Hi, everyone. Thanks for joining us. I'd like to welcome you all to today's presentation, Engaging Youth and Their Caregivers in Medication Treatment for Opioid Use Disorders. This session is sponsored by the New England Region Opioid Response Network. Next slide, please. It's great to be here with you all. My name's Jenna. I'm a technology transfer specialist working for the New England Region of the Opioid Response Network. Just some background information, the RN is funded through a grant by the Substance Abuse and Mental Health Service Administration, and our grant prime is the American Academy of Addiction Psychiatry. We provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulant use disorders, and we also cover the areas of prevention, treatment, recovery, and harm reduction. Next slide. This opportunity is provided at no cost, as it's covered through the SAMHSA grant, and one great thing about us is our organization covers the entire United States and U.S. territory, so we have a very far reach. We are broken up into regions, and so we are the New England Region, which is the six New England states, and each region has their own technology transfer specialist who can help you with any requests that you may submit. Next slide, please. If you are interested in submitting your request, here is our contact information. The best way is to go to our website, submit a request, you'll see it right there when you log in, but yeah, we'd love to hear from you all. Any request is a good request, even if you have questions, we can put together resources, so please reach out to us in the future. Next slide, please. And so before we jump into everything, I just wanted to let you all know a few of the Zoom controls just so that we're all on the same page. I have enabled live transcript, and if it isn't showing up, I'll make sure I do that after we start the session. So as I mentioned before, please drop your name in the chat so we can see who's here, who's joining us. If you have any questions, if you need any technical assistance, please reach out via the chat as well, or if you have any topic-related comments, we will be doing a Q&A session at the end. You can either raise your hand, you can come off of mute when we do the Q&A session, whatever you're most comfortable with. As I mentioned, that portion will not be recorded. And lastly, at the end of this presentation, you'll see a slide that has information on how to access our free learning management system, and that's where you'll be able to access your CEUs, because we will be offering those today. I just want to make a note that you do have to complete the evaluation and survey in order to download and receive your CEUs. We just really appreciate everybody's cooperation in taking the surveys, because it allows us to keep doing free trainings, and it allows us to see how we can improve our services. I will also email everybody all of this information, I know it's a lot to take in through a whole training on how to access your CEUs, and I'll also send the slides and recording a link on how to access that as well. That should be in the next three to five days, so just check back if you aren't seeing those with the link that I share. Without further ado, we're fortunate to have Dr. Amy Ewells as our presenter today, and I will now pass it over to her. Great, thank you, Jenna, and I'll just put another plug in for encouraging feedback. This is a newer talk for me, and so I would love any feedback that people may have about how it went and how to make things clearer in the future. So my name is Amy Ewell, and I'm a child and addiction psychiatrist, and it's really a pleasure to talk to staff from Motivating Youth in Recovery. I've been referring patients to you for the past 12 to 13 years and really appreciate all the work that you do. So today we're going to talk about engaging youth and their caregivers in medication treatments for opioid use disorders. The learning objectives are listed here, and over the next half an hour, 45 minutes or so, we'll talk about the differences in mechanism of action for medication for opioid use disorders. We'll describe differences in how to approach and engage youth and their caregivers in discussions regarding medication for opioid use disorders in comparison to how we might approach adults, and then we'll review harm reduction practices to discuss with youth who misuse opiates. And so to start with, we're going to really dive into the details of medications for opioid use disorders, and want to kind of start by highlighting, you know, why medication for opioid use disorders are important, and really for all ages, there's been an increased emphasis on the use of medication to treat opioid use disorders because these medications decrease overdose risk. We have the clearest data from studies that have been done with buprenorphine and methadone in adults, and, you know, really substantial decrease in overdose risk, so a decrease by 70 to 80 percent when individuals are stabilized on buprenorphine and methadone. There's been less studies with naltrexone extended release, looking at the specific issue of overdose risk, but we do see in studies that have been done that compare naltrexone extended release to inactive medication that there is a decreased rate of overdose in individuals treated with naltrexone in comparison to those who are not on naltrexone. And as we think about adolescents in particular and medication for opioid use disorders, you know, unfortunately, they're less likely than adults to receive these medications, and so this is a study that looked, used insurance claims data to look at youth with an opioid use disorder and the receipt of medication for an opioid use disorder, and so for youth ages 13 to 17, and these are kids, again, that have an opioid use disorder, only 5 percent of them receive medication for their opioid use disorder, and for youth 18 to 22, only 27 percent of them receive medication for their opioid use disorder, and you may say, well, this study was published, you know, a few years ago now and published in 2018, so things might be different, and, you know, we have seen an increase in buprenorphine prescriptions specifically for adults, but we actually saw a decline in buprenorphine prescriptions for adolescents, and so unfortunately, these numbers haven't changed much over the past five years. So medication is important not only to decrease overdose risk, but as we think about adolescents and young adults, medication is very important in terms of helping improve retention and care, and so this was the same study that looked at, you know, receipt of treatment and receipt of behavioral health treatment and then behavioral health and medication treatment, and then how long people stayed engaged in care, and so the figure on your left is showing you the percentage of people, percentage of youth that remain engaged in care over the course of a year, and so the higher line is better, and when they compared those who received medication and behavioral health services to those who received behavioral health services only, did see, you know, a much greater proportion of individuals who received the medication stayed in treatment for a longer period of time. And so now that we've discussed the importance of medications for obese disorders for adolescents and young adults in terms of the importance of these medications in decreasing overdose risk and their role in helping youth stay engaged in care, we're now going to switch gears and talk about some of the details of the pharmacology of these medications, and so I'm going to use the terms antagonist, partial agonist, full agonist, and just want to define kind of what these terms mean, and so within their brain we have receptors, opiate receptors, and an antagonist is a medication that binds to a receptor in the brain but does not activate that receptor, so it blocks anything from binding to that receptor, so if you have the antagonist and an opiate receptor antagonist and there's opiates around, it's going to block opiates from binding to the opiate receptor. The other thing that it does is it displaces opiates, so if you have opiates in your system and you take this antagonist medication, it has a higher affinity for the receptor and so it will, you know, displace the opiate and then bind to the receptor and again block the receptor, so it's a blocker, and then a blocker that's not doing anything, and then agonist medications are medications that actually bind to the receptor and do something, and so partial agonist binds to the receptor and causes a partial biologic response, whereas a full agonist is a medication that binds to the receptor and causes kind of a full response and so has a stronger effect, and so the medications for opioid use disorders fall into these three different groups, and we'll kind of explain a little bit more of this as we go on, but I just wanted to provide that initial background. And so the FDA-approved opiate receptor antagonist medication for opiate use disorders is naltrexone, and it's FDA-approved for individuals above the age of 18, and so this is an antagonist, so again it blocks the effects of the opiates, and I mentioned before that if you have opiates bound to your receptor and then you take this antagonist, it kicks them off and then blocks the receptor, and so if you had an opiate bound to your receptor and your receptors were used to having opiates bound there and then all of a sudden it disappeared, you would have opiate withdrawal symptoms, and so that's why for this medication people really need to be off of opiates for several days before starting the medication because if you have been taking opiates on a regular basis and then you take this antagonist medication, it's going to push you into immediate opiate withdrawal, which is very uncomfortable, and then people don't, you know, tend to continue the medication. And so if you look on the package insert, it typically says you need to be off of opiates for seven to ten days. In the inpatient setting, that's a little bit easier to support somebody who's been using opiates for a period of time and not using opiates, but in the outpatient setting that can be a little bit more difficult, and so often we'll try to kind of introduce a tiny bit of a medication after maybe three to five days and try to support somebody in transitioning to this medication after they've stopped their opiate use. And so this medication does come in a tablet and injectable form. Naltrexone is FDA approved for adults for both alcohol and opiate use disorders. For opiate use disorders, however, the medication has not been found to be effective in the tablet form. And so for, you know, thinking about using Naltrexone to treat an opiate use disorder really aren't, you know, you do have people take the tablet just to make sure they can tolerate the medication and they don't have an allergic response or adverse side effects, but then you quickly transition to the injectable form. And so the tablets and the oral medication is really just used to assess tolerability before you transition to the intramuscular injection. And so, you know, we have some nurses in the audience, and so important kind of thing to know about Naltrexone is it's a large quantity of medication that is injected. And so, and then the other kind of tricky part about this medication, especially in the outpatient setting, is that it does need to be kept refrigerated, and then you mix it shortly before injecting it. And it can cause quite a bit of discomfort. So I think often in interacting with families, they might say like, well, just give them the shot. And I'm always very clear that this isn't a flu shot, it's a gluteal injection, and there can be soreness. That soreness can be relieved by massaging the area, using a warm compress, and is definitely tolerable. But I don't want kids to think that they're just getting like a flu shot, kind of a small poke. There really is some soreness, and it is, you know, substantial amount of medication that is injected. So that's a little bit about Naltrexone Xtend release. So one other antagonist is Naloxone. And want to be really clear that Naloxone is not used to treat opioid use disorders. Naloxone is used to quickly reverse an overdose. It takes, you know, around two to three minutes to work, and lasts from 30 to 90 minutes. So the way that Naloxone works is, again, you have opiates bound to your receptors in the brain. Someone has too many opiates bound to their receptors in their brain, and so they're starting to overdose. Their breathing has slowed. They're not conscious. And so we want to quickly get them breathing, back to breathing, and make sure that they stay alive. And so this antagonist, when it's injected or kind of absorbed in the body, either through an intranasal spray or other forms, quickly displaces opiates from their receptors. And so that's how it works to save somebody from overdosing. So it kind of blocks, you know, the opiates are bound to those receptors. Naloxone comes in, pushes them off, and then blocks the receptor. But the hard part is that this doesn't last for forever. And so if you have a lot of opiates in your system, and you use Naloxone, it's going to wear off. And so it's important that people be thinking about calling 911 and getting additional help, since you want to make sure that someone is stable over time. And I think the confusing part is that we have Buprenorphine slash Naloxone. And kids and families can get confused about what Naloxone is. And so Naloxone was combined with Buprenorphine as part of the formulation and kind of approval of this medication for the oral medication. So for the tablets, and for the sublingual film, it's Buprenorphine Naloxone. But people don't absorb the Naloxone when it's administered sublingually. And so when Naloxone's administered by a nasal spray, or by an intramuscular injection, or intravenously, it's active and and is working in the brain. When you put it under your tongue, it's not absorbed or active. And so it's there to prevent people from misusing the Buprenorphine. But it's in no way protective of overdose, or doing anything to kind of stop overdose. And I think, again, kids and families can get confused about this. And so when we think about Buprenorphine Naloxone, just think more about the Buprenorphine. And so the Buprenorphine is a partial agonist and binds to the receptor and activates it to a lesser extent than methadone does. And the reason it was designed to be a partial agonist is that if you took extra Buprenorphine, there wouldn't be respiratory depression. And so with methadone, if you take extra methadone, as a full agonist, you do end up with someone may have slow breathing and would be at risk for overdose. Whereas Buprenorphine as a partial agonist does not cause that respiratory depression. There's a sealing effect. So you could take a lot of Buprenorphine, but you would still be breathing. And so that's why it was designed to be a partial agonist. It was a safety feature. And so the way that Buprenorphine works is that, again, it's an agonist. And so it binds to the receptor. By binding to the receptor, it blocks the euphoric effects of opiates. And so if you have Buprenorphine in your system at a high enough level, then any opiates that you might use, either fentanyl or other opiates, won't be active. So because the Buprenorphine is bound to the receptor, it's going to block other opiates. And then the other way that Buprenorphine is helpful in helping people to stop their opiate misuse is that it prevents or minimizes withdrawal symptoms. So it helps, you know, when people are using opiates, they're going through a state of kind of rapidly going through these states of intoxication withdrawal because there's, you know, they have these kind of periods where there's a kind of quickly a large amount of opiates bound to the receptors and then those kind of opiates go away. And so this is, you know, binding to the receptor and causing kind of a consistent response. And so then people don't have opiate withdrawal symptoms. And then it does decrease cravings. So the tricky part though about this medication is to start it, for people who have been using opiates regularly, you do need to be in opiate withdrawal because it's this partial agonist, it's not a full agonist. If you have some opiate receptors in your system that are fully activating your receptor, like fentanyl, and then you replace it, because you take this medication that kicks off the fentanyl and replace it with a partial agonist, you're only partially activating that receptor. And so then therefore you're going to have opiate withdrawal. And so this has been the tricky part about buprenorphine, especially in the era of fentanyl, where people are using really potent opiates, can be tricky to kind of time things such that people are having enough withdrawal to kind of take this medication and not have additional withdrawal symptoms. But a very effective medication and can be a good one to get people started on when they're in a residential setting. And so as we think about the formulation, you know, it was initially approved and released as a tablet, and then the film strip was developed. And those are, the film and the tablet are taken sublingually daily. And one thing to be aware of, especially as we think about youth, some youth may have been, had some experiences with buprenorphine in the past, either in a different detox or residential unit, or maybe they borrowed some from a friend or something like that. It's really important to make sure that they know how to take it sublingually. That's a different way to take medications. And so I have often found that kids are like putting it on the top of their tongue. They're not waiting for it to dissolve sublingually. They have all sorts of ideas about it. And again, get really confused by this whole buprenorphine, naloxone kind of combination. And so important to make sure that they're taking it as prescribed and taking it sublingually. And then over the past few years, there, you know, were other formulations developed at Buprenorphine, including subcutaneous injections. Some of them last for a week, some of them last for a month. The monthly formulation has been more widely available over the past few years. And so I think many of us are familiar with using this as an outpatient. The subcutaneous injection is not painful. It's, you know, again, subcutaneous. But there is kids, when they first have the injection, they kind of have this fluid, it feels like a fluid ball of sorts. And then over time, that consolidates. And you will still feel like a little bit of, it feels like a kind of hard lump that does dissipate and go away over time. But when you are doing monthly subcutaneous injections, you do rotate the site in the abdomen where you are injecting the medication. And then the oral formulation is FDA approved for youth ages 16 and above. And there, but there have been, and so that in part just means that there has been a lot of research and a lot of studies done looking at, you know, the safety and efficacy of the oral formulation for youth under the age of 18. And so the subcutaneous injection is not FDA approved, but we have been using it in youth. And there definitely are case reports published in the literature showing it to be effective and safe for youth, but it is off-label. In terms of typical doses for the oral medication, when you're using the Filmstrip or the tablet, typical doses are 8 milligrams to 24 milligrams. Pre-fentanyl, it wasn't uncommon to see people on 8 to 16 milligrams, but in the era of fentanyl with it kind of having more potent opiates, we are often seeing that adolescents and adults need to be on higher doses of buprenorphine to kind of, to stabilize and be successful with not using opiates. And as we think about the kind of the dose of the buprenorphine, I just wanted to show you a picture of the brain, and this is showing you the mu-opiate receptor occupancy. And so we talked about, and then you have these, you know, opiate receptors in the brain that these medications are binding to. And so you see, these are different kind of slices or views of the brain. And at the top, you see buprenorphine zero. That means that that's an individual who has not received buprenorphine. And you can see a lot of like green and yellow, and that means there's a lot of opiate receptors that are open and unoccupied. And then you see at 2 milligrams, you know, there's less receptors open and occupied, but there still are some that are open and occupied. But then when you get up to doses of 16 or 32, really, you know, the majority of receptors are occupied. And so, again, pre-fentanyl, when we had youth who maybe had been stabilized in a residential setting for a long time, weren't put on buprenorphine, leave the residential setting, and are interested in being on buprenorphine for their opioid use disorders, we would sometimes use lower doses of buprenorphine. But really, now, or to avoid sedation or other things like that, but now really do try to get people on at least 8 milligrams, knowing that 2 milligrams, if you're only taking 2 milligrams, you still have lots of receptors open, and you would still be at high risk for overdose if you were to use opiates. So these are kind of some of the nuances as we kind of think about practicing in the era of fentanyl. Shifting gears, we're going to talk a little bit about methadone. And so methadone is a full agonist. And so it kind of, you know, binds to the receptor and fully activates it. Similar to buprenorphine, it blocks the euphoric effect of opiates, prevents and minimizes withdrawal symptoms, and decreases cravings. It's a little bit easier to start in the sense that you don't need to have opiate withdrawal to start methadone because it's a full agonist. So again, if you have kind of full, you have opiates in your brain, you take this medicate that are fully activating the receptor, you take this medication that's a full agonist and is fully acting, activating the receptor, your brain's not going to notice a difference or a big difference. And so that's why you don't have to be experiencing opiate withdrawal symptoms to start this medication. Typical doses for stabilization did used to be, you know, kind of lower of 60 to 100 milligrams, but really are seeing that people need to be on much higher doses of methadone, again, in this era of fentanyl. Methadone is typically, or is restricted in terms of how you can access it. And you can, the only place you can access it is potentially in a detox setting or kind of in the hospital setting or through an opiate treatment program. And these opiate treatment programs are highly structured and highly supervised. And typically when someone's getting started on methadone, they have to come to the opiate treatment program every day. And in your, when you go to the opiate treatment program, you're actually taking the medication in front of a nurse. And so, you know, again, very structured. So that can be really restrictive for youth or adolescents in particular who need to be going to school every day or have these other kind of things that they're doing as part of their development. You know, it is hard to go to a methadone clinic every day to get stabilized. But, you know, some people do need this level of structure and some people do really well with this level of structure. There has been a, there was a recent change in the fall where SAMHSA changed their guidelines such that patients under the age of 18 no longer need to have two documented unsuccessful attempts at withdrawal management or non-medication for abuse disorder treatment within the past year to be eligible for medication for the abuse disorder. So it used to be under 18 year olds had to jump through like a lot of hoops or kind of demonstrate that they were failing before they could access methadone. And with increased recognition of the importance of medications for abuse disorders and just the need for medication treatments for youth, SAMHSA has relaxed those guidelines. And so it's a little bit easier for youth who might be in an area where they can't access buprenorphine or naltrexone extended release or for whom there's a role for this highly structured treatment to be able to get methadone. And so if we kind of pause and think about these three different medications, you know, first we talked about naltrexone extended release, which is an antagonist, a monthly medication that's a gluteal induction. Then we talked about buprenorphine naloxone, which is, comes in either, you can take it orally or subcutaneously. And orally it's, you take it every day, subcutaneously you can take it once a week or once a month. And this is a partial agonist. And then methadone, which is a daily treatment and an oral treatment. And so as we think about them also, you know, naltrexone extended release is like the least structured, least restricted. And methadone is the most structured, most restrictive. And as we think about buprenorphine, it's, it's kind of in between, although it's become less restricted now that you no longer need an ex waiver to prescribe it. But buprenorphine naloxone is really the medication where we have the most research on how this medication works for youth. So now we're going to switch gears a bit and talk about how do we, how do we engage youth and caregivers in thinking about these medications and taking these medications. So I think one thing that I want to emphasize is, you know, it's always really important to think about the language we're using. And in particular for when we talk about medications for opioid use disorders, when buprenorphine was first developed and released, it was referred to as medication assisted therapy. And really as a field we've shifted to medication for the treatment of opioid use disorders or medication for opioid use disorders. Because when you think about it, you know, we don't refer to SSRIs as medication assisted therapy for OCD. We don't refer to, to prescription stimulants as medication assisted therapy for ADHD. And so, you know, by saying it's assisted therapy, it implies that it's like supplemental or optional or temporary. When we know that medication, you know, is really a critical tool that might be central, really central and very important in helping an individual stabilize and kind of a key part of their treatment plan. So really shifted from, away from this assisted therapy to it's just medication. And, you know, I'm not even really sure like how we got to medication assisted therapy in the first place. But I'm glad that we've shifted to just saying it's medication for an opioid use disorder. And as we think about there's barriers and stigma specific to medication, there's a, there's a lot. And in, you know, for all ages, we have very siloed treatment systems, as I think you all are very aware of. You know, medications, you know, despite the fact that, especially for youth, many of them have a co-occurring psychiatric disorder. These medications for opioid use disorders are not well integrated into psychiatric settings. And so often youth and their caregivers are needing to go to separate treatment kind of systems or even clinics in different locations. And it makes it hard to continue on these medications when you're needing to do that. And then for all ages, you know, there's still quite a bit of concern about diversion or misuse of buprenorphine. And I think, you know, clinically in what the research has shown is that most of the buprenorphine that's being diverted or potentially taken without a prescription, you know, that that's among people that are trying to stop their opioid use on their own, and may have difficulty accessing treatment. And so I really worry less about that. And when we think about youth in particular, you know, medication for a long time, and I think even still now, is viewed as like the last resort. Like, let's try other things before we try that. And if we think about other disorders, such as depression or anxiety, if someone has less severe symptoms of depression, you know, true, we might start with just therapy only before progressing to medication. But as we think about opioid use disorders, medication really is, again, central and really important in terms of decreasing their risk of overdose, helping them stay engaged in care, and really helping them restabilize so they can be successful. And so, again, that's a, for youth in particular, though, that it really is often still viewed as like the last resort. And we want to kind of change that perception for youth and their families. And then it can be really hard. Youth have a lot of people in their lives, right? They have their caregivers, they have their friends, they have their teachers, they may have a counselor at school, a counselor in the outpatient setting. And so, it can be tricky if they're getting kind of different messages from these different people in their lives about the medication. And so, really want to, if medication is part of a person's treatment plan, want to try to get all the adults and individuals in that person's life, you know, giving consistent messaging about the role of this medication as part of their treatment plan. And then in terms of how the medication works, hopefully it's clearer to you after my explanation of how these medications work, but it's tricky. And I still even struggle, you know, to explain how it works both to you and to kids. And so, really important to not assume that the youth and caregivers know how this medication works. And, you know, it's quite possible that they got inaccurate information from peers or the media. Again, I've seen a lot of confusion among kids and families about buprenorphine naloxone, and families thinking, well, it's buprenorphine naloxone, so they're therefore just, you know, protected from overdose risk because there's the naloxone as part of the medication, and them not understanding that when you take buprenorphine naloxone sublingually, you're not absorbing the naloxone. And so, again, just have heard lots of misinformation over the years. And even though we may do our best as part of informed consent, and, you know, do try to do our best to provide really good psychoeducation when you're helping a youth get started on this medication, it's important to remember that often youth are really in crisis, and their families are often terrified and really worried or kind of, you know, struggling with a lot of stress when a youth is starting this medication. And so, they may not remember what you told them. And so, I do find that it's helpful once somebody's stabilized on the medication to revisit, you know, kind of what's your understanding of how this medication works, and just to make sure that everyone's on the same page. And then I think it's also helpful to make sure that they have trusted written and online resources for additional information that they can review in their own time. And then as we think about another issue, especially for youth, you know, really for all ages, that is adherence. And so, you know, really important to take these medications as prescribed, especially as we think about sublingual buprenorphine naloxone. And so, you know, do again want everyone in this youth's life to be kind of providing reinforcement to take the medication as prescribed, and to not make changes to the medication without talking about that with their prescriber. And so, you know, really try to engage the youth in talking about the medication. I think it can be challenging because youth are aware often that the prescriber and or their caregiver and or like everyone on the residential unit may have a strong recommendation around medication. And so as a prescriber, when kids are coming to see me, they know that, you know, I really want them to be on medication. That's what I do is I prescribe medication. I've talked to them about how important I think this medication is as part of their treatment plan. I do my best to create a space where we can, you know, use shared decision-making to make the decision about taking a medication and what medication is the right fit for them. But despite that, I mean, they know kind of what my preference or recommendation is. And so this is where I think it's very helpful to have team-based care because they might be a little bit more open about their ambivalence to medication with other team members. And it's helpful to know about that ambivalence. I try to kind of pull for that ambivalence and to kind of ask about these things with youth, but have found that sometimes they're, it's easier to talk about this with their therapist or other people on the team. And then typically, you know, we really do encourage caregiver oversight to make sure that youth are taking this medication as prescribed, you know, need their oversight to make sure that the medication is safely stored. And then to, again, monitor that they're taking it on a regular basis. Because if they're, you know, just starting this treatment, you know, have recently been unstable with their opiate use, we really want to know if they're not taking it as we think about kind of risk in their treatment plan. And so, especially kind of as someone's being released from the hospital or a residential setting, really encouraging and talking about it as kind of you're coming up with this outpatient plan, that the recommendation and kind of telling both the youth and the caregivers is, you know, that we do want your caregiver involved in helping you to kind of be successful with this medication. And so we're really recommending that they hold onto it and be giving it to you on a daily basis and that they're watching you, you know, take the medication. And, you know, I think that can be relaxed over time and it's not gonna continue for forever, but especially in that, you know, first month of being on the medication or first few months, do really encourage close oversight and whatnot. And you often have to kind of talk through this because especially some youth might not be attending school, they stay up late, you know, playing video games, doing other things, and they're sleeping in, but their caregiver may be going to work early in the morning. So, you know, what is gonna be the timing of when they take this medication? Are you planning to, is everyone kind of planning on them taking the medication at a time when everyone's awake and available and home? Some of these details, you know, really do matter as we think about helping youth and their caregivers be successful. And then a common question, especially for youth, is like, how long do I have to take this? And, you know, unfortunately we don't have a great answer. We don't have a lot of research on this, except for we do know that the longer someone takes the medication, the kind of more likely they are to be, to remain stable with their opioid use disorder. And so for youth, I really just focus on like, let's just get you started on the medication. Like, let's start it. And I really wanna see you be stable for a period of time before we make changes to the medication. But like, let's just start it, okay? You know, and really kind of focus on starting it. Once they get started on it, then kind of engage in the back and forth. And for some youth, they're like, I don't ever wanna stop this. And some are like, I don't wanna be on this very long. I'm eager to stop it. And again, it's really important to try to emphasize, you know, or be open to the idea that the youth may wanna make changes to their medication and they may wanna stop the medication before you would recommend that they stop the medication. But you wanna create space to have that conversation. Because if you don't create space where they feel like they can talk about their ambivalence or these kinds of things, they're just gonna stop it on their own without telling you. And it may do a really quick taper or even just not taper at all, just stop it. And then be at really high risk for relapse. And so, you know, I do my best again to create the space where there's shared decision-making about what medication they're taking, you know, how long they're gonna take it for. And when youth are eager to taper off, we'll try to create space to talk about like, you know, how quickly are we gonna do this and, you know, really think in detail about that. And then also talk about, you know, if we're tapering and decreasing the medication, you know, what would be signs that maybe we should go back up on the medication? Or, you know, what would be signs that maybe we should restart the medication and really have that conversation before you make changes to the medication so that you're kind of, everyone's thinking about what to monitor for and what might be an indication to restart the medication. And then I think it's important to acknowledge that, you know, medication is really just one part of their treatment plan. And youth with an opioid use disorder have often got really far off track developmentally and need a lot of other recovery supports in addition to medication to restabilize. But they may not be ready to do those other things. And so I think it's so important to be, you know, really flexible. And I, you know, have been glad to see treatment systems become more flexible over time. When I first started practicing, there were a lot of restrictions around buprenorphine. You needed to do an intensive outpatient program. You had to be in therapy. You had to attend group therapy for the duration of the time that you're on the medication. And again, there's been kind of increased recognition in terms of thinking about individualized treatment plans. However, you know, if you're trying to support a youth and maybe engaging with more of an adult treatment system, you know, it's possible that the adult treatment system may still have some of these rules or kind of requirements. And so I think important to talk with the youth and their caregiver about maybe like, why do they have these requirements? And then also advocate with that treatment system about, you know, can we start, like they're not, you know, right now that interested in therapy. Can we start without them doing therapy and then kind of think about what would be a sign that they might need therapy? And kind of approach it from that perspective as opposed to saying they have to do therapy. So again, really wanna be flexible with these youth as their motivations kind of waxing and waning, but wanna focus on, you know, also the importance of medication and helping them access medication. As we think about resources for caregivers, this is all really scary and is very, very stressful when you have a loved one with an opioid use disorder. And I think all of us worry about youth with opioid use disorders and can struggle to stay in a place where we're kind of using motivational interviewing, but this can be a really helpful technique for caregivers to learn more about. And so wanted to raise awareness about motivational interviewing for loved ones. There's an online course developed by Dr. Emily Klein in Massachusetts that's both in English and Spanish and has these short kind of e-lessons with take-home points that parents can access and engage with on their own time and at their own pace. So now for the end of the talk, just gonna switch to talking about harm reduction practices just to discuss with youth who misuse opiates and other substances. And really I do talk about these principles and practices with all youth using substances regardless of their readiness to change. And so, you know, kind of even more important, I think with kids that have high motivation to change their substance use and are really confident in their ability to change their substance use, important to create space to talk about like, well, you might hit a bump or like, this is just, I just want you to have this information, potentially share this information with your friends or other people that you care about, but really important that we be getting this information to youth so that they can stay safe. And so, you know, as part of this, I talk about the unsafe drug supply and I think you guys are all very well aware of press pills in these kind of industrious people who are dealing drugs who have, you know, bought these pill presses and kind of put powder and often illicitly manufactured fentanyl into the powder and create this press pill and then kind of sell it as potentially amphetamines or benzodiazepines. And then unknowingly, someone may take one of these press pills and be exposed to fentanyl when they thought it was something else. And it's hard to tell the difference unless you are looking really, really, really closely. And then there's just been an explosion of these press pills. And so this is showing you the number of pills containing fentanyl seized by law enforcement across the different years. And so we went from, you know, 50,000 back in 2017 of pills seized by law enforcement that were pressed and had fentanyl to 115 million in 2023, 115 million. And so I think it's really important for youth and their caregivers to know about the unsafe drug supply. And sometimes we'll introduce this as my public service announcement, you know, just kind of, have you heard about this? I just want to make sure you have this information. But do you think that this is a very powerful figure in terms of like just showing how common these press pills are now? And so as we think about ways that youth can stay safe, you know, we do have fentanyl test strips available and providers or programs can order these fentanyl test strips for free through the Massachusetts Clearinghouse. And the fentanyl test strips are helpful. I think there's some things to consider about them in that you do have to use some of your drug supply to test it. And so you're kind of using something that you may kind of losing some of your drugs. You have to dissolve it in water and then wait for a couple of minutes to then use the test strip to see if fentanyl is present. And the hard part though is you only tested part of your drug supply. So like the part that you tested may not have fentanyl but there could be fentanyl somewhere else in that kind of the drugs that you have. And so it, you know, can be helpful to have that information about this kind of small part of the drugs that you did test, but it's still important to be thinking about safety and using other strategies to decrease overdose risk. And so I think it's, you know, kind of one thing to also talk about with youth is that often overdose deaths do involve more than one substance. And so, you know, helping them think about in overdoses where you're really often kind of sedated and you stop breathing. And so what are other substances that you might be using that maybe if you take more than your body can handle might lead you to stop breathing. And so that can be binge drinking, you know, drinking and using benzodiazepines, drinking benzodiazepines, fentanyl. And then also, you know, they may be on medications that are very sedating and making sure that they're thinking about, you know, and kind of got started on these medications during treatment and going back home. I think I might still want to drink and kind of making sure that the kids have, are kind of thinking through what are, you know, kind of things to be aware of. Unfortunately, a lot of the kids that I work with will be like, well, I just stopped my medication because I wanted to drink. And so, you know, again, trying to create open the door to have these conversations is important, but I do try to talk to them about the fact that the message was not to stop your medication per se, but to, you know, kind of be thinking about risks and kind of thinking about how much you're drinking. So, and then we do know also that youth who use substances alone are really high risk for overdose death. And so just the same way that there was a lot of messaging around having a designated driver, I do try to talk to youth about, you know, can you have someone that is using less or not using at all ideally to help monitor to make sure that everyone stays safe. And then we do have these free overdose prevention helplines. Youth don't like to talk on the phone. And so I've not yet gotten a youth to like call and use one of these, you know, helplines, but I think we should be continuing to talk about this with them and help them be aware of this. And then if you have time to just practice calling and, you know, and these hotlines are very happy to take a kind of a test call, you know, when you're kind of with youth in the office to just call and kind of see what it's like to call and kind of try to decrease that barrier to them using this free support. And then important to also be distributing naloxone to all and to really normalize kind of, that's okay to have naloxone or not okay. It's important for everyone to have naloxone. And so for families that you might be working with where, you know, the youth to date has not used opiates yet you know, it can be hard for families and kids to think about the risk of overdose. And so the way that I try to normalize this is by saying, I like to talk to all families about how to recognize and respond to an opiate overdose. I hope that you'll never need this information, but I wanna make sure that you're prepared just in case. And so, you know, if any youth is using any substances they are at risk to transition to opiate misuse and then also at risk to take or press pill and be unknowingly exposed to illicit fentanyl. And so again, do you think it's important to be providing education on what does an opiate overdose look like? And then how can you respond to an opiate overdose? And so not only is it naloxone, but we talked earlier about how naloxone doesn't last, only lasts for a short period of time. And so also really important to call 911 if someone's with somebody who's overdosed and important for them to know about the Good Samaritan Law. And this law does exist in 48 out of the 50 states in the United States, including Massachusetts. And really states that if someone, you know, is with somebody who's having a drug related overdose, they're not gonna get in trouble for calling 911. And the person who overdosed is not gonna get in trouble for having overdosed. You know, that being said, you know, many of the youth we work with have had negative experiences with police or emergency responders. And so, you know, may be reluctant to call. And so if that's the case, you know, trying to again, to elicit that information, open the door to have a conversation about this and just making sure that they're aware about this law to decrease barriers to calling 911. So in summary, medication for abuse disorders is very important for youth. There are three FDA approved medications for abuse disorders for adults. One of those medications is FDA approved for ages 16 and above, which is buprenorphine naloxone. The greatest evidence for medication treatment for OUD and youth is buprenorphine. But important to kind of know about all three medications. And I think to talk about all three medications with youth and families. And then really important as we're thinking about supporting youth and being on medication for their abuse disorders to have flexible treatment plans and kind of, again, just kind of work and meet the youth and their families where they're at and, you know, work to keep them engaged in care. And then also important to discuss principles of drug safety with youth, regardless of their readiness to change. And so we wanna make sure that youth have this really important information and then also have tools to keep themselves and their peers and people in their community safe. So with that, these are some of the references that I think you'll hopefully have access to. And I think Jenna's gonna.

opioid use disorders

medication-assisted treatment

youth engagement

caregiver involvement

naltrexone

buprenorphine

methadone

harm reduction

overdose prevention