Good afternoon and thank you for joining. My name is John Renner and on behalf of the American Psychiatric Association, welcome to today's webinar, Adolescence and Substance Use Disorder, Prevention, Treatment, and Recovery. Next slide, please. Today's activity is presented on behalf of the Opioid Response Network. Next. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. This email will contain the instructions to claim your one credit hour for attending. This activity offers CE credit for physicians, nurses, nurse practitioners, pharmacists, physicians, assistants, and social workers. Next. The PDF of the slides will be available in the chat tab. Next. Captioning for today's presentation is available. To enable the captions, click show captions at the bottom of the screen. Click the arrow and select view full transcript to open the captions in a slide window. Next, please. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendees control panel. We'll reserve 10-15 minutes at the end of the presentation for Q&A. Next, please. I would now like to introduce you to the faculty for today's webinar, Dr. Hector Colon-Rivera. Dr. Colon-Rivera is a distinguished quadruple board-certified adolescent, adult, and addiction psychiatrist of the Pennsylvania medical community. He has broad experience in community-based programs, emphasizing those that help increase access for treatment for severe mental illness and substance use disorder. I welcome you to today's session and thank you for attending today's webinar. Welcome, Dr. Colon-Rivera. Thank you for the introduction, Dr. Renner. It's a pleasure being here and thank you for Open Response Network for bringing these topics. I have no disclosures. I do intend to discuss some products and other things that are not evidence-based. It's really important to mention that. I have four objectives for my presentation. I will be talking about how to identify current trends in adolescent substance use, and I will emphasize three substances today. That will be nicotine and e-cigarettes, some marijuana products as well, alcohol, and opioid use. I'm going to describe why adolescents are particularly vulnerable to opioids and substance use disorders, describe some risk and protective factor for adolescent substance use in high-priority groups, and identify evidence-based community, school, family, and peer prevention options for our adolescents. A little bit of numbers before we start talking. We have seen this graph. Some of you probably have seen this graph before. This is an age-adjusted rate of drug overdose death involving opioids. People talk about three waves. We started back in the 90s with the painkillers or pain medications back in the 90s, and then we have a wave of heroin use on the early 2000s, I would say probably 2008, 2009, and that continued on to 2003, as you can see. That graph increased, but now we're seeing a decrease in the heroin use and a spike on synthetic drugs, synthetic opioids, other than the methadone. That spike, we saw a spike back in 2010, 2011, and you can see that blue line going up. The three waves. We found that overdose is dead increased during an early pandemic period, and we're driven primarily by outside hospital death that were associated with the fentanyl use. We saw an increase in about 280 percent increase in opioid deaths due to the fentanyl use. That's a lot of people. Some of them were adolescents. Also, when we think about adolescence and prevalence of drug use in the past month, we see how alcohol is there on the top, followed by marijuana use, then followed by binge drinking and vaping devices. This is a lifetime past year, past month, and binge alcohol use. We see this still going on. These numbers are from 2019, but it's still prevalent these days. We can divide as, I mean, you guys know Monitoring the Future, we can divide it in 8th and 12th graders. This is for opioid pills or painkillers, and oxycontin is the one that they use the most, especially 12th graders, so higher risk for high school students. In terms of lifetime, when we think about lifetime, we think about lifetime use of marijuana, lifetime use of nicotine products and alcohol use, and the risk for opioid use. We see how using another drug, other drugs like the marijuana especially, put the kids and adolescents at a higher risk of using opioids. It's higher for marijuana, followed by cigarettes and, of course, alcohol. Also, there is some generic factors. I mean, as you guys might know, I mean, alcohol and cocaine use are pretty genetically linked in terms of risk for use. Also, age of starting the use, right? I mean, this study, and we talked about this back in 2017, we found that at least 13% report alcohol use before the age of 13. At least 12% use cigarettes before the age of 13, and at least 14 use marijuana use before the age 13, and it was associated with greater risk of developing a substance use disorder. For kids that use before the ages of 14, and especially those, I'm gonna mention that later on, that have a history of being abused or mistreatment, have put them at higher risk of having a substance use, in general, a substance use disorder in general. But for nicotine, it's a lot higher than other drugs, followed by alcohol and other illicit drugs. So nicotine is really high if they start before the ages of 14. In terms of developmental perspective, the brain's not fully matured until you are 24, up to 25 in order. And of course, depends on the sex, the gender. I mean, if you're female versus male, but usually females mature before males, but in average, I mean, the brain is not fully developed until you are 25. So every stride, I'm gonna call it that way, that you have by being mistreated, bullying, trauma, and substance use, I mean, it put you at higher risk of having another substance use or a detrimental mental illness like depression, anxiety, and psychosis. So it's really important to know that age is a really important factor when we're talking about risk factor or protective factor for the kid. All the protective factors or domains that we should be thinking about is community, family, school, peer, and of course, the personal protective factors or basic risk factors. When we talk about community, we're living in an area of a lot of separation and people just thinking about themselves in some ways. The race, living in an area of a lot of racism, depression, oppression, and economic deprivation in the community put you at higher risk factor of using drugs versus living in a neighborhood that is full of attachment and community connection is a protective factor. When we think about family, lack of parental supervision is a big, big factor for using substances or having a high risk of using substances versus having a parental monitoring, family connection, and having more protection from the family. Peer support is really important as well. And the same as academic success has been linked with as a protective factor. Individually, we're gonna talk more about the ACEs and trauma and early aggressive behaviors are linked with the risk factor for substance disorder versus a little bit more self-control, involving an activity, more extracurricular activities, and engagement in sports, school activities, and family activities are protective factors for our kid. Same, having a mental illness, right? Increased risk for a substance use, especially opioid use disorder. We think that having a major depressive disorder put you at higher risk of having an opioid disorder, having PTSD, trauma, trauma. We'll keep repeating trauma today because I think we don't talk about trauma as much as we should. And it's something that we can prevent on time when a trauma happen. And the more trauma you have, the more at risk you are for a substance disorder and all the mental illness. So it's really important to talk about trauma. And also, well, knowing the link between family, alcohol problem, drug use, and drug misuse in the kids is really important. So again, I mean, mental health disorders increase the risk of a substance disorder, especially if we don't treat them on time, or we don't prevent them when they're happening. It was a, there was a really a new study by Lippard and Nemeroff, and that just came out yesterday in the Green Journal. And they talk about how trauma treatment and the consequences and the windows of intervention across the development of the child. So I invite you to look at the Green Journal. It was just published yesterday, August 1st, so you should check it out. And they talk about the many critical periods where you can do a prevention of, there's an optimal window for intervention on those in kids that have history of substance disorder and trauma. So it's a pretty unique journal. I didn't have the time to add it to my presentation, but I invite you to look at it, because it's really important to the topic that we're talking about today. So when we talk about adverse childhood experiences and trauma, the ACEs, right? So no ACEs, which means no having trauma, put you at, you know, you're still at risk, because, I mean, we are at risk, and we talk about different risk factors, but not having trauma, you know, means that you have no ACEs, you have no adverse childhood experiences. Even with no ACEs, one in 16 are at risk for being a smoker or smoke, and one in 14 are for heart diseases. When we talk about one or three ACEs or adverse childhood experience, we see the big difference, right? From one to 16 to one to nine, and one to seven are heart diseases. So we're not only talking about mental illnesses, we're talking about physical and organic illnesses as well. Also, we see how alcohol and other, you know, an IV drug use, like heroin use, is increased when we have more than three adverse childhood experiences. And I'm not talking about PTSD, I'm talking about adverse childhood experience, not all trauma cause PTSD. The more trauma we have, the more adverse experiences we have, the higher is our risk to have a, a risk for substance disorder or a physical health situation. And something really important that's, you know, in Bowie, in the presentation, is that, you know, the more ACEs we have, the more at risk we are to commit suicide as well. So you can see from one to three adverse childhood experiences is one out of 10. Once we cross that line of three adverse childhood experiences is one out of five. So we're talking about 20%, you know, attempt to suicide. So really important to talk about adverse childhood experiences because these are optimal windows of intervention. This is prevention, right? We can prevent, we should not wait until the kid has three adverse childhood experiences. We should prevent and act in the first one. So talking about trauma at the beginning, at front, right? Inviting the child, inviting the adolescent to the table to talk about what happened. Tell me what happened. Tell me how you feel, Hector. And just inviting, observing changes in behaviors is really important to prevent. So, you know, every ACE is an opportunity to prevent something like a substance disorder or a mental illness. So ACEs, as we discussed, increase and predict early age of drinking onset. Prevent, I mean, it tells you the higher risk of mental illness and substance use. Continued alcohol use and alcohol, the more ACEs you have, the higher risk you are to continue smoking. 47% to 56% increase the odds of prescription drug misuse. So again, a lot of, you know, having the more ACEs, the more high risk you have for substance disorder or mental illnesses. Okay, now I'm going to start talking about the drugs in more detail, starting with alcohol use and why alcohol. Well, alcohol is the most prevalent substance use in adolescence. People ages 12 to 20 years can drink 11% of alcohol consumed in the United States. So that's like a lot of people, right? A lot of alcohol for these ages. And we're talking about, they're supposed to be starting at the age of 21, right? Unless you are from Puerto Rico, then you start drinking at the age of 18. Legally drinking age is 18 in PR. But, you know, we're talking about before the legal age drinking. And 90% of them consume in a way that is a binge drinking situation. Almost 5,000 deaths among undergrads youth and 120,000 visits. And this is per year, people. And I mean, we have seen a decrease in the last years, but these continue to be an issue, especially for college students. Some definitions are really important. Alcohol use disorder, counting with the DSM-5, we count as a relapsing brain disease characterized by impaired ability to stop and control alcohol use by adverse social, occupational and health consequences. Binge drinking defined by SAMHSA is five or more alcohol drink for males and four or more alcohol drink for females on the same occasion. And same occasion, it's at the same time within a couple of hours. Usually I describe it as, you know, one to two hours for binge drinking more than five. And we're gonna talk a little bit more about what is a drink, what I consider a drink and what the data consider a drink. Because I mean, it's 14 grams of alcohol. So it's really important to define that when you ask the question to the patient. I mean, they can say a drink, but it could be, you know, 12 ounces versus, you know, 20 versus 36 sometimes. And that's really scary. So we need to define that when we talk to the kids. Heavy alcohol drink sampling defined by heavy alcohol use and binge drinking on five or more days in the past month. And they tend to minimize the amount of alcohol in the past month. And they tend to minimize this, right? Because you say weekends, and both some weekends are long weekends and some weekends are starting on Friday, Saturday and Sunday. So a lot of consequences, but underage drinking. Binge drinking is, you know, an intoxication can occur. They have a lot of kids that have DUIs at an early age and we need to prevent this. They start having school problems, changes in brain development, problem with memory, physical problems. So we need to rule out any alcohol use or before we even try or start thinking about attention deficit disorder, for example. There's a disruption in average growth and sexual development, social and legal problems, higher risk for suicide and homicide, especially when they're intoxicated. And then from alcohol poisoning, of course, we've seen it in the news. Some kids have died from alcohol poisoning. Some screenings there that I use, I love the craft. I mean, that's something that, that's one of the best, at least in my practice, that's the one I use the most. There's the SPIRT, which is Screening Brief Intervention Referral to Treatment. Adolescent Drinking Inventory. It's pretty long, but it's useful. 24 items. The Rogers Alcohol Problem Index and the POSIT, which is Problem-Oriented Screening Instrument for Today. So I invite you guys to check them out and just pick one, pick two, and use it on your practice. I see any substance use, I see it as a pyramid. I mean, alcohol use, and I started with a lot of people who did not use, to experimenting, to then abuse, and then risk abuse. We talk a little bit about men below 65, more than four drinks and more than 14 drinks. And then females over 65 is three drinks, occasionally more than seven drinks. And this is a NIAAA definition of heavy drinking or risk use. And then we have, of course, at the top of the parameter, substance use disorder, in this case, alcohol use disorder. So how do we define a drink? So it would be 14 grams of alcohol, okay? So again, it's really important to ask this question. When you ask how much you're drinking, I drink two drinks, but what kind of drinks, right? So 14 grams are included in a 12 ounces of beer, five ounces of wine, and 1.5 ounces. Of course, there are pretty creative products out there that have a lot more alcohol than these 14 grams. And this is just a guidance. And if you're talking about craft beer versus those made in the houses, some of my patients are, you know, are crafting beers in their houses. Very important to know the content of alcohol. And, you know, they're pretty creative. So it's really important to talk about this data and compare the amount of alcohol they're using. So again, this is more of the same. One drink equals all this, and also, well, the definition of at-risk alcohol use. In terms of what do we do when we have an alcohol use disorder so there's some maintenance pharmacotherapies and there's some FDA-approved medications in the dose. And what we're trying to do is decreasing their cravings for alcohol. We're trying to reduce the post-acute and protracted withdrawal symptoms and the rewarding effects of them. FDA-approved medications. So we have three. We have Natroxin, which is an opioid receptor antagonist. And the effects, what it tried to do is decrease aphoria with alcohol, decrease alcohol cravings. It kind of decreased the heavy drinking days. So I always kind of expressed that it's not gonna stop you from drinking, but maybe stop you from drinking that extra drink. It kind of decreased the urges for the next one. And those heavy days might stop. It kind of decreased the endorphins of having that, the phoria of having that extra drink. And with time, hopefully the desire of drinking disappear. Some cautions. Of course, we need to be careful with people with cirrhosis and patients with opioid disorder. Please don't give, if there's opioids on their system, at least wait seven, 10 days, depending on how many opioids are used and what kind of opioids. Talking about methadone, long-term opioid versus short-term and how long they're being used in a chronic use versus acute use is really important, but at least 10 to 14 days. If you're doing the injectable, Natroxin, please, please, please do a Narcan challenge or a Naloxone challenge before if the patient is an opioid, especially if it's a long-acting opioid. We want to prevent an abstinence patient from getting in a really bad withdrawal psychosis at times, and we want to prevent that. The next is Desorphirin, which don't use it that often. I mean, it's a great medication, but it's not for, at least I think it's not for everyone. What it does is blocks aldehyde, dehydrogenase. It just gives you this unpleasant feeling with alcohol consumption. And what I feel and what I think, what my opinion about it is like, the reason why I don't use it that much is it kind of, it prevents you from using any type of alcohol content product, right? I mean, that includes perfumes, colognes, hand sanitizers sometimes. You can react, have a skin reaction to it. So a lot of caution when you take this. And also a lot of caution with people with heart diseases, we need to be, or esophageal viruses need to understand the effect of this medication, because it could be a pretty, you can have a lot of vomiting and react to this medication. So you need to be careful when you prescribe it. And it's not, that's why I'm saying it's not for everyone, but it does help those that take it. And we have, here is the way it works. Again, it does block this enzyme there. And it does, what it does is you, a lot of acetaldehyde is collected and you have this, you know, symptoms that make you sick. Next, we have Acamprosay or Acampro, brand name. So it's an NMDA modulator to promote glutamate and GABA balance and decrease dopamine. And what it does is decrease the cravings. I mean, pretty, pretty easy. The problem with it, I mean, I think the dosing is three times a day, but that can cause an issue for some patients. Please check with a renal, when you have a patient with renal insufficiency. And of course you need to create, to check the creatine clearance. And if you have more or less, less than half of the clearance, half a dose is indicated. So yeah, that's the only contraindication. Other than that, it's a pretty well-tolerated medication. Let's see. And of course we have psychotherapy, CBT. I do a lot of CBT on my practice. And I mean, we have groups and CBT is, it works, it works. It does change maladaptive behavior. So I mean, if you practice CBT, please use CBT for, I mean, and there's CBT for each drug. You can use CBT for opioid use disorder. You can use CBT for alcohol use disorder. I mean, there's something called seeking safety, which is great too. I mean, it's based on CBT and for people with trauma as well. So seeking safety is a good book as well that we use pretty often. Family-based therapy, brief motivational interviewing or interventions. I mean, this is really good. Brief integrated care is a good, I mean, you're integrating here with older type of physical complaints or physical disorders or conditions, and that helps. Continuous management, I don't use it that much for alcohol. Use it more for stimulants, but it's useful as well. And it's just, you know, having negative breathalyzers and you get some kind of positive reinforcement for that. So that's great. Oh, and of course, using motivational interviewing. Interviewing, even though it's not a therapy, it's a model of, it's a skill that we should practice. It's a good, good way of, you know, hanging behaviors and maladaptive behaviors as well. So next I'm gonna talk about opioid use disorder. And let's see. And that's kind of my favorite topic, opioid use. So this, I mean, and in this slide, I know, I mean, it's pretty, it's pretty busy slide, but I'm just wanting to see how, and this is the CDC report on heroin epidemic and the national drug-involved overdoses among all ages. But I just wanted to see how, you know, where we stand with opioids. I mean, as you can see, opioids is kind of the major player in there. And there's some data, of course, especially now in the last 10 years, that there is a lot of co-use of medications, including alcohol and benzodiazepines, I would say are the two major other players. And I don't know where you guys are from, but at least in Pennsylvania, benzodiazepines is a big deal. And now with psilocybin on board, you know, even though it's not causing a lot of overdoses, it's causing a lot of other comorbidities, like skin reactions, and people can use the psilocybin to make, you know, the fentanyl more potent. And of course they can over, you know, die from it, because they spend more time on the sedation part, sedation sensation, and die from it. So, you know, a lot of players. So I just want to mention that it's not only heroines kind of usually no one just use heroin these days, just a mix of something else, either psilocybin, fentanyl with psilocybin, or the mix up with benzodiazepines and alcohol. So it's really important to know on that, because we're not only treating opiate use anymore, it's just a mix of uses. So it's really important to know what is, I guess the trend on that environment to know what we're treating, because we're never treating one drug these days. Treatment option for adolescent in terms of opioid disorders. And again, we saw how in the first slide of the presentation how the different waves started with painkillers, now heroin, I mean, now the synthetic drugs, and before that, the heroin. So that's the three waves. And now we're seeing more of, you know, core use of all the drugs. I would call that a fourth wave, or why not? I mean, which is the mixing with psilocybin or other medications. Psilocybin is a clonidine analog, if you guys should check it out as well. So treatment option for adolescent with opioid disorders. So we have behavior versus pharmaceutical. Of course, detoxification is not treatment, but it's part of the, you know, it should be part of getting to treatment or linked to treatment in terms of referrals. But we have pharmacological interventions. Some people use detox with Convim, buprenorphine, methadone, why not? There's some naltrexone protocols out there as well. In terms of medication for assisted treatment for opioid use, I mean, and buprenorphine, methadone, and naltrexone are the three that are FDA approved. And you can use it for adolescents. I mean, we published this not that long ago, 2019, and we do a pretty nice review of the clinical benefits and potential risk of medication for assisted treatment for opioid disorder in adolescents. So I invite you guys to check it out. But when we talk about pharmacotherapy for opioid use, we talk about three medications, methadone, buprenorphine, and naltrexone. Methadone is a full agonist. And the tricky part about methadone is highly regulated. So only prescribed in licensed and regular specialty clinics. So, and required to use it in kids. So it's approved for 18 and over, but to use it in someone that is 18 and below 18, you need parental consent. And probably the kid has had to fail, has had to fail at least two of the treatment. And of course, to start anyone on methadone, you need to require documentation of two drug-free, also self-attempted, short-term detoxification, or drug-free treatment within 12 months before you will maintain the treatment. So for kids, it's really hard to be on methadone, but it's possible. I mean, I have had, probably I have two kids now that are on methadone, and it's because they have failed and they meet these criteria. So if you study the most retroactive trial review, I mean, they do agree that it helps with retention treatment and decrease the opioid use in kids below ages of 18. In terms of buprenorphine, we have a mu-opioid receptor partial agonist. I mean, it's FDA approved for 16 and older. We don't need the X waiver anymore. That's some good news for some of our practitioners. Three randomized controlled trials in adolescence, they didn't find any adverse effects. Headaches was the most common side effects. And most of the RCTs support treatment for at least 12 weeks with good results. So I use it a lot on 16 and over. I mean, there's some places that use it for detoxification in below 16, at least at the age, at least in Pennsylvania, there is no age for detoxification. I mean, you can use it, but for treatment, it's still 16 as FDA approved. Next, we have nitroxine, which is the antagonist, right? We have a opioid, a mu-opioid receptor antagonist. It's FDA approved for 18 years and older. Pilot studies show feasibility to use in adolescence. I usually use it for alcohol, not for opioids, but it's FDA approved for both 18 and over. Seeing an opioid level, prospective cases use looking at nitroxine for youth, I mean, it has admitted that it's well tolerated and has shown clinical improvements on the opioid use, meaning decreased opioid use after 12 weeks of use. And 12 weeks means like, you know, it's a third injection and they stay on the injection for at least 12 weeks. Hey, they stay on the injection for at least three months. It's really important to mention naloxone, an overdose prevention training. Opioid receptor is an opioid receptor antagonist, so it's really important. And just it's reverse opioid-related sedation and respiratory depression, no abuse potential. Usually acts within two to three minutes, so usually acts pretty fast. Lasts about, I would say 20 to 90 minutes, but it depends on the persons. That's why some of our first responders need one, two, probably to carry three naloxones. And I think the average dose is about four milligrams. So it's, and they're recommending now to use the nasal, it's kind of the standard, the nasal naloxone, four milligrams device. So it's really important to carry at least, you know, at least have two with you at all times. And train the family. If we're talking about kids, adolescents, train the family on how to use this overdose prevention, education, particularly for adolescents. I mean, don't be afraid of teaching them how to use these devices. It's their life, and they tend to do pretty well using it. The third drug we're talking about today is tobacco use disorder in adolescents. So, and tobacco use, I mean, close to six millions, probably more than today's American, younger than 18 will die early from smoking-related illnesses. I mean, we saw in previous slides how smoking before the age of 14 put you at higher risk of smoking after, you know, you're as an adult and having a lot of chronic medical issues with heart disease, cancer, and COPD. E-cigarettes are kind of the driving force behind this. I mean, most of my adolescents, at least here in Pennsylvania, use nicotine through, or tobacco products through E-devices. And the number of middle and high school students using E-cigarettes rose from two million, you know, to four millions. And it has been staying pretty much the same through the years, now in 2023. But we're seeing more of the E-cigarettes use. And there's a lot of marketing behind the use. I mean, the source of E-cigarettes advertising is television, I mean, social media is full of them, versus tobacco product, which is prohibited. I mean, we don't see marketing because the law passed and you can do marketing, you know, marketing tobacco product. Well, as E-cigarettes is not a tobacco product in theory, or in legally, in paper, so marketing continues. So as you can see is retail stores are full of them. I mean, you drive around and you see all the stores, there are in gas stations, there are in other retail stores. I mean, in the mall, there's a lot of stores that have this. You are exposed through the internets or social media, TikTok, Facebook, Instagram, you name it. And you are exposed through magazines and newspapers as well. And it's pretty easy to carry, they carry it to school. And let's see here. I mean, there's some examples here. And you see guys where the most commonly used tobacco product. And they come in different sizes, different potencies. And the cartridges are the key for it. I mean, it can have a lot of nicotine, a lot more nicotine if you smoke like a pack or two packs a day. So each cartridge is different. But you can have these two packages in that cartridge. And they can smoke one of them a week. So we're talking about a lot of smoking in a small device. Cigars were the most commonly used combustible tobacco products versus cigarettes. So adolescents were using more. And this is 2022. We're using more of the tobacco products. And they use it in the form of cigars. And there are certain cigars. I mean, it's pretty easily accessible in gas station and retail stores. So how do we treat this? What we can do. So in terms of FDA approval, we have seven FDA-approved medications, NRTs, which is nicotine replacement therapy. We have five different formulation, patches, nasal spray, inhaler, lozenges, gum. I only have Glock in adolescence treating with gum and the patch and bupropion. And then we have boronacycline or bicycline, boronacycline or Chantix. So in terms of the nicotine replacement therapy in adolescence, I mean, there's great data out there. I mean, it's an agonist-based pharmacotherapy. It was FDA-approved for 18 and plus. And I think, I mean, here in the study treatment group, we saw how this was between ages of 13 and 19 at 10-week RCT, comparing nicotine patch and placebo with both treatment groups, receiving weekly CBT and continuous management. So they found that patches, people had a longer abstinence in patches followed by the gum than compared to placebo. The nasal spray, I mean, there was an open-label pilot study that included nasal spray versus placebo. And nasal spray compliance was really poor and no significant growth difference was observed. So the nicotine spray, I couldn't find any good data behind that in the use of adolescence. But there's good data behind the use of patches and the gum comparing to placebo. So for the nicotine replacement therapy and nicotine patches versus gum versus nasal spray, it's more efficiency than using the other. So nicotine patch is the way to go if you want the evidence-based RCT results. And even relapse after discontinuation of NRT remain elevated. So still relapsing is a good option, but the study shows that probably you need something else. And I think bupropion is a good combination using NRTs. And it's a dopamine and norepinephrine reoptic inhibitor and nicotine blocker antagonist, the receptor antagonist. We have about four RCTs by this time. And they found a higher afterness with the 300 milligrams dose. And again, this is once a day at six weeks and six-month follow-ups. They found a higher afterness. So I use bupropion a lot, especially the ASR 300 milligrams. It may improve tobacco afterness, especially when combined with psychosocial intubation and CM. So in my experience, when you use the patch and bupropion, it's a great, great way of having a higher afterness. I don't use the patch for a long time. I use the patch until bupropion start working, and then I stop the patch. But I feel that that combination is really helpful versus placebo versus only using the gum and only using bupropion. So that's just a personal case study opinion. In terms of the tobacco use disorder, as a conclusion, counseling should be provided at all times. I like to ask, advise, assess, assist, and arrange. Please use those five A's. The math is the best thing you can do for yourself. It's something I learned in fellowship. Always ask the patient if you smoke, and always followed by the best advice I can give you is to stop smoking. The ask, advise, assess, assist, and arrange. And arrange for treatment. Arrange for a follow-up. You want to see that kid back. Improve smoking cessation rates when psychosocial intubation are combined with nicotine patch and bupropion. Yes, so again, it's the combination of medications with psychosocial intubation. And intubation is just asking. We're not talking about long therapy. We're talking about asking, how are you doing? How much are you smoking? The best thing you can do for yourself is just start smoking. It's not for yourself, for your family, for your kid. I mean, we have adolescents with kids smoking at home. So please ask. Use the five A method. Practitioners may consider trials of nicotine patch or bupropion SR in adolescent smokers who fail to respond to psychosocial treatment. Of course, I think using both is the best way to go. But always ask. When we talk about prevention options, I mean, there are plenty of prevention options. With technology and after COVID, we have seen a lot of community prevention options out there. There's a lot of apps that you can use. And for those of you that are looking to start buprenorphine, for example, there is a good app that's called BUP. And you can search or you can download it on Google or Apple stores. And it just helps you with this first three days. And it's in Spanish, too, which is great. It helps you in the three days of starting the medication I mean, buprenorphine. And it's great for adolescents. I use it a lot because, I mean, they are visual. Most of them are visual. And they like apps. And they feel that they are participating in something that really helps them. So BUP, I think it's like a diamond sign symbol. So please check it out. So community prevention, you can find places in the internet. And there are access of outlets on location. There are a few locators out there that you use. I mean, SAMHSA has a lot of locators if you're looking for someone that prescribes buprenorphine. But we need to, in terms of prevention, we need to work non-profits, private institutions in working these outlets, density areas. Continuing with the public education campaigns, right now, I mean, the APA has the annual meeting will be all about substance disorder, especially about substance disorder. So that's campaigns are going all year long this year. So it's, I mean, adolescents are pretty complex, but the use of different channels, it's really helped, especially when you're using technology. Also, prices, production, promotion, and placement of different, of the products, like what we did with tobacco products, making sure that age, we do a lot of legal age limits and consistent reinforcements in areas that people use the most, like schools, for example, I mean, or gas station, when you have a lot of gas station, that's really important to prevent the buying and the use of tobacco products in our kids or alcohol use. School prevention options, where we have the wellness teams, organizational levels, we have school connections, school policies. APA has a lot of school programs as well that you can check out. And just examples of how we prevent is universal curriculum, screening activities, full screen in small groups, one-on-ones. I mean, as I said at the beginning, if you have a kid that has any behavioral changes, invite a kid for a conversation and then observe any change of behaviors and talk to the patient. If it's more than what we can do in the schools, so we refer outside the school. So referral counseling and mentors, peer support groups in schools are really important. And ways of finding the kids that's using this, any changes in behaviors, I keep saying that, but that's really important, any changes in behavior, taking longer breaks to go to the bathroom. Of course, the smell, even if you're smoking e-cigarettes, the smell can change to mint or why not? Or if you have one or more kids going to the bathroom at the same time, maybe it's a smoking break. So just watch out for those behaviors and discuss this with your teachers and staff. And includes all staff, not only teachers and social workers. I mean, the drivers, the people that work on the school and the food pantry, people that are the security people. I mean, include those people as well, because they are dealing with kids. In terms of family probation, of course, we need to engage family. We need to engage education and train the family, not only on the use of naloxone, but also on these behavioral changes. So invite them to the conversation. I mean, they are part of the team. Listen, talk early and talk often with your child. Family support and linkage resources. I mean, counseling and peer support are really important. There's a lot of peer prevention options out there. I mean, there's something called positive youth development, peer-to-peer, opioid, thetruth.com, it's very important. Depending, every state has a different activist and a voice created by kids. There's WAVE, I think it's W-A-V-E in Facebook. There's the voiceproject.com. And all these powerful kids and adolescents are working with other adolescents to create powerful policy advocates and build skills. So, I mean, a few examples out there, but you can search yourself and have, I mean, if you can, of course, email me the questions about this. And youth and young adult recovery support. I mean, recovery high school, we have peer groups, we have college recovery programs, faith-based organization, 12-step young groups. And this would be great because now in 2023, you can use technology to find it. More opportunities, I mean, to grow. I mean, we have trauma-informed approaches and we talk about every trauma, every ACEs, every adverse effect can be a good, optimal window for prevention. We are doing a lot of training on cultural competence and humility. I mean, that's great. Every hospital is doing, I mean, this training right now. We're improving relationship and connection with technology. And social-emotional learning is another one that is increasing training in every system through the nation. So I will open to questions. I know it's a lot of information in a short amount of time. I speak really fast, so any questions are welcome. Thank you very much, Dr. Colon-Rivera. It's been a very informative presentation. We want to take a few minutes to do questions. So if anyone has questions, please put them in that section. You can submit that just by typing into the questions section. I had one thing that I wanted to ask you about to get started. The study that you were involved in using medications for opiate use disorder in adolescents. We're in an era now where there's some highly dangerous drugs on the market. People are using fentanyl, people are using xylosine. I would consider simply detoxing an adolescent who'd been addicted to opioids and trying treating them with drug-free counseling would be fairly risky at this point. And my question to you is, would you consider using buprenorphine in such an individual? And how long would you want to keep them on buprenorphine as a first part of their treatment package? Yeah, so yeah, after detoxing them, I will consider keeping them on suboxone or buprenorphine. And I think the key part would be how often you're gonna follow up the kid and how, I mean, and the social support the kid has. Every case is different, but for example, I do work on a detox program with adolescents and I always wanna see them after their discharge. How long, it depends on the client, depends on the patient and the support system they have. One case is the mom was on methadone, the sister was on methadone, the support system was not great. So I kept him as long as I could on buprenorphine with social support, meaning seeing us every week. So every seven days he gets a prescription for buprenorphine, lowest dose possible. We're talking about probably even, I mean, I think it was like an eight milligrams a day. And nowadays we have, I mean, we have suboclate and we have all the formulation, the injection, long-acting injectable buprenorphine that helps to maintain a more stable dose and kind of prevent the spikes on withdrawal symptoms and on aphoria. But I think it depends on the case, answering the question depends on the case. I will keep them after detox and I will follow him pretty often a week or two. Always including therapy. Here in Pennsylvania, we always include therapy. There is no patient on buprenorphine that is not getting therapy at least once a week. Also group therapy at least three hours a week and depends on the insurance you have. But some of this is, to be on buprenorphine you need to be on these other options. So, yes, I think I would feel more comfortable keeping them on the buprenorphine. Of course, we need to measure adherence and that's why seven days, no more than that. I see you every Wednesday and we count film sometimes. We don't count film sometimes. We use our urine toxins. But the use of psilocin, I mean, and fentanyl, we have, we can check for those now. We have strips and we can check on the office. I have fentanyl, I have psilocin strips that I can use just in case. In the case of the adolescent that you just described, do you have any criteria for the point at which you would taper them off the buprenorphine and just continue with drug-free treatment? I do not have a time. I love the time of three, six months. I always think about three, six months. Hopefully after six months, he's off or in lower dose. But again, it depends if he's going to school or not going to school. It depends how the situation at home. But I always shoot for three, six months. And any other criteria you would use besides the time and judge whether they were ready to taper off? Any other criteria? Well, yes, aptness. I mean, not using a drug, checking the drug screens. I mean, how often they give me positive or not positive. So depending on that, involvement with other treatments like NAAA, that would count as well. Some of them are in PO, probation officers, so being on top of that is a measure of success as well in my clinic. Well, I think we are at the hour right now, Dr. Colon-Rivera. I want to thank you again for a very fascinating presentation. And I want to thank all of our audience for participating in today's session. We will be having an ORN webinar on Wednesday, August 23rd from two to 3 p.m. Eastern time entitled Addressing Disparities and Opioid Use Disorder Treatment Among Individuals Experiencing Housing Instability and Other Marginalized Populations. The speaker will be Dr. Michael Hsu, who will be joining us for that webinar. Final slide. Again, thank you very much for joining us today. And we hope that you will be able to join us next month. Thank you. Thank you. So that's it. That's the information. Thank you. Presentation. Thank you very much.

adolescence

substance use disorder

prevention

treatment

alcohol

opioids

co-use

adverse childhood experiences

pharmacotherapy