Good morning, everyone. It's really nice to see you. It was really exciting to see such a large crowd. But it's fun now that we get to do this breakout work together. And I'm hoping, I'm not gonna ask anyone to like move and come forward because I know everyone gets uncomfortable about that. However, I would really appreciate it if folks have questions during the time together. Like this is the opportunity for us to hear a little bit about my reflections on how to engage youth. But I think the reality is I wish I could come and tell you by the end of this hour together, you will all walk out and know exactly what to do in terms of engaging youth in care. Like that would be amazing. And that's not what's gonna happen. But I think one thing that can happen in smaller groups like this is that we can share experiences and some of the best practices or the anecdotes that we've been touched by over the years so that we can all continue to move this field forward because it is really hard, I think, to engage youth in care. And some of it has really a lot to go back to what Steve was talking about in terms I think of making things enticing for youth and sort of giving them a reason for to actually want to come to ask us for like how do I get some support in addressing these different issues going on in my life. So, okay, let's go. So this is, I'm doing this as part of, I'm one of the opioid response network consultants. And so these are just a couple of slides that describe what the ORN is. And there'll be a, an evaluation can go out at the end. But if you want any more support around addressing opioid use in your community, you can request technical assistance through their network. I don't have any disclosures. So what are we gonna talk about? We're gonna talk about, hopefully by the end you'll be able to identify two strategies to improve the engagement of youth in care for substance use. But we'll talk about more strategies than just two. Describe the effect of stigmatizing language on adolescents who use substances and offer alternative inclusive language choices for them. And describe two ways to provide trauma-informed care to adolescents who are impacted by substance use. I'm just gonna sit like a minute about sort of who I am. So you're like, who is this person who's coming from Boston Medical Center? And does she know anything about actually taking care of youth? And so I am, I'm a med peds physician and did an addiction medicine fellowship at Boston Medical Center. And I've been working as part of a clinical program that's based in our Adolescent Primary Care Center at EMC for about 10 years, where we take care of adolescents and young adults through the age of 25 who use drugs. I think one thing, one change that has happened over that time is that initially we really, we thought of ourselves, we were a new program and thought of ourselves as like a treatment program and really have tried to just shift to thinking about providing care for adolescents because we have recognized over the years that some adolescents, like it's primary care that's bringing them. Some of them, it's really, they want to address mental health. Some of them, they're really ambivalent about their drug use and maybe they don't want to stop. And so we want to be able to talk to them about harm reduction. And so in order to be like a really responsive primary care based program, that's what we do. I'm fortunate to work with a nurse and two social workers and a psychiatrist. And so, although we're primary care based, this is like thinking back to what Steve was saying, like we have like actually a lot of, we're a well-resourced team and I do have more time with my patients when I'm seeing them than I would in a regular primary care. That's not to say, I think there aren't sort of some tips and tricks that we can sort of learn in primary care, but this idea that actually really investing and providing the necessary resources to do this work well so that we can start to address these deaths and like has to be part of the conversation as well. Okay. And so everything that I'm going to share, some of it is evidence-based and some of it, I guess, is like evidence adjacent. And that's because they're actually, we're sort of lacking a lot of really high quality, rigorous data around adolescent substance use care. And we sort of think back about the last 10 years, how adolescents access drugs has really changed, right? Like a lot of the national surveys are like, did you get it from your family and friends? Did you get it from your doctor? Did you like, where did you get it? A lot of my patients are getting it like on social media or like from their, and so maybe from their friends, but they're accessing it in different ways. And so that's changed. How teens like use drugs has also changed. So some of it is around counterfeit pills, but you think about cannabis and different ways that kids are vaping and dabbing and like these different ways that kids are using drugs have also really changed. And I think some of our advice and ways that we address that has sort of not caught up. And then the drug supply obviously is also really different. That's what we've heard about as well. And so we are sort of behind, I think, in thinking about sort of adequate strategies to address adolescent substance use. So you're going to hear some of this is like my musings and hopefully best practice with like some rationale for how we can be thinking about this. So the first idea when I think about working with youth is just this idea that like behaviors make sense. And this is a thought that maybe some of you have heard. I can picture a mentor of mine who is a psychologist in Western Mass, Scott Jeffs, sort of talking about this idea that like behaviors make sense and people do things for a reason. And a lot of times in substance use, we've talked a lot about like the hijacked brain and I sort of want to like push back a little bit against that, you know, and sort of think about like, huh, like when I talk to the kids who I take care of, they actually have some really good reasons for why they might've started to use substances. I'm not saying that it's like positive or okay or healthy for them to be making those choices, but it is important for me to understand like what was initially driving those decisions? Because the more I can understand about those behaviors and those choices they're making, the better job I can do to figure out like what's the intervention? Because is it about like, it helps them socially, and so, you know, they have a lot of social anxiety or it helps them allow to have these conversations or are they like really depressed and they're using alone in their room or did they have some kind of traumatic experience and this sort of helps sort of like numb what's going on. But all of those different reasons might lead to a slightly different intervention. And so this is really important. And that means sort of initiating conversations with curiosity and really trying to check some of the assumptions that we might have about what might've led to the, you know, substance use in the first place. And so, you know, as I was sort of saying earlier, you know, substance use can really relieve some of these distressing symptoms that people are having. And it's really our job, like it is on us to make not using substances more appealing. Like that is sort of how I think about our job. And so this is where like just say no and things like that, like why would that work? Because if I'm getting relief from something, then I need a really strong compelling reason to stop doing. You know, I think the other one thing, another thing that when I think about engaging youth is just sort of making sure that we're separating this idea of like use from substance use disorder, because a lot of, many more teams are engaged in some kind of substance use than actually have a substance use disorder. And so why is this important? Well, again, it's like about like intervention, like what are we gonna do about it to minimize the harms? So for the kids who are meeting a criteria of a substance use disorder, we should talk about that. And we wanna make sure that we are offering them evidence-based treatment. We are diagnosing, assessing them, you know, offering them evidence-based treatment and engaging with them and their families to address the substance use disorder. And, you know, most of the time co-occurring mental health disorders. But then you're gonna be like many more kids who don't meet criteria, or maybe it's like mild criteria. And so you're like, is it really substance? Is it like treatment that I should be offering? And so I think that's where we have to really think about what are the conversations that we wanna have with teens to first offer the message of like no use is safest and really thinking that, you know, and that's like an important part of the conversation that we have. And then if you're engaging in substance use, how am I gonna talk to you about minimizing the risks of that substance use? And so I think that that is, I would love to hear people's thoughts about that or how you have those conversations because I think this is a really tricky place when we're thinking about youth and what I'm sort of talking about is harm reduction here and sort of how we think about harm reduction and youth can feel uncomfortable because I think the last thing, I don't really know any of you, so I don't know, but I'm assuming that last thing any of you wanna do is like cause more harm to youth or like have bad outcomes, right? Like that is not why we are here. We really are here because we like care about taking care of kids. We want them to like recognize their potential and like live full, healthy lives. And so like, how do we get there? And so some of that is like if those short-term consequences and risks that we are trying to avoid and if we can't have conversations about safety, I don't know how we can get there, but I think it's really hard, but I saw a question back there. No, thank you for saying that. And I think it just elevates this like space of discomfort and I'm not here to tell anyone in this room exactly what to do or how to have those conversations. I think it's like, there's actually, you know, it's like this ethical issue and it's a sort of intensely personal like choice. But I think, and I think it's like, we have to deal with the reality on the ground. Like that is also the truth. And so sort of being able to come together and figure out what our best practices and what are best ways to have advice so that families and kids don't feel like they can't have these conversations with us. And it's like really hard. And it's just, you know, this is where I like, I do not have, I've been doing it. I don't have like the answer. I don't have the way, like this is exactly how we should be doing it. And I do think there, oh, I shouldn't say clean. I should say sterile syringes and sizzle. But I think this is this idea of sort of trying to introduce the idea of like harm reduction. I personally, in my work, think a lot about opioids and overdose and overdose prevention among youth. And so that's why this is sort of more focused on opioid or overdose prevention. But I think I, you know, I would sort of offer that there is this role for harm reduction. And my guess is, you know, some of you are already doing this a lot already. When I talk to other adolescent providers, they're already doing a lot of harm reduction because it's just what they have to do to keep their kids engaged. Naloxone works no matter what age you are. It, you know, there are no age restrictions in terms of like either prescribing it or now that it's over the counter, like there shouldn't be restrictions for kids being able to access naloxone. HIV prevention and PrEP is also approved for adolescents. You know, it's really poor uptake, but we should be doing that. Sterile syringes, usually over 18 is sort of like that that's the cutoff, but fentanyl test strips, like we distribute them in our clinic to teenagers. And we talk to their families about them too. Like we don't want a family member to like find some fentanyl test strip and then like cause them more problems. But like we have not found or been older age restrictions on those. And so again, it's about having these like real conversations and oftentimes it also opens these doors to other conversations with kids. They're like, oh, I can talk to you about what I'm actually doing. I can talk to you, I can like trust. And so then you have even more of an in to be able to talk to them about safety. And I think that's where like, I look at our, I'm so proud of the program we built in the trust and just how kids keep coming back. And a lot of them will say like, this was like the first time I could really talk to someone about this. And I'd like to think that that's like helping us sort of keep people safe and just recognizing because abstinence might not be the goal. Like it might be our goal and it might be the thing that we know is safe and it might not be their goal. And so does that mean we're not going to talk to them? Like, no, how can we continue the conversation and keep them engaged or certainly safer sex supplies and then protective behavioral strategies? You know, like, how are you going to get home? Who can you call? Like, if you're sort of feeling uncomfortable and feeling like it's not safe where you are or safe to get home. And so I think that, and then I just put naloxone again because I just think everyone should have naloxone. That wasn't a mistake. I saw a question though, I think in the middle of the room. Yeah, no, thank you for offering that and I you know I think that that's that's that is some of this like sort of uncomfortable space where we, I think the idea of harm reduction is more, you know, we're still not totally there but more comfortable when we're talking about adults and I, I, I would like to start thinking about how we have these conversations with youth in a way that is like developmentally appropriate. That involves family members, like, and that doesn't somehow like encourage drug use which all of which I think is like really important and deals with the reality on the ground and I think this is where you know this is where I think like the voices of families and people who have been taking care of kids, like need to come together to figure out sort of how to do it. This is why I don't have answers, answers for you, except that I do think it's how we've kept some of I think like the highest risk kids that I've taken care of over the last few years like why they keep coming back, keep coming back to us because they know that we're not going to kick them out, or not be willing to have these sort of really hard, scary, like I am scared sometimes as a provider conversations with kids. It is like a lot of risk I did not like, I don't think I fully appreciated like the amount of risk, I was taking on or like what it was going to mean when I was sort of like choosing, you know, fellowship and residency, like that was not. Yeah. So, thank you. So, the first one. The first question is really, how, how young, because I mean we've seen last three years we had two 14 year olds, three 15 year olds. We're targeting a lot of our primary prevention to seventh grade. But then I'm talking to elementary teachers, saying, all the adult kids, you know, our fifth graders, sixth graders. So, where do you begin those discussions is one question. The second question is, we're constantly fighting between the traditional prevention people, certified prevention people, who, you know, and the superintendents and principals and health teachers, the whole issue. You don't want to scare, this is not supposed to be, say no to drugs, no one's there program, we want to be realistic. And yet, I got the DBA on my butt, talking about one pill can kill. I'm seeing all seasons of the pill, and one pill can kill. I'm surprised that we haven't seen more of that root of administration say it's true. So, they don't want me to scare kids. I think the best message I'm going to hear, you're doing a lot of that. Where do you find, how do we find that sweet spot between the Nancy Reagan, just say no to, okay, you're a kid, you're going to experiment. Okay, so thank you. I feel like I planted you but I didn't plant you, I've never seen you before I don't think. So, so how young is he, I don't like I don't know and I think this is this is this is a question that I think that we really do need to grapple with in Massachusetts. We have, I don't know, I feel like it's a regressive policies towards walk zone access for kids in schools to be honest I think names actually done a really nice job and trying to improve, or that's what it you know from like an outsider like it seems much more, much more progressive. I think, like, I would say at the very least sort of certainly overdose education for like high school students and middle school students and I think trying to figure out how to sort of have conversations with elementary school kids. Part of it is because maybe their parents or other loved ones are going to have an overdose I know there was like a pilot and see there's this New York Times article from a few years ago where they were teaching elementary school kids and we tried to follow up to see if they've like written anything or have a curriculum or something and I don't think that they've done that. It is this is where it is like hard and uncomfortable, I have a five year old and eight year old and 11 year old like I so I think about this as someone who takes care of kids and I take think about this as a parent as well. Maybe not the five year old but he has food allergies and he knows about that then, you know, like, there are ways I think this is where the developmentally appropriate pieces and, like, very different the conversation I'm having with 30 year old patient about overdose prevention and like how they use drugs and like a 10 year old like those are going into we should do that I worry about that as a med peds person that sometimes you just take the adult stuff and like put it on kids like that is not what I'm suggesting like and that's where I think this thoughtful coming together to figure out what are the right principles the ways that conversations and thinking about the different ages is critical I will tell you that, you know, there was the CD, the Centers for Disease Control and Prevention published like the characteristics of 15 to 19 year old to die during a certain time period like between like 2019 2021 or something, published it last year, and like over half of the most of the overdose deaths happened in their home, like in their home or someone else's home like 80%, and two thirds of the time, there was a bystander present, who like didn't respond and naloxone was used like 30% of the time. So like we are, we are failing like that is really a problem, and it is an opportunity for doing better. And I think schools I think this is a place where it's like I want primary care providers to be doing this, and it won't get like it's a public health problem. So we should be thinking about public health solutions, not just putting everything on providers, even though they should of course be invited, like invited to the table. Yeah. Maybe not. Yeah. With the parents. With other ages, third grade and very, very young, marijuana, but you know, how do you bring the family. So, but you know I do think though the role of the family is really important and I feel and I'm sure this, you know, a lot of it then sort of has to be like, not them feeling judged but sort of like keeping it about the kid and it's safety, you know, as much as possible but I do think that is a, I do think that it's a challenge I have a like a lot of not here to talk about like criminalization of drug use I think I have a lot of concerns about the criminalization of drug use. And I, you know, also think that it's really important that we have conversations about like exposures to you know alcohol and cannabis and any drugs for a kid who has like a developing brain like we should legality doesn't matter like I don't care I don't I think where I struggle, and I'm a peer-invested provider, where I struggle is the data, I guess, controlling their use, putting that on the brink, and we don't want to talk about it. I think the way that funds are abused later, and some of these big insurance companies actually suspend evaluations of drugs a couple of years later as a plus-prime effect. So I'm struggling with putting those preferences on the brink. I'm struggling with putting those preferences on the brink. I'm going to try to answer and then I'm going to keep going. I didn't have that many slides but I should keep going. This is the School-Based Health Center. I'm just going to start there. I think that's a really interesting, exciting idea. We have School-Based Health Centers in Massachusetts and we actually did some qualitative work. We did a training and then we're writing up this qualitative study that we did with them asking them about integrating overdose prevention and actually also treatment of opioid use disorder with medications into School-Based Health Center settings. What we heard from them was there was a lot of interest. They felt like they were already doing a lot of harm reduction. There was a lot of concern about pushback from schools and parents, even though a lot of the care is confidential, but there was definitely interest. Thinking about that, where are kids showing up? That is a compelling part of thinking about School-Based Health Centers. Then I want to circle back to this idea to one pill can kill, which I have some problems with. I do think it feels very reminiscent of other messaging that is more based on scare tactics. We've used some focus groups. I have this young adult community advisory board. They've all been impacted by overdose. They had some concerns about how it felt in terms of as a scare tactic. They were also like, but it's really important information because it's true. That idea of messaging and how we don't say it's not true, because it's true, but how do we offer it in a way that is palatable and sounds like you're not trying to just scare someone. It's more of a conversation starter and not like you just can't do this. Letting people know where an option is. I think as someone who is coming from more of the treatment and harm reduction world, I recognize the tension or the challenges maybe with how do we work? Think about primary prevention. That's where I guess I just want to ask the question, do they have to be mutually exclusive? Why do they have to be opposing? In my head, those are not the conversations I have with kids. We have the safest thing for you to do is not use. Let's talk about the different ways that use can be really harmful because kids should have access to that information. They deserve all of the information. Then let's talk about how you're going to use that information in your life and how are you going to keep yourself safe? How do you think about your safety? How do you make decisions about when you're going to use drugs or how you're going to use drugs? If you're with your friends and you're not using, how are you thinking about their safety? Teens are often very worried about their friends and want to make sure their friends are okay. Leveraging peers, this idea of peers, that is also a really consistent theme we've heard in a lot of the qualitative work that we've done and with this community advisory board is just the power of peers and not actually thinking the adults. I don't know. I'm going to the Boys and Girls Club Monday night in Lawrence, Mass. I'm supposed to talk about overdose and I'm like, did they really want to hear from me? Probably not. I'm hoping they will learn something and then be peer ambassadors. I'm so anxious. I'm much more anxious. It's so easy to talk to peers. I do think that that's another opportunity, something we learned certainly from HIV prevention that peer work can be so powerful. How do we make sure we give peers accurate evidence-based information that they can use to teach their peers about safety? Engagement. This is just another thought about engagement. We often say that young adults, sometimes people with drugs, adolescents are hard to reach. I think if you talk to a lot of young people, they're like, I'm right here. You guys have messed up systems that are impossible to reach. This is not me. This is you guys. Language matters. We all know that. We've talked so much in this field about the importance of language. This idea of special populations are hard to reach. Let's think about the framing of where those words come from and maybe push back. I feel like I'm neglecting or giving it away. I mess up all the time. I'm working on my language all the time. I say things that I wish I didn't say or that are judgmental. This is just a call for all of us to have some humility as we're thinking about our language and always be willing to think about, did I say that in a way that might have been off-putting or not as inclusive as I wanted to be? Telehealth, I think, has been this really important development in the field of substance use in general over the last couple of years. This is certainly true of youth as well because we can increase access. We can reduce barriers of care. We can improve engagement, all these things that I think can be challenging for youth. There's the potential to exacerbate inequities when people don't have access to phones or Wi-Fi. I think that is a thing that is real and we need to think about. I'm laughing because I talked to a patient on Tuesday afternoon who is this young woman who is experiencing homelessness and was in the emergency department with an overdose and hypothermia over the weekend. She couldn't make it to our appointment. We changed it to telehealth. We had a long conversation while she was on the T in Boston, which was maybe not great. I tried to limit the things that I was asking her in terms of what she would disclose. We were able to address a lot of things. We actually talked for 25 minutes. I couldn't have done that or I wouldn't have been able to bill for it, I guess, a few years ago. I probably would have done it. We were able to do, I think, some good things. She's more engaged with us because we're able to offer that kind of care. That's critical. Digital apps are another space that I think, especially for youth, so many of them who do have smartphones or live in this space are really important. You'll have access to these slides or to the PDF at playbill.com. I would encourage you to go to... There's a colleague who's at Dartmouth, Lynn Filene, who has this lab where they have created these video games and have some pretty good data around substance use prevention. They are very eager and willing to partner with schools and practices to be able to share that information. I strongly encourage you to go check out their stuff. I think she's a really thoughtful person and has created some really incredible materials. That could be a place if you want to learn more. Then, I think just thinking about aligning goals as we think about engagement. I think this is where we check our assumptions and don't think that we might know what might be most important to a young person, keeping questions open-ended. These are some of the basic things that we all learn and explore if any of those goals can be motivations for behavior change. Offering a menu of options. Developmentally, youth are trying to figure out who they are, and they are trying to be independent people. The more we tell them exactly what to do, this idea of them pushing back is actually pretty developmentally appropriate. They should be trying to figure out, how do I make choices? How do I make decisions that are going to be best for me? The more we can do to give them choices, even if they might need to sometimes be limited, is a way for us to actually encourage their development, which is really important. Is it going to be in-person? How many in-person versus telehealth? Sometimes, I'm making these a little bit arbitrary choices, but then they get to choose. I'm showing them that I trust them to make that choice, which I think does improve engagement or in many experiments. What would it look like for you to cut back? What is that like, or can you make different choices? Can you not do it before? If you were going to not vape on a certain day one time, when would that time be the best time for you to not vape? Again, choice, choice, choice. Having them feel like they are engaged, I think it can be helpful. Yeah? Okay. So, one thing that comes up a lot is what does it take to keep a sense. I know there's often some unknown between what actually is allowed and what people are practicing, especially in the content field. I'm going to talk to you about that hazard between somebody, what has to be shared with them, and when somebody is old enough to make a decision to keep certain things. For example, in Adelaide, they immediately undertake a self-loss substance use treatment. They're not able to make that decision because they have to make a decision to not do that. So, I'm not sure if an opportunity is different, or what they're under doing if you were to move below a certain limit of what's allowed and what's not allowed. Yeah, no, that's a great question. So, it's interesting. I actually found something, and I think I have a slide on confidentiality, where I found in Maine that a minor could consent. I'm going to try to go back and find that reference, but I had, you know, although I didn't find like a lower limit, and I think this idea of lower limits and like where is, you know, so I am so fortunate that I get to work part of a team where oftentimes we are making those decisions together because there is a lot of, there's so much gray in terms of when should we be engaging parents, when is it okay for parents to maybe not be as engaged. It's always better to, it's almost, it's like most of the time, it's better to have families involved unless there's like a safety concern with the family member, and sometimes like the kid really doesn't want that, and so we then, I think, first try to make a decision like is there an acute safety issue, like is there a reason that even though this adolescent like or this minor does not want us to tell the parent, like we just have to do it anyway. In those cases, we still try to engage with the adolescent about like how do we have this conversation, what are the link, you know, what are the words you want us to use, how much of this do we have to disclose, and how much of it maybe do we not have to disclose. Is there a way to keep some of what you told me sort of not, confidential, but still sort of come up with a treatment plan or a safety plan where that we can all be comfortable with, and so that's usually, you know, that's usually what we do. I think we also know that this slide is on family involvement. This is perfect, that in, you know, in a perfect case that families can really like reinforce and be sort of positive allies at home because the kid, you know, I work in primary care, like I'm seeing them maybe for a half an hour, and even if they're seeing our social worker every week, like just so many more hours at home with their family, and so sort of not actually engaging and working with the people who are with them the most, like it's hard to see how that can be, like that's just going to make it our job harder, and make it harder for the kid to, you know, achieve their goals, but I rely on our team. I mean, that's sort of my answer to that is that oftentimes that gray zone, we make decisions together. have to make a decision as to whether that young person has the maturity, the understanding, but you and the adolescents really get to make that decision. You may decide it's really important to me, but every day, it's 15 or 10 times a day to pick it up. And I was trying to ask you, if you do not need a gray zone, those three things, you're probably more than fine. I just didn't want you to pick it up. So the why, that story, that's changing, but I'm sure sometimes people don't hear that. That's the why. We have a little laminated tag. I mean, that's supposed to go wherever they left it. It would be kind of, that actually sound like a beautiful, we hadn't done it, maybe they were playing. But it's like a little laminated tag that absolutely went through the five or six decks with the big and small ones. But my understanding is that they wound up on the wall. Awesome. That's great. Thank you. I know I'm Italian and Jewish, so I'm pretty loud. Well, I don't know. I think I've seen it for anybody who's been in the profession. I can fall back there. I did it 24 years. And we feel like a who's done and who's still. But I can tell you some of the things that do work. And peer-to-peer is definitely one of them. The problem with peer-to-peer sometimes is you're opening up to a lot of vulnerabilities and triggers that you need real help to support that. So you've got to be careful with that. But in the meantime, there's four things I just want to say. We're looking at COVID cells. But we thought it was not just saying no and wanting to kill, kill, kill. It's, if you have adversity in your life, what are you doing about it? Exactly to your point, are we saying, are we getting longer using drugs? That's in the framework. But what could you do when you feel angry, happy, sad, whatever it may be? So a lot of this resilience and coping skill is really working, but also like social norm. And it is a tsunami of industries that are bombarding these kids on social media and every place else. And I'm sorry, the legalization of cannabis has not helped. Sorry. Because the access and the perception of harm has gone way down. We think it's healthy, we think it's medicinal, we think it's okay. And kids can get it anywhere. Black market is everywhere. And so we've got to do something at the top. Credible people like you saying, we can't let these industries target these youth. That's where a huge problem is happening. And us in the trenches, we can't do much about it. So we would love to hear your voices like doing that kind of stuff. All of those drugs is the access as to why we need harm reduction to begin with. And also overcoming that stigma of asking for help. And so how would we do that? And to Steve's point, it's again, another tsunami that's ridiculous. But anything we can do in education on just, it's okay, it's a disease, and we're gonna wrap it with compassion. And lots of school districts, you may not know it, are really going into the training of everybody on what's not. And communities, I think there's a lot of good that is happening in communities, particularly through those ESC grants and SAMHSA and all of that. But a lot of people don't know it's happening. So anyway, just a note on youth prevention. No, I love it. I think too, that sort of gets to this, like what age and the developmentally appropriate ways to think about it. And I think, thinking about in elementary school, talking about coping, sort of teaching kids really early on about resilience and sort of thinking about before substance use potentially has started, talking to kids, because that is also the rest of your life. Like I'm an adult, I face the diversity. There are things, and there are things that I need to pull on in order to address different challenges in my life. And that's what I want sort of very young kids to be learning about as well, ways for them to be able to pull on those different tools in their toolbox to be able to do that. And I really appreciate sort of the marketing issue, because I think that is, it's very reminiscent of alcohol and tobacco. It's very reminiscent of that. And I think it's a huge, it's a huge, like it's just a huge issue. And I appreciate you thinking that I'm credible, so that's good, but I agree. I agree. I should, I will, I think that is important. And we need to be like louder about this stuff too. And I'm just so excited to hear about what's happening in terms about overdose education and naloxone in schools too, because I think that again, in my state, I've just been like trying really ineffectively to have changes. And so it's really awesome. It's just awesome to hear that. And then finally, this idea of like support for peers, I think is also just so critical. We have seen, and for this is true for adult people, and anyone doing work needs supervision and support in doing it, whatever your role is. And so we should not, this idea, which I think sometimes I have seen of like, yeah, peers being able to do it without that support is like really problematic. And it's not fair to youth to not set up those systems so that they are well supported. Oh, I did want to, the Partnership to End Addiction, I don't know if any of you are familiar with it, is this nonprofit group in New York, and they have some really nice materials for parents really targeted towards parent, like family members of like teenagers and young adults. And they have, they sort of have the continuum of like before your child might've started using substances to kids who have an substance use disorder or have had an overdose. And so can be a useful place to sort of call on getting some more evidence-informed information. And then this idea of like how to make decisions. So if we're talking about kids who have substance use disorder, I think, I always think like the best treatment is the one the adolescent is willing to engage in. And so, and it's like really important that we also make the assessment of like, what is actually the level of care that this kid needs? If I can get them to agree, like I should be really actually crystal clear about like my recommendation to you, teen and youth family member, is that this is the level of care that you are needing sort of based on your substance use disorder and like co-occurring mental health and like other medical comorbidities. Because I think sometimes I have seen like that part being missed and I just don't want that, in terms of equity, it's really important. And then, but at the end of the day, I need to get that kid engaged in that treatment and willing to engage in that treatment. So anyway, and treatment availability is challenging. Massachusetts, a lot of programs are shut down. And so like some of it is sort of trying to just do the best we can, given the resources that we have. But there's a comment. Yeah. Just, I'm sorry to interrupt you. To the point of advocacy for people in the community regarding cannabis, there's a lot of disturbing stuff going on in the legislature right now, including a bill that would remove the requirement of the THC label on edible gummies, which I don't think is of concern to children. But more importantly, there's a 90 page bill with the rewrite of cannabis laws and the Veterans and Legal Affairs Committee, the lobbyist for the industry is sitting in the workroom helping them write this law and centers on the committee and the testifier to the docs, to the caller, to the car and parking lot. I mean, it should take in the public's online. So there's a lot of distressing stuff going on in the community right now around cannabis and revising the laws that are in place dramatically in favor of the cannabis industry, including allowing minors to transport cannabis products from one business place to another. So yeah, if you're interested in that, let me see, calling your legislator and voicing your concerns about that would be helpful. Great, thank you for that. Thank you for that comment, because I think a lot, you know, we come in these spaces together and we hear about things and it can be really upsetting and we, you know, like we're empowered to do something about it too. And just such an important thing to do is to elevate our voice, call our legislators and let them know what sort of what we think is people who take care of people who use substances. So we're going to talk a little bit about language. This is, some of this might be familiar and I just have a couple of other sort of thoughts, but specific or developmentally appropriate ways that we want to think, that I think about language. You know, we know that stigma towards substance use and substance use disorder is common and is really rooted in this belief that substance use is a moral failing and that these beliefs are the result of political and social policies and really have an impact though. There's like such a strong evidence base that actually stigma has a very direct impact on people's outcomes. It isolates individuals, it creates shame. And there are ways that we can address this though in our everyday lives, starting with the, you know, thinking about the language that we use when we talk to people who use drugs and the treatment that they deserve. These are actually language, this is a, these are a couple of tables from the American Academy of Pediatrics published a policy statement in the last couple of years sort of with suggested language that people can use. So you will, I'm not going to go through all of it, but you can, you'll have access again to the PDF. And it's really about using person-centered language. I, you know, this idea of stigma towards treatment, I think I feel especially acutely when I'm taking care of youth who have opioid use disorder and are being treated with medications. Very early on in our work, taking care of adolescents and young adults, we just sort of were really sort of impressed by the beliefs that family members, but then also like agencies that were involved in youth lives, like, you know, DCF and DYS, that they had a lot of thoughts about us prescribing buprenorphine, that, you know, we're surprised, we're surprising. I was naive. I was just at a fellowship. I was surprised because I was like, this is this evidence-based thing. Aren't I doing the right thing? And like, that was, those were not the conversations I was having. And I didn't really handle them very well looking back, but we did start to write about it a little bit. And because I think I'm always thinking of, I'm a researcher too. So I'm always thinking about sort of how do we share this? How do we think about developing interventions that can have a more public health impact in including sort of elevating the issue of stigma. And then finally, youth-specific consideration. So for some youth, recovery, like that might resonate. Like that might be sort of a word, maybe their family, there are other people in recovery or sort of in their community and treatment settings. Like that is going to be, those are going to be communities that they, that's how they see themselves. I've also had patients who are like, that's not how I think about this. I don't think about myself as in recovery or that's this other group. Maybe I'm still sort of like using some drugs. Like I'm using cannabis, but I'm not using opioids. Like am I in recovery? I don't know, but I'm safer and I'm feeling healthier. And so I think that can be tricky. And so I think this is about asking people sort of how they think about themselves and how they identify and then sort of aligning our language with them. And I think this is also a space, and Steve was pointing out some limits potentially to the chronic disease model. I think, again, any of you who take care of youth, like it's really hard to have a conversation about like something that is going to be chronic and relapsing for the rest of your life with a 17-year-old, right? And so I think that sort of thinking about these like short-term implications and consequences of drug use, and so is where it is. Like it's about sort of getting to their developmental stage and helping them think about like the consequences of this drug use now is going to be the thing that is most salient. Like that is sort of well-known in terms of like taking care of youth, yeah. Just quickly, the chronic disease model piece I think can't be overemphasized as the wrong way to approach it in youth given that they have the highest self-remission rate of anyone based on use. In the neurobiology, it actually doesn't show the chronic disease achievements until they're age 25. And the clear majority of them can actually regress back to their mean of their pre-use risk if they are in a program of decreased utilization that's not consistent. So the neurobiology does not back up the chronic disease model. But it brings me to the question of as we build the adolescent version of the ASAM criteria to dimension levels of care, we're completely changing it for adolescents because the adult version isn't the wrong pathway. One of the things we're struggling with, I love your opinion on this, is the, how old is you? We're talking about how young, and many chronic diseases, like single cell, all of those kids until they're 24, 25, what we're going to put for adult care. But there's this magic 18 in a lot of what gets paid for and what's covered, and I don't see that seems to really have a lot of these kids drop out. Yeah, no, thank you for asking that question. And I, so we choose 25 in our clinic, which is just like a little bit arbitrary, to be totally honest, like we sort of had to choose, you know, and so I think I often is like more based on like studies, though, that have done sort of choose 25, 26, or sometimes 29, or 21, because that's what people are like voting, you know, like, but it's, it all does feel like a little bit arbitrary. I do think there is a strong case to be made for like, including young adults with adolescence because of what you just said, in terms of like falling off this cliff. That is where we see, I think, in general, in healthcare, sort of kids falling off in like the criminal legal system, like there are programs that do have like young adult units. So it's like, they've sort of figured out that like, we actually do need young adult specific care. And so, you know, thinking a lot about methadone, we have a, you know, a few young adults who I think would really benefit from methadone, but going to a methadone clinic is like not possible, like, it's just like not possible. But if we had young adult, like adolescent young adult methadone, or more developmentally appropriate methadone, like I do think there would, I know there would be openness of talk, you know, talk to them about it. So I would sort of think about like, is there some way to sort of have, and I don't think a 14 year old should be with a 23 year old. So is there a way to sort of say, like, we should be thinking about sort of, I don't know, 13 to 17 year olds, and then like 18 to something, you know, as this like transitional or that they also need this other kind of assessment that you know, to figure out, but that it should be probably distinct from adult care, which is hard, though, because they are adult, you know, legally adults. And so, you know, yeah. Okay, so this is just this is a quote, I'm not going to read all of it. We did this qualitative study with our patients who have opioid use disorder, and ask them questions about recovery and identity, again, because we are like always trying to be better and trying to design our programs that are to be more resident relevant to them. And this patient or this participant said, you know, they don't want their lives to continue to be defined by substance use, including if it means being not defined by your substances. And I think this idea of like not being reduced to your diagnosis, or like the one behavior you're, you know, that you're engaging in is really important. And I think, you know, I'm coming from a biomedical perspective. And like, that's what we do is we diagnose and we get people. And we tell them that these are the five things that you have and like does not always necessarily consider the whole person does not consider their like goals and motivations and the things that bring a smile to their face, the things that they're worried about, and the things that might actually be sort of more motivating for them to engage in care, not actually the diagnosis that they have. And so I keep this quote with me because it's like, it's like I need it, you know, like I need it sometimes to when I'm sort of getting busy and caught up in things to sort of center the center the work that I'm doing and grounding. But yeah, there's a question out there. So the question goes to that notion. But I'll think I've noticed this often what we find that what we're saying would like primary prevention or secondary. It relies so heavily on the diagnosis, but with adolescence, we're going to see the use but they've not developed the substance use disorder. We'll delve into that with the new edition of the exam. So I'm really looking forward to that conversation. Because as we think about adolescent use, we might be able to do that without relying just on just on what I'm going to work with the adolescents. Yeah, you know, they don't have a diagnosis. Earlier you mentioned that 25 is gone. So how do we justify it from the treatment? Yeah, can you tell me more about what setting you're in? I work for a medical cannabis agency. I'm also the director of substance use research. Okay. Yeah, no, I mean, I think this is really important. It makes me think about, we are really eager to figure out, actually, like, models to engage families whose kids don't want to talk about their drug use, but, like, how do we say to, like, parent, come in, because you're worried about your kid's cannabis use. They don't have a use disorder, so treatment isn't the right thing. But I want to somehow, like, invite families who have kids not engaged at all in anything still to be able to, like, learn some, you know, because maybe they are motivated and they're engaged. And that is, I'm just sharing, like, a struggle we have had in figuring out, like, a model. Like, we haven't been able to, I mean, to be honest, like, we haven't been able to figure that out. Are you talking about adolescents that might be using, they don't have a gun? Yeah. I love it. Yeah, we haven't, I know a little bit about craft, we haven't been able to figure out how to like integrate it into primary care, but I love that's awesome because I think that's what you need right you need any, you know, any opening is the is the right opening. Okay, I have five minutes so I'm going to, you're going to, like, we're going to go very quickly through trauma informed care, which is actually very though I think reinforcing a lot of the things that we've already talked about these are the principles of trauma informed care from the SAMHSA website. And I just wanted to offer a couple of like very specific things that we do to try to have a more trauma informed approach in our primary care setting. So one is taking the history and just sort of this remembering that sharing parts of the substance use history can be really traumatic for anyone including youth. and that when I'm just meeting someone, I'm not sure how it's going to work. I just don't know everything that's happened. So always starting the encounter with someone, acknowledging that it's a big deal to be coming in today, and really thanking them for being there, and recognizing that they may not really know who I am yet, and they don't really have a reason to trust me yet, and that's okay, and we'll be working on that over, hopefully, the time that we have together, and I try to always do that at my visits, no matter how long I've known someone, and then, you know, I have the privilege, in primary care, what I'm able to do is really focus on the history, like, and the parts that are related to, like, safety, the kinds of substances they're using, where they're using them, and how they're using them, because I am just always thinking about overdose risk, and, like, potential for withdrawal and driving risk, so that I can make sure that no matter what happens at the end of that visit, I can be offering some guidance around safety, but I'm going to have a longitudinal relationship, and so I'm able to do that. Language and transparency, these are sort of themes that we've talked about all morning, just sort of this idea of using compassionate, non-judgmental language, and I think being really clear about confidentiality from the very beginning, we are always doing that, about what the limits of confidentiality are, when we would break confidentiality, and even when we need to get DCF involved, because, like, there are times, I imagine some of you, like, I didn't know I was going to need to call DCF, or our social worker was going to need to call DCF at the end of the first visit, but, like, something comes up, and we just don't want folks to be surprised, and then this idea of choice when possible, which is, like, developmentally appropriate, and, like, you know, the thing to do, slide on confidentiality, which we have already talked about it, and here's the survey link. I think I even finished now a minute early. I'm happy to take more questions, or I can, like, hang out a little bit before the next session. Quick, very difficult question. to get them in front of you. They need to do a safe test. I'd love to see the statistics. that really need these conversations. But we don't have anything. We don't have a plan, and they're not going to come to us. But we have something to try. No, thank you so much. I mean, that's what we're seeing in Massachusetts. One of our recovery high schools is shutting down. Our programs are shutting down, and it has to do with people not being engaged. And so yet, we know that the kids are out there. So I do wonder about going a couple of thoughts. One is more of a public health approach, so thinking about schools, trying to leverage places where kids are involved. I do think about thinking about the craft and models to engage families in a more explicit way, even if we're not engaging teens first, thinking about families and parents or guardians as a first step. And then maybe there's a way for us to learn more about kids and motivate them. And then I wonder, too, I don't know. I mean, I've been increasingly thinking about, how do I partner with youth or youth organizations who maybe aren't related to substance use or mental health specific, but that maybe those kids are. That's why this Boys and Girls Club thing, I'm curious to see how this goes Monday night. Because maybe there are ways for us to not have it be central to mental health or substance use, but have that be an option or a thing they can access there. But actually, all the other reasons for why they show up there, which has to do with their positive development, are more central. But I don't know. Yeah. and they're learning their usage and their problems with the arts. So don't talk about drugs. Make it something that's real, because it's not going to completely ruin their life. I know. I was actually just, when Steve was talking, we have a local art center. And I was thinking, actually, I'm going to reach out to them. Because my kids are really, anyway, that they could be an interesting partner. So. Thank you so much. Wow. So this may be too far off, like 30,000 feet off. But if I recall, youth over the past decade or so have been using substances less from national surveys. And I wonder, does that either teach us anything, or does it give us any sort of strategy? Or do we understand that in a way that's helpful? Yeah. That's a good question. Okay, so this is like me opining. I think in general, like there have been really positive successful prevention efforts like that have led to this decrease. And so I think that some of it is we are seeing that as a result of more prevention programs in schools and strengthening families. Yet the overdose rate has gone up. And so I think that has to do with the toxicity of the drug supply. There was also this other paper that just came out from the CDC last month showing more kids who are entering substance use disorder treatment who are using alone and using to treat, you know, mental health symptoms. And so I think that also can explain, you know, increasing overdose rates in terms of why people are using. I do also think that the national surveys, there is some risk of missing some of the highest risk kids because they're just like not going to be in school or like maybe their homes are not the ones where people are, where like the national survey and drug use health are being administered. And so wonder, you know, wonder about that a lot. When I talk to like teachers or nurses in schools, like they feel like everyone's vaping. So like it's, so there is sometimes this like disconnect. And so I don't know how to, but I also don't want to diminish, diminish what I, which I do think has been some like really positive work in the prevention field to decrease, to decrease substance use too, over the last couple of decades.

engaging youth in care

substance use

best practices

anecdotes

trauma-informed care

stigmatizing language

adolescents

harm reduction

peer support

legislative changes