Kids' Wellness Matters Podcast Ep. 5: How to Handle Teenage Substance Use

It's never too early or too late to talk with children about the dangers of substance use. In this episode, Maria Rahmandar, MD, an attending physician in the Potocsnak Family Division of Adolescent and Young Adult Medicine at Lurie Children's and the Medical Director of the Substance Use and Prevention Program, discusses how parents can help prevent drug and alcohol use in their children and offers strategies for helping kids who have already developed a substance use disorder. 

“For people that start using substances as teenagers, they're much more likely to develop a substance use disorder or other problems with substance use in the future, than for people who delay and wait until their brain is more developed. You know, it's different for adults who use it than teens.”

 - Maria Rahmandar, MD

Show Notes

• Dr. Rahmandar underscores the importance of correcting misconceptions about youth substance use, pointing out that most young people are not, in fact, using substances.
• During the pandemic, while substance use in teens decreased, opioid overdoses, especially from fentanyl, rose rapidly, particularly among those aged 14 to 23. 
• Dr. Rahmandar elaborates on the dangers of fentanyl, its potency, and the risks it presents when mixed with other drugs. She emphasizes the importance of awareness and preventive measures, including fentanyl test strips and having Naloxone, an opioid blocker on hand.
• Repeated exposure to substances can impact brain development and also put people at risk of developing addiction or a substance use disorder in later years. It also increases the risk of developing other mental health conditions, such as depression and anxiety.
• Parents play a vital role in the example that they set in the home, such as modeling taking measures to avoid driving while intoxicating and not glorifying substance use. 
• Open conversations about drugs and alcohol should start early in children's lives, evolving over time based on age-appropriate contexts, and can be prompted by everyday situations rather than formal sit-down discussions.
• If parents suspect or identify substance use or related concerns in their child, they should engage in open dialogue, consider underlying issues such as anxiety or trauma, and seek guidance from professionals like pediatricians, schools, and mental health providers. 
• Lurie Children's Substance Use and Prevention Program is the first substance use treatment program for youth in a medical setting in the region. Unlike other facilities, they treat substance use, mental health, and offer medical treatment all in one place. 
• Dr. Rahmandar highlights the individualized nature of substance abuse, the importance of aligning actions with future goals, and the value of medications for co-occurring mental health conditions and substance use disorders. 

Transcript

[00:00:00] Nina Alfieri, MD: Welcome to Kids' Wellness Matters. I'm Dr. Nina Alfieri.

[00:00:07] Rob Sanchez, MD: And I'm Dr. Rob Sanchez. We are both parents and pediatricians at the world-renowned Ann & Robert H. Lurie Children's Hospital of Chicago.

[00:00:15] Nina Alfieri, MD: On this show, we'll chat with a wide range of experts about caring for children from newborn to young adult. Because Kids Wellness Matters.

[00:00:29] Rob Sanchez, MD: It's never too early or too late to talk with children about the dangers of substance use.

[00:00:34] Nina Alfieri, MD: We talk about this in every visit with our older kids. I'm so impressed with how much kids know about this and how much they've already come to our office having thought about it. It's a topic of conversation that's already out there and, that being said, I think there's a lot that we can learn as, you know, the recreational and available substances changes over time.

[00:00:56] Rob Sanchez, MD:  I'm sure, parents who are listening, have questions about things that are, relevant today, things like opioids, fentanyl, how to manage it with things like naloxone, but also other types of substances, alcohol, cannabis, the legalization of it, and how to kind of have those conversations and talk about a subject that maybe doesn't come up as much as it should, but something that we definitely want to address.

[00:01:17] Nina Alfieri, MD: Absolutely. There's a lot of help out there for parents who are concerned or teens who are struggling. I think there's a lot that we can learn So we're very excited to bring some of that cutting edge info out today.

[00:01:33] Rob Sanchez, MD: Today's guest, Dr. Mariah Rahmandar, is an expert on this topic and joins us to discuss how parents can help prevent drug and alcohol use and ways to help kids who have developed substance use disorder. She is an attending physician in the Division of Adolescent and Young Adult Medicine at Lurie Children's and the Medical Director of the Substance Use and Prevention Program. Welcome.

[00:01:53] Maria Rahmandar, MD: Hi, thank you for having me.

[00:01:54] Rob Sanchez, MD: Can you tell us about your areas of expertise and what drew you to this specific area of pediatric medicine?

[00:02:00] Maria Rahmandar, MD: So, I am a pediatrician who specialized in adolescent medicine, meaning I take care of teenagers and young adults. I love dealing with the awkward parts of life and take care of kids from, you know, as soon as they start having periods up until, after they've graduated college or whatever they've chosen in life and are moving on. What drew me to addiction medicine is I had a brother who struggled with alcohol use disorder and we ended up losing him to suicide a couple years back and that kind of solidified my decision to have this as part of my life to try to help people who are struggling and, knowing that adolescence is such a critical time for substance use because this is when people who end up having a substance use disorder start using substances. So, this is a critical time to intervene and support youth and their families.

[00:02:56] Rob Sanchez, MD: Thank you for sharing that story about your brother. This is a topic that affects so many families and really appreciate your insight, and your experience. There are so many changes in the types of substances that are available to teens in recent years with developments such as vaping, legalized marijuana, and synthetic opioids. Can you help us understand how many kids are experimenting with or using drugs, alcohol?

[00:03:20] Maria Rahmandar, MD: Good news is that most youth are not regularly using substances. Teens are making, in general, good decisions about their health. And a lot of teens who are using think everybody is, and parents kind of assume, Oh, everybody is going to, but correcting that misinformation can be helpful for people to realize. You know, if they're not using, they're not alone. And if they are, that is a little unusual and can be concerning. But as you mentioned, substances are changing all the time and new substances are being developed to circumvent the legal landscape but despite the kind of trends changing little bit over time, we still see alcohol, cannabis, and nicotine as the top substances tried and used by adolescents.

[00:04:03] Rob Sanchez, MD: And in recent years, the pandemic has affected so many aspects specifically in this adolescent population. We know that substance use went down during the pandemic and in teens and lower numbers are holding steady, but that opioid overdoses actually that rate went up in that population. With CDC data, we know that deaths from things like fentanyl poisoning are fastly growing, especially in this population between 14- to 23-year-olds. Can you say a little bit more about that particular area of substance use and, you know, what you see in your own practice and what we're seeing nationwide in terms of those types of uses?

[00:04:40] Maria Rahmandar, MD: The data are still coming out. I'd say that we're still kind of seeing where the trends are going to land, and how the pandemic has impacted youth. We do know, it's very clear how negatively it has impacted mental health and suicide rates. And, you know, mental health and substance use can be quite linked for teens, and more so than adults. That's certainly concerning. And then, you know, this overdose rates, as you said, are rising faster among adolescents than other age groups. And fortunately, the greatest number of deaths are not occurring in teens, but it is rising faster. Any deaths are concerning, but, you know, incredibly tragic among teenagers and what we see is that a lot of teens who died did not have an opioid use disorder diagnosis. So, whether that meant that it was unrecognized, or this was somebody who was using other things that were adulterated with fentanyl because we see fentanyl in so much now and it's so deadly. It's so concerning and it's something we really need to address. Fentanyl is an incredibly potent opioid, many, many times more potent than heroin. It's a synthetic opioid that is used in medical settings, but that's not how people are really accessing this. This is, being found in illicit substances. I have youth who think that they are buying Oxycodone or Percocet, and what they really are getting is something pressed or mixed with fentanyl. You know, and in that case, those are opioids. So, people are seeking out opioids and getting that and getting something way more potent than they were expecting. But I definitely have patients who thought they were getting some other drug like a Benzo or Xanax and end up having fentanyl in it. And it's sometimes mixed in because it gives a different effect or a different high in the hope that people will keep coming back for more if they survive. People are accessing fentanyl from buying drugs from the street you know, when you're not getting medications from medical sources just being aware that, really any pill or powder could have fentanyl in it at this time. So, of course, not using anything is the safest way to live, but if you do choose to use testing your drugs for fentanyl with fentanyl test strips is one way to see if there's fentanyl or some of the metabolites in there. Using small amounts before you use what you would, typically use to test to see how you feel. Not using alone. Knowing how to recognize an overdose and, a lot of teens did pass away in their house with potentially an opportunity for family or somebody else to intervene if they had the right tools to be able to do so. Having Naloxone available, or one of the brand names is Narcan, are ways to help prevent deadly overdoses during this really concerning time of fentanyl infiltrating all sorts of substances when people aren't necessarily seeking it out.

[00:07:33] Rob Sanchez, MD: Can you explain what Narcan is? And with this rising number of teen deaths from fentanyl poisoning, you know, is it wise for parents to have Narcan in the home? Or when might it be a situation to have Narcan available to help?

[00:07:46] Maria Rahmandar, MD: Basically, what Naloxone is, is it's an opioid blocker. I would love Naloxone, or one of the brand names is Narcan, that's the nasal spray, to be available to anybody who could use it. So for somebody who uses heroin, fentanyl, oxycodone, you know, other opioids, if they've overdosed, so taken so much that it has shut down their respiratory drive and they become unconscious and have trouble breathing or stop breathing, Naloxone can go in and kick the opioids off of the receptors in their body and reverse the effect of the opioid so that they can start breathing again, start coming back to consciousness again. Oftentimes, substance use is quite hidden and there can be a lot of shame and stigma wrapped around it. So, it's not always in the open and so having it can be important for saving a life when you don't know what's going on. Also, it's not just parents intervening in youth, its people are in the same house with other people who may overdose from opiates or be out in public and come across somebody who is incapacitated or unconscious and you don't know what's going on. Fortunately, Naloxone, for somebody that hasn't used opioids, it's going to do nothing. It's, you know, almost as safe as water, when in doubt, you can use it, and it may not be the answer that saves their life, but it could be. There are a couple different ways to access Naloxone for folks that are interested in getting their hands on it. So, one way is you can reach out to us at the Lurie Children's Substance Use and Prevention Program. We have Naloxone training and can dispense Narcan. Illinois provides Narcan free of charge to overdose education and Naloxone distribution programs, so we are able to get that to people for free. No charge to us. No charge to you. So, if I think it's really important from an advocacy standpoint for us to make sure that cost is not ever an issue no matter where you're getting it. For people that just want to go out and get it as soon as possible, a lot of pharmacies have standing orders to be able to dispense Naloxone. So, meaning your local pharmacy, you can go up even without a prescription and ask for Naloxone. You may be able to use your insurance card or Medicaid to be able to pay for that. And then Naloxone is over the counter. So you should be able to then purchase Naloxone without a prescription and, you know, depends on what your insurance will cover if you're able to get that without a copay or not. So hopefully this can just be more broadly accessible to folks, and it shouldn't be a question of how do you get it, it's just like, which of these many ways do you want to go for?

[00:10:17] Rob Sanchez, MD: I want to go back to some of the things that you talked about in terms of the rates of use some people may think that it is normal quote unquote, for teens to experiment with substance use. Could you say more about what your thoughts are about that narrative and how we can respond to that, how we can provide support where it's needed and intervene when necessary?

[00:10:35] Maria Rahmandar, MD: Experimentation is part of adolescence. And so, you know, teens are trying to figure out who they are, develop their independence, try new things. And when you try things, you know, not just substances, they're trying new clothes, you know all sorts of new things to see what sticks and what fits with them. Substances might be part of that. But it is so important for adults not to condone that or trivialize it. We know that teens die from taking substances. Fortunately, most don't. You know, they could get injured be in situations that they wouldn't otherwise have chosen to be in. There can be some really unfortunate or serious immediate effects of substance use. And then, with repeated exposure to substances, that can impact brain development, can put people at risk of developing addiction or a substance use disorder in the future. Also put people at risk for developing other mental health conditions, you know, like depression and anxiety and make it hard to complete school and hold down jobs and things like that for the future. This is particularly true for people that start using substances as teenagers, they're much more likely to develop a substance use disorder or other problems with substance use in the future, than for people who delay and wait until their brain is more developed. You know, it's different for adults who use than teens.

[00:11:57] Rob Sanchez, MD: Speaking to some of those differences between adults, a reality might be that you know, some parents do engage in use of some of these substances, particularly alcohol, nicotine may be part of that. And, it's recognized that it's not just about what we say, but what we do. And so if parents do use alcohol, nicotine, marijuana how can they role model responsible behavior? How can they have those conversations about that use with their children or individuals in this teenage age range.

[00:12:25] Maria Rahmandar, MD: One thing that's really important is to not drink or use drugs and drive. That is certainly a top way that adolescents die from substance use is through motor vehicle accidents. So, modeling healthy and safe ways of getting home if people do decide to use. Also, as humans, are not perfect and are going to make mistakes and are going to do things that we don't want our kids to do. It is great to be a perfect role model, but that may not always be the reality, but at the same time, not glorifying substance use. Have discussions about past substance use, if that's something that you're comfortable with and how it's impacted you or things that happened and not just having to say like all the terrible things, but really making sure that it's not, saying how hilarious and amazing it is and you know glorifying it because that can make a difference for teens in their perceptions of the risks and benefits of substance use.

[00:13:19] Rob Sanchez, MD: Drug education, can start early in schools, sometimes first or second grade. But ideally those conversations have already started in the home as well. What's your sense? At what age should parents start having conversations with their kids about drugs, alcohol, and what should those conversations sound like? Conversations can start as early as parents are comfortable, but it's not all the same. You know, you don't have the same conversation with your first grader about their bodies or sex as you do with your teenagers. So this all evolves over time and you know, it can start with when you're younger about staying away from things. So not drinking that drink that you don't know what's in it, not eating that gummy bear that if it has cannabis, then it probably shouldn't be out. But those accidental ingestions are kind of the way that younger people are having interactions with substances. These conversations can be rooted in life, so you see a beer commercial on TV and people are drinking in the back of the truck, you know, that might be a way that you bring up how do people get home safely. It doesn't have to be a sit down and let's lecture.

[00:14:26] Rob Sanchez, MD: What are some of the ways that you've seen families approach or establish expectations? And how they prioritize things like safety and understanding about decisions that young children and teens can make?

[00:14:36] Maria Rahmandar, MD: Clear, consistent rules can make a difference. It's not just about parents being in charge, but it really can decrease youth substance use by getting on the same page with other people, adults, loved ones in the house around expectations around substance use and communicating those with the kids can make a difference. And also discussing rules with friends' families, which can certainly be a little bit more uncomfortable, but you know, knowing what your kids are doing and who they're spending time with and understanding their expectations around substance use in those houses can help you decide who you're comfortable with your kids spending time with. And if you want to make your house the house that everybody comes to but isn't going to use substances at, you know, you could kind of figure out how to, create an environment like that. I love the rule that if you need to get picked up, what is your safe word or what is the thing you're going to text me, that is like, get me now and we'll do it. You know, I want you to get home safe and alive and so, we're not going to talk about it that night, we might need to talk about it another time, but you know, I don't need to know all the details. I want you to be safe and alive. But then also just having a good time with your kids. Having regular time dinners are hard for everybody and as teens have activities, it's tough. But having some time to sit down and talk and have a good positive relationship that isn't just around rules and expectations, but around love and just getting to know each other and having positive relationship between parents and teens can also have a positive influence against substance use.

[00:16:12] Rob Sanchez, MD: Conversations like you mentioned, evolve depending on the age. I'd be curious to know, are there resources that you might share with families about examples of how to have those conversations, or basically how to keep those conversations going as their young one goes from elementary school to college or even after?

[00:16:28] Maria Rahmandar, MD: The American Academy of Pediatrics, healthychildren. org, has a bunch of helpful articles that are pretty short, you know quick tips for talking to youth about substances and how to encourage substance free life, and I think that's a great place to start.  Another resource that can be helpful is the Partnership to End Addiction, which is drugfree.org, has also some helpful information for families.

[00:16:56] Rob Sanchez, MD: If a child is found to have concerns about addiction substance use disorder, what can parents do to help them? Help them to either get help, reduce harm that their child might experience? What are some of the things that parents should know?

[00:17:10] Maria Rahmandar, MD: Knowing that any substance use in youth is concerning. And so if you are concerned, even if you're not seeing substance use, but you're seeing grades slipping unhappiness, and you're not sure what's going on, could it have to do with drug or alcohol use? It might be, but does it ultimately matter? I think to like the treatment, sure, but like your concern, it is the concern. But there may be a lot that's hidden because either the teen doesn't think it's a big deal. They might be afraid of getting in trouble. Or it just might not feel like something that they can do anything about. So, talking with your teen can be a good first start because you might get the answer but you also might not. And so, understanding if there's substance use, why there is, because if somebody is using because they're anxious or miserable or have had a really hard life living in a neighborhood with gun violence or experienced trauma. You know, those are things that need to be addressed not at the expense of addressing this substance use, but those things should be handled together because they feed into each other. If you, feel like this is beyond what you can handle at home or it's not getting better because, you know, you've made rules, you guys have worked on things, have negotiated what are the next steps and things aren't getting better, or you just want to nip it in the bud, talking with your pediatrician. Because they may have resources in the area talking to the school, you know, you may not want to share all the details, but they may have resources that the youth can access. And then reaching out to mental health providers too can be helpful. And then you've got the treatment provider, and it really kind of depends on where you are, how you're going to access those resources. But, you know, SAMHSA, which is the Substance Abuse and Mental Health Services Administration, has a national website for substance use providers. And then if you're in Illinois, there's the Illinois Helpline for Opioids and Other Substances, which you can chat with, you can search their website, you can call, and they can find youth providers as well as, you know, if you have other family members or loved ones that you're concerned about, that can also be a resource.

[00:19:14] Rob Sanchez, MD: I want to talk about some of the work that you do at Lurie Children's. Can you share a little bit more about what services are offered through your program for young people and their families? And how does your approach differ from others?

[00:19:25] Maria Rahmandar, MD: We're the first substance use treatment program for youth in a medical setting in the region. We really try to break down silos where, you know, some places care for substance use, some places care for mental health and don't have access to any medical treatment, but we can do that all in one place. We know that we're not the right place for everybody all the time, but I think what's great about our program is that somebody is walking through the same doors for their substance use treatment as they would be you know, if they were a primary care patient to get their well visit. If they were coming in for STD testing or birth control or had a period problem or their gender care, it's the same waiting room. Nobody knows why you're there. It doesn't say drug treatment on the outside of the building, because a lot of teens don't think that they need drug treatment. But they might want help for their depression or they might not want to stop their cannabis use, but they do want to talk about medications for nicotine because they hate how much they have to vape throughout the day at school. And so we try to take care of what people are open to taking care of and, offering them, what their menu of options are and dealing with what their goals are first. So, we really take a harm reduction approach, meaning we certainly believe that abstinence at no substance use is the healthiest way for a brain to develop, but understand that that can be difficult, and there are lots of steps to health and happiness between all and nothing. We can keep people alive and make steps towards healthier and happier futures by focusing on goals. And that's what gets people to come back to see us is by saying what's important to you, what you want to tackle today. I'm not going to ignore the other things, but we can prioritize the things you think are important while we work on the other things along the way.

[00:21:07] Rob Sanchez, MD: These things are very complex, right? The ways that we use substances might be related to something else that is in our subconscious, but that we don't clearly see. Again, you mentioned prior traumas, you know, mental health issues. You know, working with teens, working with young individuals and their families to recognize how this all ties in together. Can you say more about that?

[00:21:25] Maria Rahmandar, MD: It is complex and everybody is different. And for people that are super motivated to make changes, traditionally, those are people that get better faster. But you don't have to have a lot of motivation when you show up to see us because working on motivation and making connections between what you're doing and how those actions may or may not align with your future goals is stuff that we and our therapists are used to working on. We certainly can offer medications where there's evidence to support the use of medication for co-occurring mental health conditions. So for depression, anxiety, PTSD, ADHD, OCD, things like that, you know, we can talk through the pros and cons of medications for opioid use disorder, for nicotine use, and alcohol use. We can talk through medications as well. And I'd say that youth are really disproportionately not offered medications, particularly for substance use disorders which can be deadly for opioid use disorder. These medications are lifesaving. And so, we really want people who are interested in considering medications or just don't know, you know, that we would love to talk through that and what are the pros and cons to medications for what's going on versus continuing treatment as you have been.

[00:22:41] Rob Sanchez, MD: What do you think is one of the most important things that parents can take away from this episode?

[00:22:46] Maria Rahmandar, MD: I know a lot of parents grew up with D. A. R. E. and Just Say No, Abstinence Only, Substance Use Education, and I wish that just telling a teen to say no was enough for them to say no but we found out that it's not and that unfortunately those programs do not seem to work and we need to be arming our teens with, refusal skills for sure. And, understanding that healthy brains and bodies develop without substances and that is the best way. But understanding that if you do use, how are ways to stop? If you do use, how are ways to make healthier decisions? Because it's not all or nothing and there's a lot of room for, I've said this before, I'll say it again, healthier and happier lives and that really, you know, evidence-based prevention education is critical and we're always learning more and education is evolving. I'd say that for parents with teens that are using substances and maybe have been for a while, there can be a lot of frustration, a lot of conflict, a lot of guilt and that not giving up, that there is hope, and, you know, reaching out for support for yourself as a parent is important. But that, you know, it can take, unfortunately, multiple times through treatment, especially for people starting young to have a successful, you know, quit or, improvement and relapse is common. That people do get better and it can take time. So trying not to give up hope and reach out for support.

[00:24:27] Rob Sanchez, MD: It's an incredibly long journey and it's commendable for individuals who are getting support from folks like you and the services that your program offers, that they don't have to go that journey alone. Maria, you have shared so much great information with us today. We will of course include links to all of the resources that we talked about during this episode in our episode information. And so please, we encourage you to check those out. Dr. Maria Rahmander, thank you so much for taking the time and sharing so much of your expertise and information on this important topic.

[00:24:53] Maria Rahmandar, MD: Thanks for having me, Rob, and I appreciate the time on this really critical topic.

[00:24:57] Rob Sanchez, MD: Thanks for listening to Kids' Wellness Matters.

[00:25:02] Nina Alfieri, MD: For more information on this episode and all things kids wellness, please visit LurieChildrens.org

Additional Resources

• The American Academy of Pediatrics
• Partnership to End Addiction