Hi, my name is Tina Nadeau and I am the Chief Justice of the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction, psychiatry, and other judges, and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. And in this module, you'll hear from Dr. Yule about the special care we need to take in understanding how substance use disorder affects the adolescent mind. All of us have heard the studies, we know that an adolescent brain is not fully evolved or developed until age 25, and it's a shocking statistic, but also explains a lot of that compulsive behavior and behavior that adolescents engage in just as a part of growing up and developing. So in this module, you learn about how to assess for those types of substance use disorders, especially in adolescents. You'll learn about the importance of family connection for adolescents, and you'll also be able to understand specifically what types of treatments are gauged toward younger adults and adolescents that works best for them in managing their substance use disorder. Hello, my name is Amy Yule. I'm a child and adolescent psychiatrist who also has training in addiction psychiatry. And I work clinically with young people with substance use disorders, many of whom have a co-occurring psychiatric disorder. And so today I'm here to talk to you about the treatment of substance use disorders in adolescents. To begin with, they have no relevant disclosures to note and just want to mention the learning objectives for this talk. So first, we'll discuss risk factors for developing a substance use disorder in adolescents. Second, we'll discuss tools that clinicians and courts and schools can use for screening for substance use and for assessing and diagnosing a substance use disorder in adolescents. Next, we'll discuss evidence-based behavioral treatments for young people. We'll also briefly discuss considerations to think about when involving a family or a caregiver in a young person's treatment. And last, we'll discuss community-based for recovery supports for young people. So to start with, we're gonna talk about risk factors for developing a substance use disorder in adolescents. And there's many factors that influence whether or not an adolescent tries alcohol or drugs. And we just want to highlight some of the factors that put adolescents at higher risk for problematic substance use and or substance use disorder. So one space to think about are environmental risk factors. So the environment is an important thing to think about when thinking about risk for an adolescent and whether or not they develop problematic substance use and or substance use disorder. And if adolescents are able to access substances and have even availability to substances for misuse, they're more likely to use them. And so adolescents are really, have an equal opportunity approach and so they'll use whatever they can access. And so if there is prescription drugs that are in the home that have not been secured, then they might, you know, start by misusing prescription drugs. If there's alcohol easily accessible in the home, then that's another thing that they might use, or the other space where they might access substances are from peers and from friends. And so they have a peer group that are frequently using substances, then that's another space where they can access substances. So having easy access to substances and having friends who are using substances really puts them at much higher risk to start using substances and potentially have problematic substance use and or substance use disorder. I mentioned the family. And there are several things to consider when thinking about risk factors within the family. And so, if there's substances in the home, that again, a person can access that will put them at increased risk. If they see a family member using substances heavily at home, that can also put them at increased risk. And this is alcohol or drug use where a family member has a substance use disorder and is having impairment related to their substance use. And so the young person sees the family member with that, that family members potentially modeling substance use as a way to cope with, or to deal with things. And that's seen as acceptable by the young person who's also living with that family member. Additionally, having a family history of a substance use disorder puts an adolescent at much greater risk to develop a substance use disorder themselves, and substance use disorders are highly heritable and about 50% of the risk for developing a substance use disorder comes from your family. And so there's a strong genetic component that might put a young person at risk for developing a substance use disorder. The other thing to consider when we're talking about adolescent substance use disorders is that their brain continues to develop until their mid 20s. And so their brain develops from the back into the front, and this frontal part of the brain, including the prefrontal cortex is the last part of the brain to mature. And so by adolescents, the reward center of their brain is fully developed, but the prefrontal cortex is a really important part of their brain that's involved with decision-making and helps individuals control their emotions and impulses. And so that part is the last part of the brain to come online. And this, we kind of give a frequent analogy that the adolescent brain is like a car and adolescents are driving a car with a functional gas pedal. Their rewards system, which is fully developed, but really weak brakes or no brakes, the prefrontal cortex that really helps them evaluate whether or not these are good decisions and what kind of helps them weigh the pros and cons of a decision, then that part of the brain is not there. And they're just really driven by this reward seeking part of their brain. And so that puts them at high risk to potentially misuse substances and then find that kind of substance use fun and rewarding and reinforcing, and then go on to develop a substance use disorder. The other part did he can take account in terms of brain development, is that since the brain is still developing, it's very sensitive to the harmful impacts of substance use and substance use can impact or impair brain development. Lastly, the last area that we want to think about in terms of risk factors for adolescents develop a substance use disorder include psychiatric disorders. And we know that children with a psychiatric disorder are at much higher risk to develop a substance use disorder. And so here, you're looking at the odds ratios, and for odds ratios, anything above one means that you're at increased risk to develop something. And so we're looking at different disorders that start during childhood and looking at the linkage between the disorder and risk for substance use disorder. And so you see quite clearly that having, for example, attention deficit hyperactivity disorder puts you at two 1/2 times greater risk to develop a substance use disorder compared to kids who do not have ADHD. Likewise, if an individual has cognitive disorder, they're at five times greater risk to develop a substance use disorder compared to kids who did not have conduct disorder during childhood. We also see this increased with risk associated with depression for later onset of a substance use disorder. And while we don't see an increased risk of statistically significant increased risk with anxiety disorders, one thing to keep in mind is that anxiety is a very heterogeneous diagnosis. And so, we do know that some types of anxiety disorders such as post-traumatic stress disorder are linked with increased risk for substance use disorder, but potentially other anxiety disorders like separation anxiety or things like that, which might kind of keep you closer attached to the family, may not put someone at an increased risk for substance use disorder. And so when they looked at this, the risk associated with having anxiety and risk for substance use disorder, all those different diagnoses were included in that category of anxiety. And so we may not see increased risk because this is such a heterogeneous category. So now moving on. We'll think about the screening tools for substance use and substance use disorder in adolescents. Now that we have an idea of some adolescents who might be at higher risk to develop a substance use disorder, and adolescents who we particularly need to be aware of, that we need to be screening for substance use with. But generally, we do recommend screening for all adolescents, just because they often don't view substance use as a problem. And if they don't feel it as a problem, they're not gonna bring it up or volunteer the information that they're doing something since they don't think it's a problem. And so, universal screening is really crucial for adolescents, and there are several different screening tools that are available for free that assess for alcohol and other substance use. And two of the screening tools that have been around for some time include the National Institute of Alcohol and Alcoholism screening questions. And those have been validated down to age nine and are developmentally sensitive, such that they ask the questions in slightly different ways based on your age. So how you're asked about your alcohol use when you're nine to 11 is different in terms of how you're asked about it from ages 12 to 14. So that's a nice tool that's really developmentally sensitive. It's just two questions and really gives you insight into whether or not a young person's at risk to have an alcohol use disorder or started to have problematic alcohol use. Another tool that's been around, is actually a screening and assessment tool, is something called the CRAFFT. And the CRAFFT asks three initial questions about substance use in the past year, any use of alcohol in the past year, any use of marijuana in the past year, any use of anything else to get high. And then based on the adolescent's response, it goes on to ask either one or six different questions that's assessing for impairment related to substance use. And so, it's called the CRAFFT because that's the mnemonic for some of the questions and the questions ask different things in terms of these different domains that are listed. So for example, car. The question for that is have you ever ridden in a car driven by somebody, including yourself who was high or had been using alcohol or drugs? And the second question is, do you ever use alcohol or drugs to relax, feel better about yourself or to fit in? And while we have a lot of data, the CRAFFT is a very strong screening tool. One thing that's hard for clinicians and for individuals that are looking at screen tools, is that it can be hard to remember all these, the mnemonic and these six questions. And so because of that, they have worked to develop newer screening tools that are a little bit more straightforward and simpler. And so you might consider implementing these newer screening tools, if you don't already have screening in your court clinic or with the clinics that you're working with and want to be implementing a new screening tool. Screening to Brief Intervention, and the Brief Screener for Tobacco, Alcohol and other Drugs, both ask the same and assess for the same substances, but they differ in that they assess frequency in a different way. And so both tools start with three initial questions that ask about commonly used substances. So, any tobacco use in the past year? Any alcohol use in the past year? Any marijuana use in the past year? If an adolescent says no to all those three questions, then you're done. If an adolescent has endorsed substance use of any of these three substances, then you go on and assess for other substances of misuse. But for all of these questions, when you're asking about frequency, you use the same question. So for Screening to Brief Intervention, in terms of frequency, you asked the adolescent, never, once or twice over the past year, monthly use over the past year or weekly or more use over the past year. And so they defer these two tools because the Brief Screener for Tobacco, Alcohol and other Drugs ask adolescents, how many days in the past year have used these substances? And so courts or clinics may have a preference between these two different types of strategies for screening, but both of them, ask the same initial questions, which is nice. And so this gives me an example of how, again, the Screening to Brief Intervention is different from the Brief Screener for Tobacco, Alcohol and other Drugs. And so each of them are asking, about the same substances and asking about use over the past year, but then differ in terms of how they ask about frequency. And so based on the adolescents, how they endorsed the question, gives you a sense of whether or not they have a high probability for substance use disorder. And so, for the BSTAD that asks about numbers of days of use over the past year, they have cutoff thresholds for different substances above which someone has a high probability of having a substance use disorder. With the Screening to Brief Intervention, if someone endorses monthly use, they have a high probability of a mild to moderate substance use disorder. And if they endorse weekly or more substance use, they have a high probability of a severe substance use disorder. With these screening tools, it's important to remember that they're screening tools. And so, if someone's screening in or has a risk for a substance use disorder, that means that you need to ask more questions and assess for substance use disorder. It doesn't guarantee that they have a substance use disorder. But this is definitely someone that you need to be concerned about and need to be talking with and assessing further. And so, in other lectures, the criteria for substance use disorder have been reviewed, that as a reminder to meet criteria for substance use disorder, you're assessing for problems related to controlling substance use, looking at problems or whether or not the substance use is causing problems socially. Functionally looking at risky use and whether or not someone has developed tolerance to substance use or is having withdrawal symptoms if they don't use substances. And so, one thing to think about when applying these criteria to adolescents and assessing for substance use disorder in adolescents, is that the criteria were not developed with adolescents in mind. And we know that a lot of adolescents are not just little adults and they're different. And so some challenges when applying these criteria include the fact that often adolescents maybe, have very problematic substance use and have kind of binge substance use patterns, but because they're not using on a daily basis or most days of the week, they're less likely to have withdrawal symptoms if they don't use substances. And that's one of the criteria you use to assess for substance use disorder. Another criteria that doesn't quite fit perfectly with adolescents is that hazardous use is often less common in youth who have less access to automobiles, for example. That's another criteria used to assess for substance use disorder. And then lastly youth are often less aware and are less willing to acknowledge that their substance use is causing problems for them. So for example, you may see someone coming into court, who's had a clear decline in academic performance. So maybe as a freshmen, sophomore, they were getting As and Bs, and now as a junior, senior, they're getting Cs and Ds or not attending school at all. The parents or caregivers, or you may have concerns that that decline in academic performance is it's really directly linked to their substance use, but when you ask the adolescent about that, they'll often just say, well, no. School was just boring. I decided I didn't want to go to college. What's the point of me studying history, if it's not gonna relate to what I do in the future? And really they're not able to make this link or kind of take a step back to think about how their daily marijuana use might be impacting their academic performance. And so this can, again, just create some challenges when assessing for substance use disorder and thinking about the severity of a substance use disorder. So now that we've talked about identifying youth, how to make the diagnosis of a substance use disorder in the young person, we're gonna switch to talking about treatment. And so one thing to keep in mind when thinking about adolescent substance use disorder treatment, that it really involves a team. And I think that that's one of the things that Judge Capeci and I really enjoy about working with adolescents with substance use disorders, is really this team aspect of it and getting to collaborate and coordinate with other providers. And so, potential components of treatment or other kind of team members for a young person may include therapy, and I'm working with a therapist who's providing regular therapy for them. Medication. There's often a role for medication in treating adolescent substance use disorders, both for their substance use disorder, but also potentially for a co-occurring psychiatric disorder. Family or caregiver involvement is really key to adolescent substance use disorder treatment. Again, many of them may have low insight into how much problems are being caused by their substance use disorder, may have low motivation to change and very low motivation to come to treatment. And, you know, it can be very helpful to have the caregivers and family involved, to help bring the person, to bring the adolescent to treatment and help facilitate treatment engagement. The other thing is that many adolescents who have a substance use disorder, most of their peers are often using substances. And so it can be very helpful to help them connect with peers who are not using substances to get more peer support as they think about making a change. And then generally also having community support for these adolescents and having opportunities, the community for them to do some activities that don't involve substance use is also very important and really kind of part of thinking about their treatment. So as we think about treatment, and we think about level of care, they're kind of different types of intensity of treatment ranging from inpatient treatment, where someone's in a locked facility receiving 24-hour care, to residential, which is generally not a locked facility that still has staff around for 24 hours, and it's still a restricted setting, but it has less intensity of treatment relative to inpatient treatment, and then outpatient treatment where someone's living the community and coming to treatment, varying from once a week to potentially five times a week. And as we think about these different levels of care, which one we choose really depends on the severity of the illness and the number of tools or supports that a young person has to support abstinence and support them in making a change. And so inpatient level of care is very restricted and very intensive, and it's really used when they're seeking safety concerns or someone is having withdrawal from substances and needs to receive medication treatment to treat the withdrawal symptoms. One thing to consider is that, really availability of specialty substance use disorder treatment services varies dramatically by region of the country or even region of a state. And for inpatient level of care in particular, there are very few units that are dedicated to treating substance use disorders for adolescents. And so sometimes adolescents will end up on an inpatient psychiatric unit that may be less well equipped to treat the substance use disorder if an adolescent is having withdrawal symptoms. It's very important for us to be advocating for these inpatient psychiatric units to be prepared to treat these these young people, since it's important as part of them engaging in care and having a positive experience with treatment, that their withdrawal symptoms are treated, and that they feel comfortable in treatment. For residential treatment, this is, again, an unlocked setting. It's often a longer term setting, which allows patients to gain skills and pursue recovery in a stable and controlled environment. And then with outpatient treatment, partial hospital programs are generally five day a week programs where someone goes from most of the day. And generally in terms of partial hospital programs, we think about young people with co-occurring disorders who are struggling with both symptoms of their substance use disorder and symptoms of a psychiatric disorder. And these programs are, ideally addressing both disorders in a more intensive fashion. Intensive outpatient programs tend to be three to four days a week, maybe for two to three hours in the afternoon. And then other outpatient services such as individual therapy, group therapy, those may be one day a week or whatnot. So in terms of my experience in Massachusetts, the more kind of commonly access levels of care include residential. And then these outpatient services such as intensive outpatient programs, individual or medication appointments on a weekly basis. And one thing that I find in working in a clinical setting, is that individuals access to these different types of level of care is really somewhat dictated by insurance. And insurance coverage really influences what kind of support a young person might be able to receive. And then also influences the availability of these programs. And so if it's hard for young people to get residential coverage, there tends not to be a lot of residential treatment programs because there's not a lot of referrals that they're receiving. And so, one thing to think about in your state and also thinking about the judicial system, is that Judge Capeci's had a very different experience and has been able to get grant funding where it's quite easy for him to access residential treatment for kids who need residential treatment, because it's working outside of this insurance-based fee for service system. So that's one thing that also influences availability of specialty care, as we think about treatment for young people. So, one piece of the treatment plan that I want to focus a little bit more on is behavioral therapy, since behavioral therapy is really the gold standard of care for young people with substance use disorders, and all young people, substance use disorders really should, there should be a recommendation that they be receiving regular behavioral therapy. They may not be interested in behavioral therapy. And so we may have to work to build their motivation to engage in this, but this is really kind of a key part of their treatment plan. And the idea behind behavioral therapy, is that we want to increase their motivation to change and then build their skills to change. It's gonna help them translate into a change in their substance use. And so we can't just expect young people to change their substance use overnight, just because we want them to. They really need to have skills. They need to build the skills to be able to make that change. And, you know, they could change their substance use. They may have already done it. And so that's the point of treatment. So again, it's often not realistic to expect a young person to just suddenly changed their substance use, and we need to work, get them treatment to get them the skills they need and the treatment they need to help them make a change with their substance use. So there's several different evidence-based therapies or behavioral treatments for substance use disorders. And these include kinds of behavioral therapy, the adolescent community reinforcement approach, motivational enhancement therapy, contingency management, and family therapy. And which evidence-based therapy we choose is often influenced by a young person's motivation or readiness to change. And so cognitive behavioral therapy is a great intervention that focuses on building, in skill building to help someone not use substances. But in order to be interested in building skills, you have to be motivated to make a change. And so, if an adolescent is not motivated yet to make a change with their substance use, cognitive behavioral therapy may not be the right fit in terms of a therapy for them. And so I'm gonna focus on today, go into a little bit more detail on the adolescent community reinforcement approach, contingency management and family therapy, because those are three approaches that can sometimes help with motivating someone to make a change. And so, contingency management is it's something that often judges are doing with people coming into their court or that we may do in treatment, and that we're really providing an immediate, tangible reward around a specific behavior. And so in treatment that's often, you know, I'll give you your prescription if you come to your appointment. And so your reward is, if an adolescent is really motivated around their medication, their reward for coming to treatment is that they get this prescription that they want. And so that's an example of contingency management. And after more working with families or caregivers, to try to put contingencies in at home to motivate someone to come to treatment. An idea that with these positive rewards, we're helping kind of motivate someone to change. And so for incentivizing negative toxicology screens and giving rewards around negative toxicology screens, then that's strengthening the reinforcement for abstinence. And then if there's consequences that are clear around continued substance use, or having toxicology screens that indicate continued use, then that's gonna weaken the reinforcement for substance use. And so it's really this kind of classic behavioral intervention that's pretty straightforward that can really kind of help catalyze change, when a young person's has really low motivation to change. We do also have to kind of keep in mind that they may not have the skills to make that change. And so if you are using contingency management, making sure that you're supporting the adolescent with treatment engagement so they can build the skills to actually make this change. And some of this can be fairly simple, or some contingency management can also just include providing positive rewards for coming to treatment. And so, we'll talk to parents often about providing kind of small, immediate rewards after coming to an appointment. So that might be stopping at their favorite coffee shop to get their coffee drink that the parent might not normally get for them after coming to treatment. So even kind of small things like that can be used to try to reward any signs of behavioral change. Another approach that I wanted to go into a little more detail about is the Adolescent Community Reinforcement Approach, which combines a motivational approach with skill-building, like skill building that is done in cognitive behavioral therapy. And this is a very patient-centered approach, which is one of the reasons I really like it. And it kind of asks the young person, are you happy? And if you're happy, sure, keep doing what you're doing, but if you're not happy, do something different. And so one of the main procedures as part of this therapy is a happiness scale, and it rates happiness in different areas of an adolescent's life. So, that includes their substance use, their relationship with friends, with parents, legal difficulties, financial difficulties, occupational difficulties, academic difficulties. So it really kind of goes through many different areas in their life. And so they may be totally happy with their substance use, which is not uncommon, but they may be really unhappy with their legal difficulties or they may be unhappy with their relationship with their parents. And so as a therapist trying to engage a young person in thinking about making a change, you focus on the areas where they're unhappy. And so if they're unhappy with their legal charges or their legal difficulties, it naturally leads to a linkage with their substance use, 'cause you ask, well, kind of why do you have that charge? Or why do you have to go to court? And then they'll say, oh, it's because of my marijuana use. Okay, well, do you want to talk about your marijuana use? And it's a natural entry point to talk about their substance use, as opposed to kind of saying directly to them or kind of lecturing to them, you need to talk about your substance use, change your substance use. You really take a more patient centered approach and kind of looking at this from their perspective and then trying to use internal motivation to help them think about making a change. And so, I mentioned that the happiness scale is one of the core procedures that's done on a regular basis. Once you get them talking about their substance use, you help them work to better understand their substance use through a functional analysis of youth. And then you also look at, you know, what's been potentially getting in the way of doing pro-social sober activities. And so often with substance use, there's something immediately rewarding associated with the substance use, but there's a lot of long-term consequences. So adolescents being driven by rewards and immediate rewards might be kind of drawn to doing substances. Whereas with pro-social sober activities, often there's not necessarily an immediate reward associated with going for a bike ride or going to a movie or doing something like that. But there may be a lot of long-term positive rewards. So going for a bike ride that helps your physical health, that helps your mood and anxiety, but you don't often see those things immediately in the same way that an adolescent may see immediate changes with the substance use. And so it really helps the adolescent kind of understand the short-term and long-term consequences and help them kind of see why there might be benefit to doing some of these pro-social sober activities, because of these positive long-term consequences or effects, and then the long-term negative effects associated with substance use. Additionally, in terms of helping these adolescents make changes, they often have pretty limited problem solving skills and their communication skills may also be limited. And so in terms of skills, you know, really help them with kind of some really basic problem-solving to help them get past some of the barriers that might be getting in the way of them doing some of these pro-social activities. And then also does, once they're more motivated, focus on relapse prevention. So helping them think about if they are making a change with their substance use, how can they maintain that change and decrease their risk of returning to substance use. The other nice thing about the Adolescent Community Reinforcement Approach is that it involves parents with the protocol and parents actually come in and learn problem solving and communication skills themselves, separate from the adolescent. And then there's a session where the adolescent and the caregiver or parent comes together with the therapist to talk through some difficulty that the adolescent and parent identify, where both the adolescent and the parent are using their communication skills to work through this difficulty, with the therapist's support. So lastly, we want to mention or highlight family interventions, since family interventions, there's a lot of data supporting the efficacy of family interventions for adolescents with substance use disorders. So I want to highlight some of these family therapies. And these family therapies are great, but they're often fairly time intensive and resource intensive. So it can be hard to get all the family members to kind of come to an outpatient office all at the same time where the therapist is available. And so, sometimes as part of these family therapies, have actually implemented in the communities that the therapist goes to the family and really makes it easier for the family to engage with these kinds of treatments. That being said, within an insurance-based system, generally insurance-based systems don't pay for the therapist to go to the family, to do these really resource intensive, time intensive interventions. And that's where the judicial system may have more flexibility to fund or support these very effective interventions, especially for family systems where there's a lot of chaos or there's a lot of barriers to an adolescent making a change. And so these can be very effective, but are sometimes difficult to find within clinical settings that are more insurance-based. And again, this is an area where Judge Capeci and I have had different experiences and he's had great success with using a multisystemic therapy in his court, that's funded by the court system. And it's really seen a lot of change with adolescents, and with families, with that particular intervention. That's not something that I've been able to see implemented within an insurance-based or outpatient clinic setting. So one thing that we have seen implemented in an outpatient insurance-based clinical setting is an intervention for the parents only, which is parent guidance to parents. So often in my setting where we can't force someone to come, we don't have the court system to kind of push them to come sometimes. They'll often, won't want to come, and we'll have to work with a parent or caregiver to increase their motivation to come. And so the community reinforcement and family training protocol is really targeted to concerned significant others to help motivate the adolescent who has the substance use disorder to engage in treatment. And what this protocol is, it teaches the principles of contingency management, which I mentioned before to really reinforce behavioral change, to really motivate an adolescent to come to treatment. It also focuses on improving the caregiver's communication and problem solving skills so that they can be more effective when communicating with their loved one that they're worried about. And then it also works on improving the caregiver's emotional functioning. So often parents who are really worried about their adolescent, who's doing all sorts of risky behaviors, they're anxious, they're sad, they're angry, they're just really overwhelmed. And they're really focused on their loved one, and aren't really thinking about their own self care. And so they're gonna be a much more effective with their communication and problem solving if they're not completely overwhelmed. And so this is a really, I think, key part of this intervention, is improving the caregiver's emotional functioning to help them be more effective when interacting with their adolescent, who they're really worried about. So this is something to consider if you're potentially interfacing with more insurance-based systems or working with clinics that you're hoping to refer adolescents who were court-involved too, for services. So, want to switch gears a little bit and talk about one other component of treatment, which is medication. And unfortunately we have limited studies on the use of medication for adolescent substance use disorders. However, it's still really important to think about medication, both for their substance use disorder, but also for their psychiatric disorder. And often, people Okay, well, it's still early on. Let's wait and see before we use medication. And sometimes that's, you know, we can't wait and see. We really need these medications to help them stabilize and engage in care. And they may not be able to engage in care without these medications. So one medication where we do have data on the use of this medication in under 18-year-olds, is with buprenorphine naloxone for adolescents, ages 16 and older with an opiate use disorder, and it is actually FDA approved. I want to kind of focus on this medication just for a second, given that opiate use disorders are associated with significant morbidity. And it's hard to think about this, but young people are dying. They've been also impacted by the opiod epidemic, and we have seen overdose deaths in young people. And it's, again, hard to think about, but this is a graph showing you the age adjusted rate of opiate overdose deaths in 2017 and breaks it into the number of deaths by different age groups. And so you can see that although opiod overdose deaths are really peaking in more 25 to 34-year-olds and higher rates in 35 to 54-year-olds than we have a 15 to 24-year-olds, it's still important to recognize that, nearly 4,000 of the opiod overdose deaths in 2017, out of the 47,000 were in 15 to 24-year-olds. So these are young children that are dying. And so just really want to highlight the point that they're not immune from the morbidity associated with substance use disorders because they're young. And so for these kids, we really can't wait and see. We need to make sure that we're helping them stabilize in medication so that they can get better and stay alive and survive this illness. And one thing that's concerning is that youth with opiod use disorders are much less likely to receive medication for their abuse disorder. And so this was a study that looked at commercial insurance database and looked at youth under the age of 18, and then youth 18 to 22. And you can see that only 5% of youth under the age of 18 received a medication for opiod use disorder. And really when we think about it, for an under 18-year-old to develop an opiate use disorder, that's a very severe illness for an under 18-year-old. It's fairly uncommon, but only 5% of them are receiving medication, life saving medication. And so we really need to kind of think about the barriers within our systems to getting these young people these medications that are life-saving. So the use of medication does improve in 18 to 22-year-olds, and it increases to 27% of 18 to 20-year-olds have received a medication for the opioid use disorder. But that's still lower than the rates that we see in people over the age of 22. And so, again, as I've highlighted, youth are not immune to the negative consequences associated with opioid use disorders, including overdose stats. And so we really need to make sure that we're helping them access these life-saving medications. So, I mentioned this before, but family involvement is really crucial and our caregiver involvement is part of a young person's treatment plan, and it can be tricky. State laws vary regarding adolescent confidentiality when adolescents are engaging in substance use disorder treatment. And so being in the legal system, you guys are probably more up to date than clinicians in the community about these laws. But, you know, this can create some challenges and young people are often very reluctant to sign releases of information, authorizing information to be shared with their parents. Sometimes they're concerned about how their caregiver or parent might react to that information. Sometimes they worry the parent may react in a much more harsh or negative way than they actually might react. And so there's some education that can be done, but really important to explain to a young person why there's this need for the release of information and why it can be helpful to have family involvement. So in our treatment program, we'll often break up the released information into different categories and include things like scheduling appointments and treatment attendance, and young people are, you know, often as we've explained, can be helpful to have your parent involved in scheduling your appointments. They're often happy to sign that release information. If you just ask them, you know, will you sign this release information for your parent to be involved in your treatment? Often, their reflexive answer initially is no. And so, really need to be clear about what you're asking for with this release information. And so we'll break it up into things. Again, as I mentioned about treatment scheduling, treatment attendance, that also includes as another level toxicology screen results, treatment recommendations, course and treatment. So, really have these different categories and we'll work with the parents because, put in place rewards for the young person. If the young person's reluctant to sign that release information, have rewards associated with them, sign the release information, because it's just really crucial that family know whether or not the young person is coming to treatment. And then we're gonna be able to be most effective if parents really know what's going on in terms of their substance use. But often young people, just again, have lots of worries or get in their head about how parents might use this information, or what information might be shared with the parents. And we often have to remind them that their parents really don't care about their conflict with their girlfriend or what happened when they stood them up for a date or something like that. The parents just want to know, are they coming into treatment, what's going on with their substance use? And so they've mentioned, you know, parents and caregivers can play a really important role in terms of encouraging treatment engagement, and then monitoring young people over time. A lot can happen between treatment appointments, especially for young people. And young people often don't volunteer that information when things haven't been going well between appointments. And so, really crucial to have that ability to talk openly with parents. The other thing is that parents or caregiver's when someone drops out of treatment, I don't have contact with them and it's hard to kind of know when are the moments where I'm gonna be more effective in motivating them or encouraging them to come back to care? And so parents can play that role to help encourage or incentivize re-engagement and care after a relapse, or if someone's fallen out of care. So one part of that though, and this is where having a multidisciplinary team or having a team is important, is that you want to have a space for the young person to feel like this is their space, that's confidential, where they can really be open about what's going on and you need their parent involvement. And so that's often where it's helpful to have at least two treatment providers working with a young person and their family, so that one person can be the point of contact for the parents and another person, really the key point of contact for the kid. And so in working in a multidisciplinary team as a medication provider where I might not see the patient as often as a therapist and the therapist is the one that really needs that key alliance with the patient to kind of work with them on a weekly basis to develop their motivation to change and maintain that change. Sometimes I'll be the point of contact for the parents to kind of really help the therapist strengthen and build that alliance with the young person. 'Cause at the end, every second that you spend talking to the parents, the young person is concerned and kind of there may be less trust for you as a provider with the young person. So lastly, one other key kind of area to think about for young people is peer support. So, if a young person, again, is spending a lot of time with peers who are using substances and you're asking them to make a change, they can feel fairly isolated and alone, if they're trying to make a change to not use substances. Often initially, they'll try to still spend time with their friends who are using substances, but then discover that it's often hard to maintain their abstinence from substances when they're spending lots of time with other peers who are using substances. They may try to distance themselves from those peers. They really need a lot of support in establishing new relationships and finding new friends for support who are not using substances. And so the whole idea behind these three different types of peer support, including mutual help organizations, recovery high schools, and collegiate recovery programs, is to increase the young person's involvement in positive activities that don't involve substance use, and then kind of really build this new community of positive influence. And so to kind of talk a little bit more in detail about some of these different types of peer recovery supports. Recovery high schools are growing in number in our educational environment that provides the whole, full range of academic services, but in an environment that's focused on recovery. So it has everyone that's coming to a recovery high school, has a goal of making changes with their substance use. And these are all young people with substance use disorders, and they have found that these are effective. In one study with youth with a substance use disorder, found that those who attended the recovery high school, when compared to youth with a substance use disorder who did not attend a recovery high school, were four times more likely to be abstinent from all substances at six months. And that's really, you know, remarkable given how hard it can be for young people with substance use disorders to make a change. So this can be a very key part of someone's recovery plan moving forward. So likewise, collegiate recovery programs are an analogous type of support on college campuses. And this is really a place where they're trying to create a supportive environment within the campus culture that reinforces recovery. And unfortunately, a lot of campus cultures are kind of, there's a lot of substance use in a lot of college campuses. And so it can be hard for, without these collegiate recovery programs for people who are trying to not use substances to connect. And so this create a way for them to connect on campus and these programs range and their intensity and kind of structure. Some provide substance free housing. Some have a space where there's an on campus mutual help meeting. Some actually organized substance free social events, and then some have a really discrete physical space, where there's staff available to provide support, space available for people just to spend time doing homework or have a place to gather on the weekends. So another important type of recovery support for individuals with a substance use disorder who are attending college. Lastly, I want to mention mutual help organizations. And often, people don't think of mutual help organizations as a resource for young people, but there's a lot of data supporting the efficacy of mutual help organizations for adolescents and young adults with substance use disorders. And so they have found that adolescents who attend Alcoholics Anonymous or Narcotics Anonymous, which are a type of mutual help organization, are much more likely to be abstinent. One thing about mutual help organizations, since people often think, oh, well, there's a lot of older adults and are these a safe place for young people? And they have established with research that young people feel safe at these meetings. And when they ask young people, what's helpful about these meetings, what they said was that, having a sense of belonging, having this space where there's people that are supportive and have been had similar experiences to them was really important and helpful. Additionally, they found it helpful to have hope that things will change and things will get better. One other thing is that, as I've mentioned before, many young people with a substance use disorder have a co-occurring psychiatric disorder, and they have looked at how effective our mutual help organizations for this group, and found that youth with a co-occurring psychiatric disorder benefit from AA just as much as youth with the substance use disorder only. And one really nice part about mutual health organizations they're in many communities, multiple meetings at different days of the week, different times of the day. And there's often meetings at times when treatment facilities or outpatient services are not available. So these are meetings on Saturday nights or things like that. And within 12 step organizations such as, again, a type of mutual help organization, these are peer led organizations. They have different types of meetings and have, actually have a young persons' meeting within AA. And so this can be a place where it can help with young people initially engaging with mutual help, that they can go to a meeting where there's other young people, as a way to kind of first start to engage with this type of support. So this is just another, again, important resource to be available or to know about when working to support young people who have a substance use disorder, in making a change. So lastly, you just want to think about, you know, how we may consider treatment for individuals with a co-occurring psychiatric disorder. And so it's important to recognize and acknowledge co-occurring psychiatric disorders since they may impact how someone with a substance use disorder is interfacing with the treatment system or even the legal system. And so if a young person has a substance use disorder and is also depressed, they may not have a lot of hope that things are gonna change and may have lower motivation, less ability to engage with treatment. They also may struggle to get as much out of treatment initially because the poor concentration or just low energy and just again, really struggling to fully engage with treatment. And so we need to think about that, if you have someone in the court system who's maybe been mandated to treatment, if they have a co-occurring depressive disorder or other psychiatric disorder. How might that psychiatric disorder be influencing, impacting their ability to engage in treatment? Likewise, individuals with a co-occurring attention deficit hyperactivity disorder, which is quite common among people with substance use disorders and with kind of rates at up to 25% of people with substance use disorder have a co-occurring attention deficit hyperactivity disorder. They may really struggle with difficulty with organization and planning. As anyone who's tried to support someone in interfacing with the substance use disorder treatment system knows, you have to be quite organized to keep track of what phone number to call, where to show up. There might be a number of different appointments that you need to track and be kind of aware of. And so people with ADHD may struggle with this and may need more support to be successful with engaging in treatment. Another thing is they may, you know, a lot of substance use disorder treatment is group-based and they may have trouble sitting still for a long period of time, or may have trouble being attentive during group or may impulsively interrupt somebody in group. And so these are, again, things to keep in mind when we're working with people who have a substance use disorder and a co-occurring psychiatric disorder. So in summary, as we think about treatment of substance use disorders in adolescents, in particular, we need to remember that adolescents are at increased risk for substance use disorder because their brain's not fully developed, and that individuals with psychiatric disorders in particular are at higher risk to develop a substance use disorder. Therefore, we need to think about, that they might have a co-occurring psychiatric disorders, we're screening, assessing and treating them. We also need to remember that it's important to screen because young people are not gonna volunteer this information. They often don't see themselves as having a problem. So really have to be systematic in asking them about this particular issue. Likewise, in terms of thinking about treatment, therapy is really kind of a key part of someone's treatment plan. It's important to not only build motivation to change, but to give adolescents skills to be able to make that change. And then family is really crucial in helping them stay engaged in treatment, helping them monitor these young people over time. And as we're thinking about involving families, we also do need to think about the fact that an adolescent needs their own space to really build a relationship with a provider so they can be, develop that trust and be as open and honest as they can with that provider. And then lastly, as I've been talking about more recently, peer support is really key for adolescents. So young people who are changing their substance use are often isolated and peer support is very important. So with that, just want to highlight that myself and Dr. Capeci are available for questions. And I want to be here to support people in working with young people with substance use disorders. We really think that these are fun kids to work with, but they do need a lot of support and resources to support them in making a change. And I'm and so happy to talk about how to support them with that if you have questions. Thank you. <v Announcer>For free localized education</v> and training designed to meet your needs, contact the Opioid Response Network.

Chief Justice Tina Nadeau

addiction in courtrooms

substance use disorder

adolescent mind

family connection

treatments for younger adults

Dr. Amy Yule

risk factors for substance use disorder

screening and assessing substance use disorders