Season 5, Episode 2: Treating Opioid Use Disorder: Adolescent Focus

Season 5, episode 2 of the Just Us podcast places an emphasis on the treatment of substance use disorder in adolescents and young adults. Psychiatrist Leeallie Carter and family medicine physician Blake Fagan discuss the interactions between human biology, adverse childhood experiences, and substance use during this developmental period. The nuances of and barriers to adolescent SUD treatment are discussed in detail. Listen in to learn more!

Resources: 

• Substance Use Disorder Treatment Resources for Youth, Young Adults, and Families: https://opa.hhs.gov/adolescent-health/substance-use-adolescence 
• Resources to Address the Opioid Epidemic: https://www.aap.org/en/patient-care/substance-use-and-prevention/resources-to-address-the-opioid-epidemic/ 
• Substance Use Disorder Treatment Resources for Youth, Young Adults, and Families: https://www.samhsa.gov/substance-use/treatment/youth-and-families 

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Music credit: "Carefree" Kevin MacLeod (incompetech.com)
  Licensed under Creative Commons: By Attribution 4.0 License
http://creativecommons.org/licenses/by/4.0/ 

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Transcript

SPEAKER_00 0:03

Hello everyone and welcome to season five of our podcast, Just Us Before Birth and Beyond. This season is all about perinatal substance use disorders and highlights Project Cara, a perinatal substance use clinic at Mayhek, the Mountain Area Health Education Center in Asheville, North Carolina. Just Us is a podcast where we explore real stories, lived experiences, and lessons learned in the world of reproductive and community health across the life course. We are so incredibly grateful that you are here ready to learn with us. Let's get started.

SPEAKER_03 0:46

Hi everyone. Today I'm joined by Dr. Liali Carter and Dr. Blake Bacon for our episode on treating opioid use disorder with an adolescent focus. Do you both mind introducing yourselves?

SPEAKER_02 0:56

Sure. So my name is Liali Carter. I am a psychiatrist working at JFK EDACT in Black Mountain, which is also located in Western North Carolina. We're a facility here taking care of people needing inpatient withdrawal management as well as a dual diagnosis approach to mental health and substance use disorders. I completed medical school at the University of North Carolina in Chapel Hill, and then during that time became interested in treating addiction. I ended up staying out here in Western North Carolina for my residency training in psychiatry at Mayhek and spent my final year there in the Child and Adolescent Fellowship and was able to merge kind of my interests in supporting transition age youth and those struggling with substance use disorders. But Mayhek is also where I met you, Blake.

SPEAKER_05 2:00

And I'm Blake Bagan. I am a family physician. I've been at Mayhack, the Mountain Area Health Education Center here in Asheville, North Carolina for 27 years. So I went through the family medicine residency and then they hired me on and I had all the jobs and everything. But um I'd say about 12, 13 years ago, I got interested in helping patients that have substance use disorders and in particular OP use disorders, and have been writing a medicine called puberty for folks that come to us and have an OP use disorder and want to uh um help to stabilize that. And then as I'm doing that, because I'm a family doc, um I see pregnant women, I see infants, children, adolescents, adults, geriatrics. We found that there's this um place right in there around adolescents that they do experiment, they do start to misuse substances, and then some people um unfortunately develop into an opiate use disorder, the new term for opiate addiction. And um so I'm positioned in there where I feel comfortable taking care of adolescents and then helping them as they stabilize to transition into adulthood. With that, I think I'll pass it back to Lauren.

SPEAKER_03 3:26

Well, well, thank you both for joining us today. Um to get us started, do you and Dr. Figgin, you already kind of started doing this, but do you mind telling us a little bit about how adolescent development can impact someone's risk of substance use?

SPEAKER_05 3:41

You take this one out, the alley.

SPEAKER_02 3:43

I'm happy to. Um, yeah, so there are a lot of different um factors that it might even be helpful to just define the age range that we're talking about whenever we use a term like adolescent. So um the World Health Organization would put the lowest age number at that around 10. Um, another way of defining is when onset of puberty begins. Social roles are changing from child to adult expectations during that time period. And then if we're thinking from a neurodevelopmental perspective, we might put that upper limit of that adolescent age range at around 25 because that's whenever we're thinking about brain maturation. I don't know if you have a different thought on that age range and your practice.

SPEAKER_06 4:36

I think that's that's good.

SPEAKER_02 4:38

Yeah, so um, so that's a pretty broad range, but there's a lot that's happening during that time. Um so we can think about it kind of in in different aspects from a purely just biological um perspective. We can think about um the brain changes that are taking place uh during that period of time, and it's actually really active period of time, more similar to that early childhood development whenever the brain is going through different processes to take somebody to be an effective adult. So there are changes where kind of those neural pathways that will help somebody be effective in whatever their life looks like. So maybe taking a test or you know, moving through into adulthood into jobs. Um, the the brain is kind of deciding what is important for us to hold on to and um to myelinate so that our information is moving more quickly, and what is not as important, and that we could refer to as pruning. You think of it imagining like you're pruning your plants where you want to take away some of that um growth that's not necessary so that your plant can flourish. And so, similarly, there are a lot of brain processes happening during that age range that are taking that brain from a child into adulthood, and so what happens during those years really sets somebody up for brain health throughout their lifetime.

SPEAKER_03 6:31

That makes a lot of sense. So now if we start kind of thinking beyond some of these biological brain changes, how do you think life experiences, adverse childhood events, and environment might impact some of these changes and then also substance use in this population?

SPEAKER_02 6:50

Whatever experiences that youth is having during the time is kind of impacting the brain in the way, again, the brain isn't making judgments about what is a good experience or a bad experience, the brain is just responding to make a person more effective. And so if what that life looks like is um good rest at night, good nutrition, uh, emotionally supportive and stable home life and school environment, then um that is what that person's development is going to prepare them to be able to respond to. However, you brought up a really important thought, which is a lot of the youth that we're going to be seeing with substance use disorders are are coming in here after having fairly chaotic environments. Um, maybe that is bullying at school, or maybe that is housing insecurity at home, but the stresses that they're under during that time is going to actually increase risk. We know that as more studies come out just following adverse child events or ACEs, that as those add up, the risk for substance use and then in adulthood use disorders increases as well. And so the environment that that child is growing up in is either going to help prepare that them for being able to respond to how to avoid um difficult interactions that may be dangerous when they're in a school environment in which they're being harassed, or how to relax and um be able to get a good night's sleep. So some of it is just kind of common sense, but whenever we then look at kind of those developmental milestones of the adolescent period, we can we can even, I guess, get a little more specific there might be helpful. Um, so if we think about a developmental milestone of managing emotions, we expect that teenagers are going to have more intense emotional experiences than at other times in their life, and so part of that developmental work is how do I feel something intensely and then respond to it in healthy ways. And again, if we are um a child is in an environment in which they have adults who are able to be emotionally attuned and responsive to their needs, then what they're able to do is receive that type of support. However, if they're in a more neglected environment in which their family is having to work multiple jobs and they're kind of left on their own more often, or they're in a household where adults have limited capacity otherwise to be able to support them. Maybe they have their own substance use issues, then what is immediately available to feel better or to decrease that distress that they're experienced emotionally again increases substance use risk, especially whenever access to those substances increases.

SPEAKER_05 10:47

So I'm gonna riff off that. Thanks to the Alien, like just defining then um ACEs or adverse childhood uh experiences. So it there's about 10 points, and you hope that most people have a zero or maybe a one, um, but the reality is that a lot of people have ACE scores that are higher than that. And so, what is an adverse childhood experience? So if you um have a parent uh or or or a caregiver in your life that a child bonds to, and then that parent or caregiver leaves that child's life because of uh divorce, death, or going into jail, then you get a point. Um if you are as a child or physically abused, you get a point. If you're sexually abused, you get a point. If you see drug use in the home, um injection, drug release, et cetera, you you get a point, if that makes sense. So you can look this up if you haven't heard about cases, but the bottom line is that the higher your A-score, the more likely you are when you touch that first substance to then move on to having a substance use disorder. As a matter of fact, the data is that if students uh so we'll call it adolescents, as we're using that term, have five or more ACE scores, they're 15 times more likely than to report an opioid misuse with that first touch, even if it's uh prescription that's a legitimate prescription from a provider, um, and then much more likely to move on to an opiate use disorder, or again, a new term that's a new term for opiate addiction. Um, and so talking about bottom line, the bottom line is that we really want um kids to not touch substances until the brain is mature. Um and that's probably around 25. The earlier they are that they touch it, the more likely they are to have um misuse and then move on to use disorders. And if they have high A scores, as you heard, much more likely. So one of the things that Liale alluded to is how do we delay use then, or or maybe even prevent it. And one of the big things we talk about is trying to not have opiates in the home. Um, so if you are listening to this and you have kids or grandkids that are in your home, one of the number one things you can do is finish this uh podcast and then go through your house and get rid of the opiates that are in these uh oftentimes unlocked cabinets in people's homes because you had a toothpole and you have just two or three um of the oxycodone or hydrocodone left, or you had your knee replaced, or what have you, but you have these substances in your homes. And the data is very clear that if if the child has an um opiates that they're given and they're sitting in the house, they're more likely to misuse them, or they're friends, but then also family members. So if they're sitting in unlocked cabinets in in people's homes, that the children that are in the home or their friends that come over much more likely to misuse them. So delaying uh first use is super important.

SPEAKER_03 14:13

Cool. So it sounds like these ACORs are really important in being able to identify who's at a higher level of risk, but then also just like what's around in the environment can impact someone's risk of um getting a substance use disorder. But are these the substances that kids are or adolescents are starting with, or what substances are you seeing then actually use? And could you tell me a little bit more about the trend you're seeing among adolescents right now?

SPEAKER_02 14:43

Yeah, absolutely. And if I could first add in one more um kind of variability that factor that influences um kind of risk of use and use disorder, and that's kind of just genetic variability. And so you think about from one kid to the next, something like impulsivity, there is going to be a spectrum of just natural impulsivity across different people. And again, going back to what the like tasks of development for that age range, they include um seeking out new experiences. And so you think about what a kid has to go to. Leaving the home and going away to college is a huge risk. Telling the person that you have a crush on that you're interested in them is a huge risk, but those are the types of risk taking that can lead to um self-efficacy and building the kind of life that that carries that youth into an adulthood that is meaningful. And so we want that we as adults supporting them, we we want to see them taking risks. Um but also there are going to be um some youth who even just genetically have different risk factors, and so um uh another thing that is important to consider whenever we're looking at what youth may need some more intervention earlier on is to think about kids with ADHD or um even if you know, so there's somewhere on that spectrum. Uh so maybe their ability to kind of organize their tasks is challenged. Well, their ability to carry out that long-term decision making is also going to be limited, and so that again is they haven't had the life experiences of somebody that has kind of carried out these risky behaviors. Um, and so there's a lot of ways that we can, as adults in their lives, whether that's in a healthcare, a neighbor, family position, be having the types of conversations that will um neutrally explore with them how trying, like you just said, like how important it is for a the age of first use. So having those conversations in early adolescence. So we're talking like 12-year-olds who are first getting exposed to media about it, maybe driving down the road and seeing marketing or hearing friends who are experimenting. That's a really crucial time period for us to be um kind of neutrally providing education that maybe whenever they're 18, they're gonna be less likely to be responsive to um more of the negative risks associated with use. So earlier on having those conversations is really important, especially if you are working with youth that have um ADHD and some of those kind of baseline risk factors for it.

SPEAKER_03 18:22

What substances are you kind of seeing these adolescent populations initially start using? And then can you tell me a little bit more about the trends you're seeing among those populations right now?

SPEAKER_02 18:36

Um yeah, so a really positive thing that we've seen is that overall substance use in adolescents has continued to decline. And so there's a lot of encouraging information. Most of it comes from survey data from middle school and high schoolers. Alcohol, cannabis, and nicotine are still the three most common substances that youth are first experimenting with or using. And unfortunately, um while opioids, the kind of rate of use is really low, the risk of use is so high that while we've seen overall encouraging trends among substance use, we have not seen we've seen an increase in kind of mortality risk, or like the the risk that can come of overdose, specifically with opioids. And again, not even with youth who are specifically seeking out pain pills or seeking out fentanyl, or but maybe are seeking out something like MOLLE or ecstasy, MDMA, a pill that they would use um recreationally in a party scene. Um, but unfortunately, we've seen fentanyl get incorporated into a lot of different illicitly obtained synthetic um pills. So uh that is I I guess part of the reason that we're here today is because of the risk, whether intentional or not intentional.

SPEAKER_05 20:33

And I I would add, um we said it's kids will experiment, the experimentation has been going down, which is great. But the the facts are that 90% of adults that have a substance use disorder, be that an opi use disorder or cocaine use disorder, methamphetamine, but 90% of adults started using substances before 18. And 50% of them that have a substance use disorder as adults started using substances before 15. And so that's why um, again, we're emphasizing this kind of delay. Um kids are gonna experiment, adults are gonna experiment as well, but we we'd like it to be the uh on the later end of adolescence, or even if we can have it into adulthood, um we think that the brain as it matures is able to handle these uh better.

SPEAKER_03 21:34

So if we know that adolescents are using these substances and experimenting with them early and then can develop something like a substance use disorder, um what are the current legal and ethical frameworks around getting them care and what do prescribers need to know about prescribing for this population?

SPEAKER_02 21:56

Yeah, so it very much depends on what state you're in. In um so encourage any prescribers to be looking into the laws there. However, specifically whenever we're talking about our setting here in North Carolina, there are legal protections specifically for treating substance use disorders in minors. And so again, some of it depends on the setting that you're finding that person in, whether they are coming to you in your clinic, for example. We would talk to our youth who may disclose substance use kind of prior to ever having that conversation with them, having just a conversation about consent and about confidentiality related to what the adults in their life, their guardians or parents, are likely to find out versus um legally required. And so there's that fine line between there are actual legal protections that if there is a minor who is seeking out um treatment for opioid use disorder, that they do not legally require the consent of an adult to receive that. However, um working with adults in addiction, having a support system is crucial for them. So it's even more important for our youth to have those support systems. So whenever possible, engaging the families who are going to be the people day in and day out, often the people providing transportation and a lot of times also providing insurance or some other kinds of support where they will um are likely to find out at some point, anyways, and just trying to provide the type of support that youth may need to have those conversations.

SPEAKER_03 24:15

Anything you'd like to add, Dr. Pegan?

SPEAKER_05 24:18

No, I I think Liale said it. I the um on the one hand, um if you have a substance use disorder, let's say you're um using fentanyl and you want help, you can come and see us and we can take care of you. Um the caregivers' parents don't have to be involved. That's the legality of it. But then the reality of it, as Liale said, is that it's so important for somebody that's 16 or 17 to have a parent or a caregiver on this journey because it is really hard. Um and we need we need somebody in their life that cares about them and loves them, and they believe cares about them, loves them on this journey of recovery. And how do you get to your appointments? How do you get from your appointments to your pharmacy to pick up your med? Um, who's there to remind you to take your med? Because sometimes uh adolescents as well as adults have trouble with getting a new routine started. Um and then who's you know paying for it if you have health insurance? There's bills that are showing up at the house. So really we want to encourage um youth that are seeking help to have uh a parent along on this journey.

SPEAKER_03 25:42

Yeah, it makes a lot of sense to me that you'd need kind of that support from the entire family or at least a trusted caregiver to help these adolescents along their journey. Um can you tell me a little bit more about what this treatment looks like if you identify an adolescent patient with a use disorder?

SPEAKER_02 26:01

Absolutely. So specifically focusing in on opioid use disorder treatment, um there is fortunately a medication that's actually FDA approved, which often in pediatric populations we're um using off-label medication because most of the studies have been done with adults. Um, and so there's not always the same um kind of we don't always have FDA approval. And so it's really um encouraging that also not new that buprenorphine is a medication that um is highly effective for the treatment of opioid use disorder, and when we think about what the goals of that treatment would even be, it's really kind of going back to helping that young person meet the developmental milestones that we talked about at the beginning of the conversation. How do we help them instead of focus on when they can get the next source of their pain pills, um, that they're able to focus on schoolwork? And how do we help them not have the types of cravings and withdrawal symptoms that that really make it difficult to engage in any kind of normal functioning? And so um buprenorphine again is a medication that um any provider with a DEA license can prescribe. It is FDA approved, and there is strong evidence not only in adult but also youth populations for its efficacy. Anything you would add to buprenorphine treatment?

SPEAKER_05 27:54

Um whether they're an adolescent or they're an adult, this medication, buprenorphine, um, FDA approved again for substance use disorders, uh for an opiate use disorder, pardon me, uh 16 and above. Um this medicine is very safe. So if used correctly, which is typically under the tongue with a tablet or a film, um it has a negligible effect on cognition. So you can drive on this, you can work, you can go to school. Um and what it does is it takes care of two things, uh cravings and withdrawal. Um and if you get those taken care of, those are driven to zero or or almost zero, then whether you're an adolescent or adult, you can quote do life, you you can think about something else. Um so if I can just pause there for a second and say, you know, what is it like when you're 16 or 17 or 18 and you're using uh fentanyl? From the time that a person wakes up until they go to bed, they think about two things like how do I get my drug and how do I get my money to get my drug? Because they fear withdrawal, which is like um the flu times 10. So they they run out of their drug, fentanyl at some point, and not be able to get more of it. And they've gone into withdrawal, and like their eyes water, their nose waters, they start yawning, their muscles and joints start to ache, they get really agitated, they can't sleep, they get nausea, sometimes even vomiting and diarrhoea, and they fear that they they don't want it. Um, so you can imagine that that they spend so much of their mental energy trying to think about how do I get my drug. Okay, I know I I know where the drug is, but I don't have the money. How do I get my money? And that's what they think about all day. And this medicine, butenorphine, can really um, if detrated incorrectly, draw drive those two things, crap, and withdrawal to essentially uh zero. And then they can do light, and I and it's a very safe medication. If taken correctly, also it it doesn't affect respiration. So um you don't have to worry about quote overdosing or um having some adolescent have their respirations go down to zero. As a matter of fact, even if uh uh an adolescent or adult had a whole month's supply of the euthanorphine in their home and then put that whole month supply of that medicine under their tongue, they would not um experience uh respiratory depression and they they would they would live uh so to speak. So it it's really a safe medication. I I don't want people to be leery or fearful of it. It's so much better than being on um, let's say fentanyl, either smoking or injecting and and not knowing exactly what you're taking or how much it is. Um adolescents take a lot of risks and they're at a really, really high risk of overdose and overdose deaths if they're taking that med. So that was a lot of me riffing there, but I'm gonna pass it back to Liale to talk about uh the other med thing.

SPEAKER_02 31:21

Yeah, so um again, um buprenorphine is the medication for opioid use disorder that is FDA approved down to 16 with evidence um for efficacy down to age 13. And so it's really an individual decision with the provider, patient, and support system. Um, now trexone, and um specifically the formulation that is a once-a-month injection is also a highly effective medication that has FDA approval in 18 and over, um, but there is also some evidence for its use in the under 18 population. So, again, this medication offers um some difference. And so, one thing again is that it's formulation, it can be a once-a-month injection, and so for um those individuals who you know maybe what the environment they want or their family wants them to be in is a residential program where they are often not actually offering um the medication that we know saves lives, and so maybe they're not able to access buprenorphine for a variety of reasons, and but they would be able to obtain a once-a-month, once-a-month shot, which would um again provide protection from overdose death if they were to relapse, but also um treating cravings once they have had a period of kind of going through the withdrawal period from coming off of whatever opioid fentanyl that they were using, and so that is an important option to be discussing with people, and then um methadone is another medication that um kind of how the three different medications work is puprenorphine is um partially um is kind of acting at those same receptors, and um, so we can talk about kind of structurally some of the differences and the ways um the three medications. So we talked about puprenorphine, we talked about naltrexone and methadone being the other. So methadone is a full agonist, so working at those same receptors in the brain and um giving a more similar effect to um the opioid medication, but providing safety in that it lasts for a long time. So if somebody is using fentanyl, then they are on a constant roller coaster every few hours of intoxicating effects to withdrawal effects. Um, like Blake mentioned, there is a lot of variability in the supply as far as potency, uh, which is part of the reason that the supply itself is causing risk for overdose death unintentionally. And so again, methadone is helping protect against that, and it's a once-a-day dosing that has to be done in a clinic. Uh eventually they they can work it out where um what they call take-home doses, or um patients are not required to present every single day, but for the most part, in the beginning, that's what we talk about is somebody needing to be transported to a clinic where they're getting that medication once a day. Um then buprenorphine is a partial agonist, so again, working on those same receptors in the brain, um, but has what we refer to as a sealing effect, and so um the risks of it, like the respiratory depression, if somebody is intoxicated with um opioids like fentanyl, their brain is not sending the same signaling out for them to breathe, which is why we see overdose deaths. And so um buprenorphine is really safe in that even if somebody were to overtake it, the risk of an overdose death from that from respiratory depression is low. Um, also, if somebody were to relapse on fentanyl, then it is kind of more tightly connected to those receptors in the brain, and so fentanyl is not able to knock it off, and in that way it's again providing protection. Whereas naltrexone is different in that it's working on those same receptors but kind of blocking the opioid effects. And so I don't know if you would add anything to the description of those medication options.

SPEAKER_05 36:35

In summary, for 16 and 17-year-olds that are uh FDA approved again um for 16 and above, but uh but like Liale said, we couldn't we can use it for 13, 14, 15 as well. But um the easiest medication to use would be the buenorphine of the three. Yeah.

SPEAKER_03 36:58

So it sounds like there's a couple options that providers have to choose from and some pretty clear benefits to treatment if we can identify these patients. Um so but I have heard that a lot of providers aren't seeing a lot of adolescent patients reporting any substance use.

SPEAKER_05 37:16

Um, why do you guys think that might be if it's okay, I'll start and then pass it to Liale. Um so a doctor 27 years ended up seeing kids and adolescents during that whole time. And um I know I know and I know now that kids are experimenting with illicit substances and misusing them, and some of them have a use uh use disorder. Um, so why why aren't we seeing them? Why aren't they coming to see us? And uh um one is um I I don't think that they're comfortable coming to primary care and disclosing this. They're they're at an exam and their parent is with them. Um even if we ask the parent to step out of the room at say an adolescent exam, which we do, they they might be very fearful or scared. Hey, if I say something to this doctor, I don't know what the consequences are, I don't know what's gonna happen next. Um, another one is that the you feel like they until they have a major event, uh they think they've got it. Um, like, hey, I know I'm using, but it's only occasionally, and then after a while it's only once a day, and now blah, blah, blah. But you see where I'm going with it. And they have to have a major event, like they have an overdose and they're revived. Um, they wake up in the emergency department, um, they find out now they're pregnant, and now there's two on this journey. Something major has to happen before they will um seek help. And uh whatever's happening though, those are all speculation. Whatever's happening, I'm just not seeing them as much as the literature says they are out there. So, one of the things we've started doing is we've started screening better for it. Instead of in our exam, let's say an adolescent exam again with a 17-year-old, and saying, like, hey, you're not using illicit substances, are you? The answer to that's no, right? Um, we kind of creep into it. This is not based on data, but um, some of us believe that it's helpful is that you start off and you're in that adolescent exam and you ask a few questions, and then you get around to, hey, do any of your friends smoke or vape? Then we ask, hey, what do you think about that? And then we ask, hey, are you smoking or vaping? And then that's the entry into when you ask the next question, hey, are you using any uh illicit substances? Are any of your friends doing that? What do you think about it? Um then, hey, in the last six months to a year, have you used any medications, prescription medications in a in a non-therapeutic way? Like you uh crushed them up, you um snorted them, you smoke them, anything like that. But you see, you have to you have to get into the conversation with the the child the the adolescents uh somehow. And one of the entry points is we feel comfortable as dots asking about hey, do you smoke or vape? And they're a little bit more comfortable fielding that question, but you get the the conversation going before you just hit them like cold question, hey, are you using fentanyl? And the answer 99.9% of the time is going to be no to that question. Um I'm gonna pass it to you, Lielli.

SPEAKER_02 40:50

Yeah, no, I think the screening point is so important, we're not going to find out information that we're not asking and seeking out most of the time. And part of that is related to stigma, and so there is uh stigma about substance use, there is stigma about medication treatment for substance use, and so depending on um the area that you find yourself in, there are going to be um kind of different uh supports and barriers related to that, whether going to a doctor or going to a community member, a friend, the internet, uh, a religious leader, who are youth going to to seek out information. And I think that that's an opportunity that we have to kind of get out of our silos, which hopefully conversations like this do, and so that there is information available in school settings so that if a youth discloses to a teacher, that teacher is able to provide information. Um, if that youth discloses to a friend that there are opportunities for kind of culturally relevant treatment services. And um so I think that there's a lot of opportunity for us to we know that youth are not coming to us seeking treatment at the same rates that they are developing youth disorders that could benefit from treatment. So asking the questions, but also um getting creative about the ways we are sharing information and developing youth-centered programs where the the voice of the youth is the one who's you know designing and guiding us in how we are offering um these services is really important.

SPEAKER_03 43:09

That sounds great. So we've talked a little bit about like the evidence-based treatment and what medicines we can use, the logistics around prescribing them. And um, let's say you have a patient that comes in that needs you've identified through these screenings that you need that needs treatment. What do those next steps kind of look like and how do you start someone on one of these medicines?

SPEAKER_02 43:37

Again, it's kind of uh going back to understanding um what they're using and why. So, in youth specifically, again, a lot of times um, first exposure to fentanyl is not by somebody seeking out fentanyl, but seeking out some other substance, and then unintentionally getting exposed to it and I'm Unfortunately, it carries the risk of death with that unintentional exposure. And so it may be that somebody initially was seeking out a different um substance, but getting regularly exposed to it enough that they developed kind of um physiologic dependence and withdrawal symptoms if they didn't obtain it. So kind of again, just going through the questions about um just diagnostically, what um do they have a use disorder and how severe that is, and then their goals of treatment. Um we earlier talked about how there are very specific brain um changes that are taking place during those years where if we're talking to a um a 30-year-old that's at a different place, maybe we take a more harm reduction focus. Uh and with youth, there's a um kind of a responsibility for us to also consider that specific time frame. So where what are they using? Why are they using it? Are there ways in which we can help them use more safely, like having naloxone available at all times if them or somebody else were to overdose? Are there ways that we can get um buy-in from them about using less frequently? And then also offering again discussing what the different treatment options are and helping them navigate what those goals are.

SPEAKER_03 45:48

Anything to add, Dr. Bacon?

SPEAKER_06 45:50

No, no, that was good.

SPEAKER_03 45:53

Well, I think we're coming close to time. Um, does anyone have any final kind of ideas or thoughts they'd like to end with?

SPEAKER_05 46:03

I appreciate having this conversation. Thanks, Lauren, for having us on. Um, and I just would like to end with everyone out there that uh has kids in their house, or uh if if your aunt, uncle, grandparents, you have kids coming through the house, one of the things we all can do is clear out all the um medications like opiates so that there's less likelihood of the of the adolescents um getting those medications and starting into misuse and then unfortunately for us a percentage of them going on to a use disorder. And then um for folks that are taking care of patients, we hope that we just demystified, if that's the right word, that um can you treat a kid, an adolescent that has a substance use disorder? Yes. Can you treat them with buprenorphine? Yes. Uh North Carolina statutes that you can do that. Um and yet we really think that you should have uh a parent or a caregiver along on the journey because it's just such a hard thing to do as a 16, 17, 18-year-old by yourself. Um and I I I wanted to have those take-home points, but I'll pass it to you, Liale, to see if you have any final thoughts.

SPEAKER_02 47:36

Yeah, I mean, I think that those points are the takeaways that um in ways that are actually unique to treating opioid use disorder versus other substance use disorders, we have really effective medication to help not only prevent overdose death, but also to help kids get back into uh creating a meaningful life, repairing relationships, and so um to all the points you just said, it should definitely be something that we are um considering and offering for those who who are um meeting for a tier for opioid use disorder.

SPEAKER_03 48:31

Absolutely. Well, thank you both so much for joining us today and giving us so much valuable information on treating adolescent substance use disorder. We hope it gave our audience some good background knowledge, some tools to identify risk and start conversations and feel empowered to provide some evidence-based life-changing care. And thank you so much for listening. Thank you.

SPEAKER_04 48:55

Thanks. Hey all, this is Carrie Delfusco. I'm the medical director of office-based opioid treatment, or OBOT, here at Mayhack. As highlighted in our conversation, it's so important to know where to go for help. And at MayHec, we have unique tools that help us understand the where and what of healthcare resources across our 18 westernmost counties. This tool is called Find My Care WNC. It's an interactive map and dashboard for transitions, access, and continuity of care. ITAC for short. You've probably heard it called that before. So I highly encourage everyone to explore it. For example, you can find location information and relevant categories such as adolescent substance use disorder, where we've taken the time to confirm those locations offering buprenorphine to 16 and 17-year-olds. We also have things like wound care and harm reduction filters, amongst a variety of other options. This is a great user-friendly resource for people who are actively seeking out health care resources in our region. I'd also like to note there's a very cool feature where community members can request an ad, a delete, or an update of an entry, and the team will reconcile it. So, on that note, your lived experience and expertise as community members in our region really does matter. We invite you to help us make it the best it can be by sharing how to improve it and helping us keep the data up to date and relevant.

SPEAKER_00 50:15

Thank you for listening to this episode of our podcast, Just Us Before, Birth and Beyond. To explore past episodes, learn more about Project Cara, or find a list of resources that were discussed today, please view the episode description. Like, follow us, and share the knowledge with all your networks. You will also find a survey link at the bottom of the episode description. We care about your thoughts, so please let us know your feedback. We hope you enjoyed this episode, and please stay tuned for more.