Hi everyone, welcome to the review course. Today we're going to talk about three important topics, substance use disorders in pregnancy, neonatal abstinence, and adolescence. And I'm Dr. Marla Kushner, I am a past president of the AOAAM, and I'm so happy for all of you to be here and to get certified in addiction medicine. So we will go ahead and get started. I have nothing to disclose at this time. The objectives for this lecture are to understand the risk of substance abuse in pregnancy, the neonate and the adolescent, to develop an understanding of the prevalence of substances used and learn options available for treatment. Let's start with pregnancy and the prevalence. In 2020, 8-11% of pregnant women ages 15-44 used illicit drugs in the past month, marijuana being the most common. And the cause could be multifactorial, could be due to poor nutrition, extreme stress, violence, poor housing conditions, exposure to environmental toxins and diseases, and depression. This includes all races, all ethnicities, all socioeconomic levels, and there's much more stigma associated with substance use disorders in pregnant women than non-pregnant women. And it may be very difficult for pregnant women to stop using substances depending on the severity of their use, the fear of symptoms of withdrawal, and there's a lot of stigma related to being identified as using substances during pregnancy. Screening in pregnancy for substance use disorder is extremely important. If you use screening, brief intervention, and referral to treatment or SBIRT, that can be very effective. There's a combination of screening questionnaires and urine drug testing is what's the most recommended. And pregnant women should be screened on the first visit and every trimester for substance use disorder. Three screening tests that we recommend for substance use disorder in pregnancy are the T-ACE, the TWEAK, and the AUDIT-C, and I want to go over each of them with you. First the screening T-ACE. The T stands for tolerance. How many drinks does it take to make you feel high? A for annoyed. Have people annoyed you by criticizing your drinking? C, cut down. Have you ever felt you ought to cut down on your drinking? And E, eye opener. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? For the A, C, and E, those are equal to one point each. The T, if greater than two, is equal to two points. So two or more in this screener is a positive and should be referred for further assessment. The next screener is the TWEAK. The T, again, stands for tolerance. How many drinks can you hold? A positive answer would be greater than or equal to six. Or how many drinks does it take before you begin to feel the first effects of alcohol? And a positive answer would be greater than or equal to three. Q for worry. Have close friends or relatives worried or complained about your drinking in the past year? E is an eye opener. Do you sometimes take a drink in the morning when you first get up? A is for amnesia. Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? And K, in quotes, cut down. Do you sometimes feel the need to cut down on your drinking? If there's a positive E, A, or K, each of those are equal to one point. A positive W and a T would be equal to two points each. And the cutoff is two points. So greater than two should be referred for further assessment. And finally, the screening audit C, which stands for alcohol use disorders identification test, concise. How often do you have a drink containing alcohol? Number would be zero. Monthly or less than one would be equal to one. Two to four times a month equals two. Two to three times a week would be three. Or four or greater a week is equal to four. And how many drinks containing alcohol do you have on a typical day when you're drinking? One to two is zero. Three to four is one. Five to six equals two. Seven to nine equals three. And ten or greater equals four. How often do you have six or more drinks on one occasion? Never is equal to zero. Monthly one. Bimonthly two. Weekly three. Daily four. And greater than equal to three would be what we would look at for risk and need further assessment. Lab testing can be helpful in pregnancy. You can look at infant urine. The meconium, which forms at 13 to 14 weeks gestation, there's a long window of exposure beginning in the second trimester. You can use cord tissue, which is used to test for in utero exposure. And then of course the maternal urine. One of the biggest concerns of using substances during pregnancy is the risk for teratogenicity. Tobacco alone, in combination with other substances, are known to have the most potential to cause teratogenicity in the human. For example, fetal alcohol syndrome. And in the first trimester, you can see significant problems, including pregnancy loss. Looking at specific drugs and what they can do during pregnancy, let's start with tobacco. And tobacco is including electronic cigarettes as well as regular cigarettes. It's strongly advised to quit smoking during pregnancy. Nicotine replacement hasn't really been found successful in pregnancy. And varincycline or Shantex can have limited safety data. With bupropion, there's no significant improvement in abstinence rates. There's been shown to be an inverse relationship between birth weight of the baby and the number of cigarettes smoked per day. So brief office-based intervention and treatment programs work for pregnant women. Now let's talk about alcohol and sedatives. Greater than 60% of women who use alcohol are able to quit during pregnancy. It may be hard to recognize early withdrawal versus normal physiologic changes of pregnancy. So that's really important to be able to distinguish that, asking the questionnaires, talking with the patients, maybe using urine drug testing early on to identify which is happening. Uncontrolled withdrawal may be life-threatening to the mom and the fetus. And it's important to note that treatment for acute withdrawal from alcohol or sedatives in pregnancy should be inpatient with an OB-N consultation. For opioids, rarely should we give naloxone or Narcan to pregnant women, except as a last resort. Precipitated withdrawal can result in spontaneous abortion, premature labor, or stillbirth. And opioid withdrawal syndrome during pregnancy can lead to fetal distress and premature labor. As we know, opioid withdrawal in an adult rarely leads to severe consequences such as death, but can lead to very uncomfortable situation. But with the fetus, it can cause fetal distress and premature labor. And medically-assisted withdrawal is not recommended due to the high rate of relapse for opioids. One of the newer drugs out, xylosine, is a non-opioid sedative or tranquilizer. It's not approved for use in people. It's frequently used to enhance the effects of fentanyl. And xylosine decreases maternal and fetal pulse rate and decreases uterine blood flow while increasing the uterine artery resistance index. Let's talk specifically about opioids. So the use of methadone or buprenorphine can improve the maternal health and nutrition. It can reduce obstetric complications. It decreases the disruption of the maternal child diet. And it enhances the woman's ability to participate in prenatal care and substance use disorder treatment. The two drugs that we use are methadone and buprenorphine, and we'll start with methadone. The maternal dose does not always correlate with the neonatal abstinence syndrome. So if the mother's on a higher dose, that doesn't necessarily mean that the baby's going to experience neonatal abstinence syndrome, and we'll discuss more of that later on. The dose of the methadone may need to be increased during the second and third trimester due to larger plasma volume, decreased plasma protein binding, and increased tissue binding, and increased methadone metabolism and clearance. And buprenorphine, there's a similar incidence of neonatal abstinence syndrome as methadone, but it requires less medication to treat, and there's a shorter duration of treatment. The onset of the neonatal abstinence syndrome may be a little later, but it is within the four days of the hospital stay. If we look at the effects of cannabis in pregnancy, we look at the most common delta-9 tetrahydrocannabinol. It easily crosses the placenta, and the fetus is exposed to this as well as carbon monoxide from smoking cannabis. Fetal growth restriction, when a baby doesn't gain the appropriate amount of weight before birth, there's a greater risk of stillbirth. Preterm birth, so being born before 37 weeks of gestation, there could be low birth weight, and long-term brain development issues affecting memory, learning, and behavior. Stimulants can cause preterm labor. They can cause premature rupture of the membranes, placental abruption, intrauterine growth retardation, and genitourinary, cardiac, and limb abnormalities. What are some options? Well, for treatment, more effective when begun during rather than after pregnancy. So it's really important to talk to the pregnant women when they first begin pregnant if you identify their substance use or substance use disorder, and begin treatment during the pregnancy. One of the medications, disulfiram, is contraindicated and can lead to specific birth defects. We do recommend methadone and buprenorphine. There are some concerns with labor and delivery. There's concerns about possibly relapsing near the end of pregnancy. So early signs of labor could be confused with withdrawal, and again, being able to distinguish those is very important. We assure that there's going to be access to adequate analgesia, and this may be regional analgesia for the patient. Pain medication should not be withheld based on the history of substance use disorder. It's very important that we help manage the pain for pregnant women and go over all the different options for when they're in labor, including non-medical options. Breastfeeding is okay if negative for HIV. It's okay if Hep B and Hep C are positive if the nipple area is not cracked or bleeding, so there's no access. Okay with methadone and buprenorphine, and it's discouraged if on benzodiazepines, cocaine, or cannabis. Legal issues that we should think about, lab screening should not be done without the patient's permission. So you need to let them know that you're going to be checking the urine drug screen, how often you're going to be checking it, what you're looking for, and positive toxicology will probably need an evaluation from Child Protective Services. Some frequent questions and suggestions regarding pregnancy and substance use that I get often, what are the patients already on buprenorphine naloxone product and they find out they're pregnant? What are the next steps? And I've had a number of women in my practice that are on buprenorphine naloxone products, find out they're pregnant and want to know what's the next step. The first question is, should they stop? And you want them to continue on the same dosage of buprenorphine naloxone. There's no need to change to the monoproduct. Education on what might happen if they start to wean off or stop, and that's very, very important. So going over the risks to themselves and to the fetus and explaining to them that when they go through withdrawal, it's usually not life-threatening, but it could be to the fetus. Discuss the possible need for an increase later in pregnancy and obtain a release of information for the OB as soon as possible and connect. This again is extremely important. I've run into OBs who really understand buprenorphine naloxone and patients who have been treated for substance use disorder and are on these medications. And I've also run into OBs who have no idea what the medication is, how to monitor it, and have actually asked patients to get off of it during their pregnancy. So it's important to talk to the OB, find out what their understanding is of substance use disorder and these medications, and to have regular contact with them and getting the patient involved with this as well. I also encourage the patient to plan on touring the delivery area and speaking with the charge nurse or the people that are going to be there when she has the baby. Having a birth plan. What does she want to happen when she gets to the hospital? Really making sure that, and this is with the help of the OB as well, that the nursing staff and the people who are in labor and delivery understand what needs to happen when she comes in, that what this medication is doing for her. Can I breastfeed? Well, we just talked about that. If they're negative for HIV, again, it's okay if Hep B and Hep C are positive if the nipple area is not cracked or bleeding. It's okay with methadone and buprenorphine, and discouraged if they're on benzodiazepines, cocaine, or cannabis. Remember, when the babies are drinking the breast milk, it's guzzled pretty quickly. There's not a lot of buprenorphine that's going to be sitting around sublingually to be absorbed, and there's not a lot in the breast milk anyway. And naloxone is not detected in the breast milk. Very small amount of buprenorphine. What about long-acting naltrexone and long-acting buprenorphine if patients are on those medications and find out that they're pregnant? So as of right now, they're not FDA approved. Again, in my practice, I have had patients who have been on both, and the first thing that I want to do is reach out to their OB and discuss this with them and what they would like the patient to do when they're on this medication. I've had some OBs that say, yes, you can continue this, and we're going to monitor them closely. I've had others who have asked to change over to the oral form of the medication. I want to talk about one case that I had that was really interesting because it involved the same patient with two pregnancies, two years apart with the same OB, but very, very different experiences. So for her first pregnancy, and this patient of mine had been struggling with opiate use disorder for years, and to the point where she would come to my office, and one time she was on her way with her mom and stopped in a gas station and actually overdosed in a gas station bathroom on her way to my office. So really struggled with substance use disorder and opiate use disorder. At one point, we were able to get her on long-acting naltrexone, and she was in my office to get her injection, and we did a pregnancy test, and it was positive because she thought she might be. And we went over the risks and benefits of staying on the medication. We were going to talk with her OB, and she said she refused to stay on the medication because she didn't know what would happen to the fetus. And she was at that time very stable, living in a sober living, going to meetings, had a sponsor, and felt very positive about her recovery. Well, what happened about 30 days later, she started to have cravings and ended up relapsing on heroin. And it took about a month to get her back into treatment and back on oral buprenorphine naloxone. And for the rest of the pregnancy, she was extremely stable and did all the things that she needed to do to stay in recovery, went to her OB visits, kept her visits with me, did really, really well. And then she went into labor and went into the hospital. and immediately after she had the baby, even though she said that everything was fine, she wanted to keep the baby with her, they took the baby away immediately. They started the baby on morphine and ended up, the baby was in the hospital for 30 days and she would go visit every single day. She'd stay there as often as she could, but felt extremely stigmatized when she was there. And it probably was something that could have been avoided. The baby had no serious signs of neonatal abstinence syndrome, it was just something that they routinely did at this hospital. So then she got pregnant for a second time, two years later, and we were discussing if she was gonna go to the same hospital, use the same OB, she really liked her OB doctor, we connected with the OB doctor and said, hey, we have to make this a different experience for this woman because that was very traumatizing and stigmatizing. And so we spent more time talking with the OB, talking with the nursing staff at the hospital, and this was a completely different experience for the patient. She went in, she gave birth, normal vaginal delivery, had skin-to-skin contact with the baby, and was able to go home within four days and everything has been fine. So again, it's very, very important to make sure that everybody in the whole process understands what's going on with patients who are on these medications, and that there is a birth plan, and that even though the OB may really have a good understanding, it's important that the hospital, the delivery area knows as well. All right, so now let's talk about neonatal abstinence syndrome. What's the definition for neonatal abstinence syndrome? It's a spectrum of clinical manifestations that are seen in neonates due to withdrawal from intrauterine drug exposure. And we most commonly associate this with opioid use. The symptoms that can be associated with it could be autonomic, which is a type of a drug that is used to induce a drug-induced seizure, and the symptoms associated with it could be autonomic instability, central nervous system irritability, feeding difficulties, poor weight gain, instability in vital signs, hyperactivity, irritability, hyper or hypotonia, difficulty sucking or excessive sucking, sleep disturbances, or high-pitched cries. And the duration and severity of intoxication or withdrawal depend on the time of the last drug exposure, the combination of substances, how the drug is metabolized, and was the baby full-term or premature? And when substance use is under consideration, the newborn should have a regular assessment for withdrawal or intoxication beginning at birth. The treatment for neonatal abstinence syndrome really depends on the drug involved. The initial treatment should be primarily supportive, so gently rocking the child, reducing noise and lights, skin-to-skin care with mom or swaddling the baby in a blanket, and breastfeeding if the mother is on methadone or buprenorphine treatment program without other illicit drugs. The indications for pharmacotherapy are seizures, or feeding, diarrhea, vomiting resulting in dehydration or excessive weight loss, the inability to sleep, significant autonomic instability with bradycardia or tachycardia, apnea or tachypnea, temperature change not due to an infection, if they're too ill to assess possible signs of withdrawal, and if there's a comorbid medical problem that would dictate that the infant won't tolerate neonatal abstinence syndrome or if they're not eating well or not thriving. It's important to look at the differential diagnosis. It could be sepsis, it could be hypoglycemia, perinatal anoxia, intracranial bleeding, and hyperthyroidism. Follow-up is extremely important for babies that have neonatal abstinence syndrome. The neonates with intrauterine drug exposure should be followed up within the hospital for at least 72 to 96 hours after birth. If they're discharged prior to that, the mother and her support system need to be informed of signs of neonatal abstinence syndrome and seek treatment as soon as possible if that occurs. Infants exposed to tobacco can become more excitable. They can have hypertonic with indications of disturbances in that CNS, GI, and visual response. A third of sudden infant death syndrome may be prevented with smoking cessation during pregnancy. In prenatal alcohol exposure, there is no known safe amount of alcohol to consume while pregnant. Alcohol is found in significant levels in the amniotic fluid, even after a single moderate dose, and fetal alcohol syndrome is a spectrum of structural anomalies and neurocognitive disabilities. Wanted to talk about it for a minute because it's so important. It's a permanent condition. Any alcohol use in pregnancy can cause this. And symptoms that infants with fetal alcohol syndrome could experience include abnormal facial features, including a smooth ridge between the nose and upper lip, a thin upper lip, and small eyes. Low body weight, short height, sleep and sucking difficulties, small head size, and vision and hearing problems. Neonatal opioid withdrawal syndrome occurs in 60 to 80% of infants with intrauterine exposure to heroin or prescription opioids. This includes methadone and buprenorphine. There's no evidence of teratogenicity of opioids. The most common ill effect is post-uterine growth restriction. And the most common complication is neonatal abstinence syndrome. A study that was done to help measure neonatal abstinence syndrome was the MOTHER study, the Maternal Opioid Treatment Human Experimental Research. And this was a modified Finnegan scale, which evaluated the infants at two hours after birth, then every four hours. Pharmacotherapy was started with a score greater than nine for two consecutive evaluations, or greater than 13 on one, until the score remained less than eight for 48 hours. If treated with morphine or methadone, it may decrease the time to regain birth weight, but it will increase the length of stay in the hospital. What happens with cannabis in pregnancy? While there could be neurodevelopment deficits in children prenatally exposed, there could be small reduction in fetal growth, an increased risk of stillbirth, impaired regulatory control, which could cause irritability, tremors, sleep disturbances, behavioral problems, decreased attention and visual motor disturbances. With stimulus, there could be irritability with feeding and quieting. Cocaine is concentrated in the amniotic fluid, and this leads to neurologic development and behavioral deficiencies when exposed prenatally. And methamphetamine leads to small for gestational age, and they're also at risk for neurodevelopmental abnormalities. So to summarize neonatal abstinence syndrome, it occurs in newborns exposed to addictive drugs in utero, typically opioids. Symptoms may include tremors, irritability, poor feeding and respiratory problems. And it requires careful monitoring and may require pharmacologic treatment to manage withdrawal. And the long-term effects may vary depending on the severity of exposure and treatment provided. All right, let's move on to adolescent substance use disorder. What is the prevalence? Well, adolescent onset of drug use greatly increases the risk for developing a substance use disorder later in life. The earlier the onset, the greater the risk later in life. And the Monitoring the Future study of 2022, which is a study that's been ongoing for many years through the University of Michigan and the National Institute of Drug Abuse funded by the NIH, looks at use of high school students 8th, 10th and 12th graders, current use, past year use and what their attitude is towards drug use. And in 2022, marijuana use in the United States the most frequent illicit substance of use, increased daily use among 8th and 10th graders, doubling in the number of kids vaping marijuana in the past year and vaping of nicotine is increased, tobacco use is at a low. Other drug use is going down. There's been a dramatic decrease in opioids and alcohol including binge drinking is going down. I wanted to read this quote by Dr. Nora Volkow who's the director of NIDA because I think it's really significant. She says, because marijuana impairs short-term memory and judgment and distorts perception, it can impair performance in school or at work and make it dangerous to drive. It also affects brain systems that are still maturing through young adulthood. So regular use by teens may have negative and long lasting effects on their cognitive development, putting them at a competitive disadvantage and possibly interfering with their wellbeing in other ways. Also, contrary to popular belief, marijuana can be addictive and its use during adolescence may make other forms of problem use or addiction more likely whether smoking or otherwise consuming marijuana has therapeutic benefits that outweigh its health risks is still an open question that science has not resolved. Although many states now permit dispensing marijuana for medicinal purposes and there is mounting anecdotal evidence for the efficacy of marijuana derived compounds, the US Food and Drug Administration has not approved medical marijuana. However, safe medicines based on cannabinoid chemicals derived from the marijuana plant have been available for decades and more are being developed. And another note on the National Institute of Drug Abuse, they have a fabulous website that has information for teens that you can share, teens can access it, or you can get information on the different drugs that teens are exposed to. There's activities that teens can do to educate themselves on drugs, but it's really very, very informative. Want to talk a little about Delta-8-THC. So Delta or Delta-8-THC, Delta-8 is a cannabinoid compound that can produce a high like marijuana. The Delta-8 stands for Delta-8-THC, which is chemically a close cousin of Delta-9-THC, the principal psychoactive compound of marijuana. And the purchase of Delta-8 products typically has no age restriction. So teens can have easy access to it. Most Delta-8 is derived from hemp, a variety of the cannabis plant, but there's no conclusive evidence that it's safer than marijuana. And 11% of 12th grade students across the United States have used this in the past year, according to the Monitoring the Future study. Confidentiality is one of the most important things when working with adolescents. So it's very important to familiarize yourself with the confidentiality laws in your state. Also familiarizing yourself with the controlled substance laws and how that pertains to adolescents. And I like to review confidentiality with the patient and the parents in the room initially if possible. So in many states, adolescents over the age of 12 can seek substance abuse treatment without their parents present. And if they do, then you wanna go over it with the adolescent individually. But if they do come with their parents or responsible adult, going over that with them, letting them know that you are not going to tell their parent any of the confidential information unless they agree to it, or unless they state that they're gonna harm themselves or someone else. The adolescent brain is an interesting thing. The adolescent brain develops well into the 20s. And during adolescent, if a youth is either habitually or binge using drugs, they greatly increase the probability that they'll have an addiction when they become adults. And for some, their addiction will begin at the age of first use. A study out of Harvard, Massachusetts General Hospital and Northwestern University Medicine looked at a casual use of marijuana. So as little as once or twice a week and as frequent as four times a week. It showed major brain abnormalities. The more they smoke, the greater the abnormalities. And adolescents are especially vulnerable to mental health disorders associated with cannabis. The younger the age of initiation, the greater the increase in development of mental health disorders. And I find this really interesting. I train pediatric residents often. And when they come to the office, they're like, well, why do I wanna talk to somebody who's a young adult, who's 25 or 26 in my practice? And I'll say, talk to them, ask them when they started to use. And it's really interesting because when they do, they will say they started to use around 12, 13, 14, 15 years old. And it may not have become a dependency at that age, but that's when they first start. We may not be seeing them until they're into their 20s. The other question that I like the pediatric residents to ask is, ask them if they started when they were a teenager, did anybody ever ask them about it? Did they have any screening tests? Did their pediatrician ask if there was a family history or ask if they were using drugs or alcohol? And most of them will say no. So it's a really good lesson that we need to be addressing this in adolescents and starting age appropriately early as we can. So the adolescent brain, again, it's particularly vulnerable to the addictive potential of cannabis and other drugs. It's a critical period for maturation of the prefrontal cortex and neural networks involved in the prefrontal cortex. So executive cognitive functions, such as attention control, impulse inhibition, working memory, and risk benefit appraisal. And exposure could interfere with development of these abilities potentially with lifelong effects. And we all know that adolescents take risks in general. So if they're having trouble looking at the risk benefit appraisal because of added substance use, it's gonna make that even more of a concern. There are three screening tests that we recommend for screening adolescents for substance use disorder. And remember, these are screeners because someone is positive with one of these screeners does not mean they have substance use disorders. It means that it needs to be sent. They need to be sent for further assessment. And before you begin doing the screeners, decide how the screening result will be used. What are you gonna do if the test is positive? What are you gonna do if the test is negative? And you wanna apply existing office practice to screening practices. What do you do for other screeners, for depression, for asthma, for any other issues? You wanna meet with the adolescent alone. You wanna let the parents know at some point in the visit, you wanna let the parents know, reassure them, this is a standard procedure. We do this with all adolescents starting at age 12. And to the youth that this is your private treatment, again, going over the confidentiality, rules with them, letting them know when you would reach out to the adult and when you are not able to. You wanna establish a tone free of judgment or confrontation, and this will eliminate barriers to confidentiality. The first test is the CRAFT interview version 2.1. And there's two parts, part A and part B. In part A, you wanna see during the past 12 months and how many days did you, one, drink more than a few sips of beer, wine, any alcoholic drink. Two, use any marijuana product or synthetic marijuana or THC products, including weed, oil, smoking, vaping, edibles, K2, spice. Three, use anything else to get high, other illicit drugs, over-the-counter or prescription medications, things that can be sniffed, huffed or vaped. And part B, first you wanna see, did the patient answer zero for all the questions in part A? If they answered yes, you only need to ask the CRA. If they answered no, then you wanna ask the full CRAFT. And the C is, have you ever, have you been in a car driven by someone, including yourself, who is high or under the influence of drugs or alcohol? The R, do you ever use drugs or alcohol to relax, feel better about yourself or to fit in? A, do you ever use drugs or alcohol when you're by yourself or alone? F, do you ever forget things while you're using drugs or alcohol? The next F, do your friends or family ever tell you that you should cut down on your drinking or drug use? And T, have you ever gotten in trouble while using drugs or alcohol? So any positive part of this test, any positive answer would be a point. Anything greater than two points, you would want to refer for further assessment. The next test is the BSTAD, the Brief Screener Tobacco Alcohol Drugs. This is a single frequency question for the past year, asked about three substances most used by the adolescents, 12 to 17 years old. And the responses are categorized into levels of risk. So for alcohol, if they've used two or more days, the rate of substance use disorder in a primary clinic would be 4%. For marijuana, again, two days, it would be 11% for rate of use of disorder in primary care clinic. And for tobacco, six or more days per year would be a 5% rate of use of disorder in primary care clinic. And the third screener is the S2BI, which is Screen to Brief Intervention. A single frequency question for the patient's years of use of the three most used substances in adolescence. A positive response prompts further questions about types of substances used. For each substance, responses can be categorized by risk, high sensitivity and specificity for severity, and it provides a range. So if they say there's no use, then there's no criteria from the DSM-5 for substance use disorder. Frequency of use is once or twice. There is use without a disorder, it's low risk. Monthly use, it could be mild, two to three criteria. Moderate, four to five criteria. High risk, weekly or more, severe use disorder. Next thing that I would like to look at is the Contract for Life. And this was started by Students Against Drunk Driving. And it's a contract, Foundation for Trust and Caring, that is given between the young person and the parent. And it's designed to facilitate communication between young people and their parents about potential destructive decisions related to alcohol, drugs, peer pressure and behavior. The issues facing young people today are often too difficult for them to address alone. And SADD believes that effective parent-child communication is critically important to helping young adults to make healthy decisions. So for the young person, what they're going to sign is something saying that I recognize there's many potentially destructive decisions I face every day and commit to you that I will do everything in my power to avoid making decisions that will jeopardize my health, my safety and overall well-being. Or you're trusting me. I understand the dangers associated with the use of alcohol and drugs and the destructive behaviors often associated with impairment. By signing below, I pledge my best effort to remain from alcohol and drugs. I agree that I will never drive under the influence. I agree that I will never ride with an impaired driver. And I agree that I will always wear a seatbelt. Finally, I agree to call you if I'm ever in a situation that threatens my safety and to communicate with you regularly about issues of importance to both of us. And then the parent or the responsible caregiver also has to sign. So they're committed to you and to your health and safety. By signing below, I pledge to do everything in my power to understand and communicate with you about the many different difficult and potentially destructive decisions you face. Further, I agree to provide you safe, sober transportation home if you are ever in a situation that threatens your safety and to defer discussion about the situation at a time when we can both have a discussion in a calm and caring manner. I also pledge to you that I will not drive under the influence of alcohol or drugs. And I will always seek safe, sober transportation home. And I will always wear a seatbelt. So I like that the young person is signing it, the parents agreeing to help in that difficult situation, and the parent is also agreeing not to put themselves in that situation. So the substances that adolescents use can be inhalants, nicotine, alcohol, cannabis, stimulants, opioids, and there's always something new. Some signs that you can see of adolescent substance use, changes in their personality. Their grades are dropping, loss of interest in usual formal activities, emotional or behavioral instability. They start to get secretive or lying, using friends, and where there's smoke, look for fire. The risk is real despite cultural minimization. So the progression from experimentation to impairment and use disorder, it's really important to be able to differentiate that. Exposure to progressive deviant peer groups. So everyone's doing it. You may hear that from the adolescent. When we know from all the research that everyone is not doing it, and we need to talk with them about that and reassure them of that. And levels of use seen by teens as normal can be associated with academic decline, falling off the growth curve of psychosocial functioning, and psychiatric morbidity. So we can see worsening depression and anxiety over time. Although rare, psychosis rates doubled with marijuana use. One in five people between 13 and 18 years have had seriously debilitating mental disorders. And how do you ascertain the severity? How bad is it? You know, any of these indicators suggest referral to an addiction specialist. If there's regular use, antisocial behaviors, major health effects, major consequences, social role impairment, and progressive use of substances such as opioids. Brief intervention and motivational interviewing really make a difference. We want to look at what are their pros and cons of use? Why are they telling you that you're using? Again, ask nonjudgmental, open-ended questions. What are the adolescent's view of impact and risk? Again, that's something that the Monitoring the Future study looks at. Their perceived risk of using drugs like marijuana has gone way down because it's become legal in many states. There's medical marijuana. So they feel that using it is a very low risk. Connect to personal concerns and goals. What are some of the consequences that they have already experienced? Have they noticed that their grades are dropping? Have they noticed that they haven't been able to participate in sports the way they want to? Has their friend group changed? And what's the discrepancy between behaviors and personal goals that they have? They want to go to college. They want to participate in college sports or academic teams, and they may not be able to because of their use. Urine drug testing is extremely important. You want to normalize this as part of routine testing. For example, when a teen comes into your office, you may routinely do a urinalysis. You may routinely do a blood test. You're doing their vital signs. You want to normalize this as part of what you do as a routine. And recognize it is an inflection point. They're going to say, well, why are you doing this? Who's going to know? What are you looking for? You want to medicalize the conversation around it. So you're going to talk about it as a urine drug test, not a drop. The results that you get are going to be positive or negative or expected or unexpected, not dirty or clean. Practicing your narrative around it is so important. And it's also really important that your staff buys into this as well. So that when your medical assistant or your other staff members are helping you with this, that they're speaking the same as you are. Talking with the parents can be really tricky territory, depending. You know, confidentiality, variables in different states, family culture. Remember, families come in all shapes and sizes. Family history can be very instructive. If you know that one or both of the parents are in recovery or actively using, or there's a sibling that's using drugs or alcohol or in recovery, grandparents. Education-only school programs are largely ineffective. Parental attitude and influence, that matters. When we see the commercials that, you know, parents are the anti-drug, there is definitely truth to that. Parental attitudes make a difference. Some parents will minimize the impairment. They're over-permissive. Oh, it's only alcohol. Oh, they only drink in my house. They're not going to get in a car. And some parents will be an alarmist. They're punitive, over-intrusive, even with maybe a first experimentation with drugs or alcohol. And we want to talk about the change in marijuana's potency. So kids now believe that marijuana is safe due to it being recognized as a legal substance and a prescribed medicine. Many parents also believe this and believe that marijuana is not a problem due to their personal use decades ago. But remember, the potency of the parents' marijuana of the 70s to 2000s is minuscule in comparison to the potency of THC now. How do we communicate with the teens? What are some ways to talk about it? Well, letting them know this is your private treatment. It stays between us unless I'm concerned about your health and safety. I can't help if I don't know the whole story. We may want to bring your parents in, do it together. I'll run interference. They'll find out anyway, and it's better coming for you. Medical decision-making about risk and urgency. You know, is there imminent harm versus postponement for further discussion? Are they using opioids on a regular basis for benzodiazepines? You know, how serious is this, and how soon do we need to intervene? And we want to get to yes for getting to treatment. What's available for treatment? So there's intensive outpatient treatment, which is usually four hours a day, either in the morning or the evening. If there's students in school, they may want an after-school program. There is partial hospitalization, which would require the adolescent to come during the day, spend the day, and then go home in the evening. Sometimes school is part of the partial hospitalization. And then there's residential treatment, where the teen would be spending the night there and going through treatment on-site. And learn which programs in your community offer programs for teens. It's really important to know this before you need it. Have the information at your ready so that if a teen and their family decide they want to send them, they can. There are sober living facilities for teenagers that can be really helpful. They can offer school and meetings and drug test monitoring. There are sober schools in many areas. And there are many collegiate recovery programs, and many more are being developed. So you may want to be looking in that for a teenager that's about to go off to college. Other support available. There's young people in recovery. There's Alcoholics Anonymous and other 12-step programs for young people. The public health department. Community mental health centers. And employee assistance programs. If the parents are working and their company has an EAP, that could be a great source of connection for what's available and could be paid for through the parent's job. There's also medication-assisted treatment for opiate use disorder. Three things I want to talk about. Buprenorphine naloxone, naltrexone, and naloxone. What does the American Academy of Pediatrics think of all this? Well, this is important. The American Academy of Pediatrics advocates for increased resources for medication-assisted treatment within a primary care and access to developmentally appropriate substance use disorder counseling in community settings. They recommend that pediatricians consider offering medication-assisted treatment to adolescents with severe opiate use disorder or refer to other providers. And the AAP supports further research focus on developmentally appropriate treatment of substance use disorders in adolescent and young adults. Including primary and secondary prevention behavior, behavioral interventions, and medication treatment. Naloxone is the medication approved by the FDA designed to rapidly reverse opioid overdose. It can be given intranasal, intramuscular, or intravenously. It's an opioid antagonist, so it will reverse the effects of an opioid. And it's temporary. The effects don't last long, so it's important to get emergency services as soon as possible. It's given to all patients with opioid use disorder or prescribed opiates and instruct family members on how to use this. It used to be that only first responders were given this medication, but now it's recommended to give it to all patients. And family members, especially parents of adolescents who are using opioids, feel a sense of relief knowing that they have this. Most of the opioid overdoses that we see in adolescents will be in the home. And if parents walk in and see their child and call 911, it could take up to nine minutes for the ambulance to get there. If they have this, they can use it immediately and increase the chances of survival. Buprenorphine products, we recommend buprenorphine naloxone as opposed to the monoproduct due to less risk of diversion and getting high. The special certification is no longer needed. So really any licensed physician can prescribe buprenorphine products at this time. It's approved for ages 16 and up. It's recommended that there's an induction. So you want to start slowly and increase the dose as needed. The patients need to be in withdrawal when they first start the medication, and then it's tapered up. Patients will become physically dependent on the buprenorphine product, and it's important that they know that. And it requires a slow tapering if they want to get off of it. Know the individual state laws. In many states, again, adolescents over the age of 12 can seek treatment for substance use disorder without a parent. But in some states, like Wisconsin, they need a parental consent to get a controlled substance. So it can be a little tricky. It's important to know those laws. Naltrexone, it's an opioid antagonist, long-acting. It blocks opioid receptors. It reduces cravings for opioids and alcohol. It's a daily pill or monthly injection. There's no special license to dispense it. They must be free of heroin or other opioids for at least 7 to 10 days prior to taking it to prevent a precipitated withdrawal. And it's only approved for ages 18 and over. There's no tapering necessary. When patients want to stop, they can just stop without any withdrawal. If you need to refer a patient, you want to learn your local resources and develop your network. You know, assess the quality of the network that you have. And if you can't find great, it's okay to go for good or even okay. Any of these resources are going to be more helpful than not sending them for help. Promote reciprocal communication with the referral. So if you're going to be sending them to a treatment center, you want updates. And one thing that I really stress when I'm working with a referral source is that I feel that discharge planning should start on day one of treatment. So even though they may need to go through detoxification and all sorts of things, looking at what's going to happen after they leave is very important. The worst scenario is when I get a call after a patient is discharged from the patient saying, okay, I'm out. What do I do now? So we want to be planning for when, while they're in treatment as to what the aftercare is. And reassure the teen it's easy for them to jump to the worst case scenario. We simply want to do an evaluation first. So once those screening tests are positive and we send them for an evaluation, then we'll take it step by step. So for monitoring, you want to prepare your questions. You want to praise positive behaviors. If they've cut down, if they've stopped, if anything has changed in a positive direction, how have they been able to do it? What's changed for them? And what are they able to do moving forward? You want to problem solve any concerns and barriers. You don't want to argue with them. That's not going to work. It'll be real easy to go in and say, hey, you should do this, this, and this, and that'll be fine. But what are you able to do? And what concerns do you have? Again, normalizing that you're in drug test. It's important to do that whenever you see them. Remind them that this is a health-related issue. This is not a judgment on their character. And you may have to make these recommendations multiple times when you're working with the adolescent. You wanna check for comorbidities, medical comorbidities, sexual risky behaviors, and sexually transmitted infections are not uncommon. So you wanna screen for those. Pregnancy prevention is also something that you wanna screen for. Smoking, tobacco or marijuana, reactive airway disease. So many of the teenagers that have asthma may not associate the fact that using tobacco or marijuana is making their asthma worse. So you wanna talk with them about that. And injuries that may occur because of their substance use. And then mental health, depression and anxiety. And then you wanna talk to them for patients who are ADHD and have been on stimulant prescriptions most of their life as they become adolescents, talking to them about how important it is that they take their medication as prescribed, that they don't share their medication. They don't give it to anybody else that some people may ask them for it if they find out that they're on it. I have a few cases that I wanted to go over that I thought were interesting illustrating the adolescent. So the first is EP. And she is an 18 year old female presenting after two overdoses in the past two months. She's currently in a local intensive outpatient program. She started smoking cannabis at age 14, has been using Xanax and Percocet recently. She vapes nicotine and smoke cigarettes. She's been able to maintain sobriety for the last 30 days. She's been experiencing feelings of withdrawal and is interested in a medication that will help her cravings. She states she's motivated to maintain sobriety from opioids and benzodiazepines, but not cannabis. And her parents are with her at the initial visit. So what questions do you wanna know? You know, what are their information about her? What medication assisted treatment options are available to her? Well, she's over 18 and she's been sober for 30 days. We could really look at long acting naltrexone or short acting naltrexone. We could use it, look at buprenorphine products. And what about the parental involvement? In this particular case, she agreed at this time to have her parents involved in treatment. She's allowing them to see her urine drug screen results. She's allowing them to come to her visits not to be in the room with her, but I am allowed to let them know if she does come and what her drug screen results are. What are the risks and benefits of the medications to her? Well, in this situation, after going through all the options with the patient, she decided on long acting naltrexone. She is also living at home with her parents. It's her senior year, it's her senior year of high school. She'll be going away to college next year. And so they are going to help monitor and she'll be able to come in every month to get her injection and to do her urine drug screen. She is still involved with her outpatient program and with a therapist as well. We need to talk to her about any side effects that she may be experiencing from getting the shot. She had not experienced many other than soreness in the area. How long will it take before she experienced relief in her cravings? And that can happen soon after getting the shot. What other therapies would benefit her? Well, again, continuing with her program, we've connected her with young people, 12-step meetings, which has been very helpful. And then we're also looking into what options are available for college for her, for collegiate recovery programs. And she's looking into that. I like to see her every month. She knows she can come in sooner if she wants to, but we're seeing her every month and she's doing really, really well. She has stopped using cannabis at this time because her parents said if her drug screens were negative for cannabis, that she could get a belly button piercing and that worked for her. So she has her piercing and she's continuing to stay abstinent. So contingency management in some of these cases is really helpful and continuing. So what's the next thing? She got the belly button piercing and now they're keep coming up with other things. So she has been abstinent from all drugs and alcohol and is doing very well. The next case that I wanted to talk to you about is AG. And he is a 16 year old male with a newly diagnosed bipolar two disorder presenting for management of polysubstance use. He's been discharged from inpatient rehab to a sober living house and intensive outpatient program. He started smoking cannabis and drinking alcohol at age 13. He subsequently progressed to MDMA, LSD, cocaine, narco Xanax, and eventually he started snorting and injecting heroin. And he was detaxed with comfort meds only over a seven day period and is complaining of intense craving and still some withdrawal symptoms. And he was brought in with his mother as well. So what else do you wanna know about his history? Well, I can tell you his family history is his mom is in recovery for alcoholism. He lives with both of his parents. They brought him in. What medication assisted treatment would be available for this patient? Well, he could possibly look at long acting naltrexone or he could look at starting on buprenorphine naloxone cause he's over age 16. And that is what he chose to do after going through all the different options available to him, he decided to start that. And at that time I was doing inductions only in the office. So he came in the office in, it'd been over seven days. So he wasn't in acute withdrawal but he was still having severe cravings. So our goal was to have the cravings decrease. And so we started him on a small dose. We started with two milligrams and then slowly built him up and he's currently on 12 milligrams a day and that has taken away his cravings. He's not having any withdrawal. What concerns do you have about his Xanax use? Well, serious concerns. And again, we've talked to him about Xanax use and how it could affect being on this medication along with other consequences. And he has stated that he's not going to be using Xanax at this time. He's working a 12 step program. He has a sponsor. He's living in sober living at this time. Should he still be able to use cannabis? So that my recommendation is no because of using cannabis at his age and the possible long-term consequences along with using cannabis and how it could lead him back to using his other drugs. And he's agreed to stop at this time. So he is six feet tall. He weighs 232 pounds. What initial dosing would you prescribe? Again, it doesn't matter how tall or how much somebody weighs when you're prescribing buprenorphine naloxone. It's what everybody's doses individually. We always start slow and build up so that they don't have a precipitated withdrawal and that they don't have side effects that could be associated with. Most commonly, I'll see nausea if we go up too high. So initially, we got him up to eight milligrams. And then at his follow-up appointment, he said he was struggling with cravings. What would we do? So then we would increase it a little bit more which we got up to 12 milligrams. Is drug screening indicated for this patient and how often? Absolutely, we do a drug screen initially when we met him and which was negative at that time because the drugs were out of his system and he had not been on any buprenorphine products at that time. But every time I see him and randomly we'll do drug screens. And do we need a parent's consent to treat him? Well, he's in the state of Illinois. So in the state of Illinois, no, we don't officially need one. But what I've learned is that even in the states where it's not required to have a parental consent, it's always recommended that you get parents involved or a responsible adult if the patient is willing to do that. What other suggestions do we have? Again, the longer that he can stay in treatment, the better. The longer he can stay at his sober living, the longer that he can be connected with his treatment program, working with his sponsor, the better that he will do. And again, looking at him after one year of sobriety, he's doing well, attending meetings multiple times a week, maintaining a strong relationship with a sponsor, not experiencing any cravings or thoughts of use. And our next steps are to keep it going, especially with young people that are on buprenorphine. This is a maintenance medication, especially for young people. They wanna be on it as long as possible. It's allowing him to live his life. And again, we're gonna be talking about, does he wanna go to college? Looking at a collegiate recovery program, or if he wants to go to vocational school, how is he gonna be able to do this? Now, one of the things that I have found really interesting when working with adolescents and parents is when parents come in like AG and sit down and you talk to them about their substance use disorder and you let them know that here's the things that you need to do to help your child come in remission and have long-term sobriety and less consequences of this disease, many parents will pick and choose what they need to do. So what I'll do is I'll sit down with them and I'll say, okay, let's take a different scenario. Let's say you came in here with your 16, 17, 18 year old, and God forbid we said, oh, your child has a brain tumor and here's what you need to do to put this in remission. First of all, we've gotta take it out. So they're gonna need to have surgery. And then they're probably gonna need to have chemotherapy and then possibly radiation therapy after that. They're gonna have to have scans every three months initially maybe every six months, yearly follow-ups, and they may have to be on medication long-term to keep this under control. Parents, what would you do? And they say, well, of course we would do everything that you recommend to put this in remission or to get rid of this tumor. But when I say, okay, for your child, they have this disease of opiate use disorder that's killing more young people today than brain tumors. Here's what you need to do to put it in remission. First of all, they need detoxification to get them and get them medically stable. Then it's best for them to be on a medication-assisted treatment. And we can go over the options for that. The best thing for them would to be in a sober living environment. So they can be around other people that are in the same situation. They can be monitored with urine drug testing. They can have meetings available to them. And then they're gonna need to keep their monthly doctor visits to get their medication and have their urine drug screens going to meetings. And all of this is gonna need to go on an ongoing basis. And the first thing that most parents will say as well, we can have them go to detox, but they're not gonna be able to do regular meetings or visits because they need to work or they have school. So there's always a justification as to why they aren't able to follow through with all the recommendations. Even though I'm telling them, if you follow all of these things, the chance of the patient, your child getting into remission is very, very high. So it's interesting. So sometimes they'll look at it differently after we present it as if it were another chronic potentially life-threatening disease. And then the third case that I wanted you to look at is AS. And she's a 17-year-old female with a history of anxiety, previously in recovery for one year on six milligrams of buprenorphine naloxone a day, presenting after relapse with heroin last month. Patient's mother also experiences opioid use disorder and the patient has an unstable home life. She was kicked out of her home two months ago, was unable to stay on the buprenorphine naloxone and she'd like to restart the medication. She did any other illicit drugs but smokes a pack of cigarettes a day. So this is really complicated because we have so many factors. She's currently using, she doesn't have a safe living environment. She did well on the medication, but did have a relapse. So one of the first things we need to do to help her is find a safe living environment for her, whether it's a recovery home, a sober living, treatment center, or another responsible family member that she's able to stay with. And then what I did with her is I wanted to get her back on her medication, but increase her to at least eight milligrams a day because she's not gonna be tapering off of it anytime soon. I usually go with a minimum of eight milligrams a day that will block her receptors and hopefully prevent her from having cravings. And then if she needs to go up, I would monitor her very closely. I would start with weekly visits, urine drug screens. Then when she's more stable, spread it out to every two weeks. And then I would look at possibly going to a month at the longest. We can provide resources for the mother if she's interested in getting help, but we wanna find somebody that she can connect with that is gonna be a sober support for her. And then we can also talk to her about her cigarette smoking and see if she is willing to look at cutting down or stopping. Again, motivational interviewing would be really helpful with her as to where she's at and what we can do. And the best part about this is that she did reach out and she does want help. So hopefully we can get her the help that she needs. Another really great resource is the Society for Adolescent Health and Medicine. And this is their website. If you go on, these are the resources for substance use and substance use disorders all over the country online. And so I would recommend using this as another resource. So to sum it up for adolescent substance use, confidentiality is key. If patients don't feel like you're going to keep what they say confidential, they may not do well. They may continue to not tell you the truth. They may not wanna come in the office and see you. So it's really important that you go over confidentiality. And it's important that you know what the laws are in your state. They may vary slightly from state to state. Screening and assessment is very important. And with adolescents, anytime you see them, most often they're not gonna come to you saying, hey, I have a problem with drugs and alcohol, help me. They're gonna be coming to you for their annual physical or their sports physical, sore throat, injury, whatever it is, use that opportunity to do a screening and assessment. You wanna do a good evaluation, including a physical exam and the urine drug test. Remember, just because a urine drug test is negative doesn't mean they're not using substances. And just because it's positive doesn't mean that they have a substance use disorder. You need to put all of this together, your history, your assessment, your physical and your urine drug test. Know that there are treatment options for adolescents. Medications are available. Buprenorphine, naloxone over age 16, naltrexone over age 18, and that there are a lot of other non-medication supports available for them, 12-step meetings, inpatient, outpatient treatments. And then having a close follow-up with adolescents is extremely important. You don't see them and say, okay, I'll see you next year. Have something scheduled when they leave. If they're currently using again, I would recommend seeing them a week later. And now we can do telemedicine. If they're not able to come in the office, we can see them that way. And then you wanna compare this to serious life-threatening diseases in teens. Again, for parents who look at it as, well, it's just substances, we can get them to stop. They don't have to change their life around for this. They need a job, they need all these other things. Really compare it to other life-threatening diseases that are not killing adolescents at this high of a rate. Thank you very much. If you have any questions, feel free to reach out to me and I will be available at the Q&A sessions that are gonna be held by AOAAM. Thank you.

substance use disorders

pregnancy

neonatal abstinence syndrome

adolescent substance use

screening tests

teratogenic risks

treatment approaches

methadone

buprenorphine

long-term effects

family involvement