Substance Use Disorder and Fentanyl Overdose in Teens – PediaCast 570
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Description
- Dr Scott Hadland visits the studio as we consider substance use disorder and fentanyl overdose in teenagers. Fentanyl deaths in teens are on the rise, with about 22 high school students dying each week in the United States. We provide tips for pediatricians, parents, schools, and communities aimed at preventing these tragedies. We hope you can join us!
Topics
- Substance Use Disorder
- Fentanyl Overdose
Guests
- Dr Scott Hadland
Chief of Adolescent Medicine
Mass General Hospital for Children
Associate Professor of Pediatrics
Harvard Medical School
Links
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast is brought to you by Adolescent Medicine and Educational Services at Nationwide Children's Hospital. Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads.
This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital, and welcome to another episode of PediaCast. We're in Columbus, Ohio. It's episode 570.
We're calling this one Substance Use Disorder and Fentanyl Overdose in Teens. I want to welcome all of you to the program. We have another important topic for you this week as we consider substance use disorder and fentanyl overdoses.
It's really important because it impacts way too many teenagers and families, and all of these overdose deaths in teenagers, especially from fentanyl, is preventable. Now, in the first year of the pandemic, fentanyl-related deaths in teenagers skyrocketed, increasing by 177%. Now, thankfully, this increase slowed to 2% between 2022 and 2023, which is more in line with the increases that we were seeing pre-pandemic.
However, we are still seeing a trend upward to the point where overdose deaths in teenagers is one of the leading causes of deaths in this age group. And as it turns out, still today, about 22 high school-aged teenagers die each week in the United States from fentanyl overdoses. So again, way too many kids.
As I learned during the course of this interview, it's really about a classroom of high school students every week in the United States who dies from a fentanyl overdose. And again, these are preventable. Every single one of these deaths is a tragedy.
So, we're going to dive into substance use disorder and fentanyl overdose in teens. We're going to look at the trends. We're going to talk about why we are seeing these trends.
We'll talk about risk factors for substance use disorder and fentanyl overdoses in teenagers. We'll talk about the signs and symptoms of a fentanyl overdose and how these are managed, and then the roles of pediatricians, parents, schools, and communities in preventing these tragedies. Of course, in our usual PediaCast fashion, we have a terrific guest joining us this week.
Dr. Scott Hadland is Chief of Adolescent Medicine at Mass General for Children and an Associate Professor of Pediatrics at Harvard Medical School. I want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
If you're concerned about your child's health, be sure to call your health care provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. So, let's take a quick break.
We'll get Dr. Scott Hadland settled into the studio, and then we will be back to talk about substance use disorder and fentanyl overdose in teenagers. It's coming up right after this. Dr. Scott Hadland is Chief of Adolescent Medicine at Massachusetts General Hospital for Children and an Associate Professor of Pediatrics at Harvard Medical School. He is also an international expert in teen health, whose clinical care and research focus on preventing and treating drug and alcohol use disorders. Dr. Hadland's work is funded by the National Institutes of Health, the Patient-Centered Outcomes Research Institute, and the U.S. Centers for Disease Control and Prevention. He's here to talk about substance abuse disorder and fentanyl overdose in teenagers.
But before we get into that, let's offer a warm PediaCast welcome to Dr. Scott Hadland. Thank you so much for visiting with us today. Thank you so much for having me.
Yeah, I really appreciate you taking time out of your busy schedule to join us. You are here at Nationwide Children's Hospital giving a Grand Rounds lecture, and we're very happy that you were able to stop by the studio to talk with us about substance use disorder. And I really wanted to start right there.
What is meant by that term, substance use disorder? What exactly is that?
[Dr Scott Hadland]
When we talk about substance use disorders, we're talking about addiction. Substance use disorders mean that somebody is using a substance and starting to have problems from it.
And so, you know, teens or really anybody of any age who's starting to have a problem with a substance use disorder will be unable to cut back on their substance use. They'll be using more than they intended, and they'll start to have negative consequences that spill over into their daily life. Meaning, you know, for teenagers, they might be struggling at school or their relationships with friends and family might start to fall apart.
For people who are adults, they might be having problems at work. And so, this is really the idea is that a substance use disorder, or addiction is somebody using a substance and having negative consequences from it. Yeah.
[Dr Mike Patrick]
And I think that can get a little bit confusing for folks because traditionally that word addiction makes you sound like you are dependent on a particular drug just to get to the point that you even feel normal. Like at first you get the high and excitement, and then you start to feel kind of down, and now you need to use that same drug just to even feel normal again. Like when we think about physical addiction.
But I think the point here is that you don't even have to be in that far if the use is interfering with your daily life, then that's a problem.
[Dr Scott Hadland]
Well, that's right. And actually, there's a really important distinction here. So, you know, people who have pain, for example, who use medications like opioids to treat that pain, sometimes their functioning gets better when they receive an opioid, right?
They were in pain, they couldn't go about their daily activities, they couldn't go to school, they couldn't work, they couldn't engage with people because they were in so much pain. They use an opioid; their pain gets better. That's not addiction.
So even though they're using an opioid every day, their functioning improves. And so that is very different. And that's why it's really important when we think about addiction to think about worsening functioning, to be thinking about problems getting worse because of that substance.
[Dr Mike Patrick]
Yeah, yeah. And you could potentially then become physically addicted to something. Again, I use that term kind of loosely, just as the general public would understand it, but actually have improved life.
And then that may not actually be a substance use disorder, but it still could be addiction if you physically are dependent on that drug.
[Dr Scott Hadland]
Right. The way that we'll usually sort of think about it is we'll actually save the word addiction for somebody who has a substance use disorder. And if somebody is using a substance every day, but actually getting better functioning from it, we'll call that sort of a physiologic dependence or sort of a need for that substance, but not actually call it a substance use disorder and not actually call it addiction.
[Dr Mike Patrick]
Yeah. So, the big thing here is that it's interfering with your life and your quality of life, your ability to function within your family, your friend circle, your job, and those sorts of things. So, as we think about teenagers, then how common is this problem?
[Dr Scott Hadland]
It's a really common problem. So, if we look at national survey data from across the US, actually about 8.7% of teenagers between the ages of 12 and 17 or about one in 12 teenagers has a substance use disorder. And this can be related to use of nicotine, cannabis, alcohol, or even more serious substances like opioids or stimulants like cocaine.
Yeah.
[Dr Mike Patrick]
When we think about this with substance use disorder, a lot of times this starts in the teenage years, right? So, like if we want to make an impact on adult substance use and adult addiction, we really do have to look at the teenage population because a lot of times that's when this all gets started.
[Dr Scott Hadland]
Oh, that's exactly it. I mean, addiction is a pediatric onset condition. If you look at the age at which people who struggle with addiction first started, 90% of the time or nine times out of 10, they first started using substances before the age of 18.
So, it really shows how pediatricians like you and me are really on the front lines of this work.
[Dr Mike Patrick]
Yeah, absolutely. And so, are parents, right? So how can parents sort of be on the lookout for this?
You know, are there subtle signs or something that they can be watching for that might, you know, make the alarm bells go off that there could be a substance use disorder in their kid's life? Because, you know, kids aren't exactly letting their parents know that this is a problem most of the time.
[Dr Scott Hadland]
Right. That's the tricky thing about substance use and substance use disorders is that they often happen in secret, right? And so, problems often are getting much, much worse before they rise to the attention of a parent or a doctor, right?
So, it's very important for parents to be on the lookout. In some cases, sure, a parent might uncover, you know, some evidence, right? They might come across a vape that's hidden underneath their child's bed, or they might smell alcohol on their child when they come home from a party.
And so, there are these moments where you actually get sort of, you know, real physical sort of evidence that something is going on. But that actually is not usually how it presents. How things usually present are that young people start to have sort of some of the problems that we talked about before, right?
Their grades might start to suffer. Their relationships might start to change at school. They might be hanging out with different kids than they did before.
They might be less engaged in sports and other extracurricular activities that they used to love. And so, parents should be on the lookout for some of these clues, which are the softer clues that something might be going on.
[Dr Mike Patrick]
Yeah. And I would think that it's also important to make kids feel comfortable talking with you about maybe controversial topics. I mean, it's tough because you don't want to be permissive, but you also don't want to be so judgmental that they're not going to come to you when they really have a problem.
I mean, that's sort of a fine line to walk, isn't it?
[Dr Scott Hadland]
You just highlighted the central challenge here and yet the central goal of what parents should try to accomplish, right? So, I think it is really critical in an era in which, you know, cannabis, for example, is legalized and its use is increasingly normalized. And many young people see cannabis as natural and green and legal, and therefore it must be safe.
In an era in which vaping is really common, in an era in which alcohol is positively depicted on television and in movies, there's a lot of mixed messaging around substance use. And it's really important for parents to send a clear message to their child and to their teen, hey, look, I don't want you to use because that's the best decision for your health and for your safety. And at the same time, parents working hard to foster the kind of conversations and relationships with their teen in which their teen can come to them if they are using substances or if they've been invited to use substances by a peer so that there's a safe space for parents to work through that.
[Dr Mike Patrick]
Yeah. Are there particular risk factors for developing a substance use disorder? So, in addition to those signs that you're talking about, are there particular teenagers that we should be more attentive to for the development of a substance use disorder?
[Dr Scott Hadland]
Absolutely. Just for context, you know, I work in a subspecialty addiction treatment center at Mass General for Children, and we get referrals of teenagers between the ages of 13, well, really up to the age of 25. So, you know, young adults as well who are struggling with substance use disorders.
And it is really the rule and not the exception that the teens that I care for who are really struggling have other mental health challenges that they're working through. And the most common diagnoses that we see are teens who are struggling with depression that may have gone untreated, often anxiety that's gone untreated or undertreated. They may have a history of trauma.
And in other cases, they might be struggling with more severe substance use related to say opioids or stimulants, but often there were issues with nicotine, cannabis or alcohol that preceded that that went sort of under addressed.
[Dr Mike Patrick]
Yeah. And so, a lot of these kids are really just trying to make themselves feel better. I mean, we all want to feel good.
And so, if you can identify those kids who do struggle with depression and anxiety, and there may be really subtle signs of that because again, they're not necessarily advertising those issues with their parents all the time. But I guess the more that you are engaged in your child's life and having open channels of communication, the more likely you're going to be tuned into subtle changes and then hopefully feel comfortable talking about those things.
[Dr Scott Hadland]
Right. That's exactly it. And so, I really encourage parents to come at these conversations from a place of curiosity.
I think it's really easy, you know, as a parent, and I'm a parent of young kids, albeit not of teenagers, but I think it's really easy as a parent to immediately get into sort of lecture mode, right? To say like, you know, this is what I want for you, you know, thou shalt not use drugs and to be really sort of prescriptive. And, you know, if your child is using substances or is caught using substances, to immediately go to a place of sort of punishment.
And certainly, you know, young people should have limits and should be monitored and there should be boundaries around their behavior. But it's really important to, as a parent, make sure that you keep a level head, have thoughtful conversations, ask teens, you know, what are you seeing? What's going on with your peers?
Have you ever been offered, you know, drugs or alcohol? How did you handle that situation? And really sort of come at this from a place of trying to understand the context in which teens are living, because what you want to be able to do as a parent is help them navigate those moments successfully.
[Dr Mike Patrick]
And I think once it gets to the point that there really is a physical dependency, as we think about opioids, for example, it's going to be important not to just say stop, but actually to go get help because it may be dangerous to their health just to stop for certain drugs.
[Dr Scott Hadland]
That is true. So, withdrawal from substances, in particular alcohol or medications called benzodiazepines, some of the brand names that, you know, the audience may have heard of include medications like Xanax, for example. These medications can actually be quite dangerous to stop immediately.
It can be very dangerous to stop alcohol immediately. Stopping opioids is less dangerous, but it's very uncomfortable. And so, this is a place where a physician, a good pediatrician, can actually help to manage some of these withdrawal symptoms and make sure that it's done safely.
[Dr Mike Patrick]
Yeah, absolutely. I want to change our focus a little bit to overdosing. So, this would be when there's too much of a substance and then it starts to have, you know, potentially life-threatening effects.
How common are overdoses in teenagers who are using substances?
[Dr Scott Hadland]
Actually, overdoses have become extremely common in the United States. And in fact, sort of in the time leading up to COVID and then further accelerated by COVID, overdose rates among teenagers have hit an all-time high. We're actually at a point right now where overdoses and poisonings, most commonly caused by high-potency opioids like fentanyl, which we can talk about, have actually become the third leading cause of death in children under the age of 19 in the United States.
So that is an enormous health burden, and I think a very big surprise for many of my pediatrician peers and many parents and teachers who might be listening. And so, this is truly urgent. We're actually at the point right now where overdoses kill the equivalent of a high school classroom of teenagers every week across the United States.
[Dr Mike Patrick]
Wow, I thought you were going to say every year. Every week. Every week, a classroom full of teenagers dies because of a drug overdose.
And those overdoses most often start as substance abuse disorders. And so, we really do want to, you know, be in tune with our kids and make sure that we're kind of figuring out where they are, what they're doing, what's going on in their lives.
[Dr Scott Hadland]
Well, it's really interesting. Actually, there are a number that do start off with substance use disorders, meaning, you know, teens who are struggling with drugs, particularly, might be struggling with opioids, use fentanyl, and then overdose. That is certainly a population of young people who overdose.
And historically, that has been the highest risk group. What we're seeing now, though, is the epidemiology is shifting, that mere experimentation with a counterfeit pill that's been spiked with fentanyl. Again, we can talk about what these are and where they are and how teens are getting their hands on them.
But just experimentation, even just once or twice or a small handful of times, can actually be fatal.
[Dr Mike Patrick]
Yeah. As you mentioned, fentanyl, is that the leading cause of deaths in teenagers who are using substances?
[Dr Scott Hadland]
It is, yes. We did a recent analysis, and we looked at overdose deaths across the country in the last few years and have found that fentanyl is involved in probably about 8 out of every 10 overdose deaths among teenagers across the United States. Fentanyl is an opioid.
It's an opioid like medications that you may have heard of, oxycodone or oxycontin, but it's really potent. In fact, heroin, another opioid that we think of as being very potent, fentanyl is probably about 50 times more potent than heroin. And so, this is something that is associated with really high risk of overdose.
And what we're finding in the U.S. is that there's a big market for counterfeit pills right now. So, pills that look exactly like pills prescribed by a doctor, pills like oxycontin, for example, have the same color, have the same shape, but actually they've been illicitly manufactured, often outside of the U.S., brought into the country, and made to look like these real pills, but actually contain fentanyl in them. Fentanyl being highly potent but producing the same sedating effects as these other medications that they're meant to mimic.
And so, there's a market for these, but they're very dangerous, especially for teens.
[Dr Mike Patrick]
Yeah. So why do folks who are making counterfeit pills, why do they lace those with fentanyl, especially if that makes it more dangerous? You think you would want to keep your customers alive so that they keep buying, but we know that this can be deadly.
Why do they do this? Why is fentanyl making its way into counterfeit pills?
[Dr Scott Hadland]
There are a few different reasons. One, fentanyl is cheap, and it's much less expensive to import into the country something that is highly potent and takes up a small amount of volume. That's just sort of easier to bring into the U.S., so that is one key reason why fentanyl has found its way in. The other reason is that there is a market for these pills, and so among adults, for example, who struggle with addiction, they actually may be looking for more potent opioids to use as part of their addiction, and so there is a market for these. I guess the last thing I would say is that this is not a high-quality, pharmaceutical-grade production process, right? This is sort of done with low quality, and so some of these pills may have a little bit of fentanyl in them, and other pills may have a lot of them in it, and that's what actually makes this so challenging, is that it can be difficult to predict what's exactly in a pill that a young person may be using.
[Dr Mike Patrick]
Yeah. I want to make one point, since you mentioned medical grade versus sort of street fentanyl. We do actually use fentanyl quite a bit in the emergency department, especially in kids who are in extreme pain, and I think about broken bones as probably the leading reason that we use fentanyl.
But when we use it, again, we are using medical-grade fentanyl. The doses are in micrograms, so I mean these are really tiny doses, which to your point is one of the reasons it's popular in pills, because you don't need much of it to get an effect. But I just wanted to point out, because a lot of parents kind of raise their eyebrows, which is actually kind of a good thing when we mention that we want to give your kid a dose of fentanyl.
So, there is that awareness out there, at least, that this is a dangerous drug. But I did just want to point out that in a medically controlled environment, for a particular reason, one dose of fentanyl is most likely not going to be an issue for their child who's in pain.
[Dr Scott Hadland]
That's exactly right. It's extremely effective at treating pain. It's often used as part of anesthesia.
And in this context, it's very safe. It's done in a very controlled, again, with pharmaceutical-grade product, done in a very thoughtful way. It also is likely not associated with long-term risk for addiction or problems down the road.
[Dr Mike Patrick]
So then how is fentanyl dangerous? What are the side effects that are occurring that we worry about?
[Dr Scott Hadland]
Right. When fentanyl enters the body, it binds to opioid receptors throughout the body, but in particular in the brain. And what it does sort of initially and most dangerously is binds to receptors that cause a decrease in somebody's respiration or a decrease in their breathing.
And so, what the hallmarks of an opioid overdose are that somebody will have decreased breathing. They may have stopped breathing altogether. As a result, they will often have mental status changes because fentanyl and opioids are also quite sedating.
And so, somebody will either be unconscious or maybe starting to look quite sleepy. And as their respirations or their breathing decrease, their heart rate will go down. And so, if you check a pulse, the pulse may be low or absent.
And then because they're not breathing, they'll start to turn a little bit pale or blue. And so, if you look around the lips or look at the fingertips, somebody might appear blue.
[Dr Mike Patrick]
Yeah. So, this is respiratory depression. So, their respiratory center in their brain that keeps you breathing basically is going to sleep from the fentanyl.
But you stop breathing, then your heart's not getting the oxygen it needs, and then the heart rate goes down and a death can occur from there.
[Dr Scott Hadland]
That's exactly it. But the key here is that this is all mediated or caused by opioids like fentanyl binding to receptors in the brain. And so, this offers us a key opportunity if we can sort of break into that by using an opioid blocker.
And actually, that's what naloxone is. It's an opioid blocker. And we can certainly talk about what naloxone is, where you can get it, but it is a life-saving medication that can interrupt that process.
[Dr Mike Patrick]
Yeah. So, the brand name Narcan is what some folks are probably used to hearing, but the drug name is naloxone. And tell us how folks can get a hold of that.
[Dr Scott Hadland]
Yeah. Naloxone or Narcan is truly lifesaving. When administered, it saves a life within minutes.
And Narcan is typically most commonly in the US in the formulation that it comes in, which is a nasal spray sprayed up the nose. And so, it's super easy to administer. I mean, there are cold medications that people use that are sprayed up the nose.
And so, people are often familiar with this sort of way of administering a medication. It's very easy to get. It actually recently became over the counter.
And I actually had an amazing opportunity to actually testify to the US Food and Drug Administration when they were thinking about making this change. And last year they did make this change. They made Narcan available over the counter so that anybody across the United States can walk into a pharmacy and purchase it.
You can get a kit of two of these devices for $45 from any pharmacy. You can actually get it online through vendors like Amazon.com, for example. And so, it's readily available.
Now, having said that, even me as an addiction provider who wants to carry this around with me in case I need to respond to an overdose in the community, $45 is a lot of money. And I don't expect that many people want to pay that money. And so, there are other avenues that are much less expensive.
And what that means is that then the prescription can go through your insurance. And many insurance companies will cover Naloxone or Narcan without any copay or with a very low copay. And so, for example, when I walk into a pharmacy and say, hey, pharmacist, I want Narcan under the state standing order, they bill it to my insurance, and I pay $0.
[Dr Mike Patrick]
Does that put any kind of mark on you? Does it go on your permanent record that you got Narcan from the pharmacy? Would that be a red flag for future employment or is there any way that that would be an issue?
[Dr Scott Hadland]
In the year 2024, usually not. Earlier on, say like 8 to 10 years ago when you did this, there was some worry that, for example, life insurance companies, when you're applying for life insurance, might look back and see that you had requested a prescription for Narcan and say, hey, what's going on there? We're going to increase your premiums as a result.
That has largely gone away, but it is just one thing to think about depending on where you live and whether that might come up. I guess I would say the third way that many people can get Narcan is that it's often just given out by community-based programs. It's often available increasingly in schools, in many school districts, and so it's widely available for free in many places.
[Dr Mike Patrick]
You go to community festivals and sometimes there'll be a booth that they're handing out Narcan, so definitely watch for those opportunities. Of course, the Narcan has to be available to use when someone is down and you're worried that they have an opioid overdose or a fentanyl overdose, so it's going to be important to actually keep it with you even after you get it because it's not going to do anyone any good in the medicine cabinet.
[Dr Scott Hadland]
Right. That's exactly it. It's not just enough for us to be giving out Narcan as doctors and getting Narcan as community members.
What I personally do is I make sure that I take that kit of two that comes when you fill a prescription, and I keep one of those in my backpack so that I'm always carrying it around with me, and I keep the other one in our junk drawer at home, meaning that same drawer in the kitchen where we've got pencils and pens and paperclips and tape and all the stuff that people commonly reach for. It's in the central location, and we think about it the way that we think about a fire extinguisher, right? We have a fire extinguisher in our home.
Everybody knows where it is, and of course we don't expect that one of us is going to burn down our house, but if something ever happened, we want to be prepared in case of an emergency. So, it's important to have it on hand and have it available. I would say the other thing is that it's important to know what an overdose looks like, right?
So, we talked about this. So, somebody will appear sleepy or might be unconscious. Their breathing will have slowed down or even stopped, and they'll appear pale or even blue.
Those are the signs that you should give somebody a dose of Narcan, and Narcan is safe to administer even if somebody is not having an overdose, even if they've had a stroke or they're in diabetic coma. It is safe to administer somebody Narcan, but because you don't always know what happened there, it's critical to still call 911, make sure that that person gets medical attention even as you give them Narcan, because if it's not an overdose or even if it is an overdose, you want to make sure that they get medical professionals looking at them.
[Dr Mike Patrick]
Some parents may be thinking, well, if my child, I find them like that, I give them Narcan, they wake up, and now I've called 911. Now are they going to get in trouble for having used an opioid? And we can say they probably did since Narcan worked.
Is that an issue?
[Dr Scott Hadland]
It is an issue in some states, and it's important for parents to look up whether their state has what's called a good Samaritan law. So here in Ohio, where we're speaking right now, in my home state of Massachusetts, both of these states have good Samaritan laws, and most states in the U.S. have these, which are laws that protect the person that called 911. Meaning, if you're a teenager or if you as a parent call 911 because somebody has overdosed and there are drugs on the scene, it actually turns out that you can't be charged for possession of those drugs because you did the right thing by calling 911 for somebody who needed medical attention.
Not every state has these good Samaritan laws, but many do.
[Dr Mike Patrick]
Yeah, really important. But even more important than that is saving your child's life. And so, you know, in that moment, it's better to give the Narcan, deal with the consequences later, because now your child's alive instead of dead.
Exactly. Yeah, very, very important. Are there particular risk factors then for overdose?
We talked about risk factors, especially the mental health ones. For substance use disorder, are there particular teens that are at a higher risk for actually overdosing?
[Dr Scott Hadland]
Yeah, I take it back to the things that I said earlier. So, there are some youths who struggle with addiction. They're going to be at very high risk of overdose.
And so, you know, even if your teen is struggling with cannabis, alcohol, nicotine, it's worth having the conversation around, you know, how to keep yourself safe from overdose, what do overdoses look like, and what is Narcan and where are we going to keep it in the house for everybody to use? Also, young people, as we mentioned before, with mental health problems, particularly if those mental health problems have gone untreated or undertreated. And then there are also teens who, you know, and here's where we're learning a lot as pediatricians, might just be experimenting.
And this is the part that worries me, and I think scares a lot of parents is that, you know, these counterfeit pills are available for purchase on social media, on platforms like Snapchat, Instagram, TikTok. They're also available through illicit online pharmacies and through the dark web. And it's pretty easy to track these down and to purchase them even as a teenager.
And so, this is, again, because it's going to be hard to predict exactly which teens might experiment when and why, for parents to be having these really open conversations rather than treating this as a taboo topic that nobody talks about.
[Dr Mike Patrick]
Yeah, yeah. Really, really important. What is the role then of pediatricians?
And even though this is a podcast for parents, we do have a lot of medical providers who also listen in. It seems like there's so many pressures from different sides for pediatricians to address particular topics in the exam room, especially at well checkups. This is a really important one, though, isn't it?
I mean, we really ought to be talking to all of our teenagers about this issue.
[Dr Scott Hadland]
Yeah. You know, on the one hand, I completely understand. In addition to being an addiction treatment provider, I also have a primary care panel, and I know how much is asked of all of us to do in a short visit.
It's truly overwhelming. On the other hand, you know, we just finished saying that overdoses and poisonings have become the third leading cause of death in children. And so, it really behooves us to be talking about this.
The way that I think about it is I think about it as anticipatory guidance in the same way that I counsel my patients about wearing bike helmets or wearing seat belts when they're driving a car. I talk to them briefly about safety, and I will ask them, have you seen any pills? Are you hearing about people at school using pills?
What do you know about fentanyl? What do you know about how to respond to an overdose? And, you know, based on the responses that you get, you can then have a relatively brief, but I think highly informative conversation with a teenager and with family members too about safety.
[Dr Mike Patrick]
I love asking them questions and then engaging in a conversation. That just sounds so much more that they would be more receptive to that than a lecture. Like, now, are you seeing pills?
Don't do the pills. But, you know, asking, hey, what do you know about this really opens up the door for discussion. I love that.
Do you do that with the parents in or out of the room?
[Dr Scott Hadland]
I do a bit of both. It really depends on the particular patient who's in front of me. And so if a patient has disclosed to me that they're using substances or that this is going on and their parents don't know, then I have a thoughtful conversation with them where I lay all of this out and sort of like, you know, ask them what's going on and then give them targeted sort of safety counseling based on what they tell me.
Now, I will say, you know, we in the past typically have helped maintain teens' confidentiality and privacy if they are using things like cannabis and it's not causing a safety issue. We often will work primarily with the teen and not necessarily immediately disclose that to parents because that's not the standard of practice. The standard of practice is to keep teens' information confidential and safe and private.
I am working really hard now in this era in which, you know, just a single use of fentanyl can be deadly to really partner with teens to help them have that conversation with their parents and to offer to have that conversation with their parents for them if they don't feel comfortable with it because the goal is really for the entire family to understand about safety.
[Dr Mike Patrick]
Yeah, because you don't want to be in a situation where a kid overdoses and dies, and you had an opportunity to make an impact with their parent. At the same time, you don't want to create an issue at home where the child is scared or that, you know, there may be a parent with anger issues. And so again, that's another really fine line that we have to navigate.
[Dr Scott Hadland]
That's right. And some of what I try to do in my own practice is just trying to normalize these conversations so that families understand that it's not happening just specifically for their teen. You know, I will say to the teen in front of me if I'm alone with them or, you know, to the teen in front of me if they're with their parent, you know, we are living in a time right now in which overdoses are killing more teenagers than ever before.
As a standard part of my practice, I make sure that I talk to all teens and families about this stuff. Can I invite you into a conversation about this? Yeah.
[Dr Mike Patrick]
And we've really talked about the role of parents in preventing substance use disorder and also overdoses. Just I think the biggest one is having those open channels of communication, asking probing questions, being engaged and involved in your child's life. But that really does start early.
And I love the fact that, you know, you have little kids and you're like already having conversations so that then it's not a weird, unnatural feeling thing when they're teenagers. We talk about hard things all the time.
[Dr Scott Hadland]
Yeah, I think that's exactly right, is that there are developmentally appropriate ways to talk about these things at every age. And so, for my four-year-old and six-year-old at home, when they see me having a glass of wine and they say, hey, daddy, can I have a sip? I'll say, you know, this is actually something that's only meant for adults.
This is something called alcohol. I don't try to hide it and say this is daddy juice, right? Or, you know, I don't try to sort of brush it under the rug.
I will say very clearly, no, this is something that's only safe for adults to drink. And that's what age-appropriate conversations look like at that age. But at every age, there's sort of a different age-appropriate, sort of real talk way of talking about these things.
[Dr Mike Patrick]
So, communication, having Narcan at home, even if you don't suspect that your kids are experimenting, a lot of times you can't tell. And so just having that Narcan at home is going to be an important thing too.
[Dr Scott Hadland]
Right. And to be very clear, we are talking about the very end stages of substance use and addiction, right? This is kind of akin to if we just took everybody in America and waited until the moment that they had a heart attack rather than addressing the preceding diabetes and hypertension and other issues that we know lead to problems down the road.
When we talk about naloxone, it's the equivalent to talking about putting a stent in somebody who's already having a heart attack, right? The goal is actually to work much more upstream. So, what does that look like for parents?
Well, it's one step upstream. It's making sure that if your child has a mental health problem, that you're getting them connected, talk to your pediatrician, make sure that they're getting mental health support, which may include therapy or medications in some cases. Moving even more upstream from that, it's really loving your kid and having these open conversations and being available to them as a parent so that when each of these issues come up, whether it's mental health or substance use or whatever it may be, you're poised and ready.
Yeah. And then what's the role of schools in preventing these things? I think schools can play a lot of different roles.
Sometimes schools are the first people to identify that a teen's having a problem. And so, if there are any teachers or educators listening, I really encourage you to think about how you might ensure that young people who are struggling with substance use or mental health are getting connected to services in your context, how you're working with parents to help support that journey. I think schools often have an opportunity to, frankly, have NARCAN in them.
And so, some of the biggest school districts in the country, an example is the LA Unified School District, which is the second biggest in the country, have made sure that NARCAN is in every single school, including the younger ages. Yeah.
[Dr Mike Patrick]
And because you don't know what littler kids are going to come across. And of course, they're very impressionable. And even though you don't think about it, it does happen.
[Dr Scott Hadland]
That's right. And the last thing I would say is that drug prevention works. We have decades of data that when drug prevention is done in a high-quality way, it actually does reduce the rates at which young people experiment with substances.
It does prevent young people from going on to have more serious problems with substance use. And so, I would really encourage educators and folks in positions of power to implement programs and make sure that they're well-funded to understand that this is inexpensive, and it works.
[Dr Mike Patrick]
Yeah. And if those kinds of programs are not available in your school, you can always go to a school board meeting and raise awareness of the issue. Kind of be the squeaky wheel in your district to get something going.
[Dr Scott Hadland]
That's right. We talked earlier on about mixed messages that teens hear around substances, that they'll actually get some positive messaging around how substance use is helpful or good or natural or safe. It's actually really important that they get that counter-messaging, that they understand that substance use at any level is associated with poorer health outcomes.
Yeah.
[Dr Mike Patrick]
In addition to just wanting to feel good, there are medications that kids use that they think are going to help them concentrate or do better in school or there may be pressures on them to do well so they can get into a good college. And so, medicines like Adderall, there are counterfeit tablets of stimulants that can also be laced with fentanyl that we have to think about.
[Dr Scott Hadland]
That's right. Yes. There is actually a rising market of stimulant tablets, most commonly made to look like Adderall, that actually contain, in some cases, fentanyl.
In other cases, it actually may contain methamphetamine, which is an illicit stimulant, which is sort of the highly potent, cheap-to-import kind of or to manufacture version of a stimulant, kind of in the same way that fentanyl is incorporated into illicit tablets to kind of produce a sedating effect. Methamphetamine is producing a stimulant effect in these fake Adderall tablets. They're not nearly as widespread, but there's something to be aware of and another reminder of why any pill that a young person takes, you should make sure has been prescribed by a doctor and dispensed by a pharmacist and that you can confirm that.
[Dr Mike Patrick]
Yeah, for sure. So, you know, a lot of teenagers are taking stimulants for diagnosed ADHD. And so, parents, you know, may be wondering, could that lead to them trying other substances or could they become addicted to that stimulant medicine?
Or other parents may not even want their kids to take a stimulant medicine when they really do need it and could benefit from it. What do you say to those parents?
[Dr Scott Hadland]
It's a great question that comes up all the time in my practice and certainly medications to treat ADHD like Adderall can be misused and actually are commonly misused, particularly in college kids. I will say when a child or a teenager has a diagnosis of ADHD, a wealth of studies shows that actually their risk of having a problem with substance use or addiction down the road gets better when you treat them with a stimulant. And so actually it is better to make sure that that ADHD goes treated with a stimulant to prevent downstream addiction harms.
[Dr Mike Patrick]
That's right. And then what about communities as a whole? You know, we may have listeners who don't have any kids at all who are just interested in pediatrics.
We have a lot of trainees who are listening. How can we get involved in advocacy, legislative impact in our communities?
[Dr Scott Hadland]
There's a couple different ways. I mean, the world of addiction care and treatment has long been underfunded. It has long been siloed away from the rest of medicine, right?
I mean, you see this on TV all the time. A character in a TV show will struggle with addiction and what do they do? They go off to rehab, right?
That's the thing that they'll say. They went to rehab. Well, why is this separate from medical treatment, right?
We treat everything else in a doctor's office. Why don't we treat addiction in a doctor's office? A big part of that has been stigma, but then also funding that it is actually really quite time-consuming for physicians who want to do this work right to spend time with a teen and with a family to make sure that they get the attention that they need.
And this care goes underfunded. As somebody who leads a division at my hospital, I see the numbers and I know that it's actually more lucrative for a practice to see a bunch of children who have sore throats or runny noses or ear infections than it is to take the time to spend with a teen and family who's struggling with addiction. And so, ways that we can advocate are to improve funding and support for high-quality addiction treatment to support doctors to be able to do this work.
That's one really key thing. And then of course, prevention, making sure that it's available in schools and in other community settings to help prevent the onset of substance use and making sure that Narcan is available throughout communities.
[Dr Mike Patrick]
Really good points all around. Great conversation. So glad that you were able to stop by today.
We are going to have some resources in the show notes for folks who would like to learn more about the things we've been talking about over at pediacast.org. This is episode 570. And one of those articles, Dr. Hadland was actually senior author of called the Overdose Crisis Among U.S. Adolescents. And then another one in the journal Pediatrics, Anticipatory Guidance to Prevent Adolescent Overdoses. That's going to be really of interest to the providers in the crowd. And we'll have links to both of those articles in the show notes over at pediacast.org.
So once again, Dr. Scott Hadland, Chief of Adolescent Medicine at Mass General Hospital for Children and Associate Professor of Pediatrics at Harvard Medical School. Thank you so much for stopping by today. Thank you for having me.
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. And of course, thanks to our guest this week, Dr. Scott Hadland. Chief of Adolescent Medicine at Mass General Hospital for Children and Associate Professor of Pediatrics at Harvard Medical School. Don't forget, you can find us wherever you find your podcasts. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, YouTube, and most other podcast apps for iOS and Android.
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That stands for Continuing Medical Education. It is similar to this program. We do turn the science up a couple notches and offer free continuing medical education credit for those who listen.
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And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
