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Substance Use: Insights from Dr. Jennifer Sharpe Potter · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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  Music.
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  Cases, updates, and discussions for the busy pediatric practitioner.
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  Click on the link in this podcast for free credit that may include CME,
• 0:13
  MOC, or ethics credit depending on our topic or podcast.
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  I'm thrilled today because here in the podcast studio is Dr. Jennifer Sharp Potter.
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  She is a professor of psychiatry at the University of Texas Health Science Center
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  and director of the Be Well Institute.
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  Dr. Potter, thank you so much for being here today. Thanks so much,
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  Holly. Holly, I'm glad to be here.
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  It's a big topic we're tackling, one that the pediatric practitioner sees on
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  a regular basis, and it's so challenging with everything that's coming at them.
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  What is your top piece of advice starting out?
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  We start with a big one. One of the things that I so appreciate the opportunity
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  for a podcast like this is that we have to start talking more about substance use.
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  And so that's the big story and takeaway is that if we can get to a place where
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  the pediatric physician and other health care providers in that system learn,
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  one, how important it is, but I suspect they already know,
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  but also feel that they can acquire skills that increase their confidence in
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  managing these situations.
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  Situations, often substance use disorder, because it is so stigmatizing, is swept under the rug.
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  That's often because people won't bring it up. But it's also because I think
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  in many ways, clinicians, when they don't have good solutions to a problem,
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  aren't always sure how to bring it up. And it is a complicated topic.
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  But so again, the big takeaway is I would love more pediatricians to focus on
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  substance use when they suspect it.
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  And it's happening younger and younger. If a patient is 12 or younger...
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  That's still that child should be screened. Yes, the U.S. Public Health Task
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  Force actually recommends screening and you can do screening and a few easy questions.
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  It's also, I think, surprising. An easy way to surprise a community member is
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  to remind them that the age of first use of alcohol and drugs has been going
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  down steadily in the United States.
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  So now we tend to think that the most common, there are young people that are
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  exposed to alcohol and drugs that are as young as 12 and 13.
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  So that's a modal age. So that tells you that there are even young people exposed
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  to this even younger than that.
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  So it's important to recognize drugs, just like firearms and other safety issues,
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  can be exposed to young people at surprisingly early ages.
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  So should this be the questions be asked on a regular basis?
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  Or what would you say to the pediatric practitioner there? It's so tough with
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  there's, like we said, when there's so much to cover in the exam room. Yeah.
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  So it's really challenging. And it's easy for me to sit here and say,
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  everyone should be asked these questions.
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  And I understand that you can't do that on every visit.
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  I liken it to how often you may be assessing as a best practice in your patient
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  population, manipulation, other psychiatric issues.
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  So you're checking on mood or you're paying attention to the warning signs.
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  There are some formal questions you can ask. The simplest one being,
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  have you ever tried X alcohol or drugs?
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  And again, it depends on the clinician's judgment. And I would never want to
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  say you have to do that all the time.
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  But it is increasingly important to be aware that young people are exposed to drugs and alcohol.
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  And so if you notice warning signs or if you're noticing issues that make you
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  suspect something's off, it's probably a good idea to start asking.
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  Or providing education at a younger age about drugs and alcohol and the dangers
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  and risks, even to the parent, so that the parent knows that should something
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  come up, this is a safe space to have that conversation.
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  Because quite honestly, it is still the case, and I hope this is surprising
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  to your audience, but it is still the case that people in our community and
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  the patients and the parents that you will see in your practices are afraid to bring up the topic.
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  So even the act of asking and making people aware to pay attention to it is
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  a real gift that you can give your patients and their families.
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  So ask in front of the parent or caregiver?
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  Sure. I mean, you can ask about drugs and alcohol. I mean, generally speaking,
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  we often will think that the answer might be no, but the act of asking is very, very useful.
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  You may get a signal like, well, you know, the occasional at holiday they've
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  had a sip or I'm not going to stop a young person from drinking,
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  that boys will be boys or girls will be girls or whatever.
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  But you're going to get a data point from that.
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  But I was actually backing up even further and suggesting that if you make a
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  decision as a provider that that's just not on the table for you.
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  It still is important to educate about drugs and alcohol. We know that schools do this as well.
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  But the symbolic act of asking creates a pathway for that parent or that child
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  to re-engage at a future date.
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  And so even if that child or adolescent doesn't respond back with the truth,
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  that's still powerful, you say? Yes, absolutely.
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  Because the act of asking again, if I mention it once, which I already have,
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  I'll mention it again and I'll probably say it again.
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  I can't emphasize enough how stigmatizing substance use is.
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  And I think the United States and the world have come a long way acknowledging
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  depression and mental illness as things that we have to talk about.
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  In part, because of some of the concerns we've had about youth suicide.
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  And we know talking about things is not dangerous.
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  Bringing these topics up is not dangerous. In fact, it can be life-saving.
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  And so by bringing it up, you're creating space for them to recognize that you
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  are a place where people can ask these questions.
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  They can talk about it. And substance use is so much more stigmatizing,
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  quite honestly, than a lot of the mental health conditions that you will see.
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  And we know that it is one of the major reasons why people don't seek treatment. Right.
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  In addition, if we back up a little
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  bit, the entire concept of treating substance use is relatively new.
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  Historically, if we go back 50 or 100 years, this was really not thought of as a medical issue.
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  This was an act of a moral failure. It's an act of weak character.
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  It was something that if people could just get it together, that they would be able to circumvent.
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  And so using drugs or alcohol in excess, despite the fact that we very commonly
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  use alcohol in our culture, was really thought of as something that somebody
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  just needed to deal with.
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  And so it might be a faith issue or it might be this or that.
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  What we know now is not only is there a medical underpinning of this,
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  but that there are solutions that we can offer to treat substance use disorder.
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  But the community hasn't caught up with that. And so asking and bringing it
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  into the conversation, even once, creates the idea that there is a field called addiction medicine.
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  There are tools that pediatric providers can use or they can refer to.
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  And again, that's really important because this is a life-threatening condition.
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  We have had significant spikes in overdose deaths in children under the age of 18 in Texas.
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  This reflects a national trend. And I'd rather see someone ask than find out
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  that that patient won't be coming back because they had an overdose in their high school.
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  And unfortunately, that's becoming a reality in Texas today.
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  And it's that not talking about it that increases the chance of it being deadly?
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  I think so. I mean, again, it's complex.
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  It's not the case that talking about it will necessarily circumvent any problem,
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  but it at least creates those moments of opportunity for engagement.
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  Another thing, I'm jumping a little bit, but another thing that's really important
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  is that if you have families that are used to, for example, we were chatting
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  before we started about marijuana, marijuana is much more potent now than it ever was.
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  So I like to say that parents need to understand, and I would say this for alcohol
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  as well, this is not the pot that you grew up with.
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  It is a different quality and purity. It is much more addictive.
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  And while it is true that marijuana is not as dangerous to use as heroin,
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  it is very much the case that it can be harmful to young people,
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  at least some young people.
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  We know that it may increase the likelihood for someone at risk for schizophrenia
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  to have a psychotic break or increase the onset or escalate the onset.
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  We know that it's contraindicated for people with anxiety disorders.
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  And if you look at the rates of anxiety disorders in young people these days,
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  I'd be pretty concerned about my kiddo trying pot if he's someone that's,
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  he or she is someone that's going to be at risk for an anxiety disorder.
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  And we hear so much about fentanyl, which is terrible, and fentanyl being put
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  in marijuana, but the data isn't quite showing that yet.
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  Yeah, I'm a little less concerned about fentanyl and marijuana.
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  There's a considerable amount of skepticism about the likelihood of that happening.
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  I'm not a toxicologist, so I don't want to speak on something that I'm not an expert on.
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  But to my knowledge and my colleagues, that is less of a concern.
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  But I will share what's more of a concern for young people and adults.
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  Is fentanyl that's mixed into other things. And so I'm more concerned about
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  young people who are sharing medications.
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  We know, for example, on college campuses, and we've seen this in younger populations,
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  that stimulants or pill form medications are often shared.
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  Unfortunately, unless you know where you got that medication from,
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  you can no longer guarantee that that is medication that was made by a pharmaceutical
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  company and distributed.
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  So I equate it now with, yes, it looks like a pill, but it may not be medication.
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  And that's a really simple way to explain it. Just because it looks like a pill
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  doesn't mean it's a medicine.
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  And there have been cases where people, by report,
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  appear to have thought that they were taking a prescribed medicine like Adderall
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  that was actually made somewhere else in what I would call a pill mill,
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  which is often perhaps a garage.
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  And the pill press is something that was acquired by a guy named Joe or a woman
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  named Sally. No offense to Joe and Sally.
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  And they're sticking it in a garage
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  somewhere and they're illegally manufacturing what looks to be a pill.
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  They will stamp it just like a medication.
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  So it looks like Adderall. It looks like whatever, oxycodone.
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  It looks like a medicine. And it's absolutely not. Thank you.
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  The reason that's important, and I know this is a long answer,
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  but it's complicated and it's important.
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  The reason that's important is because people making illegal medications,
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  people making these illegal pill-like looking substances really don't care what's in it.
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  One of the ways to get an effect is to put something that's highly potent into a pill.
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  Fentanyl is extremely potent. It will trigger a response.
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  It's also the case that these are not clean rooms. Pharmaceutical companies
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  do have high-grade equipment that mitigates contamination.
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  Pill presses in a garage or a factory or wherever they're being made don't.
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  And so someone can think they're taking an Adderall and have completely no stimulant
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  in it, only opioid, or they can have a mix of all sorts of contaminants.
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  And if you have not been exposed to fentanyl, the risk of an overdose is incredible.
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  So people need to not use other people's pills.
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  They need to use what's prescribed for them. And that's really an important piece of this as well.
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  And even if, should we be telling the patients, our children,
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  if a friend is offering you an ibuprofen at school, even don't take that.
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  I think that's really wise. People shouldn't share medicines.
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  I hope that's a great opportunity for the school nurse with a permission slip,
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  or parents to be educated on how to give their children appropriate medicines,
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  understand them, and monitor.
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  It's completely the case. When I first learned in my family that there was pill
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  sharing, the first thing I did was I sat down with my children and made them
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  aware of this because it is so incredibly risky.
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  And there are lives definitely that have been lost as a result of medication sharing.
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  Nobody should be sharing medications these days.
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  That's an excellent point. And.
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  The biggest threat, though, that pediatric practitioners will see that's much
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  more common is marijuana and alcohol use.
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  Yes, it's still the case that alcohol is omnipresent and very dangerous for young people.
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  I liken it to, and again, apologies for the extreme example,
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  but I think of it as playing brush and roulette with your kid or a family member.
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  It's just when people are young, and there's a reason for that.
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  There was actually a study out of Europe, a beautiful epidemiologic study a
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  number of years ago with the French model.
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  The French model is a little sip of wine, a lot of water, and then young people
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  will—this is how I was raised by my family—and that if you have a little dabble
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  and a little nip underage, you're going to learn how to manage your alcohol.
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  So this beautiful study looked in France where this was more common,
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  and then they looked at countries where this wasn't the practice.
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  They actually observed in this very large epidemiologic study that it is,
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  in fact, not true, and that, in fact, early exposure to alcohol in this study
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  actually did increase the likelihood of a substance use disorder.
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  There are lots and lots of other studies that bear this out.
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  In the United States that demonstrate that the greatest risk factor for a substance
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  use disorder is the early age of alcohol and drug initiation.
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  So those young people I was talking about before, those people that are exposed
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  to drugs and alcohol at 12 are at much greater risk than somebody who starts drinking at 18 or 19.
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  And note those are still under the legal age for alcohol and still in this state
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  illegal to use marijuana.
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  So the longer that young person waits, the more protected they are for probably
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  a lot of different reasons from going on to develop a substance use disorder.
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  Because we know a lot of kids try drugs and alcohol. It's just reality.
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  The vast majority don't go on to develop a problem.
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  But children with mental health issues and children with early age of exposure
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  are definitely more at risk to develop an addiction.
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  Well, and the other day at the dinner table, my teenage son was pretending to
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  smoke pot, you know, as if to be funny.
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  It's like, it's almost like marijuana. I don't know if accepted is the right
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  reason, but it's not taken seriously enough that how dangerous this is and damaging
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  it can be. Yeah, it's a really great point.
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  And again, there's so much exposure. It would surprise me if a child didn't
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  sometimes make a gesture of marijuana.
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  And in fact, someone smoking marijuana, want to. It's so much more common now
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  to see that than even perhaps cigarette smoking, which is a really good thing.
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  I like that we don't see kids pretending to smoke candy cigarettes anymore and things like that.
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  But it is something that you're exposed to in the media.
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  And that's why parents and caregivers are just so important in modeling healthy behaviors.
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  I would not recommend smoking pot around your children. If you choose to partake, that is your choice.
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  And I think that with all substances, but what you model for your children is important.
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  The second piece of your statement I think is even more important is that there's
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  this perception that, well, it's marijuana, you get a little stoned,
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  feel a little chill, who's ever had a fight with someone using pot?
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  And all of those things, to some extent, depending on who you are are true.
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  It's actually not the case everyone feels that way, but that's the archetype.
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  It is a drug. It's a toxin that you are exposing a person's brain to,
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  that they are choosing to do, and there are consequences for that.
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  The amount of, for example, edibles or these chewable type things can be dangerous
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  and toxic for a young person, especially if they don't know what they're using.
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  I've seen some of the stuff coming out of Colorado that looks like a candy that
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  you might just pop in your mouth like a caramel.
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  Well, a young person, let alone an adult, should not be popping a caramel-sized
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  edible into their mouth.
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  And so there's an education piece that needs to happen.
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  And it's also the case, as I mentioned before, that we are living a very potentially
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  high-risk natural experiment with the legalization of marijuana.
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  We don't have enough research because it had been so hard to do marijuana research
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  in the United States to understand for individuals who are using it chronically
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  for recreational use what's going to happen.
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  But we are seeing signals of danger.
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  The other thing I'll just say about
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  this is I tend to say it as a joke to colleagues, but it's very much true.
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  One in 10 individuals, this is not the joke part, one in 10 individuals exposed
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  to marijuana will develop in all likelihood had a substance use disorder.
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  That's like the general number now. It's about one in 10, so 10% of chronic users.
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  And I have never had an easier time recruiting for a clinical trial than when
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  I put out an advertisement that I am recruiting for treatment for marijuana.
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  We just completed two clinical trials for treatments, and the phone calls were impressive.
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  And so there are a lot of people who would like to stop using marijuana.
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  The tragedy of that is we still don't have good treatments.
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  And a lot of the clinics don't have good solutions. So we have creating a generation
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  of people who may develop a substance use disorder for which we do not have a treatment yet.
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  And there's this perception that it's not addictive. Correct.
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  Who started that? Well, I think there's a difference between addictive and evaluating
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  the danger of that addiction.
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  So, for example, caffeine can create physical dependence.
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  I drink caffeine every day. If I stopped using caffeine, suddenly I would experience
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  withdrawal, which for me would be a really bad headache.
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  Right, me too. But a headache is a headache. And so if you look at it only as
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  the physiological dependence, the withdrawal from marijuana is arguable.
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  It's a different type of process.
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  But if you look at the consequences on social and occupational functioning,
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  I can give lots of examples of people.
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  You know, one example from an older marijuana study I did was a young person,
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  age 35, who was being dropped off by their mom.
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  And the social and occupational negative consequences of that chronic marijuana
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  use was that he was 35 and living with his mom and was unable to achieve goals
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  that this individual wanted. to get out of the house.
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  I think 35 is a good time to look at whether or not you might live elsewhere,
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  but he couldn't hold a job because he was more and more and more and more time
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  spent acquiring, using, or recovering the effects of marijuana.
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  And that had cost him his ability to function.
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  And he had a desire to stop and cut back, but was unable to do so.
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  So what I did there for diagnostic people was I just gave you three criteria
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  for a substance use disorder.
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  And if you have three, you meet criteria.
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  And then from there, it's time to refer out somewhere?
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  Well, this is the challenge. Yes, absolutely. I think it's a great point to
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  if somebody has that, it's really great to have them evaluated.
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  I will say, though, that's absolutely what a pediatrician should do at that point. Unfortunately.
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  Anyone in your audience is probably thinking now, oh, well, good luck.
• 20:43
  Right. It's such a, I mean, we have a dearth of psychiatric providers in the
• 20:48
  state of Texas and in a lot of states. Yes.
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  So what are we going to do about that? Mm-hmm. I hope that pediatricians continue
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  to stay apprised because they can be a real solution.
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  There are some places to refer, but we have to do more research than invest
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  in research for treatment and understanding the course of marijuana use.
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  But I'd be lying. And I don't. I wish I had an answer for the access issues.
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  We are trying, for example, here in San Antonio, we've just recruited an individual
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  who will be joining our clinic in the fall who's specifically boarded in addiction
• 21:21
  medicine and treats adolescents.
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  And we did that quite intentionally because we do not have that capability right now in San Antonio.
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  And our listeners in Texas know about CPAN as a number you can call and get
• 21:37
  a psychiatrist on the phone within 10 minutes. No call is too small.
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  I love their slogan. And then T-Chat, where a parent can contact the school
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  and go through the school system to have telehealth visits with University of
• 21:52
  Texas Health Science Center here in San Antonio Psychiatrist.
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  Can you tell us about the Be Well Texas Institute and how the mission is to help the entire state?
• 22:03
  Sure. Well, thank you. Just before I do that, since you mentioned CPAN and TCHAT,
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  I will tell you there's a really wonderful initiative with the school-based
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  programs that has created a referral source for substance use.
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  Awesome. And so when you call those lines, there is now infrastructure that
• 22:21
  is very broadly in Texas that makes it possible for that young person to be
• 22:27
  assessed for a substance use disorder and depending on the severity, treated or referred.
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  That is brand new. And what I love about that is the connection with mental
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  health and substance use.
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  We separate these things too often. And so that is a significant advancement
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  with the Children's Mental Health Consortium and what they're doing in Texas.
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  Be Well Institute has a program or a clinic called the Be Well Clinic.
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  And the Be Well Clinic is specifically to treat substance use disorders,
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  where that seems to be the primary diagnosis.
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  And the severity of that substance use disorder is quite significant.
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  The neat thing is that we treat outpatients. So we are not a rehab.
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  We are not a send someone away.
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  By the way, as one of the myths about substance use treatment,
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  that that's the only way to have effective care.
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  There are a lot of things that we can do outpatient that are supportive of a
• 23:19
  person's life, living in their context, and can still have a successful treatment
• 23:24
  outcome. So it's low barrier.
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  And the program is funded in part by the state of Texas.
• 23:31
  It allows us to treat anyone anywhere in Texas, regardless of their ability to pay.
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  In Texas, there is a large number of people that do not have health insurance.
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  And that's one of the barriers to treatment, too, is when you don't have the
• 23:43
  money to pay, let alone for a physical or a vaccine, but you can't pay for addiction treatment.
• 23:48
  And so we are able to treat folks and cover the costs of medicines and their
• 23:52
  lab visits and everything.
• 23:54
  And for your physicians, particularly because you see things in the parents
• 23:59
  that you're not treating, know that that is a resource that is available right now for 18 and older.
• 24:05
  We will have capability to treat under the age of 18 beginning in the fall, excuse me, 18 and under.
• 24:12
  Amazing. Yeah. So that's, I think, the biggest thing. We deliver our services.
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  Last year, we served about 35,000 people throughout the state.
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  And we provide not only treatment, but recovery support services.
• 24:25
  Often this is delivered by peers.
• 24:27
  Another thing that your listeners might be interested in is we also have housing
• 24:32
  programs for emerging adults.
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  So not quite under the age of 18, but that 18 to 23, that's a critical age too.
• 24:40
  And often frustrated families or people who've left home and don't have anywhere
• 24:45
  to support their recovery.
• 24:47
  And we know it's a lot harder to deal with substance use when you're under stress
• 24:50
  and have nowhere to live.
• 24:51
  And so our housing programs are designed to help those transitional age youth
• 24:55
  be embedded in care and recovery, and that takes some of the pressure off the
• 25:00
  other support system they might have.
• 25:03
  And Jennifer, should our listeners go to the Be Well Texas Institute website
• 25:07
  and then give that information to the patient or the family?
• 25:12
  Sure. So there's two ways to get in touch with us most quickly.
• 25:15
  The first is through our website, and that's BeWellTexas.org.
• 25:20
  On there, there is a place for a family member or even for anyone to make a referral.
• 25:26
  And there's also a clinician portal there, and we will contact you.
• 25:30
  We also have a phone number, 888-85-BEWELL.
• 25:35
  And that number is answered 24-7. It is answered not by a call service,
• 25:40
  but it will be either answered by our front desk ask or a peer will answer.
• 25:45
  And a peer is someone with lived experience of recovery.
• 25:48
  This means that they're trained, they're certified, and they're able to offer
• 25:52
  support to someone who has a substance use disorder or is using substances.
• 25:57
  And they will be speaking with someone who has lived experience of recovery.
• 26:02
  They've been down this road, they have achieved recovery, and they are here
• 26:07
  to support other people on that journey.
• 26:09
  Sometimes, like many issues, a peer can be more effective in conveying important
• 26:15
  information than a clinician. They serve different purposes.
• 26:20
  And so we see that as really essential to what we do because the conversations are quite different.
• 26:26
  And often the messages are heard in a different way. So it's really part of being a team.
• 26:32
  And do you have any advice for our listeners elsewhere in the United States
• 26:37
  and around the world? Sure.
• 26:40
  So the good news in the United States is that it's hard to say it's good news.
• 26:46
  It's a lemonade out of lemons.
• 26:49
  There has never been a time in the United States, to my knowledge,
• 26:53
  where we have spent more time building infrastructure to support people with
• 26:58
  the substance use disorder and the people around them.
• 27:01
  And so most states in the U.S. now have resources.
• 27:07
  If we look more broadly, we are seeing very similar phenomena.
• 27:11
  So broadly speaking, I know Canada has 800 numbers.
• 27:15
  One of the easiest things to do now is use a public search engine.
• 27:21
  And when I say public, I'm talking about the major ones, not one that locks down privacy.
• 27:25
  And when you enter something like addiction or substance use disorder,
• 27:29
  what you are going to get at the top of that search engine, and by the way,
• 27:33
  these browser services have intentionally done this, is you are going to get
• 27:36
  reliable numbers to call to ask for help. This includes in the U.S. 988.
• 27:42
  It also includes the Substance Abuse and Mental Health Services Administration,
• 27:48
  or SAMHSA, and I can give you this link as well.
• 27:52
  And there is a treatment locator on there that tells you everything from how
• 27:58
  much, whether they charge, whether it's free, what type of insurance they take.
• 28:02
  But it's also really important to know right now as a clinician that you should
• 28:06
  not have to pay extraordinary amounts to get good evidence-based care and referrals.
• 28:12
  And that's important. And you just made me think of one other thing.
• 28:16
  If you are prescribing opioids...
• 28:19
  Or if you're not prescribing opioids, I recommend that you as a clinician find
• 28:26
  out where to get access to no-cost naloxone.
• 28:30
  Naloxone is an opioid antagonist that will reverse an opioid overdose.
• 28:35
  The more we saturate, so if you have someone that you suspect or know is using
• 28:41
  drugs, or even if you know there's opioids in the family for medication,
• 28:44
  someone is, God forbid, dying of have cancer and they're on palliative care
• 28:48
  and they have pain medications.
• 28:50
  Everyone should have naloxone. If you have somebody who's going off to college,
• 28:54
  you should give them naloxone.
• 28:56
  If you have a young person that you're concerned about or a parent that you're
• 29:00
  concerned about, you should know the source for free naloxone.
• 29:04
  In Texas right now, you can go to naloxontexas.org or naloxontexas.com and you
• 29:13
  will get access to a way to order free naloxone.
• 29:16
  It is critical, critical that we have this available.
• 29:20
  It's also critical to educate people around someone who uses opioids and that they should use it.
• 29:26
  It's low risk to use this if you find someone unconscious.
• 29:30
  A person who uses drugs cannot reverse their own overdose.
• 29:34
  The family members and the other people around them can, and you can save a life.
• 29:39
  Dr. Jennifer Sharp-Potter with the University of Texas Health Science Center
• 29:44
  at San Antonio and the B-Well Institute, thank you so much for being here today on Pediatrics Now.
• 29:51
  Great job. Thanks. Coming up next week, part two of our series on tackling substance abuse.
• 29:59
  Most importantly, it's letting kids know that right now illegal drugs are not safe.
• 30:05
  They are very harmful. And so it is a really important time not to use drugs in our society.
• 30:37
  You just heard? We'll put that in our Pediatrics Now for Parents podcast,
• 30:42
  Health News in Small Bites for the Busy Parent. That's Pediatrics Now for Parents.
• 30:47
  Anywhere you get your podcast or the web address is pediatricsnowforparents.com.
• 30:53
  I love this quote by Nelson Mandela, History will judge us by the difference
• 30:58
  we make in the everyday lives of children.
• 31:00
  Thank you for making a difference.