more would immediately qualify for the 21-milligram patch. One-half to one pod, 14 milligrams. The patient that’s taking a few hits a day, you would start with a 7-milligram patch.

I will say that in ASAAP, a lot of the pediatricians tend to prefer to start with the lowest patch. So they are– if they’re not sure, they’re going to err and start with a 7-milligram patch and then instruct the patient to use either the gum or the lozenge, PRN, as needed for superimposed cravings or withdrawal symptoms.

So they’re wearing the 7-milligram patch and then they’re feeling withdrawal or they feel a craving, and so they use one of these other forms. And then ideally, if you follow up with a patient in one or two weeks, if they’re using 20 lozenges a day, then you are probably underdosing them on the patch. So again, it’s more of a gestalt with vaping devices.

So if you’re instructing patients to use the gum, there is a technique. This is– I say to patients, it’s not just like using a piece of Trident. There’s a method that’s called the chew-and-park method for using nicotine gum. And the idea is you put the piece of gum in your mouth, you start chewing it, then there’s this peppery taste as the nicotine is released, and then you want to park it in between your teeth and your gums for a few minutes.

And the idea is that if you chew it too quickly, you will swallow a lot of nicotine, and this usually makes patients feel nauseated, they don’t feel good. So you want to make sure they’re doing it in a more measured way so that it takes about 30 minutes for the gum to take place.

Certainly I’ve met patients who have sensitivities. They don’t like wearing things on their skin. And so it’s possible for those patients to just use the oral replacement therapy. It’s not as effective, but you work with what you have. And so in that case, you can have patients use these short-acting forms aggressively and then slowly cut back.

So we know from the adult smoking literature that both varenciline and bupropion have been shown to be effective for smoking cessation. So these are certainly sometimes used for patients who are vaping. Varenicline or Chantix is, in fact, the most effective monotherapy for adult smoking cessation. So this is appropriate for use in adolescents 17 or older.

We’ll be talking next time about opioid use and buprenorphine which is also a partial agonist. And so varenicline works the same way. It binds to the nicotinic receptor as a partial agonist, and as such, it gently stimulates the receptor and causes a decrease in both cravings and withdrawal symptoms. I’ve given you the dosing on this slide. Ideally, a patient would set a quit date and then start Chantix one to two weeks before for maximal effectiveness.

There was an FDA black box warning a few years back about possible suicidal ideation or adverse neuropsychiatric events. That was not borne out in larger studies, and so it was removed. The contraindication for both of these pharmaceutical products is seizure disorder. So if you have a patient who is vaping and has a seizure disorder, they are not a candidate for either of these medications.

Wellbutrin is an antidepressant. I’m sure you’re familiar with it. And this is a great choice for patients when you’re concerned about depression and also they’re vaping. We’re not exactly sure how it works, but it does work. The initial dose is 150 milligrams a day, and then after three days, you double the dose.

You can continue this for seven to 12 weeks. If a patient is doing well, you could continue it as an antidepressant. As I mentioned, the contraindication is seizure disorder, and also for this medication, an eating disorder.

So in terms of resources– I am going to stop momentarily so that we have time for questions. There are resources listed at the end of this presentation which you’ll certainly have access to. Number one resources, I encourage you to use our consult line if you’re seeing a patient with either of these problems and you’d like advice. We will call you back on the same day. And as I also mentioned, there is virtual counseling available through this service for your patients.

So conclusions for today. We know that adolescent cannabis and nicotine use are at concerning levels. In part, this has been fueled by the unprecedented popularity of vaping. We know that cannabis and nicotine have a number of adverse health effects, particularly in our population, particularly with adolescent brain development.

So you guys are in an excellent position to address this problem. There are a number of things that you can have in your toolbox, including screening patients for substance use, using these brief interventions to discuss substance use with your patients. Every patient should hear you recommend abstinence even if this is followed by harm reduction.

Nicotine replacement therapy works. I encourage you to use it, get comfortable with it. This should be your go-to for patients who are vaping. And for any of these scenarios, the most important thing is to follow up. This is not a one-and-done type of visit where you’ll fix it with one intervention, but it’s following these patients over time which will really lead to the best outcomes.

I’d like to finish with this slide. This is how I feel sometimes in my clinic talking to adolescents about cannabis and nicotine use. Certainly it is challenging, but I never shy away from a challenge, and this can be really rewarding as you go forward.

Thank you. I am going to stop for questions. There are a few additional slides which show resources, but I’m going to allow you to peruse that at your leisure.

All right, so I am opening it up for slides about nicotine or cannabis. And you can put it in the chat or we’d love to hear your voice, see your face. Virginia, do you want to see if there’s anything in the chat?

VIRGINIA SANABIA: Yes, I’ll check right–

MIRIAM SCHIZER: And if not– people are quiet, we can just look at the resources.

VIRGINIA SANABIA: OK. I don’t see any questions coming in. So let’s go ahead and give you control back.

MIRIAM SCHIZER: All right. Thank you for the back-and-forth, Virginia, thank you.

VIRGINIA SANABIA: Yeah.

MIRIAM SCHIZER: All right. So I think what I really want to emphasize is there are a lot of wonderful online resources for you to get more comfortable understanding vaping, understanding nicotine use, and talking to your patients. So there was an AAP policy statement talking about e-cigarettes, and there’s a curriculum that’s available online so that you can understand these devices better and talk to your patients.

So the AAP Richmond Center is another wonderful resource with really all you could ever want to know about vaping. And so again, I encourage you to look at some of these resources, tip sheets for parents, and other summaries.

This is particularly good. This is a fact sheet talking about nicotine replacement therapy. If we were all in the same room, I would ask for a show of hands of how many of you have used NRT or feel comfortable with it. Generally, it’s the more you do it, the more comfortable you feel and then get feedback from your patients. So you’ll see what works and what doesn’t.

Stanford has another valuable toolkit, tobacco prevention toolkit which will give you a lot of information about everything you need to know about these devices. So we recommend that adolescents check out the website teen.smokefree.gov. This is very age-appropriate targeted at adolescents with messaging around vaping. As I mentioned, there are apps that kids can use.

And the advantage of these strategies is that they are very much geared towards adolescents, and so I’d encourage you to check these out as well, smokefree.gov, so you can recommend it to your adolescent patients. Here’s another app, QuitSTART smoking.

VIRGINIA SANABIA: Sorry. We had a question come in. Is there a set of resources for parents to find?

MIRIAM SCHIZER: I would recommend some of these tip sheets. The Richmond Center had something for parents. NIDA is also a very good resource. That’s the National Institute on Drug Abuse. That’s a wonderful resource, you can spend some minutes checking it out. And they have information for clinicians, information for teens, and information for parents. So NIDA would be something that I’d encourage you in your free time to spend some time checking it out so that you can recommend it to parents. Thank you, excellent question.

All right, other questions, other thoughts? Anyone want to share an experience they’ve had in their practice with a patient with cannabis or vaping? Do you feel like you can do this? Do you feel like you can have these conversations and follow up with your patients? People feel confident that they can take this on?

Do I have the screen, Virginia? I think that might be the last slide.

VIRGINIA SANABIA: I can check. I think you have the control right now.

MIRIAM SCHIZER: I do, thank you.

VIRGINIA SANABIA: Yeah.

MIRIAM SCHIZER: All right. This is a very complicated decision tree, which I would encourage you to have at your access, and it just takes you through how to follow a patient, when to refer them to pulmonary, when to consider NRT counseling, et cetera. It fits a lot in on one slide. It’s a busy slide, but it’s a really nice summary.

The Impact of Opioids on the Adolescent Brain

MIRIAM SCHIZER: Opioid use in adolescents. So the objectives for these 40 minutes, we’re goingto talk some about epidemiology, we’re going to talk about the neurobiology of opioids, and thenvery importantly, I’m going to highlight the appropriate use of medication to treat patients withopioid use disorder.

It’s very important to think about Narcan or naloxone for the reversal of opioid overdose. And thenI’d like to close with some uplifting thoughts about how parents and medical providers can actuallyprevent– ideally prevent opioid addiction from ever taking place.

I’m going to do a free promotion. Our program has been asked by the PPOC to give a series of two-hour trainings on how to prescribe buprenorphine. This has to do with upcoming changes to theMassHealth ACO that are going to take place in 2023. And so I’m actually giving the firstbuprenorphine training on Tuesday, October 25. And so we’re going to talk about buprenorphinetoday, but this next session will be a much deeper dive. So again, please pay attention today, and ifyou’re interested, you could attend one of these trainings and really become more of an expert inprescribing buprenorphine.

So just to set the stage, I like to say that you would have had to be living under a rock to be unawareof the extent of America’s opioid crisis. I always use the slide because I find it visually arresting. Thiswas the cover of a New York Times Sunday Magazine a few years ago. “Inside a Killer DrugEpidemic– A Look at America’s Opioid Crisis.”

So this is data from 2020 looking at the number of national drug-involved overdose deaths, and Ithink this picture tells its own story. You can see how the number of people dying each year hasincreased dramatically over the last few years. The next slide is similar, except it’s only showing youdeaths in which an opioid was the cause of death. And you can see, if you compare the numbers,this is about– this is a very significant percentage of all overdose deaths.

This breaks it down by agent. This is an important slide. You will see that, especially since about2014, 2015, the steepest rise in overdose deaths are attributed to synthetic opioids other thanmethadone. Whenever you see that phrase, that is referring to fentanyl.

So fentanyl has become the major factor driving this dramatic increase in overdose deaths. You’llsee that prescription opioids was also related, and then heroin, and we’re going to talk about that ina couple of minutes. We’re also following a significant increase in overdose deaths due topsychostimulants, which is methamphetamine, because cocaine is a separate category.

So it’s interesting to think of the history of the opioid crisis. What we saw initially was the first wavewas a rise in overdose deaths directly tied to prescription opioid use that’s in– I’m going to call thatteal. Then the second wave was a heroin overdose deaths. And then the third wave, which we’re inthe midst of right now, is fentanyl. And then this line in black just tells you overdose deaths due toany of these opioids.

So the pandemic made a bad situation worse. We know that there was an increase in overdosedeaths. We’ve seen the mental health crisis that resulted from the pandemic, and so this was noexception. You can see that from– in the 12 months prior to April 2021, we were thick in the middleof the pandemic at that point. There were 100,000 deaths. And if you went back five years ago,there was just about half that number of deaths. So the pandemic definitely made the situationworse.

We’re seeing an increase in overdose deaths in our population, in adolescents without a doubt. Andyou can see from 2019 to 2021, this is a very alarming increase, and this is fentanyl.

All right, so now we’re going to talk about some of the nuts and bolts of opioids and theirneurobiology. So it’s important to know the language. I would encourage you, whenever you arereferring to these compounds, to use the umbrella term, which is opioids. So if you catch yourselfusing opiate, then you want to use opioid instead.

Opiate actually has a very narrow definition. These are natural compounds that are derived from theopium poppy. There’s a milky sap that you can derive from opium which contains morphine andcodeine. Generally, opioids is the term that includes everything that binds to the mu opioidreceptors.

So this includes opiates, endogenous opioid– so those are your endorphins, your runner’s high as itused to be called. Opiates we’ve discussed. Semi-synthetic opioids is an important category thatincludes heroin, which is diacetylmorphine that’s derived from morphine, buprenorphine, andoxycodone. And then fully synthetic opioids really refers to two important drugs, fentanyl andmethadone.

So if you’re interested in trivia, there are actually three different types of opioid receptors in humans,but we’re going to be talking about the mu opioid receptor, which is responsible for all the clinicallysignificant effects in humans.

All right, so what do opioids do physiologically? When an opioid binds to a mu receptor in thecentral nervous system, you can get a number of different effects. Not surprisingly, analgesia, weknow that these are exploited for their potential as painkillers. Sedation.

Some patients will experience euphoria and that’s not universal. Pinpoint pupils is a well known sideeffect of opioid use. And then patients will develop a decrease in respiration and a decrease in heartrate. This is what is potentially lethal in overdose, particularly respiratory depression. Nausea is afrequent side effect of opioids.

We know that there are more receptors in the gut, which, when bound or when activated, candecrease motility and can cause constipation. That’s a common side effect.

So it’s important to recognize the symptoms and signs of opioid intoxication. So the classicsymptom is euphoria. We’ve also talked about analgesia. This is a classic downer, if you will. Sopatients are somnolent, they’re calm. Nodding off is a classic effect.

So the signs are, everything slows down. So heart rate, respiratory rate, patients breathe moreshallowly. I’ve mentioned the pinpoint pupils. Blood pressure decreases, temperature decreases.These patients are sedated. You might notice a slowed down movement, speech can be slurred,and again, nodding off is a classic sign of opioid use. I know I have a lot of patients in my practicewho parents will know that they relapsed when they start nodding off again.

It’s important to understand tolerance and withdrawal in the context of opioids. As we talked aboutin the first session, tolerance refers to the need for increasing amounts of the substance to achievethe desired effect. This also takes place with patients who are taking their opioid prescription asprescribed. You often need to increase the dose because of tolerance.

Withdrawal is a very important component of opioid use, which means that the patient has a certainset of symptoms if there is a rapid decline in receptor binding. And this can take place if there’s theopioid is not there. The patient is using fentanyl every day and then they run out. So there’s going tobe withdrawal. Or if you introduce a blocking agent such as naloxone or naltrexone, then you willhave physiologic withdrawal.

Patients develop tolerance to opioid effects and this is really important to understand as you thinkabout patients with opioid use disorder. What’s interesting is tolerance develops differentially todifferent effects. And so patients rapidly develop tolerance to sedation, euphoria, respiratorydepression, and nausea.

Surprisingly, they don’t develop tolerance to the constipation or the pupil constriction. And so this isreally important because if a patient is abstinent for a period of time– let’s say they are doing well,they’re not using, or they’re incarcerated, or they’re taking naltrexone and they’re not using, theylose their tolerance, and what frequently happens is if a patient has a slip, they use the dose thatthey were using previously.

They don’t factor in this loss of tolerance. And so this becomes a lethal dose. That’s a unfortunatelya common scenario for overdose deaths.

So it’s important to be familiar with the signs and symptoms of opioid withdrawal. Generally, opioidwithdrawal is not life-threatening like alcohol and benzodiazepines, which is potentially a life-threatening withdrawal syndrome, but it’s incredibly unpleasant and people– patients really dreadhaving these symptoms.

I would think of it as like a bad case of the flu or, these days, COVID. Typical symptoms are GI, youcan have cramping, nausea, vomiting, diarrhea. Patients have really bad muscle aches or boneaches. So think of the myalgia that you had the last time you had the flu. Generally, patients are veryanxious as well.

Signs, things that you can objectively measure would include increased blood pressure, increasedheart rate, increased body temperature. Generally when you think of a withdrawal state, I’ve saidthis before, it’s the opposite of the intoxication state. So this all makes sense.

Patients can have a runny nose, watery eyes, pathological yawning. You can see goose pimples– Ithink that’s what I call called it when I was a kid. It’s important to understand the timing ofwithdrawal symptoms.

For short-acting opioids, these symptoms can set in fairly rapidly, as soon as six hours after the lastuse. Patients can already start feeling withdrawal symptoms and this is often what drives thecompulsive use. Not so much the euphoria, which patients stop experiencing, but the desire toavoid feeling sick.

For long-acting opioids such as methadone, withdrawal symptoms are delayed. They start later andthen they end later. Shorter-acting opioids, generally after about five days you start feeling better.

So how did we get in this situation? It’s important to understand what happened in the era from,let’s say, 1990 to about 2015. There was a lot of attention paid to the importance of physiciansadequately prescribing and treating pain. This coincided with the advent of some very potentprescription opioids which were advertised as non-addictive. And so this led to a dramatic increasein opioid prescribing which you could see in this period in question.

And this, unfortunately, led to the creation of an opioid reservoir. An example would be a patient whowas prescribed Vicodin for oral surgery, was given 30 Vicodin, used one or two, and then put therest in a medicine cabinet. And so we know that this is where adolescents in many, many casesoften got their hands on opioids.

The good news is that there’s been a lot of attention paid to this phenomenon, and the medicalcommunity in general has gotten a lot better about not prescribing controlled substances, includingopioids, as aggressively.

So we’ve talked about monitoring the future before. This is looking at rates of opioid misuse by 12thgraders, you can see, between 1975 and 2000. I think close to where we are now. Sorry, that’s areally small number. And so you can see that this is the period in question when there was thisopioid reservoir, and so adolescents were misusing opioids at much higher rates, and thankfully,we’ve seen that number go down.

So adolescents were asked why they were misusing opioids. The answers were really consistentover this period of time. They were easy to get. Adolescents are opportunists to a large degree. Soyou could get them either in your family’s medicine cabinet or friends.

And I always want to point out that when patients are misusing prescription drugs, there’s always afalse perception of safety, that because this is a prescription drug, because a doctor wrote aprescription for it, it must be safer than a street drug. And we know, we looked at overdose deathsfrom prescription opioids, that is not necessarily the case. But this was the gestalt for rationale formisusing opioids.

It’s interesting. If you look at reasons that people give for what we call non-medical use of painrelievers, a lot of patients are, quote, “self-medicating.” They’re using this for what we callinstrumental reasons, which is they really think they’re doing this to help them, either by relievingpain, relieving tension, helping with their emotions, or helping with sleep.

But regardless of their intention– in other words, as opposed to recreational use or to try to gethigh, but all of these patients, regardless of why they’re using it, are at greater risk of going on tomisuse opioids and develop an opioid use disorder.

I want to say a few words about heroin and fentanyl. We’re not seeing a lot of heroin right now. Ihaven’t seen a patient actively using heroin in a few years now, but heroin is diacetylmorphine. Itrapidly crosses the blood-brain barrier. And we know that all of the drugs that are used for abuse aretypically fast-acting, that’s what people are looking for.

And so heroin, it used to be less potent, and so you would have to use it by injection, but over time,it’s gotten a lot more potent, and so patients– or individuals can also use it by smoking or bysnorting or by insulation. And this, unfortunately, lowered the barrier for a lot of people for usingheroin.

What was often the case, we were seeing patients who were using prescription opioids, theybecame too expensive, and so they transitioned to heroin, which is essentially the same effect, but itwas much cheaper.

Now there’s a new kid on the block, very lethal kid on the block, fentanyl, which is a syntheticopioid, which is 50 times more potent than heroin, 100 times more potent than morphine. It’s widelyavailable. It comes in either powder or pills. And this is, as we saw, this is what’s driving a lot of theuptick in overdose deaths.

So fentanyl is showing up in other substances. There was some press about overdose deaths inConnecticut from marijuana that was found to be laced with fentanyl. So this is really scary stuff. It’sabsolutely fair to share this with your patients.

The DEA is doing an important campaign. You can have this phrase in your head and tell patients,”One Pill Can Kill.” Very catchy phrase. And this refers to what I had also on a previous slide, whichis, fentanyl is often added to other substances because it’s relatively inexpensive and a very smallamount can produce a high.

So patients can think that they’re purchasing something else and they end up– they’re gettingfentanyl and the fentanyl can be lethal. So there are fake pills that are available. Your adolescentpatients can get access to these pills. Sometimes they’re rainbow-colored, which is particularlyalarming.

And it turns out that of the pills that are found to contain fentanyl, about 40% of them have apotentially lethal dose. So if you recall the slide that I showed you with a very dramatic increase inadolescent overdose deaths, this is a big contributor. So certainly have a very low threshold fortalking to your patients about Narcan or naloxone. I’m going to say a few words– a few more wordsin a couple of minutes.

So hopefully this is a familiar theme to this group that– it could be like a mantra for our learningsession, that the younger an adolescent is when they begin using a substance, the more likely theyare to have a fulminant disorder. And so this is also true for non-medical use of prescription drugs.So as always, you’re going to be even more worried about your younger patients.

As I’ve said to this audience before, you can really think about cannabis, alcohol, and nicotine as thegateway drugs. It’s uncommon for a patient to start their journey of abusing– of using substancesby using opioids. And so, in fact, this is data from a secondary analysis of– let’s see. About 1,400patients in the Youth Risk Behavior Survey who reported non-medical opioid use, and then theywere asked have you used cigarettes, e-cigarettes, alcohol, and marijuana?

Yes is blue, no is orange. And you can see that these patients had used other substances. And soagain, talking to your patients about all substance use remains a very important intervention.

This was a study that showed, of patients who misused opioids, there were really two categoriesthere. The category of patients who were using it to relieve pain, they’re, I guess you could say, self-medicating. And then the other category who are using it to get high.

And what this shows you is– I’m starting in the lower-right– patients who are prescribed an opioidhave a elevated odds ratio, so they’re about a third more likely to go on to misuse opioids. So evengiving someone illicit prescription for opioids puts them more at risk of misusing opioids. Patientswho are using opioids for pain relief but not as prescribed have a higher odds ratio. And then notsurprisingly, patients who try recreational use of opioids have a much higher odds ratio of going onto continue to misuse opioids.

This is just a reminder that should always be mindful of the mental health of your patient as riskfactors for more serious substance use disorder. We know that these are odds of developing asevere substance use disorder. All of these are risk factors.

So patients with depression, anxiety, familiar substance use– we’ve talked about genetic loading,and there are also environmental factors when a parent is using substances. And PTSD tends to beassociated with a particularly hard-to-treat form of substance use disorder.

All right, now we’re going to segue into treatment of patients with opioid use disorder. And then thisintroduces you to the two important categories, non-pharmacologic and pharmacologic. This is notan either/or scenario, this is a both. So when I talk about non-pharmacologic treatment, in our firstsession, we talked about levels of care.

A lot of these patients, when they present with opioid use disorder, would benefit from residentialtreatment, or at least an IOP or a partial hospital program, something more than seeing you and yourpractice. These patients have really, by definition, a severe substance use disorder. Individualcounseling is essential. Some patients will do well with group therapy, that adolescents tend to likethat because of the peer component.

Family therapy has very strong evidence base for adolescent substance use in general. And then alot of patients with opioid use disorder will do well in a cloistered environment in a recovery highschool or a therapeutic school.

Pharmacologic management is what we’re going to talk about now, and this starts with managingthe patient’s withdrawal symptoms. And then we’re going to talk about agonist therapy. I’m going toexplain what all this means, which is buprenorphine or methadone. And then antagonist therapy,which is your naltrexone.

All right, so I told you that patients who are withdrawing from opioids feel really sick. Think aboutbad flu or bad COVID. And so even patients who want to stop using, this is often the impediment.And so treating them for these symptoms with comfort medications can go a long way.

Clonidine works particularly well for the overarching restlessness and anxiety. That’s a locuscoeruleus type of symptom. Then the GI symptoms you can treat with an anti-diarrheal orondansetron. And then over-the-counter analgesics– the pain– the muscle aches tend to be veryprofound.

Or if a patient is willing to go to a facility, often they’re given a short course of methadone orbuprenorphine, which can be administered. They usually get a high dose and then a taper over afew days. And because this is a different opioid, it treats the withdrawal symptoms beautifully.

So medically supervised withdrawal, what we used to call detox, is really important because it canbe the first step in helping a patient consider treatment, but it’s important to know that this is notdefinitive treatment. The patient who was, quote, “in and out of detox,” end quote, but is still using.That’s because this is not definitive treatment. This is just really the step that gets them ready fordefinitive treatment.

All right, so now we’re going to talk about definitive treatment, which is the medications for opioiduse disorder. I would encourage all of you to read this. We can make this available to today’saudience. “Medication-Assisted Treatment of Adolescents With Opioid Use Disorders.” This was apolicy statement that was published in the American Academy of Pediatrics a few years ago. Ithappens to be beautifully written and really reads as a call to action.

Pediatricians should be comfortable prescribing these medications because they save lives, end ofstory. And if you’re not going to be a prescriber, then you should at least understand the importanceand refer your patients to someone who will prescribe.

I like to do a little aside about stigmatizing language. I think we’ve done a nice job in the field ofaddiction medicine of becoming much more aware of the language that we’re using and thepotential harm of that language. For an example, I would encourage you to lose the term “substanceabuse” from your language. We even changed the name of our program so that “substance abuse”was not in the title.

“Addict,” “substance abuser,” these are all very negative, pejorative terms. And so the preferredterm would be a person with a substance use disorder, person-first language.

The reason I put this here is that we used to use– “medication-assisted treatment” was the buzzphrase for these medications, but we’re now using medication for opioid use disorder– you’ll oftensee M-O-U-D– for this.

And the idea is that the medication is not a secondary treatment, it is an essential treatment. And Iwould encourage you to think that you wouldn’t call insulin medication-assisted treatment forpatients with diabetes, it’s the treatment. And so I want you to think about these medications in thesame way.

So now we’re going to talk about how these medications work. This is a brief overview. And again, Ireally want to put in a plug for the two-hour buprenorphine training that we’re going to be doing on aseries of different dates starting next Tuesday because that will give you a more comprehensiveunderstanding if you’d like to start prescribing.

So as you think about these medications, it’s important to understand that there are three categoriesfor opioid function and receptors. We’re going to talk about full agonists, partial agonists, andantagonists. And it’s important to remember that antagonists will have the highest affinity for thereceptor and full agonists will have the lowest. That will make sense in just a few minutes.

So if you look at my little schematics, when we talk about the full opioid agonists, this is yourmethadone, fentanyl, oxycodone, morphine, codeine. So these form, as you can see, a perfect lock-and-key fit with the mu opioid receptor. As such, these have the highest degree of opioid activity atthe receptor. So these are the most reinforcing and the greatest potential for development of a usedisorder.

Buprenorphine is a special category. This is a partial agonist which, as you can see by theschematic, does sit on the opioid receptor but has an imperfect fit. So this results in what I wouldcall gentle stimulation of the opioid receptor. You heard the patient in the clip say he’s not high whenhe takes Suboxone, but he just has this feeling of well-being. And we know that there’s lesspotential for misuse of buprenorphine because it’s not a full agonist, but the potential for misuse isnot zero.

So antagonists are the third category. These are blocking agents. So they sit on the receptors, suchas my wine cork, and they block the receptor, but they don’t stimulate it. So this includes naltrexone,which is used as a medication for opioid use disorder, and naloxone or Narcan.

And it’s important to understand that these compounds have the greatest affinity for the receptor.So if there’s something else on the receptor and you give an antagonist, it will displace the opioidresulting in withdrawal. And that’s how it treats an overdose.

I’m not going to say much about methadone. I don’t have any experience prescribing methadone.This is available at methadone clinics, but it’s important to understand that it’s out there. This doeswork as a full agonist at the opioid receptor. And patients do well in methadone. These are not youryounger adolescents, these are generally patients 18 and up.

And over the years, we’ve had a small number of patients who haven’t done well with buprenorphineand we’ve referred them to methadone and they’ve done well. Patients who generally need a lot ofstructure do well with methadone.

So buprenorphine was a game-changer when it came along. It was FDA-approved in 2002 for thetreatment of opioid use disorder and patients 16 and up. The beauty of buprenorphine is it can beprescribed. You don’t need a freestanding clinic, it can be prescribed from a physician’s office.

It is a controlled substance. It’s generally– when you talk about Suboxone, it’s a combinationproduct. It’s conjugated to naloxone, which limits the misuse potential. Generally, because it’s apartial agonist, it’s much safer. It’s very hard to overdose on buprenorphine. And it is mildlyreinforcing, which can support medication adherence.

When you think about side effects for buprenorphine, they’re similar to general side effects foropioids. Constipation is the biggie. If a patient had constipation when they were using an opioid,they’re probably going to have constipation with buprenorphine, but it’s usually not dose-limiting.

Patients often have nausea and fatigue in the beginning of treatment, but those effects wear off. Asmall percentage of patients will have neurologic symptoms, but that’s uncommon.

It is important to know about diversion potential for buprenorphine. If you’re prescribingbuprenorphine, there is a, quote, “street value” of this medication. And so we often have parentshold on to the medication and dispense it.

Usually people who are buying buprenorphine on the street are using opioids and they may want tohave buprenorphine for days when they don’t have an opioid and they’re feeling withdrawalsymptoms. So it’s important to do pill counts, and ideally a parent would hold the buprenorphineprescription.

So there used to be a requirement for an eight our course in order to get an X-waiver from the DEAto prescribe buprenorphine. I’m happy to say that in 2021, those restrictions were– or thoserequirements were liberalized. So if you’re going to be prescribing for fewer than 30 patients at atime, which most of us– I don’t treat 30 patients at one time, and then you don’t need a specifictraining, and so you could come to my two-hour training and then do the paperwork and be able toprescribe.

So we also have experience using naltrexone for the treatment of opioid use disorder. This works bya different mechanism. This is an antagonist. And so patients will take naltrexone. This will sit on theopioid receptor. And so if they use an opioid, there’s not going to be any effect.

Patients are aware of this, and so they’re less likely to use it. And there also is a measurabledecrease in cravings over time. This is also FDA-approved for the treatment of patients with alcoholuse disorder. So certainly if you have a patient that’s using alcohol and opioids, this becomes a no-brainer.

We know that the blockade lasts generally from one to three days. The dose for naltrexone is 50milligrams a day. What we like to do is we will have a patient take it orally, and then if they tolerate it,we’ll transition to Vivitrol, which is a trade name, which is a 30-day preparation of naltrexone thatyou can give them, see them once a month for an injection, and then they’re good for a month, theydon’t have to take a daily medication.

What’s tricky about naltrexone is– remember I told you that the antagonists have a greater affinity atthe opioid receptor. And so you need to wait a few days after the patient last used an opioid to makesure there’s none lingering because if you give them naltrexone and they recently used an opioid,the naltrexone will displace the opioid from the receptor and this will give what we call precipitatedwithdrawal.

The patient will have withdrawal squared. They’ll feel really sick and they’ll probably never comeback and see you again. So that’s the one tricky part for naltrexone.

There are some side effects, GI side effects, headache, dizziness. We usually try to work aroundthese side effects by starting on a lower dose and ramping up. And generally, this is a well-toleratedmedication. There are some case reports of hepatotoxicity, and so if you’re going to prescribenaltrexone, I would recommend that you always get a set of baseline LFTs before starting treatment.

All right. So in our last 10 minutes or so, we’re going to talk about evaluating a patient with an opioiduse disorder. You want to take a detailed history. It’s always important to know what is their opioidof choice, what are they using, how often, how are they using it? Are they taking it orally? Are they’resnorting or insulating? Are they injecting? Are they smoking? Are they using other substances at thesame time?

Patients with a history of a prior overdose have a dramatically increased risk for fatal overdose, sothat’s something you want to illicit in your history. Are parents aware of their use? And what is theirwillingness to engage in treatment? That’s a crucial question.

Any patient with a history of, I’m going to say, any pill use– One Pill Can Kill, you should make sureto prescribe Narcan or naloxone. If a patient is treatment-seeking or willing to engage in treatment,start high, do residential treatment, at least, or partial hospital program. These patients generallyneed very aggressive treatment at the outset.

For those patients that you’ve discovered they have an opioid use disorder and they’re saying “nothank you” to treatment, these are the patients that I would really encourage you to considerbreaking confidentiality. I know that might damage the therapeutic relationship, but if someone isusing fentanyl daily, this is a life-threatening condition.

So these are the patients that you’re really going to consider breaking confidentiality. If you do that,if you talk to the parents, and the patient, again, is resistant to treatment, parents might have to goto the court and file a Section 35, which is asking the court to hospitalize their child involuntarily, andusually that’s about a 30-day hospitalization.

So as we follow patients with opioid use disorder, urine drug testing is important. This is a greaturine drug test result for a patient who’s undergoing treatment. You’re seeing that the buprenorphineand the norbuprenorphine is in their urine, as you would hope it would be, but there’s nothing else.

This is actually the same urine drug test that we looked at before. This is a patient who’s not doingwell in treatment and needs– probably needs to be sectioned.

I’d like to say a few words about opioid overdose and the importance of Narcan or naloxone. Thereare different risk factors as you think about where does this patient fall in terms of risk? I would saythe most important risk factor is what opioid they’re using. When we know that a patient is usingfentanyl, that alone is a profound risk factor for opioid overdose.

Generally, we worry more about patients who are doing polydrug use or polypharmacy, particularlythe combination of alcohol, benzodiazepines, and/or opioids can be– you can have an overdosewith lower amounts because of the synergy and the respiratory depression.

Certainly we worry about patients who are using alone, patients who have medical problems. And asI mentioned earlier in the talk, patients who’ve had a period of abstinence are particularly high-riskbecause they’ve lost their tolerance, they go back to the dose they were using, and then thatbecomes a lethal dose.

Another category which is important to keep in mind is there’s a real last hurrah phenomenon thatI’ve seen unfortunately in our own practice, which is a patient is about to go to residential treatment,and so they have this last hurrah, and that can be life-threatening as well.

So here’s my schematic for Narcan. We talked about how opioid antagonists have a greater affinityat the opioid receptor. So naloxone, you give them naloxone and it will push the opioid off thereceptor. The patient will have precipitated withdrawal and wake up and start breathing again.

Generally, this is available as an intranasal and an auto injector. It works in one to three minutes.Just like if a patient used an EpiPen, you would say they should go to an ED. Very similar withNarcan because the Narcan will wear off, and potentially if they use a longer-acting opioid, theycould have another overdose after the naloxone wears off. So all of these patients should bemonitored in an ED.

If you think a patient may have overdose but you’re not sure, there’s really no downside to givingNarcan. If it’s not an opioid overdose, it just won’t have an effect.

All right, so in our last couple of minutes, we’re going to talk about prevention. So ideally, how wouldyou prevent patients from ever misusing an opioid or developing an opioid use disorder? And I’vealways loved being a pediatrician with the task of anticipatory guidance.

And so important take-home points are that we know that typically alcohol and cannabis use– Ishould add nicotine use– will proceed opioid use. It’s very unusual for patients to start by misusingan opioids. And so talking to parents about that as a risk factor for misusing opioids and, again, nottaking this type of substance use lightly is an important intervention.

Parents can set a good example. It’s really important that families not share their prescriptions. Itsends teens the wrong message. I’m not going to use someone else’s prescription, only use whatyou’re prescribed by a physician. It really does make a difference to talk to teens about drug use,including pills. One Pill Can Kill.

Parents should take alcohol and cannabis use seriously. And I showed you the picture of the opioidreservoir. Families– this is something that you should include in routine anticipatory guidance, thatfamilies should not store leftover medication because they can be an invitation to an adolescent at alater date.

I think there just was a take-back date. I think it’s in April and October, but every community has away in between these take-back days for families to get rid of prescription medication.

So my last thoughts are about what primary care clinicians can do to minimize the harm of opioiduse in adolescents. Hopefully as you’re sitting through this talk, you’re thinking that you’re going toset the bar really, really high forever prescribing an opioid.

If you have a patient with some sort of an acute pain problem, I would encourage you to bend overbackwards to use non-opioid analgesics, rely on the good old fashioned stuff like physical therapy,ice, everything else that is in your toolbox for treating patients with pain other than using opioids.

The picture on the lower-right is to remind me that patients with mental health disorders areparticularly tricky, their pain can be harder to treat, but they’re also, as we discussed earlier, moresusceptible to developing substance use disorders. So you want to be particularly careful withpatients with diagnoses of anxiety and depression.

Certainly we talked about the importance of screening. The STBI is your friend. So if you’re thinkingabout prescribing an opioid, you want to screen the patients. If they have a history of substance use,they are more high-risk, and again, you want to do everything you can to avoid opioid-prescribing.

If you feel like you don’t have a choice, then I would recommend that the parent be involved, theparent hold the prescription, dispense the medication, and then dispose of it as soon as the pain ismore manageable.

I think we do a nice job at Boston Children’s talking to families about the voluntary, non-opioiddirective. This is available at Boston Children’s Hospital. It really is just more of an educational pointthat if a family agrees, what this means is if a patient signs this form– or if you’re under 18, theparent signs the form, then you are saying that if I end up in your hospital emergency department,please don’t give me an opioid, please use other alternatives.

This is voluntary. Patients can rescind it when they present. So it’s really more of a teaching point.It’s really more of a formality. But I think finding a way in your practice to talk to families,adolescents, and their parents about avoiding opioid prescriptions, if at all possible, is aconversation that is really worth having.

So in conclusion, we know that opioid use among adolescents and young adults is a seriousproblem. I haven’t been subtle about listing the life-threatening consequences of this.

And you guys can do a lot, starting with screening your patients for opioid use, using caution andprescribing opioids, talking to your patients about prescription drug misuse, and then beingchampions for patients to be prescribed medication if they have developed a severe opioid usedisorder. You can prescribe buprenorphine yourself. Please come see me at one of these trainings.And certainly have a very low bar for prescribing Narcan to families with any high-risk features.

Screening and Handoff to Counseling for PCPs

SHANNON MOUNTAIN-RAY: Hello, and welcome to today’s presentation for screening and referral for adolescents who use substances. I’m Shannon Mountain-Ray, Director of Integrated Care for the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. 

Today, we’ll focus on discussing the importance of using a valid and reliable screening tool. We’ll discuss the Screening to Brief Intervention, otherwise known as the STBI, and describe recommended interventions based on those screening results. 

One question we often find ourselves asking is, do health care providers really need a structured tool for substance use screening? Do we really have a good sense of what’s going on? And do our own questions allow us to have the most accurate information? 

In a study that our team did, we asked many participating primary care providers what their perception of adolescent substance use was in their communities. Some of the responses were things like, “It’s a very small city. I wouldn’t think that kids are really using drugs and alcohol.” 

Another provider said, “If patients are drinking, it’s like stupid high school kids who go out and have a couple of beers on the weekend here and there. It’s not like chronic alcohol problems.” And when discussing the idea of screening, this primary care provider said “There hasn’t been much agreement among the physicians in my practice about the need for a screening tool on adolescent drug and alcohol use.” 

What we actually know is medical providers really do benefit from a structured, valid, and reliable screening tool. This was a study that was done comparing medical providers’ impressions with what was actually happening using a diagnostic interview. 

So what we see here is a good number of providers were actually able to identify whether or not there was any use. Just over 60% were able to identify that their patients were using on some level. Often in those situations, it was because the patient disclosed their use. 

But when we get into the other areas of any problem, any disorder, or severe substance use disorder, the providers were not as accurate. So just over 1% were able to identify whether or not there was any problem related to substance use. 1% were able to identify whether there was any disorder. And none of them were able to identify whether or not there was a severe substance use disorder. 

So that leads us to understand that we do need a valid and reliable tool in order to accurately screen for adolescent substance use. So for today’s topic, we’re going to be introducing the Screening to Brief Intervention, otherwise known as the STBI. The STBI is a valid and reliable screening tool. It has been validated for adolescent patients ages 12 to 17. 

The STBI consist of frequency questions for different substances and focuses on use in the past year. This is actually a summary slide of what the STBI looks like. When you’re actually utilizing the STBI, you want to ask these frequency questions for each individual substance that’s bulleted on this slide. 

So for example, you would ask, in the past year, how many times have you used tobacco or nicotine? And we give some examples in parentheses. And the patient would identify whether or not they’ve used never, once or twice, monthly, or weekly. And then you would move on to ask the same frequency questions for alcohol, marijuana, and get a sense of that. 

If the patient actually answers never to all three of those, you can stop the screen at that point. As you may know, the most widely used substances by far amongst adolescents are tobacco, nicotine, alcohol, and marijuana. Very few patients who are using substances are not also using those substances. So if they answer never to all three questions, in order to save yourself a little bit of time you can stop the screen at that point. 

However, if they answer– if they indicate any frequency– once or twice, monthly, or weekly for any of those top three substances– then you’ll want to move on to ask about the other substances listed below. So prescription drugs, illegal drugs, inhalants, herbs, or synthetic drugs. 

You use the frequency to assess risk. So what we know is the sensitivity and specificity of the STBI is very high for identifying any substance use and also for identifying a severe substance use disorder. 

So previously, we have classifications of substance use disorders in the DSM-4 and the DSM-4-TR that were focused on areas of “abuse,” quote, unquote, and dependence. But in May of 2013, the DSM-5 was released, and the DSM-5 combines the DSM-4 categories and actually creates a single disorder measured on a continuum from mild to severe. So it’s mild, moderate, or severe substance use disorder. 

And each specific substance is addressed as a separate substance use disorder. So for example, it might be a mild alcohol use disorder and a severe opioid use disorder. So each substance that they use, if they meet criteria for a substance use disorder, is then identified as mild, moderate, or severe based on the number of criteria that they indicate. 

The DSM-5 criteria for substance use disorders includes 11 different areas. So everything from tolerance and withdrawal to persistent desire or unsuccessful efforts to cut down or quit, failure to fulfill major role obligations, recurrent use, and physically hazardous situations, et cetera. 

When we are talking with a patient and asking them about these 11 different criteria, based on the number that they endorse will indicate whether or not they meet criteria for a mild, moderate, or severe substance use disorder. So as you can see on the right-hand side of this slide, a 0 to 1 endorsement is no substance use disorder diagnosis. 2 to 3 indicate a mild substance use disorder, 4 to 5 a moderate substance use disorder, and 6 or more a severe substance use disorder. 

So when we think about substance use, we can think about it on a continuum or a pyramid with no use being down at the bottom. So hopefully, most kids that are being screened fall into that bottom category. 

And in the middle category, no substance use disorder. So there may be some level of substance use, but they don’t meet criteria for a substance use disorder. And then some may fit into the category of mild to moderate substance use disorder, and then even fewer may fit into the category of severe substance use disorder. 

When we take a look at the frequency questions, there is an algorithm that helps us decide exactly what we should do based on the screening results. And so as you can see, for each frequency answer there is a corresponding intervention, including in situations where someone reports that they have not used any substance. 

So some of the intervention goals include, for example, if a patient doesn’t report any substance use, the provider can provide positive reinforcement to help delay initiation. Research has shown that some intervention providing positive reinforcement can not only delay initiation, but also can reduce the frequency and the quantity of which someone may use. 

If there is substance use but no substance use disorder, the intervention could be giving brief advice and encouraging cessation of all use. If they meet criteria for a mild or moderate substance use disorder, it might be a motivational intervention, again, to encourage cessation, or at minimum, reduce use. 

And then a severe substance use disorder, which is a more intensive motivational intervention to stop or reduce use of risky behaviors. In these situations, patients may require a higher level of care. And adolescents with nicotine, alcohol, opioid, or cannabis use disorders may also benefit from medications. 

One thing to consider as you’re identifying what the appropriate intervention is is confidentiality. So it’s always best to interview the adolescent without parents or caregivers present when possible, and expressing that information can remain confidential unless safety is at risk. However, sometimes that can be a gray area. 

So we recommend checking state laws and guidelines regarding when confidentiality must be broken. What identify– what qualifies as a safety risk? And when confidentiality must be broken, discuss it first with the patient. Try out the words to use and avoid revealing small details unless they’re absolutely necessary. 

So we often try to have conversations with the patients and let them know why we have to share the information that we have to share, what we will share, and if possible, explore with the patient their thoughts and feelings about that. When these kinds of interventions are done well and thoughtful and in collaboration with the patient, often not only do they seem to go smoothly, but they can also actually help to deepen the clinical relationship that you have with these patients. 

So again, when we’re thinking about no use, what we are recommending is positive reinforcement for their safe choices around alcohol and drugs. When you’re providing positive reinforcement, the best options are to give positive feedback, very specific, clear, positive feedback. And frame it as a decision if appropriate, that they are making a choice to not use substances. 

And for younger kids, you can include a norms correction. So you can help them understand that quote, unquote, “not every kid” is using drugs and alcohol. Or any other questions or incorrect or inaccurate information they may have. 

So we’re going to talk about Sarah. Sarah’s a 16-year-old girl with no past year use of any substance. She meets with her primary care provider who says to her, “You’ve made a very good decision not to drink or use drugs, and I hope you keep it up. When kids do use, they can put themselves at risk like getting injured or even having unwanted sex.” So again, very clear, positive praise, framed it as a decision, and also shared some important information about what some of the risks of adolescent substance use might be. 

One of the other things that we would suggest strongly is doing– is including car safety as a part of this brief intervention. So teens should not drive even after a single drink or use of any substance. Often, teens don’t notice the early effects of alcohol and other substances, which can affect their ability to drive. 

So one of the conversations can be around thinking about alternative and safe ways to getting home, being very explicit that you are suggesting that they not drive if they are under the influence of any substance. This includes alcohol, cannabis, opioids, sedatives, et cetera. 

But thinking about safe and alternative ways to get home, and give maybe some suggestions, or see if they can give you some suggestions like getting a ride from someone who hasn’t been using. Stay overnight and then go home the next morning. Call for a safe ride from parents. 

One really great resource is the Contract for Life. This was developed by the Students Against Destructive Decisions. The Contract for Life includes commitments on the part of a young person, as well as the parent or caring adult in their life around making safe choices specifically related to alcohol and drugs, and what they will do in the event that they cannot find a safe ride home. 

So for the young person, they really commit to trying to do everything in their power to make safe choices for themselves overall, and very specifically that they will not drive or ride in a car with someone who’s been using alcohol or drugs. They also agree to wear their seatbelt, and that in the event that they need a ride home or they don’t have a safe ride home that they will call and request a ride home or find an alternative way home. 

The parent or caring adult also agrees to make safe decisions for themselves, and they will also wear their seatbelt and will not drive under the influence of alcohol or drugs. And they agree to provide safe and sober transportation home in the event that the young person needs it. In addition to that, the parent or caring adult also agrees that they will defer discussions until everyone is in a calmer– in a calmer place and can have these discussions in a clear and caring manner. 

For young people who indicate that they’ve used substances a couple of times, we would recommend continuing on with a follow-up STBI questions, providing some brief advice, and considering a possible referral for evaluation or education related to substance use. So in these situations, again, we would recommend brief advice. 

So we would advise abstinence. There is no level of substance use that is safe for adolescents, so as a caring provider we suggest that they abstain from all substances. It doesn’t mean that they will, and they get to make their own choice, but at least they know where we stand on the topic. 

You can talk about health consequences related to use. Use a strengths-based approach and give an option for referral to, for example, a social worker for brief intervention such as education, planning, or support. 

Meet Marcus. He’s a 16-year-old boy who comes into the office after injuring his ankle at football practice. He reports that he’s used cannabis once or twice in the past year, but not at the time of his injury. 

His primary care provider says, I would recommend that for your sake– for your health that you quit smoking cannabis. It can affect your concentration and over time impact your mood and affect your performance on the football field. You’re such a good athlete. I would hate to see anything get in the way of your future. If you’re interested in learning a bit more about the effects of cannabis, we have someone on our team who knows a lot about this topic and would love to talk with you. 

In situations where a young person reports monthly use, again, can continue on with the follow-up STBI questions and refer to some level of treatment. Monthly use correlates directly to a mild to moderate substance use disorder, and early intervention is always better. So the earlier we can get someone into some level of treatment, usually outpatient treatment, depending on the level of substance use, the better. And the goal would be to stop– to abstain if at all possible, or at minimum reduce use and risky behaviors. 

So here’s Katie. She’s 17 years old and she comes into the office for a well child visit. She reports past year alcohol and cannabis use, but does not use any other substances and reports that she’s using alcohol on a monthly basis. 

So you’ve asked her the STBI questions, and you may go into a little bit of a further assessment. There are some structured assessments out there, or you could just ask. Tell me a little bit more about your alcohol use. Katie says that she started drinking at parties as a freshman, she now drinks about twice a month, and she’s drinking four to six shots, which is enough to get her drunk. 

You can ask about problems associated with her alcohol use. She reports that she was suspended for two weeks because she was drunk at the homecoming game and threw up in the bathroom. She believes her grades have dropped in part because she’s missed so much school and is having a lot of trouble catching up. She says her parents were very upset and grounded her, and she said she would stop drinking, but she continued to drink with friends. 

Have you ever had sexual contact after drinking? She reports that she’s had sex while drunk twice. Two days ago she had sex while drunk and did not use a condom. 

Have you ever tried to quit? Katie has never tried to quit before. She says she drinks less than her friends and doesn’t think it’s a problem. She’s not really interested in quitting. 

So the primary care provider might summarize and identify some of the challenges. You enjoy drinking with your friends and alcohol has also gotten to you– gotten you into some trouble. Where should we go from here? 

Katie doesn’t think that she has an alcohol problem and isn’t interested in quitting, but she does mention that she struggles with anxiety and can contribute– and that can contribute to her alcohol use. So the primary care provider might say something like, I care about you and your health. As your PCP, it’s my recommendation that you don’t drink at all, but I understand that has to be your decision. 

It sounds like anxiety is a struggle for you. I have a team member who works with young people who are struggling with things like anxiety and stress. I think it would be a good idea for you to meet with them and help you learn skills to cope with and hopefully alleviate your anxiety. 

So the important piece about this intervention is Katie’s not ready to talk about her alcohol use. She doesn’t think it’s a problem and she’s not interested in quitting, but she is identifying some other areas that she’s struggling with. For example, her anxiety. So getting– so focusing on what she wants and what she’s identifying as her needs would be a really great way to getting her into at least some initial level of counseling, even if she’s not willing to go and discuss her substance use. 

For people who report weekly use, again, ask those follow up STBI questions and refer to treatment. And the idea is probably providing ongoing treatment. Again, this can range from an outpatient level of care all the way up to residential or inpatient level of care, depending on the patient’s needs. 

Alex is 15 years old, and he presents for a school physical. He reports weekly cannabis use. So just by that report, we know that he meets criteria for severe cannabis use disorder. 

He reports that he started smoking six months ago and is now smoking daily. He uses when he feels stressed. He often smokes by himself. His mother caught him smoking a few times and is now, quote unquote, “constantly on his case.” But he thinks she’s overreacting because “weed is not that bad.” 

He was brought home by the police who caught him smoking in the woods, but no charges were filed. His grades have dropped this year because high school’s a lot harder. He doesn’t believe his cannabis use has anything to do with it. 

Alex doesn’t want to quit, and he can’t imagine how he would manage his stress without using cannabis. His primary care provider acknowledges that stress management is difficult, and he recommends that he talk to a counselor to help him with that and also to talk about his cannabis use. Alex is reluctant, but he agrees. 

So what about the caregivers in these situations? So you’ve had these conversations with the young people, and in this case Alex has agreed to go to talk to a counselor. So you might want to assess, what do the parents or caregivers know about their substance use? 

If they say that their parents do know, you could say something like, I imagine they’ll be happy that you’re ready to talk to someone about it. In my experience, kids do best when their parents and other family members are supporting them. And if you agree, I’d like to tell them that you’re agreeing to see a counselor. 

If the answer is no, you can explore what would happen if they found out. What we know from research is kids do better when parents or caregivers are involved in their care, but you’re going to want to screen for things like active domestic violence or mental health or substance use issues, or anything that could create a situation that might be unsafe for the patient.

If it is safe, you can encourage the teen to involve parents or other family members. Offer support in breaking the news and emphasize that the teen is seeking treatment. You can practice with them beforehand so that they know exactly the words that you’ll use. 

So in Alex’s case, his PCP praises him and asks permission to invite his mother in. The PCP points out that this could be really good for relieving some of that stress at home. Alex agrees, and they talk to Mom together. Mom agrees to help Alex get to his first counseling appointment. And I can tell you, in many situations that is the most important step, because very frequently once they get to that first appointment, they often come back for follow-up visits. 

And finally, one other intervention that primary care providers can offer is caregiver guidance. The primary care provider can provide education and support to parents in most cases. So in situations where parents are concerned but the patient isn’t, or parents are concerned and haven’t explored this with their child, primary care providers can educate parents around the risks of adolescent substance use and the benefits of treatment. They can also help strategize how to increase the likelihood that the patient will accept a referral. And in some situations, some restrictions may apply for patients over 18 in terms of what can be shared with parents in those situations. 

But the most important thing is for primary care providers to screen for adolescent substance use and be prepared to provide brief intervention based on those results. I appreciate you being here today, and I hope you enjoyed this presentation. 

Stigma Reduction and Language for Clinical and Administrative Staff

ARIEL BOTTA: We’re very excited to provide this presentation for you today. My name is Dr. Ariel Botta, and I’m the Coordinator of Group Psychotherapy, and my dear colleague, Shannon Mountain-Ray, is the Director of Integrated Treatment in the Adolescent Substance Use and Addiction Program in the Division of Developmental Medicine at Boston Children’s Hospital.

And today, we’ll be talking to you about working with youth who use substances. We were brought to you by the TREAT ME Representatives in Maine. And TREAT ME stands for Treatment, Recovery, Education, Advocacy for Teens with Substance Use Disorder. The representatives reach out to the Opioid Response Network to develop a training on how to provide compassionate and inclusive care to youth who use substances.

We are brought to you today in partnership with the Opioid Response Network, and we want to thank ORN so much for funding us and for the opportunity to partnership. The ORN is a SAMHSA-funded initiative, which assists states, organizations, and individuals by providing the resources as well as the technical assistance needed to address the opioid and stimulant use crisis. The ORN supports evidence-based prevention, treatment, and recovery initiatives. The ORN connects local, experienced consultants, who work in prevention, treatment, and recovery, like Shannon and myself, to organizations, such as yours. The ORN accepts requests for education and training similar to the requests the TREAT ME representatives made for us to provide this training to you today. And each state and territory has a designated team led by a Regional Technical Transfer Specialist, who has experience and expertise in implementing evidence-based practices. Shannon and I have no financial interests or relationships to disclose today.

We have some pretest questions for you to think about as you hear the material we’re going to share with you today. And at the end of the presentation, we’ll ask you the same questions to determine if your views have changed. Number one, true or false, how a staff member interacts with patients and families on the phone or in-person can impact whether they continue to engage in care? Number two, the best way or ways to support patients and families while they’re waiting to receive care is to, A, have concrete resources readily available to offer them, B, have an identified person in the practice, who can respond quickly to immediate or urgent patient concerns, or C, both A and B? Number three, an example of Person-First language is A, substance abuser, B, addict, C, person who uses substances, or D, A and C? Number four, it is common for staff to have challenging feelings towards patients and families. When this happens, the best thing to do is, A, do nothing, the feeling will subside, B, express your frustrations to a colleague, or C, talk with your supervisor to get guidance and support. And lastly, number five is true or false, parental consent is required for patients under the age of 18 to receive treatment for substance use in the state of Maine.

The red thread that runs through our presentation today is that Shannon and I believe that every interaction is therapeutic, from start to finish. And what we know from research is that 4.5% of adolescents between the ages of 12 and 17 were diagnosed with a past substance use disorder. However, only 8.3% of them receive treatment. And this data really speaks to the two biggest challenges that we have in working with youth who use substances, which are engagement and retention.

Shannon and I really believe that people remember the first thing you say to them and the last thing you say to them. So as administrative assistants, your roles are crucial. You’re often the first point of contact for patients and families. And ensuring that they feel heard, understood, and cared for will increase the likelihood that they’ll stay engaged in treatment exponentially. And today we’re going to be talking about strategies for increasing engagement and retention. We’ll talk about how to create an inclusive environment, how to provide compassionate care, and how to lower barriers to care.

One of the requests made for this presentation was to address how to create an inclusive environment in which all people feel welcome. The most important thing to keep in mind when creating inclusive environments is to know your patients and client population. You may be working with individuals who are experiencing homelessness, immigrants, refugees, people who are undocumented in the United States, individuals who are experiencing economic hardship, and/or those who are experiencing oppression, or feeling disenfranchised due to other intersecting identities, such as race, ethnicity, sexual orientation, or gender identity, for example. There are many reasons why people can feel marginalized, and it’s crucial that we know the population with whom we work, and that we listen to the barriers to care that they identify. In this slide we’ll give a few examples of how to be inclusive with particular populations. And in the next slide we will share a few of the many resources that are out there that can guide you in your practice in creating an inclusive environment for all.

I often work with gender diverse and transgender youth. And so I’m very accustomed to asking what people’s chosen names and pronouns are. If I’m in-person, I often wear a pin with my chosen pronouns. And if I’m working virtually, you may see from my image, that I’ll always put my chosen pronouns next to my name and credentials. And by doing this, I’m letting people know we’re members of the gender diverse or transgender community, that this is an inclusive environment, and that everybody will be sharing pronouns, and we’re not just asking people who identify as transgender or gender diverse to do so.

Another great question is, what is the best way to contact you? And this really speaks to the fact that lots of youth who are using substances may be living– maybe transient, so they may not be living in the same place. It indicates to them that we’re not making assumptions that they’re living with their families of origin or always in the same place between visits. And also, we’re acknowledging that some youth may be experiencing homelessness. So Shannon and I are pretty accustomed to asking every single visit what the best way to contact our clients is, because that may change from visit to visit.

Another question is, do you need any immediate resources, and if so, what can we help you find and this is a great way to be doing an ongoing needs assessment. So rather than making assumptions about what our clients need we simply ask them, and then keep track of what they tell us and this will really help us figure out what the barriers to care are and what resources we need to be creating for our populations. It’s also helpful to have a wide array of visual representation and resources that focus on unique needs of various populations in your practice and to have them available in different languages whenever possible.

When thinking about the last point, in terms of representation and resources, here are some examples of helpful information and resources for different populations that your practice, program, or service may see. This is not at all a comprehensive list, but it is a start, and we suggest that you create a process to evaluate your own population to identify what they may need and how you may create an inclusive environment where all feel heard, represented, and cared for. The purposes of this presentation, I’ll just review the first three resources. And when you receive the slide deck, the links for each of the resources will be at the back of the PowerPoint presentation.

The New Mainers Resource Center is a Portland Adult Education program servicing immigrants, refugees, and employers in the Greater Portland Area, with the mission of supporting Maine’s economic development by facilitating the professional integration of immigrants and refugees and by meeting employers’ demands for a skilled and culturally diverse workforce. The website provides information for people seeking employment, employers interested in hiring, and other community resources that may be helpful for immigrants and refugees new to Maine.

The second resource, Stigma-Free West Virginia, is a free and easily accessible resource that provides four distinct ways that providers and practice staff can decrease stigma when providing care to those who are using substances. The four ways include changing our language and labels, which I’ll talk about in a moment, learning about the issue, which Shannon and I are here today to talk to you about, listening to people’s personal experiences rather than making assumptions about what they’re experiencing, and reviewing practices and policies.

And lastly, the pediatrician’s guide to an LGBTQ-friendly practice includes how to create a safe and affirming environment and the important role that front desk staff play. This website offers many tips and suggestions and includes brief, helpful videos to use in considering your practices and procedures. And Shannon and I are big fans of this website.

Part of creating an inclusive environment is knowing who can receive services. It is very important to note that any minor may consent to treatment for substance use disorder or for emotional or psychological problems in the state of Maine. And a minor is defined as anyone less than 18 years of age. There is no lower age defined in the state of Maine.

The statute varies between states. For example, in Massachusetts, where Shannon and I practice, the lower age defined is 12. And as you can see from this slide, in 2018, Maine’s legislature attempted to pass legislation to define a lower cutoff limit to consent, but it did not pass. So it’s important to remember that currently Maine patients under the age of 18 do not need parental or guardian permission to receive care.

In providing compassionate care, it’s important to use an empathic approach when interacting with patients. Shannon and I often say it’s important to put ourselves in their shoes. We also practice taking a non-judgmental stance and understanding that ambivalence is a normal part of the treatment process. It’s not a behavioral problem. And that no-shows are incredibly common, and should be expected, and it does not mean that a patient is not engaged in care. As we mentioned there are many barriers to care when youth are trying to access services.

And people may present in many different ways. They may come to visits or virtual visits under the influence. They may present to you unhoused or having not been able to be. And it’s important that we approach each person and their situation with compassion.

It’s also really important to be aware of both our verbal and nonverbal communication. How we act towards others is as important as what we say to them. And to recognize our own feelings judgments and biases. And to seek support from a supervisor when strong or challenging feelings arise with certain patients and families, and they will, because it’s natural, and we all have biases.

There’s a wonderful campaign called Language Matters. And it emphasizes the importance of using non-stigmatizing person-first language in all interactions related to patient care with people who are using substances. This campaign really emphasizes the importance of replacing old language, such as junkie, druggie, addict, substance abuser with person who uses substances. And rather than using substance abuse, saying substance use, substance misuse. Rather than the term clean, we say somebody is in recovery, remission, abstinent, or sober. Rather than referring to dirty urine, we say that someone had an unexpected test result. Rather than replacement therapy, we say someone is in treatment. And rather than saying someone’s born addicted, we say they were substance-exposed.

In terms of lowering barriers to care, if someone asks for support, it’s really critical to respond immediately to strike while the iron is hot. This is an absolute indication that they are ready for care. And readiness is everything when it comes to providing treatment for substance use.

It’s also important to make access to care as easy as possible and to alleviate client burden. This is, again, why we’re always listening really carefully for what the barriers to care are, so that we can break down those barriers. And to remember that navigating systems can be incredibly challenging, especially for adolescents and young adults, who don’t have experience doing this yet. And many young people don’t have support from parents, guardians, or other adults in their lives as they’re trying to navigate systems. Some practical ways to lower barriers to care are to talk to your team about creating a plan to support patients during wait times and to have concrete resources at your fingertips, like websites or internal resources. It can also be very helpful to identify a go-to person in your practice to get the right answers and responses when questions arise. And now, Shannon is going to demonstrate how creating an inclusive environment, providing compassionate care, and lowering barriers to care can be put into action by using some scripts that we’ve developed for you.

SHANNON MOUNTAIN-RAY: Thank you so much, Ariel. What we know is that one of the best strategies for ensuring that you provide compassionate and inclusive care is being prepared, and really trying to anticipate those different scenarios that may present themselves and have resources, and protocols, and some scripts in place for when that happens.

So we’re going to start by using an example of an introductory interaction. So this can be when a patient comes in or family comes into the office for the first time or calls the office. Or, maybe not even the first time, but presents with a new request or a new need.

So you, as the front desk staff person, may say, good morning. Thank you for calling general pediatrics. How may I help you today? And the patient may respond by saying something like, I’m really struggling with my alcohol and drug use, and I’m trying to find some help.

In order to present in a really compassionate way, you can say something like, I’m so glad that you reached out. My name is Ariel, and my chosen pronouns are she/her/hers. Let’s work together to see what your needs are and how we can provide support and guidance. First, can you tell me your chosen name, chosen pronouns, and your date of birth?

And the patient may respond, and say, my name is Charlotte Smith, and my date of birth is 7/11/2005. So you go into the system, and you attempt to look up the patient, but you’re not finding that patient in your system. So this can happen particularly in situations where a young person may be transgender.

And in this case, Charlotte was actually born male and under a different name. And so when you’re prepared for these kinds of things, you can minimize any kind of shock or reaction. And you can say, I’m not finding a patient of that name in our system. Could it be under another name?

And the patient might say, it might be under Charles Smith. And you may get the sense that they are prepared for a reaction. That they are defending themselves against some shock or some kind of judgment or bias.

And so you can say, thank you. I found it. I’ll make sure that your chosen name and pronouns are reflected accurately in our system. This may take some time, but please know that we are working diligently on this important matter. So you’re reassuring them that you understand how important this is, and that you’ll make sure that the situation is remedied.

And we might dive a little bit further. And we want to identify what are the needs or what is the need of the person that you’re talking with. It’s really important in these circumstances to have a protocol in place of how you address these needs ahead of time. So it may be a protocol where you have an identified person in the practice who you can refer patients to, like a triage nurse, or a resource specialist, or even providers in the practice. Or, it may be that you don’t have access to that kind of thing and you, yourself, may be the resource itself. And so you will want to, as Ariel mentioned, have a list of resources at your fingertips or have an easy way of accessing resources that you may not have readily available.

So you might say, do you have a sense of what you’re looking for, in terms of support? Sometimes patients will know exactly what they want, and they can be very specific. But other times, they just say no. I just know I need help.

And so you might respond, and say, OK, we’re here to help. You mentioned that you’re looking for help around your substance use. I’m going to connect you with our triage nurse to help you find what you need. If you have any trouble reaching them, please give me a call back, and I’ll help make sure you get connected to someone. So often when there are lapses in time, or there’s a need to call people back, or things like that, we lose the opportunity, so by inviting them to call you back in the event that they don’t hear from someone, or they don’t get what they need, or for some reason they get disconnected is really critical in letting them know that you’re there and you really want to help them. So again, as Ariel mentioned, providing resources, if there’s a delay in care. So again, often if it’s a situation where someone wants to see a provider in your practice, or program, or organization, or some other access to a resource where there might be a wait time, it’s really important that there’s a plan in place to help support them during that time.

So in a situation, for example, where they may request to be seen by one of your providers or it’s determined that they should be seen by one of your providers, but there will be a delay in services, you can say, currently, there may be a wait time to have you seen by one of our providers. I’m going to give you some names and numbers of programs and supports that might be helpful for you during the waiting period. What is the best way for me to– [AUDIO OUT] And back to Ariel’s point, about getting the most updated contact information, but doing so without having them to have to explain where they’re living, what they do and don’t have access to. So if you just check in, what’s the best way for me to reach you, They will tell you and they don’t have to explain anything about the circumstance.

So the patient may say, thank you. I don’t have a cell phone or access to email, at the moment, so giving them to me now would be the best thing. So again, having at least some resources available to you, in that moment, will be very helpful in these situations. And you might say, perfect, and provide those resources.

In some circumstances, you may have a patient who’s really, really struggling, in that moment. And they may say, I’m really worried, because I’m really struggling right now and not sure I can wait. So having a plan in place for how you respond to immediate needs or crises, in the moment, is really critical.

You might say, I’m so sorry that you’re having such a hard time. If you’re worried about your safety, we suggest calling 9-1-1, or going to your nearest emergency room to get immediate support. After you’ve been seen by the emergency room and a plan has been made, please call us back so we can continue to help support you. So again, this is a situation where some of the biggest challenges in our system of care is that when people transition between providers or different levels of care often people get lost in the system. So inviting them to make sure that they reach back out to you, and they tell you, this is where I’ve been, and this is what I need, and being available to help them in that way is really, really important. So as we talked about in the beginning, remember that every interaction is therapeutic. From the minute someone walks into the office, or calls on the phone, and the hello that you give them, all the way through identifying their needs and finding resources for support, every interaction you have is therapeutic.

In summary, first impressions matter. Engagement and retention begins with each of you. And creating an inclusive environment will help us to reach our most vulnerable patients. Remember, that youth are the identified patients and main contact. Parental consent is not required for them to engage in care. Provide compassionate care, and be aware of your own biases and judgments, and respond to youth needs expeditiously and guide them in navigating systems. This is a really wonderful website presented by the National Child Traumatic Stress Network and gives a lot of really wonderful tools and strategies for engaging adolescents in treatment. Again, this will be on the final slide with all of the resources.

When you’re working with your practices or programs or organizations to think about how you can create a compassionate and inclusive environment with low barriers to care here are some questions to consider. What resources do we have in place to support patients during wait times? Who do I talk to if I’m having challenging feelings towards a patient or a family? And what do we have or what do we need to create an inclusive environment?

Circling back to the pretest questions, after having gone through this presentation, hopefully these answers will come easily to you. But number one, true or false, how a staff member interacts with patients and families on the phone or in-person can impact whether they continue to engage in care? Number two, the best way to support patients and families while they’re waiting to receive care is to A, have concrete resources readily available to offer them, B, have an identified person in the practice who can respond quickly to immediate or urgent patient concerns, C, both A and B. Number three, an example of person-first language is A, substance abuser, B, addict, C, person who used substances, D, both A and C. Number four, it’s common for staff to have challenging feelings towards patients and families. When this happens the best thing to do is, A, do nothing, the feelings will subside, B, express your frustrations to a colleague, C, talk with your supervisor to get guidance and support. And lastly, number five, true or false, parental consent is required for patients under 18 to receive treatment for substance use.

We thank you all for being here today. And if you have a brief moment, please take time to fill out this survey. Your feedback is really important to us. Thank you.

ARIEL BOTTA: We’re very excited to provide this presentation for you today. My name is Dr. Ariel Botta, and I’m the Coordinator of Group Psychotherapy, and my dear colleague, Shannon Mountain-Ray, is the Director of Integrated Treatment in the Adolescent Substance Use and Addiction Program in the Division of Developmental Medicine at Boston Children’s Hospital.

And today, we’ll be talking to you about working with youth who use substances. We were brought to you by the TREAT ME Representatives in Maine. And TREAT ME stands for Treatment, Recovery, Education, Advocacy for Teens with Substance Use Disorder. The representatives reach out to the Opioid Response Network to develop a training on how to provide compassionate and inclusive care to youth who use substances.

We are brought to you today in partnership with the Opioid Response Network, and we want to thank ORN so much for funding us and for the opportunity to partnership. The ORN is a SAMHSA-funded initiative, which assists states, organizations, and individuals by providing the resources as well as the technical assistance needed to address the opioid and stimulant use crisis. The ORN supports evidence-based prevention, treatment, and recovery initiatives. The ORN connects local, experienced consultants, who work in prevention, treatment, and recovery, like Shannon and myself, to organizations, such as yours. The ORN accepts requests for education and training similar to the requests the TREAT ME representatives made for us to provide this training to you today. And each state and territory has a designated team led by a Regional Technical Transfer Specialist, who has experience and expertise in implementing evidence-based practices. Shannon and I have no financial interests or relationships to disclose today.

We have some pretest questions for you to think about as you hear the material we’re going to share with you today. And at the end of the presentation, we’ll ask you the same questions to determine if your views have changed. Number one, true or false, how a staff member interacts with patients and families on the phone or in-person can impact whether they continue to engage in care? Number two, the best way or ways to support patients and families while they’re waiting to receive care is to, A, have concrete resources readily available to offer them, B, have an identified person in the practice, who can respond quickly to immediate or urgent patient concerns, or C, both A and B? Number three, an example of Person-First language is A, substance abuser, B, addict, C, person who uses substances, or D, A and C? Number four, it is common for staff to have challenging feelings towards patients and families. When this happens, the best thing to do is, A, do nothing, the feeling will subside, B, express your frustrations to a colleague, or C, talk with your supervisor to get guidance and support. And lastly, number five is true or false, parental consent is required for patients under the age of 18 to receive treatment for substance use in the state of Maine.

The red thread that runs through our presentation today is that Shannon and I believe that every interaction is therapeutic, from start to finish. And what we know from research is that 4.5% of adolescents between the ages of 12 and 17 were diagnosed with a past substance use disorder. However, only 8.3% of them receive treatment. And this data really speaks to the two biggest challenges that we have in working with youth who use substances, which are engagement and retention.

Shannon and I really believe that people remember the first thing you say to them and the last thing you say to them. So as administrative assistants, your roles are crucial. You’re often the first point of contact for patients and families. And ensuring that they feel heard, understood, and cared for will increase the likelihood that they’ll stay engaged in treatment exponentially. And today we’re going to be talking about strategies for increasing engagement and retention. We’ll talk about how to create an inclusive environment, how to provide compassionate care, and how to lower barriers to care.

One of the requests made for this presentation was to address how to create an inclusive environment in which all people feel welcome. The most important thing to keep in mind when creating inclusive environments is to know your patients and client population. You may be working with individuals who are experiencing homelessness, immigrants, refugees, people who are undocumented in the United States, individuals who are experiencing economic hardship, and/or those who are experiencing oppression, or feeling disenfranchised due to other intersecting identities, such as race, ethnicity, sexual orientation, or gender identity, for example. There are many reasons why people can feel marginalized, and it’s crucial that we know the population with whom we work, and that we listen to the barriers to care that they identify. In this slide we’ll give a few examples of how to be inclusive with particular populations. And in the next slide we will share a few of the many resources that are out there that can guide you in your practice in creating an inclusive environment for all.

I often work with gender diverse and transgender youth. And so I’m very accustomed to asking what people’s chosen names and pronouns are. If I’m in-person, I often wear a pin with my chosen pronouns. And if I’m working virtually, you may see from my image, that I’ll always put my chosen pronouns next to my name and credentials. And by doing this, I’m letting people know we’re members of the gender diverse or transgender community, that this is an inclusive environment, and that everybody will be sharing pronouns, and we’re not just asking people who identify as transgender or gender diverse to do so.

Another great question is, what is the best way to contact you? And this really speaks to the fact that lots of youth who are using substances may be living– maybe transient, so they may not be living in the same place. It indicates to them that we’re not making assumptions that they’re living with their families of origin or always in the same place between visits. And also, we’re acknowledging that some youth may be experiencing homelessness. So Shannon and I are pretty accustomed to asking every single visit what the best way to contact our clients is, because that may change from visit to visit.

Another question is, do you need any immediate resources, and if so, what can we help you find and this is a great way to be doing an ongoing needs assessment. So rather than making assumptions about what our clients need we simply ask them, and then keep track of what they tell us and this will really help us figure out what the barriers to care are and what resources we need to be creating for our populations. It’s also helpful to have a wide array of visual representation and resources that focus on unique needs of various populations in your practice and to have them available in different languages whenever possible.

When thinking about the last point, in terms of representation and resources, here are some examples of helpful information and resources for different populations that your practice, program, or service may see. This is not at all a comprehensive list, but it is a start, and we suggest that you create a process to evaluate your own population to identify what they may need and how you may create an inclusive environment where all feel heard, represented, and cared for. The purposes of this presentation, I’ll just review the first three resources. And when you receive the slide deck, the links for each of the resources will be at the back of the PowerPoint presentation.

The New Mainers Resource Center is a Portland Adult Education program servicing immigrants, refugees, and employers in the Greater Portland Area, with the mission of supporting Maine’s economic development by facilitating the professional integration of immigrants and refugees and by meeting employers’ demands for a skilled and culturally diverse workforce. The website provides information for people seeking employment, employers interested in hiring, and other community resources that may be helpful for immigrants and refugees new to Maine.

The second resource, Stigma-Free West Virginia, is a free and easily accessible resource that provides four distinct ways that providers and practice staff can decrease stigma when providing care to those who are using substances. The four ways include changing our language and labels, which I’ll talk about in a moment, learning about the issue, which Shannon and I are here today to talk to you about, listening to people’s personal experiences rather than making assumptions about what they’re experiencing, and reviewing practices and policies.

And lastly, the pediatrician’s guide to an LGBTQ-friendly practice includes how to create a safe and affirming environment and the important role that front desk staff play. This website offers many tips and suggestions and includes brief, helpful videos to use in considering your practices and procedures. And Shannon and I are big fans of this website.

Part of creating an inclusive environment is knowing who can receive services. It is very important to note that any minor may consent to treatment for substance use disorder or for emotional or psychological problems in the state of Maine. And a minor is defined as anyone less than 18 years of age. There is no lower age defined in the state of Maine.

The statute varies between states. For example, in Massachusetts, where Shannon and I practice, the lower age defined is 12. And as you can see from this slide, in 2018, Maine’s legislature attempted to pass legislation to define a lower cutoff limit to consent, but it did not pass. So it’s important to remember that currently Maine patients under the age of 18 do not need parental or guardian permission to receive care.

In providing compassionate care, it’s important to use an empathic approach when interacting with patients. Shannon and I often say it’s important to put ourselves in their shoes. We also practice taking a non-judgmental stance and understanding that ambivalence is a normal part of the treatment process. It’s not a behavioral problem. And that no-shows are incredibly common, and should be expected, and it does not mean that a patient is not engaged in care. As we mentioned there are many barriers to care when youth are trying to access services.

And people may present in many different ways. They may come to visits or virtual visits under the influence. They may present to you unhoused or having not been able to be. And it’s important that we approach each person and their situation with compassion.

It’s also really important to be aware of both our verbal and nonverbal communication. How we act towards others is as important as what we say to them. And to recognize our own feelings judgments and biases. And to seek support from a supervisor when strong or challenging feelings arise with certain patients and families, and they will, because it’s natural, and we all have biases.

There’s a wonderful campaign called Language Matters. And it emphasizes the importance of using non-stigmatizing person-first language in all interactions related to patient care with people who are using substances. This campaign really emphasizes the importance of replacing old language, such as junkie, druggie, addict, substance abuser with person who uses substances. And rather than using substance abuse, saying substance use, substance misuse. Rather than the term clean, we say somebody is in recovery, remission, abstinent, or sober. Rather than referring to dirty urine, we say that someone had an unexpected test result. Rather than replacement therapy, we say someone is in treatment. And rather than saying someone’s born addicted, we say they were substance-exposed.

In terms of lowering barriers to care, if someone asks for support, it’s really critical to respond immediately to strike while the iron is hot. This is an absolute indication that they are ready for care. And readiness is everything when it comes to providing treatment for substance use.

It’s also important to make access to care as easy as possible and to alleviate client burden. This is, again, why we’re always listening really carefully for what the barriers to care are, so that we can break down those barriers. And to remember that navigating systems can be incredibly challenging, especially for adolescents and young adults, who don’t have experience doing this yet. And many young people don’t have support from parents, guardians, or other adults in their lives as they’re trying to navigate systems. Some practical ways to lower barriers to care are to talk to your team about creating a plan to support patients during wait times and to have concrete resources at your fingertips, like websites or internal resources. It can also be very helpful to identify a go-to person in your practice to get the right answers and responses when questions arise. And now, Shannon is going to demonstrate how creating an inclusive environment, providing compassionate care, and lowering barriers to care can be put into action by using some scripts that we’ve developed for you.

SHANNON MOUNTAIN-RAY: Thank you so much, Ariel. What we know is that one of the best strategies for ensuring that you provide compassionate and inclusive care is being prepared, and really trying to anticipate those different scenarios that may present themselves and have resources, and protocols, and some scripts in place for when that happens.

So we’re going to start by using an example of an introductory interaction. So this can be when a patient comes in or family comes into the office for the first time or calls the office. Or, maybe not even the first time, but presents with a new request or a new need.

So you, as the front desk staff person, may say, good morning. Thank you for calling general pediatrics. How may I help you today? And the patient may respond by saying something like, I’m really struggling with my alcohol and drug use, and I’m trying to find some help.

In order to present in a really compassionate way, you can say something like, I’m so glad that you reached out. My name is Ariel, and my chosen pronouns are she/her/hers. Let’s work together to see what your needs are and how we can provide support and guidance. First, can you tell me your chosen name, chosen pronouns, and your date of birth?

And the patient may respond, and say, my name is Charlotte Smith, and my date of birth is 7/11/2005. So you go into the system, and you attempt to look up the patient, but you’re not finding that patient in your system. So this can happen particularly in situations where a young person may be transgender.

And in this case, Charlotte was actually born male and under a different name. And so when you’re prepared for these kinds of things, you can minimize any kind of shock or reaction. And you can say, I’m not finding a patient of that name in our system. Could it be under another name?

And the patient might say, it might be under Charles Smith. And you may get the sense that they are prepared for a reaction. That they are defending themselves against some shock or some kind of judgment or bias.

And so you can say, thank you. I found it. I’ll make sure that your chosen name and pronouns are reflected accurately in our system. This may take some time, but please know that we are working diligently on this important matter. So you’re reassuring them that you understand how important this is, and that you’ll make sure that the situation is remedied.

And we might dive a little bit further. And we want to identify what are the needs or what is the need of the person that you’re talking with. It’s really important in these circumstances to have a protocol in place of how you address these needs ahead of time. So it may be a protocol where you have an identified person in the practice who you can refer patients to, like a triage nurse, or a resource specialist, or even providers in the practice. Or, it may be that you don’t have access to that kind of thing and you, yourself, may be the resource itself. And so you will want to, as Ariel mentioned, have a list of resources at your fingertips or have an easy way of accessing resources that you may not have readily available.

So you might say, do you have a sense of what you’re looking for, in terms of support? Sometimes patients will know exactly what they want, and they can be very specific. But other times, they just say no. I just know I need help.

And so you might respond, and say, OK, we’re here to help. You mentioned that you’re looking for help around your substance use. I’m going to connect you with our triage nurse to help you find what you need. If you have any trouble reaching them, please give me a call back, and I’ll help make sure you get connected to someone. So often when there are lapses in time, or there’s a need to call people back, or things like that, we lose the opportunity, so by inviting them to call you back in the event that they don’t hear from someone, or they don’t get what they need, or for some reason they get disconnected is really critical in letting them know that you’re there and you really want to help them. So again, as Ariel mentioned, providing resources, if there’s a delay in care. So again, often if it’s a situation where someone wants to see a provider in your practice, or program, or organization, or some other access to a resource where there might be a wait time, it’s really important that there’s a plan in place to help support them during that time.

So in a situation, for example, where they may request to be seen by one of your providers or it’s determined that they should be seen by one of your providers, but there will be a delay in services, you can say, currently, there may be a wait time to have you seen by one of our providers. I’m going to give you some names and numbers of programs and supports that might be helpful for you during the waiting period. What is the best way for me to– [AUDIO OUT] And back to Ariel’s point, about getting the most updated contact information, but doing so without having them to have to explain where they’re living, what they do and don’t have access to. So if you just check in, what’s the best way for me to reach you, They will tell you and they don’t have to explain anything about the circumstance.

So the patient may say, thank you. I don’t have a cell phone or access to email, at the moment, so giving them to me now would be the best thing. So again, having at least some resources available to you, in that moment, will be very helpful in these situations. And you might say, perfect, and provide those resources.

In some circumstances, you may have a patient who’s really, really struggling, in that moment. And they may say, I’m really worried, because I’m really struggling right now and not sure I can wait. So having a plan in place for how you respond to immediate needs or crises, in the moment, is really critical.

You might say, I’m so sorry that you’re having such a hard time. If you’re worried about your safety, we suggest calling 9-1-1, or going to your nearest emergency room to get immediate support. After you’ve been seen by the emergency room and a plan has been made, please call us back so we can continue to help support you. So again, this is a situation where some of the biggest challenges in our system of care is that when people transition between providers or different levels of care often people get lost in the system. So inviting them to make sure that they reach back out to you, and they tell you, this is where I’ve been, and this is what I need, and being available to help them in that way is really, really important. So as we talked about in the beginning, remember that every interaction is therapeutic. From the minute someone walks into the office, or calls on the phone, and the hello that you give them, all the way through identifying their needs and finding resources for support, every interaction you have is therapeutic.

In summary, first impressions matter. Engagement and retention begins with each of you. And creating an inclusive environment will help us to reach our most vulnerable patients. Remember, that youth are the identified patients and main contact. Parental consent is not required for them to engage in care. Provide compassionate care, and be aware of your own biases and judgments, and respond to youth needs expeditiously and guide them in navigating systems. This is a really wonderful website presented by the National Child Traumatic Stress Network and gives a lot of really wonderful tools and strategies for engaging adolescents in treatment. Again, this will be on the final slide with all of the resources.

When you’re working with your practices or programs or organizations to think about how you can create a compassionate and inclusive environment with low barriers to care here are some questions to consider. What resources do we have in place to support patients during wait times? Who do I talk to if I’m having challenging feelings towards a patient or a family? And what do we have or what do we need to create an inclusive environment?

Circling back to the pretest questions, after having gone through this presentation, hopefully these answers will come easily to you. But number one, true or false, how a staff member interacts with patients and families on the phone or in-person can impact whether they continue to engage in care? Number two, the best way to support patients and families while they’re waiting to receive care is to A, have concrete resources readily available to offer them, B, have an identified person in the practice who can respond quickly to immediate or urgent patient concerns, C, both A and B. Number three, an example of person-first language is A, substance abuser, B, addict, C, person who used substances, D, both A and C. Number four, it’s common for staff to have challenging feelings towards patients and families. When this happens the best thing to do is, A, do nothing, the feelings will subside, B, express your frustrations to a colleague, C, talk with your supervisor to get guidance and support. And lastly, number five, true or false, parental consent is required for patients under 18 to receive treatment for substance use.

We thank you all for being here today. And if you have a brief moment, please take time to fill out this survey. Your feedback is really important to us. Thank you.

Giving Parental Guidance and Using Behavioral Contracts

SHAWN KELLY: Hello. And welcome to this session entitled “Parent Involvement in the Treatment of Adolescent Substance Use Disorder.” My name is Dr. Shawn Kelly. I am a former fellow of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. Thank you for attending. 

Today’s objectives will include our rationale for family involvement in the treatment of adolescent substance use and substance use disorder. We will discuss the conceptual framework around that involvement and treatment. We’ll discuss the stages of change. 

We will share our methods and tools we use in the program and some of the ASAP experience. We will review certain special cases as an opportunity to employ certain concepts or strategies for you, the learner. I have no relevant disclosures. 

I’d like to start with a definition of adolescence that includes the functional anatomy and the development of the brain of young people. This definition is very pictorial, as you can see. And what we describe is that adolescence is the period between full maturation of the nucleus accumbens and the prefrontal cortex. 

The nucleus accumbens and prefrontal is most often associated with the reward pathway. We talk about the gas pedal when we’re using an analogy. And the prefrontal cortex associated with reasoning, impulse control, perseverance, problem-solving can be thought of as the brakes. So this is the period when the gas is fully mature and the brakes are yet to mature fully. 

We have known for a long time that family involvement is an important factor in the initiation of substance use. In fact, from what we have studied, it appears to be the most important factor that can reduce the initiation of substance use of various substances at various time points for adolescents. 

It has become part of the mainstream of people who treat adolescents for substance use to involve the families. This is becoming a more widespread practice. And we’re seeing some literature being disseminated that reinforce this view. 

There is actually some improving body of evidence that says that even a relative low intensity and even group setting parent interventions can have a long-lasting and effective change in the amount of substance use that is occurring, or is about to occur, with various adolescents. 

We have known for a long time that there are some high-risk factors for substance use disorder. This list comes from the CDC. In blue are some of the special cases that might be relevant. Family history of substance use and parental substance use are very important points. Even the attitude in the house is an important risk factor. 

Association with delinquent or substance-using peers– and this is relevant because we hear a lot of the time that if we weren’t associating with these peers or those peers that things might be a lot better. And there is some truth to that fact and that assertion that we will hear frequently from parents. 

Mental health issues is a short bullet point that encompasses a lot of diagnoses, the most commonly being anxiety, followed by a major depressive disorder. 

And so we know that there are also factors that can predict a decrease in this use. From the research that we’ve seen before and from some other sources, we know that parent or family engagement is very important; the support or a supportive relationship in the impression of the adolescent. 

And the parents’ attitude– again, parents who are monitoring and looking in and very involved in their children’s lives. And a sense of connectedness and success in the academic setting is also very important and predictive. 

Just for a second to review of short bit of the data talking about what kind of rates of substance use we have in considering the recent changes that have occurred during the global pandemic. From the data that was released in 2021 that included the surveys up to the year 2020, we saw sort of a relative stabilizing of cannabis use. 

There is a bit more of a preference towards vaped cannabis that was occurring in adolescents across high school. And there was a brief decline noted in terms of daily cannabis use amongst 10th graders. These are sort of relevant things that show maybe a planing off, maybe a certain deflection downwards in the overall rates of cannabis use in that first year of the pandemic. 

From the same data, we see the weird and wonderful substances were on the uptick, thinking of cough medicines, amphetamines, and inhalants. These are sort of the drugstore/hardware store highs that we often see. And this is a bit of a troubling trend. And it sort of seems that people were using what they had access to at this point of the pandemic. 

This set of data actually looks at a slightly older age range, but includes some of the people that we do see at ASAP and some of the people that may be encountered in one’s practice. Looking at young adults, we saw that in 2021, there has sort of– since 2011, we have the highest rates of marijuana use. And hallucinogens have really come back, to a certain extent. And that is a– the data shows what has anecdotally been true for the last two years or so. 

So why do we do this, and to what end? We know that family skills training can decrease adolescent substance use. In ASAP, at the very most, we have four hours of contact with the patient and two hours with the parents per month. And that is at the very most. So any hope of sustained implementation of our evidence-based treatment recommendations is reliant upon parental empowerment and parental training. 

There’s a way that we want this to go. And the whole purpose of our parent guidance sessions are to narrow down all of the possibilities that deviate from the one that we want– to put girders along the side of the road, so that we can get to the destination we’re seeking and cut off some of the possibilities that are less favorable. 

The theory behind it is largely related to the theory of contingency management. Contingency management, in this context, is best described as external control of the environment and consequences for behaviors that is supposed to lead to more favorable behaviors and in a sustained way. 

We know, actually, that the contingency management strategy is the number one most effective intervention that we can do for things like substance– stimulant use disorder in the adult population. We know that for cannabis use in the adult population, contingency management is the best way to do it. And essentially, we are rewarding the behavior that we want. That is the most common definition of contingency management. I think it’s useful to use both sides, and we’ll discuss that as we go forward– positive and negative consequences. 

Just to review the ASAP approach, at the beginning of our sessions there is a part 1 interview, which is the data collection from the young person, where a member of the ASAP team, typically a medical provider, obtains a history and performs as much physical exams as possible through the medium that this interview is occurring. Part 2 is a parent interview. It’s totally separate. It’s run on a script, and we collect data from the parents as well. 

The team reviews the presented case and the recommendations thereof and makes certain tweaks to those recommendations. And at the family meeting, those recommendations are presented to the youth and their parents. 

At this point, the parents and youth are sort of separated in the treatment ongoing at ASAP. And one provider is assigned to the parents for parental guidance and sometimes some educational sessions. A different provider, or different providers, are assigned to the patient for ongoing motivational interviewing and relapse prevention-based therapies, medical follow-ups, perhaps psychopharmacological evaluations, et cetera, and education sessions as well. 

But there is a separation. And at this point, this is a very useful time to separate things, so that each member of the family feels that they have ownership over their therapeutic interactions within the ASAP program. 

OK. So just to briefly review, this is the stages of change from Prochaska and DiClemente that is frequently used in discussing readiness for change. And the important point is that meeting the patient where they’re at means meeting the parents where they are, too. And so the stages of change that we often discuss when we’re talking about readiness include precontemplation, contemplation, preparation, action, maintenance. Sometimes we can talk about relapse or termination as well. 

While this diagram shows a very smooth progression from one stage to the other, we know that in practice there is movement forward and backwards– sometimes even more movement forward and backwards within the same session or sentence for either patients or parents. But it’s important to know where people are at. 

Because if we start giving strategies for action or preparation for somebody who is in contemplation, sliding back into precontemplation, we may actually push them further away from the change that they need to make. And so this is very important, too. And it’s sometimes a challenging thing for the provider because we really want to start to intervene. We know that this is a meaningful intervention. 

However, if we approach parents who are not ready to make the change, it’s just like approaching a patient who’s not ready to make the change. We may push them away, and we may get further away from the endpoint that we are seeking. 

So ASAP is a program of carrots and sticks. This is something that one of my mentors, Dr. Mimi Schizer, likes to frequently say. And I think this is a wonderful analogy and a wonderful description for what we continue to do in ASAP. We want to have a somewhat enticing reward, and we want to have a behavior that we’d like to change. 

In terms of those carrots, what do they look like? For most adolescents– and oftentimes, this is a very useful list– there’s the 7 Cs of leverage. We can talk about cash or currency. I like to think of Amazon dollars or some other sort of electronic currency that can be used more safely than cash these days, which are chores; curfew; car access– that’s a big one; cell phone– that might be the juiciest carrot on the list; the companions we are able to see; and access to the computer. These are our various carrots. And what we need to do is select the carrots based on the interest of the adolescent. 

So oftentimes, in those initial interviews with the patient and parent, we’re talking about what kind of access to the car do these children have? Who is paying the phone bill? Do we have a bed time at home, et cetera. So we already have a pretty good sense of which carrots might be very useful to begin with. 

So we have carrots, and we need to hang them from sticks. The sticks are the behaviors that we would like to change. And then we like to put this framework into something written down in what we call a behavioral contract. Here are some useful concepts to make a good behavioral contract. 

We need to match the scale of the consequence and the behavior. So if there’s a small change that we would like, we don’t hang the juiciest carrot from that. And if there is a big change that we make, we need to have something that is rewarding as a positive or negative consequence from that behavior. 

Ideally, these are logical consequences that have a bit of a connection that can be seen by both parents and by the patient. Something like if there’s cannabis use in the car, one loses access to the car is a good example of that sort of thing. 

They need to be enforceable. This is very important. And this goes back to the stage of change that the parents are in. We can write up many a behavioral contract and lay down the law, so to speak. 

And if we aren’t able to enforce when the contract is violated or fulfilled– perhaps we can’t come through with the reward that we have promised– the contract loses its power. And we actually lose some credibility with our adolescents, both the parents and the providers here. We need to be able to monitor this. So we need to be looking. We need to be checking, that sort of thing. 

Level expectations– that’s level, the verb. We want to try to make this– any sort of expectations for the behavior need to be outlined in the contract. We don’t want to have any unspoken or imagined expectations, be it on either side. That’s something that’s very important. 

And the other thing is that we have one carrot for one stick. If the cell phone is a particularly potent motivator, we can’t tether all the behaviors we want to cell phone access. Because if we have three behaviors that we want, and we come through with two and not one, does that lead to the reward or not? And it becomes very complicated. So we need to find multiple carrots. 

This is an old example of a behavioral contract that was written up and used as a vague template. They can be as formal as this. I like to have them written down. I find it to be a useful go-to, and we can sort of return to the document when there is any dispute over how to enforce. Because sometimes at the time of enforcement, it is really nice to have a policy written out that is– we can make reference to for both people. 

And so what we see here is across the top, we have the series of expectations and the series of sticks. And then coming down the side, we have the carrot. And so this example, what we see is drug tests. That is the behavior that we want. And so what the behavior is outlined here– all drug tests are negative for three consecutive months. 

I think that this older contract, in my practice, would be modified slightly. And my preference is often not to– right away, anyways– hang our reward on the negative or absence of substance from the urine tests. What I want is participation in the urine tests more often. And sometimes, that’s where we begin. 

And so if we have participation in the drug test– you submit your urine test when asked, or on the schedule that we have created, or whatever parameters we need to write in for this individual in this family– then if we meet that expectation, there is a reward. You may have access to your friends after school– whatever it may be. And if you don’t submit a test, then we are stuck at home until you do submit a test– something like that. So it’s logical. The scale is right. It’s enforceable, hopefully. And that’s what we do. So this is a good example. 

And so sometimes we can– it’s important to have both. When we meet the expectations it’s not– sometimes there is a reward there. And it’s not just if you don’t meet the expectations we’re taking something away or you’re losing out. So I think this is a very nice framework for doing these contracts, and I think it’s very useful. 

So when we’re talking to parents about how to talk to their children at this time, it’s very difficult for a lot of parents. And we hear this often. She lies constantly, or he lies, or they lie constantly. And I think that this is a nice thing to say to parents, and it’s a nice thing for parents to hear. It’s a nice thing for providers to hear. Because we’re not always getting the full story or the truth. 

Adolescents do lie a lot. But this is not due to inherent dishonesty, but due to a strong preference to meet a perceived expectation rather than disclose a hard truth. When I said leveling expectations earlier, this is one of the roles I see for urine testing. 

When we do urine testing, it helps us sort of set the table. And now we are dealing with facts, and we are not dealing with imagined expectations or real expectations from either side, spoken or unspoken. We are dealing with the truth. And it’s a much more inviting game and sort of interaction when we have all of those unspoken things just swept off– swept out of the way. It just allows us to interact in a much more useful and much more productive way. 

So I like this image. Family is enjoying a lovely breakfast, and the youth is being– shutting his ears. This is a good metaphor for what happens in some houses. And the youth in question who is using substances, at every interaction that they’re having with their parent or parents, there is a discussion about use. 

Oh, you’re not going to go out tonight and use. These people– you’re not going to see this person. Or yesterday you came home high. And sometimes we have youth who try to be at home less, or parents who are shutting the door in their office. And what we have is sometimes this avoidance of the conflict that is constantly happening at home. 

So I think it’s really important, and we can make a major shift in the tone of the interactions at home, by scheduling a time and a place for review. This might mean that on Tuesdays at 7:00 after dinner, we talk for 15 minutes about what’s been going on with the contract and with substance use this week. We won’t talk about it outside of that time unless there’s an emergency. 

And if parents can stick to that and keep their concerns for a scheduled time– perhaps it needs to be multiple times a week. But if we can do that, then we see less avoidance, and we see a nicer tone during the times that we know we’re not going to have to have a discussion about substance use. So I think this is a very useful tool. Sort of– sometimes we are misguided in our approach, and it’s nice to roll it back a little bit. 

These special circumstances are exceptionally difficult and require sometimes patience, sometimes novel approaches, sometimes involvement of other health professionals. But when we have parents who use, this is very difficult. It’s very difficult to change a child’s behavior when one of their most important models is– he is living in a different way than we are suggesting. 

Sometimes the education level of parents can make it difficult. Or even beyond education level, preconceptions and attitudes are very important. When there is a more complicated relationship between the parents and child, be it sort of– adoption is one, and divorced parents is another. 

And what it is, is a slightly more complicated dynamic where there is certain pressures, and there are certain levers that the adolescent may be able to use, or the parents may be able to use, to sort of complicate matters. What’s really important is, in the case of divorce or separation, is having a united front and an agreed upon plan whenever we can. 

OK. So here are some important elements of parental responsibility. First and foremost, clear messaging on use of substances. One of the ones that we frequently use in ASAP has always been, I don’t want you to use anything. It’s not good for your developing brain. 

I’ll say that again. I don’t want you to use anything. It’s not good for your developing brain. That is an abstinence message, and that’s what we can put as our goal and we. And that can be the idea that echoes in the voice of the ASAP provider, or in the voice of the adolescent’s parents when the situation arises. 

We need to have enforcement of the behavioral contract. And so if it is urine testing or the other consequences, positive or negative, we need to have these things set at a level that work. 

We want to have a balance between surveillance and independence because we can’t have parents acting as the prefrontal cortex of their young people and constantly looking. And we need the young people to have some sense of independence. This is a developmental need at that time. And setting the tone is really important, too. 

Just to review and to think of what we might be able to do with cases, and if you’re doing this with people, you may want to pause. Otherwise, just think to yourself, what principles from before might be applicable in this situation. 

So you are meeting the parents of a 14-year-old young person. He was diagnosed with moderate cannabis use disorder, moderate nicotine use disorder, alcohol use, and dextromethorphan use. Additionally, he has diagnoses of generalized anxiety disorder and a question regarding depression versus bipolar, too. 

We have highly educated and cooperating parents. They’ve done several iterations of behavioral contracts that we have helped make. And we’ve had really limited follow-through there. So the enforceability issue has come up. And today we were asked to tell this 14-year-old that he needs to go to inpatient therapy. 

This is an important consequence of failure of the initial approach, and sort of– we may have lost some of the potency of the carrot and stick model when the carrots have been given– or the stick has been shortened, and the carrot has been reached anyway. So that’s an important case. 

Case number two– a 17-year-old with mild alcohol, moderate nicotine, and severe cannabis use disorder also has a diagnosis of depression and has had previous multiple inpatient treatments for four months total. We receive a distressed email from Dad #1. We are in a crisis. And 17, our patient, has been increasing as cannabis use again in and around the home in the presence of his younger sibling. 

There is a separation occurring between the parents. And Dad #2 is staying in the house on alternate weeks, and the two are no longer romantically involved. Dad #2, however, smokes cannabis daily in the evenings before retiring to sleep. This is a significant case where we need to have a unified front, and we need to find a way to make messaging make sense to this young person. 

Case number three– a young adult here with moderate alcohol use disorder, severe nicotine use disorder, developmental delay, ADHD, and major depressive disorder. We had some success with nicotine early on. But now the substance use has escalated, and we are now smoking crack on the weekends. Mom and dad had been very faithful to the behavioral contracts I’ve written. What can we do? 

When we’ve been faithful to the behavioral contracts as written, perhaps and the enforcement has been good, perhaps what we need to do is change what we are enforcing, and we can sort of change our behaviors around these things, and make the consequences harsher or sweeter, depending on the end that we’re talking about. Or maybe this person is beyond the reach of a system of behavioral contracts. I think that that’s also an important consideration– knowing when these tools may not be as useful as others. 

So the conclusions. We know that parent guidance is an effective strategy for decreasing adolescent substance use before and after initiation. Expectations for behavior must be clear and tethered to enforceable positive and negative consequences. 

We are asking parents to change their behaviors. As such, we must respect readiness and meet them where they are at. Scheduling a time for review can help change the tone of parent-child interactions from confrontational to collaborative. 

So thank you very much for attending the session. Bye for now. 

Drug Testing Pearls

Today’s presenter is Miriam Schizer, Medical Director of the Adolescent Substance Abuse and Addiction Program at Boston Children’s Hospital, Assistant Professor of Pediatrics at Ha rvard Medical School, and Dsiplomat at General Pediatrics and Addiction Medicine. And with that, I’ll hand it over to Mimi. Let me give you, uh, control.

Thank you, Virginia. Yep. All right. Welcome everyone, and thank you for joining us for our third session for this curriculum. I have no financial disclosures, but I will disclose that we’re covering a lot of material. So towards the end, there’s a chance I may not go through every slide, but you will have them for your own review.

All right, so let’s talk about drug testing. In this part of the talk, we’re gonna go over the indications for drug testing. Very importantly, how to collect, uh, urine specimens with proper collection technique. And then we’re gonna talk about how to interpret drug test results with the two important categories of false negative results and false positive results.

We’ll also go over how to share the positive drug test result with the adolescent. And his or her parents. And then we’re gonna finish by discussing how to use weekly or regular drug testing in the treatment of patients with known substance use disorders. So there are a number of different biological matrices that can be tested for drugs.

Um, and we’re gonna go over these, but the focus of today’s talk is gonna be urine drug testing, and that’s what we do at asap. So you are aware of, uh, breath testing. We know this is well established for alcohol testing. This is use of a breathalyzer. The disadvantage is that this is really only valuable for alcohol and other volatile substances.

There’s a [00:02:00] relatively short window of detection. Uh, I’ve never seen this in a clinical setting, so we know this is done for, uh, law enforcement, but not for clinical settings. I think you are gonna hear more about oral fluid testing in the years to come. There are a number of advantages. It’s non-invasive.

You can directly observe specimen collection. You can collect someone’s saliva, that’s not invasive. It’s relatively easy to collect, and I think we’re gonna see this more in what we call point of care testing. The disadvantages, as you’ll learn, compared to urine, there’s a shorter window of detection. Um, you do it, if you’re gonna do it the proper way, you do need to supervise the patient for about 30 minutes prior to collection so they don’t manipulate the test, and that’s pretty impractical.

Some patients have a dry mouth and will have difficulty generating the required specimen. Blood testing is something that I rarely see. Um, certainly you can detect recent use through blood testing, and this is [00:03:00] established. I’ve seen this mainly in inpatient and emergency room settings. The disadvantages compared to urine testing, you have a relatively limited window of detection after use.

It’s invasive. This requires phlebotomy, and you need someone who’s specially trained to collect a specimen. I’ve actually never seen this. Um, but you can theoretically test the sweat for drugs. Uh, there’s a sweat patch that was approved by the F D A. The patient comes in, has it put on, comes in, has it taken off, and you can detect use in about a three to seven day window.

Again, I’ve never seen it. I think it’s not widely available, and the patient can always accidentally, or not, remove the patch. I have heard about hair testing from time to time. This is done in some legal settings. The advantage of hair testing is you have the longest window of detection. Generally about three months after use.

You can easily, directly observe. You can cut off a piece of someone’s hair, and it’s difficult to substitute or adulterate. [00:04:00] The disadvantages because of the way hair grows, you’re not gonna detect use that’s occurred within the past seven to 10 days. It’s difficult to interpret results. Apparently hair type can influence results, so that makes it, um, not the most objective test.

And then the specimen can always be removed by shaving. So in ASAP, in our program, we use urine drug testing. I think this is really the gold standard. It’s well-studied, standardized, non-invasive, compared to getting somebody’s blood specimen. And we know that the concentrations of either the parent drug or the metabolite are relatively high in the urine and you have a pretty long window.

You’re gonna learn that it’s on average 48 to 72 hours after use, uh, to detect it in the urine. So indications for drug testing, this can be particularly useful when you’re evaluating an adolescent and you suspect substance use or a substance use disorder. As we’ve learned in the practice of medicine, the lab test is never the most important part of the evaluation, and that’s true in this case as well.

And so before you make that determination, you wanna perform a history, talk to the parents if you can, and do a physical exam. Towards the end of the talk, we’re gonna talk about drug testing. Not just for, um, one time use, but for monitoring for patients with known substance use. So just a few reminders when you’re taking a history of an adolescent with suspected substance use, we talk a lot in ASAP about red flags, and there are certain elements in the history that would make you concerned about a substance use problem.

And this includes a change in academic performance, a child who’s suddenly skipping school. Um, loss of interest in previous activities. It’s a big one. We know that adolescents are moody by nature, but kind of exaggerated moodiness can suggest substance use, as well as, uh, change in friends and changes in the sleep and wake cycle.

Given that we’re talking about drug testing today, as you’re evaluating the patient, it’s [00:06:00] important to know what medications they’re taking.

Physical exam findings. Um, you will hear me say that for the majority of adolescents, even those with serious substance use disorders, the physical exam is gonna be unremarkable, but it’s important to check, particularly a few things. Uh, you wanna always monitor for weight loss. That can be a sign of ongoing substance use.

Decreased attention to personal hygiene I’ve actually almost never seen that. Uh, you wanna always check inside of the nose to look for injury to the nasal epithelium. Insufflation is the medical term for snorting, uh, and then it would be bad form to miss track marks or injection sites. We typically check the upper and the lower extremities.

So drug testing should be considered when there are some elements of either/or and /or the history and the physical, which suggests recent drug use, but the adolescent is denying. So we’re gonna go over a series of very [00:07:00] short cases, which are used to illustrate some points. So the first case is where there’s smoke, there’s fire.

Billy is a 15 year old boy, you’re following him in your practice. He has previous problem use of cannabis, which means that he didn’t meet DSM five criteria for, uh, cannabis use disorder, but there has been some use. He’s done super well with new use in the past three months. He comes home from a school dance.

His eyes are red. His parents can smell cannabis. They call you the next morning and they request a drug test. So just for fun, um, anyone who’s already super awake, can you put in the chat, um, do you wanna do a drug test? Do you wanna hear more? Just a kind of a quick survey of ideas. Who is interested in getting a drug test for Billy with this clinical scenario?

Any takers?

All right. “He smells like pot.” “I think we should talk to Billy first because if he admits it, it’s not worth testing.” “Of course he’s using.” Alright. Thank you. Thank you for the people who participated. Alright, so all very good thoughts. So this slide goes over, um, when it’s more useful to think about getting a drug test versus less useful.

Um, so in this case we have specific symptoms of intoxication. That means it’s more useful. In this case it was red eyes. You can have a patient with a, um, alcohol on the breath nodding off as a classic sign of opioids. Um, in general, drug testing is gonna be more useful clinically if you are aware of the substance that you’re concerned about.

And also as we’ve talked about, or as I suggested earlier on, the timeframe is really important. So to think about doing a drug test, you are, um, looking for use that’s occurred within about 72 hours prior to the discussion. On the, um, on the right would be, uh, less useful. Uh, Um, scenarios generally, if a parent comes to you with vague concerns, they’re worried about substance use, running in the family.

Uh, I remember being a resident, you never wanted to be accused of doing a fishing expedition. That was not a good thing. Um, so again, if it’s vague in general, you wanna have a discussion with the parents about their concerns, but you wouldn’t necessarily, uh, be in a rush to do a urine drug test. It’s important to know that some substances are not easily detectable in the urine.

Inhalants really are the best example. If you’re concerned that a patient is huffing, then a drug test wouldn’t help you because there are no metabolites that make it to the urine. Um, if there’s concern about use, but it occurred weeks ago, then again you wanna discuss it, but not necessarily do a drug test.

Back to Billy. He denies cannabis use. He does agree to a drug test. The results are, uh, the screen is positive for cannabis. The urine creatinine is 150. We’re gonna talk about what that means, and the GCMS confirmation is positive for cannabis. So you talk to Billy, he says, no way, no. How It must have been secondhand smoke.

What do you do next? Um, any thoughts about that? And again, this is just meant to kind of make sure everyone’s had their coffee and is awake. Do people like that it’s secondhand smoke or not so much? Any thoughts for the chat?

Alright, you wanna hear more? Well, let’s see what I have to say. So now I’d like to go over when you order a urine drug test, what you’re getting. And the answer is you’re getting two separate components. The first component is, uh, uses immunoassay technology. This is the quick and inexpensive part of the test.

As you can see by my panel, the picture, you are, you’re able to screen for multiple drugs at the same time. And it’s very important to understand that this is concentration based. So for each drug that you’re testing for, uh, there’s a ]predetermined cutoff value, which means if the drug or the metabolite is present in the urine above that concentration, the screen will be read as positive.

If it’s below that concentration, it will be read as negative. So this is generally a good screening test with a good sensitivity. The downside is there are, uh, gonna be a lot of false positives. And that’s why it’s important that it be coupled with a confirmatory test, which is either gonna be gas chromatography or liquid chromatography, mass spectrometry.

So you might see GCMS or LCMS. This is the gold standard in drug testing. This will give you highly specific results so you know exactly what’s in the urine. You can also get quantitative levels, which we’re gonna talk about as useful for THC. This is where the cost lies. This is really the expensive part

of the test when you order it. So when you order a urine drug test on a patient, uh, get to know your lab. It’s really important to know what’s included in the custom panel at your lab. They all vary a little bit. We’re gonna talk today about how you can order additional tests as needed based on what you’re concerned about.

And then this is a really important point… when you’re talking to an adolescent about getting a drug test, set the ground rules before you get the test, which is who will get the results. So if the adolescent agrees that parents will get the result, you wanna establish that in advance. So back to Billy.

Um, if we were in the same room, I’d ask, uh, by a show of hands who’s familiar with Hotboxing. This is a phenomenon where teens are usually in a small enclosed space. Some will be using the substance (?) Cannabis, some will not. But even the ones who are not using are in that small space intentionally with the um, with interest in getting the effects.

And so unfortunately, this often takes place in cars. Um, my daughter was at Brown. She said they there would be hot boxing in the shower. I’d never heard of that. So in general, this is intentional use. This was the case with Billy, and it should be considered a positive drug test. All right, case number two, big gulp.

Alex is a 16 year old who was caught with cannabis. He was suspended from school. He says, absolutely not. I’ve not used cannabis. I was holding it for a friend. Um, he agrees to drug test and this is his result. So the screen was negative, the urine creatinine was 6 with a specific gravity of 1.001. So you’re all thinking about what this result means.

All right, so now we’re gonna talk about the first category of interpretation, which is false negative drug test results. So there are five categories that I wanna review, which are common sources of false negative drug test results. The first, which was the case for Alex, was intentional dilution of a urine sample.

Number two would be adulteration of a urine sample. A chemical is added to interfere with the testing. Number three is substitution of a different urine sample. Four and five are a little more nuanced, but I would also consider them [00:14:00] false negative test results. Number four, the patient has used a substance, but it’s not gonna be detectable by the drug panel that you’re using.

And number five is the patient did use a substance, in the panel, but it was outside of the timeframe detectable by the test. So these are the five important categories of false negative drug test results. Probably the most important and the one you’re most likely to see is dilution. This is one of the most common methods for attempting to defeat a urine drug test.

Uh, In this case, most of the time the patient consumes a large amount of fluids, which is in vivo dilution in order to dilute the specimen. And remember that this immunoassay is concentration based, so if they’ve managed to dilute the sample, you might miss the present of the drug or the metabolite in the urine.

Patients can also do this, uh, in vitro, which is adding fluid to the actual urine specimen. And that’s why it’s really important when you’re ordering a urine drug test to make sure you check the random urine creatinine. [00:15:00] As well as the specific gravity. So as a product of normal muscle metabolism, there is creatinine in the urine.

Normally it should be present at a number above 50. So if you see a creatinine above 50, it’s all good. For creatinine between 20 and 50, that’s really borderline. This is moderately dilute. This could be a patient who tried intentional dilution, but it can also be a well hydrated patient. So if that’s the case, I would recommend that you, uh, repeat the test with specific instructions to the patient to limit their fluid intake in the two hours before giving you a urine sample.

It gets a little more interesting when the creatinine is between 5 and 20. This is. Very, very dilute and and should be considered a positive test because it’d be difficult to get a urine this dilute without really making an effort. Every now and then we’ll see a creatinine of 0 or 1, which is not consistent with human urine, and that means someone has given you something other than urine, which of course is positive as well.

Uh, so for dilution, a patient can drink a large volume of fluid. They can get fancy and use diuretics. Patients who are using creatine, which you can get at health food stores, can be tricky because that can give you an artificially high creatinine in the urine and so you might miss dilution. Um, I met one patient who was using vitamin B, which can actually increase the pigment of the urine, so you can miss the fact visually of how diluted it is.

The next category for false negative testing, uh, was adulteration. And this means that someone has added a chemical to the test to interfere with either the immunoassay or the confirmatory test. And a number of relatively common household products such as these listed on the slide can be used for this purpose.

Uh, unfortunately, there’s a thriving business available on the internet where you can look for products to try to defeat a drug test. These are some examples. You can purchase synthetic urine, a urine detoxifier, which is an adulterant, [00:17:00] or uh, you could purchase real powdered urine, a 10 pack. So this is someone who’s undergoing some form of regular testing.

So all is not lost. Uh, it’s just important how you collect the sample and then you could really minimize, uh, the effects of, of this manipulation. The gold standard for urine drug testing is direct observation. We sometimes take advantage of that in our practice. For families who are doing home collection, we’ll suggest that a parent,

a same sex parent, be in the bathroom with their child, particularly if the child’s already tried to manipulate the test. Um, there are times when this is not appropriate or seems too invasive, and then there’s something called the Department of Transportation Protocol, which is available, uh, certain labs will offer this service.

And if not, you can use elements of this protocol when you ask families to do home collection. So in the lab, the patient has to show a picture ID, they’re required to empty their pockets before they go into the laboratory, so they don’t have, um, someone else’s urine or any kind of adulterant in their pockets. In the laboratory, there’s no running water.

The toilet water has dye blue. This is so water can’t be added to the specimen. And then immediately after voiding the patient hands the specimen to the lab technician who checks the temperature, and it should be body temperature if they’ve just voided. Um, you can also ask your lab to do, um, do some heavy lifting for you.

It’s really important to get specimen validity testing as part of the lab test that you order. This includes the pH. Um, adulterants will sometimes interfere with the pH and patients will sometimes store their urine and try to use old urine, and that will often have an … uh, an alkaline pH. We already talked about checking the creatinine, and then some labs will actually give you a specific test for oxidants or adulterants. Um, substitution,

so the patient has gotten hold of someone else’s urine or their own urine before they used a substance and they’re using it, um, for the test. Unfortunately, there are devices available on the internet such as this one, which will maintain body temperature if you’re using a substituted urine. There’s a lot of creativity on the internet for this, unfortunately.

So the last two categories of false negative tests, a patient might be using a substance that’s not included in your panel. So it’s generally important to have a good sense of what you’re worried about and what tests you can add to the panel if they’re not already included. Um, but as I mentioned, some of the designer drugs and inhalants really are not,

um, you’re not gonna be able to test for them in the urine. So that’s something you’ll, you’ll have to ascertain in another way. So missed window of detection is my last category. This is a, a slide that shows you a typical lab panel. So you can look at the eight substances on the left. That’s what would be included in this panel.

And then on the right would be the detection window for each substance. I would encourage you to remember two to three days as the window that’s applicable for most substances. Cocaine is interesting. It’s a slightly shorter window, so you have to be a little more aggressive with drug testing if you’re worried about cocaine.

Uh, THC, you could see there’s a broad detection window. I’m gonna explain that in just a few minutes. All right. My third case is unexpected result. Angela is a 15 year old. Her parents come to you because they’re concerned about nicotine vaping and they think she’s also using cannabis occasionally.

They’re not worried about anything else at this point. She is on sertraline for an anxiety disorder. She agrees to drug test. So her screening test is positive for benzodiazepines as well as nicotine and cotinine. We like the random urine creatinine, and then the confirmatory test is only positive for nicotine and cotinine.

So what’s the story with the benzodiazepines? That’s my segue to talk about the next category of interpretation, which is false positive test results. So we’ve talked about how the initial part of the urine drug test is an immunoassay. Um, and I told you that there are a large number of false positives that can be generated, and this is because the immunoassay can recognize other, other substances that could have a similar structure chemically.

And so they react to the immunoassay. Um, but then what you need to know is the confirmatory test will be negative. And that’s why it’s really important when you order a lab test to make sure that you’re also getting the confirmatory test. So a very common example would be, uh, benzodiazepines, which do cause a.

I’m sorry, sertraline, and I’m sure you have a number of patients in your practice who are taking sertraline or Zoloft. This will often yield a positive test result for benzodiazepines, but the confirmatory test is the test that you should rely on, and that will be negative. Um, another example is if a patient has used dextromethorphan, uh, they might have a positive screen for PCP which is very frightening if you see it, except that the confirmatory test will be negative.

So with Angela, that was the story. Um, she was not using benzodiazepines. This was simply because she was taking sertraline. And so, again, always remember to order a confirmatory test. Um, and most, most labs will give you a reflex confirmatory test for all positive screens. Usually that’s what you get, but it’s always important to confirm.

I like to show this slide just because, um, amphetamine has the most, um, the largest number of medication that will cross-react with the immunoassay. This is a favorite board’s question on the addiction medicine boards. If you have a patient on any of these medications and you’re doing a urine drug test, they might have a positive screen for amphetamine, but again, the confirmatory test, which is what you should go by, will be negative.

This is another category of false positive results, but you can see I have quotation marks around it because this is not, um, generally, what we mean by false positives. But my point is you will get a positive immunoassay [00:23:00] and a positive confirmatory test in these cases, but the patient is not illicitly using a substance.

It would be licit use of either a food or a medication. And so, uh, any Seinfeld fans in the audience, this is a picture of an everything bagel. Poppy seeds are interesting. They, they are derived from opium and so if a patient eats an everything bagel, you will potentially see morphine and codeine in their urine, both by screen and by confirmation.

Um, and then this is because of their ingestion. Uh, another important example would be if they’re prescribed a stimulant for ADHD. Certainly they will have a positive confirmatory test for amphetamine, but this would be licit use. This isn’t, um, necessarily illicit use of amphetamines. All right, so we’ve talked about false negative drug test results.

We’ve talked about false positives, and now I just wanna mention a few other things that you should know, um, as you, uh, work on drug testing your patients. So cannabis is an interesting story. Remember on my, on my list it said detection for 3 to 30 days. The way to think about cannabis is, um, we talked at our last session about how it’s lipophilic.

THC is lipophilic and stored in adipose tissue. What you need to know is if a patient is using cannabis occasionally, let’s say someone is using it once a week, then you’ll be able to detect THC in their urine for about three to four days as you would any other substance. The exception is patients who are heavy users of cannabis.

Um, let’s say, let’s say I use daily and then I stop using on January 1st. Because I will have accumulated THC stores, then I could still have THC in my urine drug tests for up to four to six weeks. After I stop using, and that’s because you’re seeing this phenomenon of delayed excretion. That’s where it’s valuable to get quantitative levels, because if the patient has actually stopped, then the levels will come down in a linear fashion until they hit zero.

So we’re talking about adolescents in this, um, learning curriculum, so it’s really important to test them for alcohol in a urine drug test. Interestingly, ethanol is very fleeting in the urine. You’re only gonna bet get about a 12 hour window to detect ethanol after someone has used it. And so what we recommend and what labs will offer is you wanna test for alcohol metabolites in the urine.

And typically these are. Glucuronide and ethyl sulfate. These are detectable for up to 80 hours, usually three to five days after use. You often won’t see this on a standard panel, but you can request, um, to test for these metabolites. Um, you can add this to what you’re testing. We’ve done a lot of testing in the last few years for nicotine and cotinine given the number of patients we see who are vaping nicotine.

Um, usually these tests include cotinine, which is the primary metabolite of nicotine, which has a longer detection window than nicotine. So you can see cotinine usually for about three days in the urine after a patient has used nicotine, either by smoking or by vaping. This is typically not included in a custom pa in a panel, but you can add it on request. In just a few minutes

we’re gonna be talking about opioids. Um, the language is important. It’s important to know what your panel includes. If there’s an opiate screen that’s gonna test for morphine and codeine, which is usually heroin use. Um, It’s important to make sure the lab is also testing for oxycodone, which is what you’re gonna see if a patient has used a prescription opioid.

And then fentanyl will not show up in either an opiate screen or an oxycodone screen. You need to test separately for fentanyl and these days, that’s super important. All right. Case number four. It’s my right to refuse a drug test. Um, so all of the patients so far have very conveniently agreed to drug test.

That’s not always gonna be the case. So Adam is 16. The school is very worried about him because of a number of red flags that they’ve observed. So they’ve contacted his parents and they’ve asked his parents to bring him to see you for an evaluation. You meet with Adam. He’s, um, you know, not impressed that he’s there.

He says, yes, occasional cannabis, occasional alcohol. He’s not acknowledging any other use, and he seems irritated that he’s in your office about this. Then you have a separate meeting with his parents for a collateral history, and you hear about a number of concerning historical factors, and so you ask Adam for a drug test and he refuses.

So the way this plays out is, uh, you’re not gonna force Adam to do a drug test. Adam’s parents say, you know what? We’re really worried about you, Adam. We’re not comfortable with you driving because we’re not sure what’s going on. And so we’re not gonna let you drive until you participate in weekly random drug testing.

So Adam says, not gonna do it. Then about a week goes by and he agrees to drug test so he can have his car back. The first test comes back for a low level of cannabis. Adam says that’s old. His parents let him continue [00:28:00] driving. And then the second test is positive for cannabis and oxycodone. Uh, and the idea is if you do, uh, more than one test, if there is ongoing use, the odds are very strong that you’re gonna catch it.

And that was the case with Adam. So the American Academy of Pediatrics is very explicit that physicians should not order a drug test without the adolescent’s knowledge or consent. I remember someone asked me about this at the last session, and it was a great question. So, if a patient refuses a drug test, then the answer is to set limits using logical consequences.

You’re not gonna drive test. I’m worried that you’re using something so you, you’re not gonna drive, or something similar to that. And there is a clinical report published by the AAP talking about testing for drugs and children and adolescents. And this is a direct quote, “drug testing of a competent adolescent without his or her consent, is it best impractical?

And without his or her knowledge is unethical and illegal.” Uh, every now and then we’ll see someone in ASAP who, uh, was tested without his consent. But I would say if you get a positive test, how do you begin to have the conversation? Because the adolescent didn’t even know that he or she was being drug tested.

So now we’re gonna talk about how to talk to an adolescent about a positive drug test. In general, when you have a test, it’s always better to meet with the patient face-to-face, either in person or via zoom. You wanna talk to the adolescent first without the parent present, and, uh, get a sense of what’s going on.

We have a trick in ASAP that we never lead with a test result. You don’t say your test was positive for cannabis and oxycodone. We’ll say there was an unexpected test result. You know, tell me what you’ve been using, tell me what’s going on. And the advantage of that technique is they might tell you about use that you, you didn’t have in the test.

So it’s a way to get free information if you will. Once you’ve had this conversation, you tell the adolescent what the result was. Um, and then again, if you’ve established that parents will get the result, you’ll talk to the adolescent about sharing that result with the parent. Occasionally, an adolescent might wanna tell the parent on his or her own, in which case you would need to just verify afterwards that the conversation took place.

Um, ideally if there’s a positive drug test, the adolescent has agreed to some form of treatment, either to see a behavioral health clinician or to do another drug test next week so that there’s something that you can present to the parents as the adolescents advocate. So I’ve had a number of these conversations in my lifetime.

They can be ugly. You really wanna kind of keep it to what you’re reporting. You’re sharing the drug test result and then you’re saying, this is what we’re gonna do next. We’re gonna get a drug test. Um, what’s my example here? Joe is committed to not using drugs. He’s gonna continue testing and see a counselor.

So that should be, you wanna diffuse the situation and just focus on, okay, what are we gonna do now? All right, so for the last few minutes of this topic, we’re gonna talk about how to use drug testing [00:31:00] for, uh, as a therapeutic tool. So we talked about screening. You have patients in your practice with known substance use disorders.

This can be a very convenient, uh, a very useful way to monitor them. Um, often this type of regular drug testing is paired with what we call contingency management. So there are predetermined positive consequences for improving results and negative consequences or restrictions for ongoing use. As we discussed, a patient may initially refuse drug testing, but um, you know, using MI and consequences, you can sometimes influence that decision.

So we have a, a robust drug testing program at ASAP typically will suggest 12 weeks, which is just a nice length of time to get started. Uh, it’s important that the testing be random so the adolescent doesn’t try to use around the testing date. Our patients will do, um, collection either in lab, we use Quest Diagnostics, or at home.

I would say we prefer home supervised collection cuz you have a little bit more control over how it’s done. Uh, and we always encourage getting the first morning void because it tends to be the most concentrated. So you don’t have to worry about a low creatinine and what’s this intentional? If a patient has a result that you weren’t expecting,

um, we typically, uh, as I just mentioned, we like to talk to the adolescent face-to-face. Um, if we get a result such as fentanyl or cocaine that we were not expecting, then we treat that as an emergency and we call the parent urgently, just, um, from a safety standpoint. So we do a lot of, uh, drug testing for patients with cannabis use disorder.

Maybe they’re not willing to stop, but we try to incentivize them to at least cut back on their use. And so we look at quantitative THC levels in the urine, um, and we get these levels. I’m gonna show you an example. We take the raw THC value, divide by the urine creatinine, and multiply by a hundred.

And this gives us a number that we can compare from test to test, cuz we’re factoring out concentration. Um, This is my own categorization. It’s not in the literature, but generally there are three categories. The below levels, which fall below a hundred, the bell-shaped curve is really between a hundred to a thousand, which is where a lot of these levels live.

And then the highest levels are in the four digits. These are typically patients who are using a high potency cannabis device on a regular basis. They’re gonna get the highest values. So this is an example of a patient, uh, urine drug test results that we followed in ASAP. Uh, he liked using cannabis.

Parents said, you know what? We’re not gonna let you drive until you’ve stopped. This was based on our recommendation. So he came to see us on December 11th, agreed to stop using cannabis. This is an example of the delayed excretion that I told you about, where even though he stopped on December 11th, it took a few weeks for him to clear THC. And so you can see that there’s a significant dropping in the levels over time. He saw us on January 21st and we said, yes, he’s allowed to drive. He hasn’t [00:34:00] used. So we’re gonna end this part of the talk with a few, um, urine drug test results just so you can see what these look like. And these are ASAP patients.

Luke was a 16 year old who was seeing us with severe cannabis and nicotine use disorder. He would come in monthly to review his drug test results. He was contemplative and so we were working with him on cutting down on his use. This is a nice tool for patients with ambivalence. So I just wanna show you, um, how we do the calculation.

You’ll see the raw score is 1778. We divide it by the creatinine and then multiply by a hundred. So this would give you a value of 926, which is on the high end of moderate use. Uh, I remember Aiden, who was a 15 year old from the Cape with severe cannabis and nicotine use disorder. Also a very significant mental health history.

I’d always get nervous when he came in to see me. So we got an unexpected drug test result. Um, as you can see, his test was positive for methamphetamine. I’ve only seen this a handful of times in my years at ASAP. Um, but it’s out there so it’s important. And, and you see amphetamine, it’s important to know that methamphetamine breaks down into amphetamine, not the other way around.

So you’re only gonna see methamphetamine if the patient used methamphetamine. Dennis was a 14 year old with a cannabis use disorder. We didn’t know of any other substance use. And so, uh, lo and behold, uh, Dennis had a positive screen for opiates with a relatively low level of morphine in his urine. This is consistent with dietary ingestion.

So we talked to, uh, Dennis and his parents and he had eaten and everything bagel within a day or so prior to giving us the urine sample. So we asked him to please avoid poppy seeds for the duration of the testing. Uh, this patient was very difficult to treat. 23 year old with severe opioid and alcohol use disorder.

She would, um, come back and forth to ASAP after going to a higher level of care. She had a history of multiple non-fatal overdoses, um, and her mom was sectioning her a number of times because of her, uh, life threatening condition. And so we thought she was doing well, but we got this urine drug test. You can see she was taking buprenorphine, um, as prescribed, but she was also using fentanyl, um, alcohol and cocaine.

So this is basically a floridly positive urine drug test. Jessica was a 15 year old who came to ASAP with marijuana and nicotine use. She seemed like a relatively light user by our history, so we were surprised when we got this urine drug test with a random urine creatinine of less than one. And it turns out she had given her mother, um, I don’t remember if it was Kool-Aid or something like that, but this was not consistent with urine, and her next urine drug test was positive for nicotine.

She didn’t want her mother to know. For some patients, lab testing may not be an option, um, perhaps if insurance won’t cover it or something like that. And so you, um, it’s perfectly kosher to use home drug testing. You wanna encourage your families to use CLIA waved tests. That’s a form of quality control.

The advantage of home testing is you’ll be able to get immediate results. The disadvantage is that this is typically aminoassay based. You don’t have a confirmatory test when you get home tests, so you might have a false positive. Uh, you usually won’t get alcohol included or nicotine as part of a panel, although you can get a separate home test for cotinine.

Those are becoming more widely available. You’re not gonna get the quantitative THC levels, which we like to use to follow patients. And I would say for a patient who’s complicated and is using a number of different substances, you really wanna use a lab for, for comprehensive testing. So to wrap up this part of our talk today, uh, urine drug testing is complicated, but actually very gratifying.

It’s a really great way to get information, um, to help your patients. You wanna make sure you’re using proper collection procedures, always check for dilution, always use confirmatory testing. Know what you’re worried about as best you can for a patient, and, um, add additional tests as necessary. And then always use caution in interpreting tests.

Urine Drug Testing

MIRIAM SCHIZER: Good morning, everyone. It’s a pleasure to be here this morning to be talking to you. My name is Dr. Miriam Schizer. I work at the Adolescent Substance Use and Addiction Program. We call ourselves ASAP at Boston Children’s Hospital. And I’ll be speaking with you this morning about urine drug testing in adolescents.

I would like to thank the Opioid Response Network for sponsoring this talk. So we have a lot to cover in the next 30 minutes. These are my objectives. We’re going to start with the discussion of the indications for drug testing. When would you want to order a drug test on a patient?

Then we’re going to review proper urine collection procedures which is very important. And then we’ll segway into a discussion of how to interpret drug test results? And I’m going to be focusing specifically on potential false negative and false positive test results. We’re going to review optimal strategies for sharing a positive test result with the adolescent and the parents. And then we’re going to finish by looking at weekly drug testing or serial drug testing for the treatment of patients with known substance use disorders.

So there are a number of biological matrices that can be tested for drugs. Our talk today will focus on urine drug testing, but it’s good to know what else is out there. We do have the capacity to test breath, saliva, blood, sweat, and hair.

Breath testing would be breathalyzer testing. Saliva I think you will be hearing more about in the years to come. That’s becoming more popular. Blood testing is really only used in emergency department settings. Sweat testing is uncommon. The advantage of hair testing is that you do have a longer detection window on the order of weeks to months.

So that being said, at ASAP up at my program we use urine drug testing. And this is very reliable. We know that this is well studied, standardized, non-invasive compared to testing blood. We also know that the concentration of the parent drug or the metabolite is relatively high in the urine. And we have a relatively long window of excretion after the patient uses a substance in which we can detect it. Generally speaking this is about 48 to 72 hours.

So let’s think about the indications for drug testing. We know that this can be a useful adjunct when you’re evaluating a patient with suspected substance use or suspected substance use disorder. We’ve been taught that the lab test is never the most important part of an evaluation. This is also true for drug testing. So before you consider ordering this test, you would want to make sure to do a history, do a physical.

In this work it’s also very important to talk to parents. We call that obtaining a collateral history to find out what’s going on. I will also say at the end that we use drug testing in the treatment of patients with known substance use.

So this slide goes over what to look for in the history when you’re evaluating a patient for potential substance use. There are a number of what we refer to as red flags that suspect this might be going on. I want to highlight a few which include academic difficulties, falling grades, skipping school. We know that adolescents are moody by nature, but if parents are reporting exaggerated moodiness, increased hostility, loss of interest in previous activities, that’s a big one, change in friends, and then noticeable changes in sleep and awake cycles.

Because we’re talking about drug testing today, it’s also important to ask the adolescent what prescription medication and over-the-counter medication they might be taking. This slide goes over physical exam findings. I will say that the majority of cases, the physical exam will be normal even in a patient with a severe substance use disorder.

On the other hand, you do want to look for any recent weight loss, decreased attention to personal hygiene. It’s always a good idea to look in the nose for injury to the nasal epithelium. This would be from snorting. The medical word for snorting is insufflation. And certainly you would never want to miss track marks or injection sites. We usually check the upper and lower extremities to look for those.

All right. So we’ve done the history. We’ve done the physical. Drug testing should be considered when there’s something in the history and/or the physical which is suggesting recent drug use, but the adolescent is denying. So this slide reviews when drug testing would be more useful column on the left versus less useful when you’re assessing an adolescent.

Generally speaking if there are specific symptoms of intoxication noted, you’re going to have a higher yield with your urine drug test. Examples would be the eyes are red. That would be cannabis. Alcohol on the breath. Nodding off is a classic sign of opioid use.

In general, if you’re ordering a drug test, if you know the specific substance that you’re worried about you’re more likely to get a positive test. And of course, the time frame is very important. As I mentioned earlier, we generally have about 72 hours after use to see the drug or metabolite in the urine.

The column on the right reviews less useful scenarios. Generally, if a parent is reporting vague concerns in general, any kind of vague concerns, you certainly want to talk to the parent about that. But your go to wouldn’t necessarily be a urine drug test.

It’s also worth noting that there are a number of substances that are not detectable in the urine. The best example would be inhalants. So if you’re concerned about inhalant use, urine drug testing would not help you. And again, the time frame is really important. If you’re concerned about use that might have taken place a month ago, you wouldn’t necessarily want to follow up with a urine drug test.

Now we’re going to talk about what the test is comprised of when you order a urine drug test. Typically there are two different components. The first component that is done is the screening test, which is the immunoassay. Generally this is the inexpensive component of the test.

It allows you to screen for multiple drugs at the same time. You can see the panel appearing on the right using immunoassay technology. What’s really important about the screening test is that it’s concentration based. And so the screen will read as positive if the metabolite is present in the urine above a certain concentration.

So for example, for cannabis, if THC is present in the urine greater than 50 nanograms per mL you’ll get a positive screen. If it’s below that, the screen will be read as negative. So as you might expect with the screening test, this gives you a good sensitivity but the prices there’s a high rate of false positives.

So it’s very important that the urine drug test also include a confirmatory component, which is typically gas or liquid chromatography mass spectrometry. You might see GCMS or LCMS written on the test. This is your gold standard. This will give you a highly specific result. You won’t get the false positives with a confirmatory test.

We also get quantitative levels. And I’m going to review how we use those. This is where the cost lies. So this is the more expensive component. And I have seen labs in the community over the years that omit this step, but then you don’t have a solution for your false positives.

So in general when you’re ordering a urine drug test for a patient, it’s really important to know exactly what you’re ordering. Know what’s included in the lab’s custom panel. These vary by site. And you would have the capacity to order additional tests as needed based on the patient’s history. So you’ll get a panel and then you could add potentially extra tests to that.

It’s also really important when you order a drug test that you establish with the family who’s going to get the result once it’s available. So if the parents are going to know then everyone understands that at the get go.

This is an example of a typical test result. We use Quest Diagnostics at Boston Children’s Hospital. And so you’ll see in the bottom of the screen, these would be the components of the panel. This is what we’re testing for. This patient tested positive for cannabis.

We are adding a lot of nicotine cotinine testing because of the vaping crisis that we’re dealing with. So you’ll see that pictured on the top. And that was an add on. All right.

Now we’re going to talk about interpreting urine drug test results. And the first topic would be false negative test results. So there are a number of ways you could get a false negative. And generally what I mean by a false negative is the patient is using a substance and for one of these reasons your test will be negative.

So probably the most common reason would be intentional dilution of the urine sample. We’re going to talk about that. The patient may add a chemical to the urine sample that interferes with the test. That is called adulteration. You might be getting a urine sample that is not the patient’s urine. That would be substitution.

The last four categories are a little more nuanced. We’re talking about for category number four the patient is using a substance that you’re not testing for. So that would be the explanation for the false negative. And then the last category is the patient is using a substance that you’re testing for, but use fell outside of the detection window.

So it’s really important to understand dilute tests. This is probably the most common way that individuals will try to defeat a urine drug test. And generally speaking, the patient will consume a large amount of fluid shortly before the urine drug test. And what this does is remember the immunoassay is concentration based.

So if the drug is present below the screening concentration, the test will be read as negative. So the way that you get around this is it’s very important to check the concentration of the urine sample so you’ll know if there’s a problem with dilution. And we usually recommend checking not just the specific gravity, but also the random urine creatinine.

So creatinine is present in urine. It’s a product of muscle metabolism. If you see the number greater than 50, you’re good. That means the specimen is adequately concentrated. In general, if the random urine creatinine is in that 25 to 50 range this suggests that the patient might have tried to dilute the sample, but it’s not conclusive. And so in this case, you would ask the patient to give you another sample with specific instructions to limit fluid intake for 2 hours before giving the test.

Generally speaking, a creatinine lower than 25 is a slam dunk. You can think of that as intentional dilution and that can be considered a positive test. Every now and then to make life interesting we’ll get a creatinine of 0 or 1, which means that someone has given you a sample that isn’t human urine. So that’s always interesting.

The next category for false negative tests would be adulteration. And so someone has added something to the urine sample which interferes with either the immunoassay or the confirmatory testing. And what’s interesting is relatively common household products such as those listed on the slide can achieve that result.

Certainly patients turn to the internet if they’re looking to defeat a drug test. This is a sample of what’s available. You can purchase synthetic urine. You can purchase a urine detoxify. There’s your adulterant. And you can even purchase a 10 pack of real powdered urine.

So the importance in avoiding these categories would be to add specimen validity testing to your test. As I mentioned, you want to make sure you’re checking the concentration. Urine ph is valuable. You want to make sure that the ph of the specimen falls between 4.5 and 9. With adulterants it can sometimes be very low or very high. And as I mentioned, you want to check the specific gravity. Some labs will perform specific testing for adulterants, which is a valuable service.

So as I mentioned earlier, it’s important how you collect the urine specimen. The gold standard would be direct observation would be to have someone in the room when the patient voids. Sometimes this is invasive or clinically inappropriate. So the next best option would be to use what we call the department of transportation protocol. And labs will often use this or you could teach parents how to do something similar in the home.

So if this is in a laboratory when the patient arrives, they’re required to show their picture identification so they are who they say they are. They empty their pockets before going into the testing room and they wash their hands. In the laboratory, it’s important that there’s no running water. They can’t add water to their sample. Similarly, the toilet water is dyed blue.

And then very important when they hand the sample to the technician or to a parent, the temperature of the urine is checked immediately. Urine should be body temperature right after voiding. All right.

So the last couple of categories for false negative testing would be that you’re ordering a test, but the patient is using a substance that’s not covered by the testing panel. And that’s why I encourage you to know what you’re testing for and add tests as indicated. For example, very few labs will include fentanyl in their panel. So you might want to add fentanyl. We can add dextromethorphan, synthetic cannabinoids, et cetera. So it’s always a good idea to know what substances are most prevalent in your community and to make sure that you’re testing for them.

As I said, the last category for false negatives is yes, the patient used a substance included in the panel, but outside of the window of detection. And so this slide goes over what would be a standard testing panel and then what the detection window is for these substances. I will tell you if you want to remember one time frame 48 to 72 hours is accurate for most substances.

You can see that for amphetamines, cocaine, and opiates. That’s pretty reliable. There are a few exceptions to the rule. Benzodiazepines, methadone typically are detectable in the urine for longer periods of time.

And I want to mention the cannabis story because that’s really a unique story. In terms of how long you have to detect cannabis in the urine, there are really two different populations for patients who are using cannabis sporadically let’s say once a week. You have about 3 to 5 days to detect THC in the urine for occasional users.

For patients who are using heavily, let’s say patients who are using cannabis daily, what happens is they accumulate stores of THC in their adipose tissue. It’s highly lipophilic. And so even after they stop using, you’ll be able to detect THC in the urine for up to 4 to 6 weeks. If you’re getting a quantitative value, you will see that value go down linearly in that time period until it eventually hits zero.

I did want to mention testing for alcohol because it’s very important with adolescents. If you have ethanol in your panel then you’re only going to be able to detect it for about 12 hours. It’s a very short detection window. And so what we recommend is testing for a couple of metabolites of alcohol. And these are ethyl gluconate and ethyl sulfate. These will be detectable for about 3 to 5 days after detection. So you should see if your lab has the capacity to check for these two metabolites.

And then for opioids it’s always important just to review the terminology. Opiates refer specifically to morphine and codeine. If a patient used heroin, they’ll have a positive test for opiates. Opioid is a broader term which includes prescription opioids. If you’re looking for prescription opioids, you’ll want to make sure that oxycodone is included in your testing panel.

And as I mentioned earlier, fentanyl is a separate test. If you’re looking for fentanyl, you would need to order a fentanyl and metabolite test. All right. So we’ve talked about false negative test results.

Now I’d like to mention false positive test results, which is an important category. So the way this works is we’ve talked about how the immunoassay is the initial screen. The immunoassay can recognize a structure that’s similar to the drug that you’re looking for. And this can result in a false positive screen.

On the other hand if you do the confirmatory test, that will be able to rule out false positives because your confirmatory test will then be negative. As an example looking at this slide, if a patient is taking amoxicillin they could theoretically or actually have a positive screening test for cocaine, but the confirmatory test will be negative because that test is highly specific and will be able to tell the difference.

I like to show this slide because it turns out that the amphetamine immunoassay has the most false positives of any of the components of a immunoassay. So all of these medications if a patient is taking them these might trigger a positive screening test for amphetamine. But as I mentioned, the confirmatory test will be negative.

Urine drug testing in general is very reliable if you’re doing both the screening test and the confirmatory test. You can feel confident in the results that you’re achieving. You’re going to identify 95% to 98% of true negative results. So you can trust your negative tests. And you’re going to identify 99% to 100% of the actual positives. So again, the most important advice is to make sure you’re doing both the screen and the confirmatory test.

This category is slightly different. Now I’m talking about clinical false positives. This is in quotes. This is different from the false positive category I just mentioned. In this in this situation, a patient has ingested a food or is taking a medication which will yield a positive result, but they’re not actually using illicit substances.

So if you see the picture on this slide, this is a poppy seed bagel. And it is true that poppy seeds are broken down to morphine encoding. So a patient who’s eaten an everything bagel could definitely have a positive test for opiates. Both the screen and the confirmatory test will be positive.

If you get a history, you’ll discover that this was dietary and this was not use of heroin. Another important example would be a patient who’s taken a stimulant for treatment of ADHD certainly will have a positive test for amphetamine, but this doesn’t represent illicit use.

All right. So now if you’ve asked a patient for a drug test and they refuse, what do you do? I really want to make sure everyone understands that you’re not supposed to get a drug test without the patient’s consent. This is absolutely a no no. The American Academy of Pediatrics is explicit that physicians should not order a drug test without the adolescent’s knowledge or consent.

If a patient refuses a drug test obviously that’s going to make you highly concerned about what’s going on. The best solution would be to work with the parents who could use appropriate consequences. So a good example would be the patient refuses a drug test so the parents say, well, I’m really worried and I’m not sure what you’re doing. So I’m not going to let you drive the family car until you’ve consented to a drug test. That would be a very appropriate way to manage the patient’s refusal.

All right. So let’s say you’ve gotten a drug test, you have the positive result, now what do you do with it? We always recommend that you meet with the patient privately without the parents present to go over the test result. And again, in the old days this was in person. Now we’re doing a lot of this virtually.

So our strategy when you have a positive test result is to be vague with the adolescent. So you say to the adolescent, we have an unexpected test result or there was a problem with your test. And then you ask them to tell you what they may have used. The advantage of this strategy is they don’t actually know what you have in the urine drug test so they might give you more information than you actually have.

So if you’ve established an advance that the result will be shared with the parent as you wrap up with the adolescent you’re going to say, OK, this is what I’m going to tell your parents. And again, less is more. You can just focus on the drug test result. The patient might ask that they tell their parents themselves. You can do that if it feels comfortable and then you just want to make sure you have a follow up conversation to make sure that the conversation took place.

These conversations can get very heated when you’re telling parents about test results. And I would recommend really keeping the report simple and brief. So an example would be Joe had a dilute drug test and told me he used cannabis and took some pills last week. So you’re giving them the facts.

As I mentioned, these conversations can become heated. Parents sometimes don’t take the news well. But when you’re in the room, you want to be the advocate for the adolescent. You want to focus on what they are willing to do. So if they’re willing to see a counselor or give you another drug test next week, that’s what you’re going to focus on just to keep the conversation from becoming a shouting match.

So the last thing that we’re going to cover is using drug testing for longitudinal care of patients with substance use disorders. And this is something that we do in our program all the time. We typically recommend weekly random drug testing to monitor the patient’s progress. You’re also inviting them to make progress and cut back. And then you’ll be able to see that.

So this works best when it’s paired with a contingency management approach. So patients can sometimes be offered small and appropriate rewards if their drug tests are showing improvement. As I mentioned earlier, the patient may initially refuse drug testing but you can work with parents to make it a little more appealing by using consequences.

So at ASAP in my program typically we do weekly testing for a 12 week window. Random testing is important so the adolescent doesn’t know the date in advance. Typically our collection is done either in the lab or at home. I think if the parents can swing supervised collection at home that tends to work best. And we usually prefer the first morning sample because typically that’s the most concentrated and we don’t have to worry about intentional dilution.

As I mentioned, if the patient has an unexpected drug test result or a positive test, we would try to see the patient for an appointment to discuss the result. If we get something that’s suggestive of very high risk use and unexpected such as getting a test for fentanyl, cocaine, oxycodone, typically the parent will get a call immediately as soon as we have that result for safety.

So as I mentioned, confirmatory testing does give you quantitative levels. And we find this very helpful when we’re monitoring a patient with a cannabis use disorder. And what you can do is you can compare these levels from test to test.

Here’s a little math trick. So to compare the tests, the THC values you take the raw THC, you divide it by the random urine creatinine, and you multiply by 100. I’m going to show you an example of this. And then that gives you a value that you can compare from test to test because you’ve corrected for differences in concentration.

Generally speaking, levels can fall in one of three categories. If the corrected THC is less than 100, that’s on the low end. Moderate use would be 100 to 1000 typically. And then the kids who are using most heavily typically very concentrated THC as well will have levels in the four digits.

So this is an example of an ASAP patient who was using cannabis. Parents said, you know what, we’re not going to allow you to drive until you’ve stopped which is what we recommend. And so the patient did weekly drug testing. He met with us in early December. And you could see after that if you follow the levels, they are decreasing because he stopped using. And then in mid-January he got his car keys back.

I’d like to finish with a few slides that show examples of actual drug tests from actual ASAP patients. All right. So Aidan is a 15-year-old boy with severe cannabis and nicotine use disorders who was participating in our drug testing program. So he does have marijuana. Just to go over the calculation that I showed you, so you would take the marijuana metabolite, which is 14, divide it by the creatinine, which is 172.5, multiplied by 100, you would get a value of 8 which is a low level.

The reason I’m showing you this slide is his test was positive for methamphetamine. We’re not seeing thankfully a lot of this in eastern Massachusetts. So this was a very alarming and unusual result for us.

Dennis is a 14-year-old boy with a moderate cannabis use disorder. No history of other substance use who was participating in our drug testing program. So if you look at this test result, yes, he had a positive test for marijuana as we expected. And then he also had a positive test for opiates. You can see that his morphine level was 139.

We talked to Dennis and it turns out he had eaten an everything bagel before giving the urine test. So that would be a result consistent with dietary ingestion. All right.

I remember Kristen well. She’s a 23-year-old young woman with a severe opioid and alcohol use disorder. She was in and out of outpatient treatment. She had a history of recurrent overdoses. She would go to residential treatment. She would come back. And we had a very hard time treating her effectively.

So this is an example of a [INAUDIBLE] positive urine drug test result. You will see that she was prescribed buprenorphine. She was taking it. You could see it in her urine, but it wasn’t effective because you can also see fentanyl and norfentanyl in her urine. She was also using cocaine. Benzoylecgonine is the cocaine metabolite we see in the urine. And these are the alcohol metabolites that we talked about. Ethyl glucuronide and ethyl sulfate. All right.

So Jessica is a 15-year-old girl who came to us with marijuana and nicotine use. We thought she had a relatively not serious problem. And then she gave us a urine drug test. So as you can see this creatinine was less than one. I’m not sure what beverage she gave us is her urine sample, but this was not consistent with human urine. All right.

So for some patients you might consider home drug testing. Particularly if insurance isn’t covering weekly drug testing. It certainly can be an option for some patients. You should always use CLIA waived tests. If you see that on the test, that’s essentially quality control. The advantage of home testing is families get immediate results.

The disadvantage though is these typically rely only on immunoassay or enzyme testing. And so you certainly can have false positives with this mode of testing. Panels are generally not as elaborate as what I’ve showed you is what Quest gives us. You’re not going to get the quantitative THC levels. So I would suggest if there’s a patient with use of multiple substances, a patient that you’re really worried about, they’re not a great candidate for home testing.

So in summary, hopefully I have shown you and convinced you that urine drug testing is a relatively complex, but still doable procedure. It’s very important to use proper collection procedures. You want to check for dilution. You want to use confirmatory testing for all of your positive screens.

Definitely think about what substance you’re looking for and use an extended panel if indicated by the patient’s history. And always use some degree of caution in interpreting tests. Thank you so much.

Adolescent Substance Use Disorders and Co-Occurring Medical Illness

I’ll be talking about the adolescent substance use disorders and co-occurring medical illness. On behalf of the Opioid Response Network thank you so much for having me. I’m so happy to be here with Treat Me and to be presenting today. again, I’m here on behalf of the Opioid Response Network, and Orrin does accept requests for education and training, and each state or territory has a technology transfer specialist who’s an expert in implementing evidence-based practices. And if you have any questions, would like to submit a request for technical assistance. Here’s the contact information that you can find on this slide. And I have no relevant disclosures.

So today I’d be I’d like to talk about a, a couple different things that we see with substance use concerns in youth. Uh, the first is when to consider initiating prep pre-exposure prophylaxis for HIV. An overview of the management. Uh, I would like to also do an overview of HCV Hepatitis C virus with an emphasis on screening and treatment. And then finally, it seems like adolescents always have a number of questions with respect to binge drinking and how much one can drink safely. So I wanted to just address some common binge drinking questions that were, are often posed by youth in the office setting.

So let’s start with Hepatitis C virus, and we’ll start right with epidemiology. Thankfully, the prevalence of chronic Hepatitis C is lower in children than adults. So we have some good news right off the bat in this presentation. It’s been estimated about 3.5 to 5 million children globally are suffering from chronic HCV infection. And as far as at home in the United States, about 0.2% of six to 11 year olds, which comprises about 31,000 kiddos and 0.4% of 12 to 19 year olds, which comprises just over a hundred thousand adolescents are HCV antibody positive.

So we do see it, it’s rare, but it does exist, and it’s something that we need to be aware of as clinicians discussing the modes of transmission is important, and they include vertical or perinatal transmission. Sexual transmission, which is somewhat rare, and I’ll talk about that a little bit more in a couple of slides, as well as exposure to infected blood in children. Perinatal transmission is by far the most common source of infection. However, we do know that acquired HCV infections are reemerging. And when I say acquired, I mean non-perinatally transmitted HCV infections and the HCV infections that are reemerging are mirror mirroring the opioid epidemic. And this makes sense, right? Because we know youth are sometimes, in some cases, prone to experiment with prescription opioids very often in their own home or their grandparents’ home prescriptions that they find that aren’t secured in those locations. And then in some kids, that experimentation could progress to intravenous or intranasal heroin or fentanyl use. And as soon as you go into the intravenous or intranasal categories, you’re at risk for exposure to infected blood. So it, it makes sense that we see acquired HCV infections mirroring the opioid epidemic.

A word about vertical transmission or perinatal transmission. If a child is born to a parent with chronic hepatitis C, that is a known risk for infection. And that’s not necessarily surprising. I don’t think the rate of mother to child or birthing parent to child transmission is about 5%. Rates are higher among children who were born, uh, to parents with inadequately controlled HIV co-infection or kiddos born to parents with higher HCV RNA levels higher viral load, which is more than six log 10 international units. And the risk of sexual transmission is, is actually quite low or rare. Uh, we do see it, but generally that mode of transmission is, is rather inefficient. However, it is more efficient in individuals who participate in anal intercourse, individuals who have multiple sexual partners and individuals who are living with HIV. This is why it’s imperative for us to procure a good social history. It’s important that we ask our teen patients what’s going on in, in your, in your social life? What’s going on with substances? Are you having unprotected intercourse? What, what type of partner do you have? Is it, is it men? Is it women? Let’s talk about those things. These can be uncomfortable conversations, but they can also be an avenue to providing excellent care for our patients. So it’s important that we help ourselves be comfortable having what can be awkward conversations that social history is so, so important in so many ways as far as reducing transmission.

We wanna avoid high risk behaviors, right? And I’ve already discussed some of those high risk behaviors. I want to add a few more here. We wanna avoid, have teens avoid self-tattooing and self-piercing as at asap um, at a children’s hospital. You know, one of the questions we ask on standard, uh initial evaluations are, do you have any tattoos? Do you have any piercings? And if so, have you performed them or have they been professionally applied? And you would be shocked at the number of teens that tell me they have done their own piercings or tattoos. It’s, it’s staggering. Uh, so that’s something we really need to keep in mind and ask that important question. And then if they say yes, we have to ask about did you sterilize the needle? How did you go about doing this? We also always wanna be aware of, um, not sharing equipment for individuals who use substances. And this pertains not just to injection drug use or IV drug use. This also applies to intranasal substance use as well. That also is a mode of transmission. So we wanna counsel patients in that regard as well.

We also know that barrier methods are recommended for adolescents who have HIV infection or adolescents who have multiple sexual partners or a history of sexually transmitted infections because we wanna prevent the transmission of HCV or HIV or other STIs, right? However, kiddos who do have chronic HCV infection, they should be counseled that their risk of transmitting this to another partner is, is actually quite low. Again, it’s inefficient, and unless they are in a category where they’re participating anal sex or multiple sexual partners, but the Hepatitis C virus is actually quite inefficient with that form of transmission. But again, we should still encourage those kids to use barrier precautions for other reasons, like preventing pregnancy and prevention of other STIs. In my work with youth and knowing where they are with that prefrontal cortex still developing until age 25, I am comfortable in my practice of just saying to kids, regardless of their status with HIV Hepatitis C, I’m comfortable just saying, please use a barrier precaution. End of story, end of story. Please use a barrier precaution if the kid has HCV and is really worried about transmitting it sexually. We’ll talk about that a little bit more, but I, I generally recommend barrier precautions all the way across the board for, for all my patients.

A few more recommendations, especially when we’re talking about children and adolescents with respect to school and recreational activities. We need to have parents that are educated regarding the ways in which Hepatitis C is transmitted and the ways it is not transmitted, because we do not want children who are afflicted with it to be discriminated against in a school or recreational setting, right? So other kids are not at risk if a child with HCV is participating in soccer with them, or school, gym, class, or other regular childhood activities. Kiddos can participate and should participate without restrictions. We do need to have parents aware that universal precautions should be employed, however, both at home and at school, right? So if you have a kid with Hepatitis C virus and they get epistaxis, that’s something that should be managed accordingly. We don’t wanna share toothbrushes or razors or nail clippers because that could lead to inadvertently to blood borne transmission, right? And of course, use gloves and dilute bleach to clean up any blood as well. Really important for us to empower our parents so they can really help their child participate in the community appropriately.

With respect to HCV screening, it’s really not warranted in most communities. And in as routine screening in our kids, however, selected screening is very appropriate in several groups that are at increased risk for HCV. And that includes children with clinical evidence of hepatitis regardless of their history. If you have a kiddo with clinical evidence of hepatitis, you’re gonna test for all the hepatitis, right, including hepatitis C. this also includes an unexplained elevation of ALT or AST, even if the, if the kiddo is asymptomatic, we wanna also be looking for HCV and infants and children whose moms we know are, have, have HCV or have a history of IV drug use. So if you have a, a child in your office and mom says, wow, I just did mare, I just completed her bony treatment, you’re gonna wanna screen her child, right? Siblings and children with vertically acquired chronic HCV born to the same birthing parent. We’re gonna wanna screen them as well, children who are international adoptees or refugees, and we also wanna screen children or adolescents with HIV infection. And then of course, children who are the, victims of sexual assault or adolescents with a history of multiple sexual partners will also want to screen. And, and this is kind of more where I come in, adolescents with a history or suspicion of illicit injection drug use, it’s important to screen them as well. In adolescents with IV drug use, you are gonna wanna consider screening more than once in a lifetime. At this point, we’re doing lifetime screening, one time screening. But if you have a child or an adolescent that you are concerned about due to risk either exposure or risk activities, consider screening them more frequently. The guidelines vary with different organizations. but the Infectious Disease Society of America recommends screening every 12 months. I’ve seen other societies recommending, recommending every six months. But again, it’s okay to rescreen if needed and just talking about what tests do we actually order. If you have a patient who is over 18 months old, you’re gonna order the the HCV antibody test, right? And if it’s positive, you’re gonna confirm with an HCV RNA test to confirm the diagnosis. If the patient is less than 18 months old, we’re gonna do HCV RNA one time until 18 months old. And then at 18 months old, you can go to the antibody testing. The reason behind that is simply because some of the maternal antibodies will persist, and that can show positive when, when the baby is less than 18 months old. And you might have a baby that really does not have Hepatitis C infection. It’s just the maternal antibody showing, okay? What we do know is that children born to people with HCV should certainly be evaluated and should be tested for HCV. There’s no doubt about that. And we should follow these kids and treat them as recommended, which we’ll get into in a little bit. And again, HCV RNA testing is a preferred assay for HCV infection early in life. Fortunately, about 25 to 50% of infected infants will spontaneously resolve the HCV infection which is loss of HCV, detectable HCV RNA by about four years old. So this is very, very encouraging. So it’s important to counsel our parents. Don’t panic if, if your baby tests positive, it’s okay. up to half of them, we’ll, we’ll clear this on their own.

And on HCV monitoring and medical management, I just like to say a few words about this. I think there’s definitely a role for, for primary care clinicians in this regard. And there’s obviously a role for referral to a hepatologist as well, which we’ll go through. So you have a child and they have a confirmed diagnosis of HCV. What do we do next? Well, first of all, let, let’s just exclude other causes of, of liver disease, right? It would be a travesty if we missed a hepatoblastoma or another type of liver of a liver disease. So we wanna make sure that we’re not missing anything. First, we wanna assess the disease severity and detect extra hepatic manifestations. So they have cryoglobulinemia, do they have rashes? do they have decompensated cirrhosis? Things we wanna look for. We want tests for concomitant hepatitis B virus and HIV and we also wanna confirm they have immunity to hepatitis A virus. And that’s recommended because that’s a shared risk factor. We wanna vaccinate non-immune children against hepatitis A and hepatitis B viruses. And maybe these kids haven’t had their routine childhood vaccinations. Hopefully they have. And as far as the disease progression, liver disease due to chronic HCV, thankfully in children progresses very, very slowly. And cirrhosis and liver cancer or hepatocellular carcinoma occur infrequently. So this is, this is good news. Kids generally fare quite well. We know that elevated aminotransferase levels are often noted in HCV infected children younger than three years old. However, they, they virtually never developed advanced liver disease. So this is also some good news.

So how are we gonna say this? We’re gonna get a physical, we’re gonna do a good physical exam. We’re gonna try and assess for hepatomegaly splenomegaly. We’re gonna order routine labs, albumins, serum aminotransferase levels, total bili INR, and platelet counts every six to 12 months. And then, you know, there is a role for serum fibrosis markers, but it needs some more validation in studies. It’s also, while we’re ordering aminotransferase levels, it, and we should be ordering them, but we also need to take it with a grain of salt because they are not consistently reflective of disease severity in children. And once the study, nearly a third of children had normal a s t and a L T levels, but significant inflammation and biopsy and biopsy is, is really the gold standard. So what else would we do? We would wanna evaluate for splenomegaly and venous collaterals on imaging. And what kind of imaging? Well, we wanna spare our patients radiation if possible. And liver ultrasound is a great way to do that. Instead of ct, we don’t wanna flippantly up irradiate our, our patient’s abdomen or pelvis, right? SO liver ultrasound, I’d like, it’s widely available. And again, it spares the, the kiddo ionizing radiation. M R i, of course, does not have ionizing radiation, but, you know, getting a six-year-old in an M R I tube is, can be challenging, right? Without sedation. So again, liver ultrasound is a great test to utilize. And again, that gold standard regarding the grade of inflammation or fibrosis is a liver biopsy. But realistically, most parents and most providers don’t wanna go through that degree of invasive assessment, although it, it can be done. And then we also have some stuff on the horizon, ultrasound based liver elastography in children. Uh, it requires specialized probes. There’s different parameters and those used in adults, but it does look promising in monitoring kiddos with chronic HCV infection, and that is still in the work. So just things to, to be aware of. Talk a little bit more about treatment. You know, as clinicians, we, we have a duty for do no harm, right? And we want to avoid medications that are known to accelerate hepatic fibrosis. So methotrexate, right? That can accelerate hepatic fibrosis. So if you, if you have a kiddo with ra, maybe, maybe you’re not gonna use that medicine. Um, you wanna avoid NSAIDs in kids with cirrhosis or esophageal varices, though, those can be problematic. Abs absence from alcohol use is strongly advised to minimize disease progression. This is where I come in a little bit more, right? a lot of times adolescents wanna experiment with alcohol, and we really want to counsel them that that is not a good idea for them. It just isn’t. And we can talk more about this in our third objective where we talk about alcohol use in adolescents a little bit more corticosteroids and other immunosuppressants, they can enhance HCV replication. And I think this was the big question when Covid was really on the horizon. Um, and really in the, for the forefront of our minds was, if I have a patient who’s wheezing do I give them steroids in the beginning you know, in, in 2020? And, and, you know, corticosteroids, yes, it, it can provide room for viral replication, but people also need to breathe. And for the same reason, corticosteroids and immunosuppressants are not contraindicated in kids with H C V infection. They should be used diligently, but they can be used, uh, when we weigh risks versus benefits. So if you have a kid with HCV with an asthma exacerbation, and, and they need the prednisolone, give them the prednisolone, it’s okay, give them the prednisone. Like all of our patients, we wanna make sure our, our, our kiddos have healthy body weight and healthy body habitus especially for kids with HCV. Why? Because we do not want them to develop insulin resistance. We do not want them to develop nafld. We do not want this to progress. Uh, due to the you know, concomitant comorbidities of HCV infection and obesity, or nafl insulin resistance antimicrobial agents, anti-epileptics and cardiovascular agents should be dosed per standard recommendations. We don’t have to stress about those too much. And acetaminophen is safe and effective. We can give those to our kids with chronic HCV just per package instruction. So we should be reassuring parents about that. Here are some more recommendation recommendations from the Infectious Disease Society of America. We wanna get our liver biochemistries at initial diagnosis, and at least annually thereafter, we want to make sure our kids are appropriately vaccinated. We wanna assess disease severity through the, the measures I discussed earlier, laboratory and physical exam testing, as well as non-invasive modalities that are still evolving. In the meantime, we have ultrasound kiddos with cirrhosis should undergo hepatocellular carcinoma surveillance and endoscopic surveillance for varices. And, and these, these are the kids that are gonna be with hepatologist, right? The hepatotoxic drugs. They should be used with caution. and we should always consider risks versus benefits. But we can use corticosteroids, cytotoxic, chemotherapy, therapeutic doses of acetaminophen. They are not contraindicated solid organ transplantation and bone marrow transplantation are not contraindicated. So these kids still have a lot of options, which is great. And again, we wanna give the adolescent and their family anticipatory guidance about the use of alcohol down the road. And if they’re already using alcohol, we wanna help hook them up with resources to achieve abstinence.

 Now, I just wanted to say a word about DAAT. Uh, there are high success rates with the DAAT regimens in adults and chronic HCV infection. and they’ve been replicated in the pediatric population. So direct acting antiviral therapy, we’re good to go. It’s okay to, to give it to these kiddos. it’s safe, it’s well tolerated, it’s, it’s efficacious, right? there are a number of different formulations we can give these kids, and I’ve listed them here from anything between ages of 12 to 17 year olds over six. what, what I’d like to say is if we’re getting into treatment, this, this is probably a child that belongs in the hands of a hepatologist for treatment. some of them are dependent on genotype of HCV, some of them are not. so again, this is when your patient should be with a specialist.

Recommendations that I also wanna discuss for children and adolescents with HCV infection. Again, this is kind of the same thing we just talked about. For all children and adolescents with HCV infection that are over three years old, they will benefit from antiviral therapy. So we should be sending them to someone that can manage that, right? If the child has extra hepatic manifestations this is a cause or concern and also should prompt early antiviral therapy to minimize future morbidity and mortality.

 Um, I, myself seem to do better with algorithmic representations of guidelines. So this is just the algorithmic representation of that acute or chronic HCV infection and a child or adolescent. Are they rapidly having rapidly progressive disease cirrhosis, HIV or HPV? The answer is yes, referral to a specialist. Uh, if the answer is no, if they’re less than three years old, we defer treatment. If they’re greater than three years old we can initiate one of the DAAT uh, regimens. for myself personally, I’m more comfortable when it comes to DAAT having them be in the hands of a hepatologist.

 I’d like to move on to HIV Now,

this is just a picture of the HIV virus, and I just want to review the the anatomy of the HIV virus. ’cause it kind of helps me at least understand the transmission. So you have the HIV caps, and that is the core that contains the HIV RNA, the envelope, which is the outer surface of the HIV, the HIV enzymes, which are the, the proteins like integrase, reverse transcriptase that carry out the steps in the HIV lifecycle. And of course, we have the P 24 glycoproteins that are embedded on the HIV envelope. And that facilitates fusion with the CD4 cell. And then the HIV RNA is obviously HIV’s genetic material.

And again, I’m a visual person. And this works for me. Uh, this is basically the HIV life cycle in a nutshell. And you’ll realize that every step in this life cycle, there’s an opportunity to stop HIV. Uh, so it starts with binding. The HIV binds itself to the receptors of the CD4 cells with the glycoprotein it fuses and the CD4 cell and the HIV virus joined together, and HIV can now inhibit, or I’m sorry, can now enter the CD4 cell reverse transcription occurs utilizing reverse transcriptase one of those HIV enzymes, and it converts the RNA to D N A upon becoming d n a. The the HIV D N A now can access the nucleus of the CD4 cell, where it can be integrated, step four with the cellular D N A. And now it’s really hijacked that CV four cell, right? It now is put outside the nucleus, it replicates and it is making long proteins of HIV, uh, that are immature, but are about to be formed into a new HIV virus, right? And then you have budding. And those, the newly formed and immature or non-infectious HIV pushes itself outside that host cell, that outside that CD4 host cell and protease will break up those long protein chains of the immature virus and create immature or infectious virus. And on and on we go. so it’s, it’s absolutely terrible how HIV can hijack a CD4 cell. and you can see how people got so quick, so early, um, before we knew much about HIV, but I’m encouraged and draw hope from the fact that there’s a place in each step of the cycle. We have drugs that can stop it.

 I wanna talk about the safety of HIV briefly. We have viral transmission. We have acute HIV infection, and we have chronic HIV infection. And chronic HIV infection is further subdivided into chronic infection without aids and aids and advanced, a advanced HIV infection.

 Um, viral transmission is acquired through certain sexual behaviors on receptive anal intercourse that is condomless is one of them, exposure to infected blood, including injection drug use and perinatal or vertical transmission. and of course high viral load presence of ulcerative STIs and participation in high risk sexual behaviors and lack of circumcision All increase the risk of viral transmission.

And some of the terminology I have always found confusing, and it seems to be ever changing. So I just wanted to review that for all of us right now, acute HIV infection, those are the signs and symptoms immediately following acquisition of the virus. That is influenza-like virus that people experience immediately following the acquisition of HIV Acute. HIV infection is also known as primary HIV infection, which is also known as acute seroconversion syndrome. They’re all referring to the same thing. Then you have early HIV infection, which is the first six months of infection, okay? And that’s when you have rapid viral replication. You have very, very high RNA levels viral, RNA levels. When you get to that six month mark, you really do hit plasma viremia with a steady state you get a viral set point, okay? So acute is signs and symptoms early as the first six months of infection

and a word on acute PV infection. This mimics a lot of other things, right? Uh, there’s fevers, there’s weight loss, malaise, you know, neuropathy, headache, lymphadenopathy, sore throat, thrush, myalgia, nausea, vomiting. I mean, this could be so many things that walk through our doorway. It could be Covid, it could be strep influenza B symptoms. It, it, it could make up so many different things. And that’s why we always have to have this on our radar and cast a broad differential. And then apart from that, again, having those uncomfortable conversations. If we have a kid coming in with these symptoms and we know they participate in injection drug use, HIV is gonna be higher on our differential rate.

 So, chronic HIV infection without aids, let’s talk about that briefly. This is a period of pretty stable plasma viral level, but a decline in CD4 cells and without ART. The average time to CD4 ART being antiretroviral therapy the average time to CD4 being less than 200, also known as AIDS, is about eight to 10 years. So that’s without ART eight to 10 years. Uh, and during this time of chronic, HIV without aids, clinical manifestations are few to none for, for many, many people. some patients do experience fever sweats, weight loss, persistent, generalized lymphadenopathy. But for many folks, it’s, it’s not that symptomatic. And, you know, for the people that do experience symptoms, it, it, it’s somewhat vague.

 And then I just want to review some of the infections that we can see in early symptomatic HIV infection, opportunistic infections, right? We all know about that. Thrush, vaginal candidiasis, oral hair, leukoplakia, cervical carcinoma, zoster, um, constitutional symptoms, ITP. and you see these in, obviously in folks with greater frequency and severity in the setting of HIV infection even in the absence of severe immunosuppression.

And then we have aids, and that’s the outcome of chronic HIV infection resulting in depleted CD4 cells. And that’s defined as CD4 counts less than 200, or in AIDS defining condition, regardless of CD4 count. You could have a CD4 count of 400, but if you have

 compose sarcoma, you now have aids, you’re now considered to have aids. Pneumocystis jiroveccii pneumonia, you have aids, right? Uh, regardless of your CD4 count there your chronic HIV has progressed. And here is a list of, of really a whole host of things that are age defining illnesses.

 And then we have advanced HIV infection, which refers to the CD4 count being less than 50.

Again, for visual people, I have this graphic representation of the different stages that we talked about

and treatment. Let’s move on to something a little bit more hopeful here. Magic Johnson. This is when HIV kind of first came into my awareness. I remember it was the early nineties. I remember watching Nickelodeon with my mom, and we watched Nick News with Linda Ellerbe, and Magic Johnson was on there. And we watched it. And I knew about him because I knew there was a basketball player who was diagnosed with HIV. And I remember thinking it was an absolute death sentence and asking my mom, and she was like, yeah, he will probably die very soon. Yet here he is alive and well with from what I know, undetectable, Undetectable HIV.

 With the a with the advent of ART in high income countries, inter individuals can live in your normal lifespan. So that’s highly encouraging.

 And we have a role to help people not acquire HIV in the first place, and that’s with prep or pre-exposure prophylaxis. And again, we can’t offer this if we don’t know about our patient’s substance use history and sexual histories. We, we can only help if we know, if we know some, some things right. Prep reduces the risk of getting HIV from intercourse by about 99% when taken as prescribed. There’s less information studies available for, for people who inject drugs. However, we know that prep pills reduce the risk by about 74, 70 4% of contracting. HIV, again, when taken as prescribed. Prep shots are not recommended for people who inject drugs. Uh, we just don’t see that it’s played out in the, in the studies. And prep is less effective when not taken as prescribed, which we need to be hammering home with our patients.

 Additionally, not enough healthcare providers know about prep. We’ve discussed the first two statistics to the left of the slide, but one in three primary care doctors and nurses haven’t heard about prep, which is scary because that we’re the front lines, right? Uh, so this is something we need to have on our radar.

 Uh, Truvada, there’s,      there’s three main forms, Truvada, Descovy, and Apretude. Truvada I have in red. And that’s because that is a pill form for HIV prevention in individuals with injection drug use and or high risk sexual behaviors. So that is, is my go-to for people. with injection drug use,

 how can I help as a clinician employ the screening recommendations? Uh, screen your patients for HIV, which I’ll talk about in a, in another slide. And remember, it’s okay to screen again if a patient discloses high risk behaviors.

 So right now, the USPSTF recommends screening adolescents and adults aged 50, 15 to 65, all pregnant women and people under age 15, or over age 65, who has, who have risk factors for HIV infection. Um, and that’s, that’s a recommendation as far as the interval for screening. At this point, it’s, it’s lifetime screening. but again, if you have a patient, there’s insufficient evidence to recommend intervals. But if you have a patient that you’re worried about where they have risk factors, by all means, screen them again.

Again, how can we help consider prep when it is indicated? Consider PEP or post-exposure prophylaxis, which you would do if you had a needle stick at work, HIV exposure through intercourse or through injection drug use. It’s very important. You wanna get that in within 72 hours as early as possible, and use your resources. At Boston Children’s, we have the Happens Clinic, which is basically an adolescent as part of adolescent medicine, and it treats youth with HIV. and that is what they do, and they are available and happy to help. They’re wonderful folks that work over, over there.

And how can I help? As a clinician, harm reduction, we should be encouraging syringe services programs, or SSPs and needle exchange programs as well. And we also wanna model non-stigmatizing languages and behave language and behaviors for our patients as well. Right?

sharing needle syringes or other drug injection equipment puts people at risk for getting or transmitting HIV. And about one 10 new HIV diagnoses in the US are attributed to drug injection, um, or male tomale, sexual contact and injection drug use. So people who essentially were assigned male birth, but reported both risk factors

 and syringe services programs about one in 10 HIV diagnosis diagnosis are among people who inject drugs. About 50% of people who inject drugs use a syringe services program in 2015, but only one in four got all of their syringes in from sterile sources in 2015.

 And syringe services programs are awesome. They not only just provide syringes, they provide safe disposal, they provide referral to mental health and overdose treatment like Narcan, hepatitis A and B vaccination counseling. Uh, a lot of times communities are reluctant to have SSPs in their community, but We need to know that they, they help, they reduce HIV risk. There’s no increasing crime. There’s actually fewer needles in public spaces, reduced overdose deaths and reduced HIV risk. So they’re really, they’re really win-win programs.

And last but not least, you know, in substance use, we put so much value on using non-stigmatizing language, and that is reflected with both HIV and HCV infections as well, right? we don’t wanna say full blown aids, we wanna say an AIDS diagnosis. We don’t wanna say, how did you get it? We wanna say, are you in care? Things like that.

And again, here are some more examples of that as well.

And you know, when I walk into an exam room, one of the things I remind myself are ways that I cannot contract. HIV. You know, we, we practice in an enlightened era, and I remind myself when I see someone who has HIV, I do not need to gown and glove. I can shake their hand if they’re sweaty, I can put my stethoscope on their chest and not be worried about, about getting this. so I always like to remind myself the ways I cannot get HIV I think that’s really important for us as providers.

Briefly, I wanna discuss binge drinking. Again, I think we all see kids that have questions. Uh, binge drinking is defined by the C D C as consuming five or more drinks for, for people assigned male at birth, and four or more drinks on occasion for people assigned female at birth. Most people who have binge drink are not dependent on alcohol, and they don’t have a u d alcohol use disorder, but it can be harmful in its own right. binge drinking can be associated with higher risk for alcohol use disorder. However,

 I don’t know, I don’t think that we’re surprised to see that, you know, college kids binge drink based on this graph. one of the things that always surprises me and I’ve seen this a number of times, but I’m always surprised to see that the 25 to 34 year old group has a bar that is so high. it’s most common in younger adults. Um, 49.3% of full-time college students drink alcohol in the past month. And of, of those 27.4% engaged in binge drinking in the same timeframe,

consequences of binge drinking assault or sexual assault. One of our questions at ASAP and initial evaluations are, have you ever been taken advantage of when you were binge drinking? And the answer can be yes more often than we’d like it to be. Academic diff difficulties, higher risk for alcohol use disorder, suicide attempts and unsafe sexual behavior, unsafe driving under the influence and unfortunately, death.

 And what, what does heavy drinking mean? Sometimes people say heavy drinking. Uh, what, what do we mean by that? For persons assigned male at birth, heavy drinking is defined as 15 drinks or more week. For, for people assigned female at birth is considered consuming eight drinks or more per week.

 How do I know if it’s okay to drink? so there are some people that just should not be drinking. Uh, people who are pregnant or might be pregnant, people who are under the legal age, certain medical conditions or certain medications that I’ll go through in a bit. People that have a u d or it, it is just difficult for them to, to regulate the number of drinks

I am underage, is drinking bad for my health, your patient says, yes, it is. it increases the risk of both fatal and non-fatal injuries. We also know that people who drink before age 15 or six times more likely to become alcohol dependent than those, those who wait until after age 21. And how do I know if I, if I have a drinking problem, your life is imploding from it, right? Trouble with relationships in schools, social activities, biologic dependence, cravings, tolerance, withdrawal.

Uh, can I drink if I’m currently taking medication? Uh, sometimes yes, but other times, no medications that should absolutely not be taken with alcohol include pain medications. We do not want respiratory de depression, anxiety, medications like Ativan and Xanax. Again, respiratory depression is bad. Sleeping pills, respiratory depression is bad, right? A D H D medications, we wanna be careful of alcohol can can amplify the side effect profile of them. Certain antibiotics we wanna be careful with. Azithromycin, we wanna be careful with for cardiac arrhythmias. We also wanna be careful certainly with Metro Metronidazole, right? Do that diam like ran and, um, and nitrate and blood pressure medications. We also certainly want to be, um, cognizant of

 resources. We love aa, it has a lot of evidence behind it. and here is some resource information there for you in the link. The National Drug and Alcohol Treatment Referral Routing service. They can help, uh, hook folks up with resources in their community. And of course, SAMHSA’s National Helpline. Uh, these are my references, and, and that’s what I got.