Thank you, Dr. Westritz, for a wonderful presentation. I know that was a long symposium, but we are going to move straight into the clinical case conference. So, if people need to get up, go ahead and do so, but I do hope that you'll join us for a case study on treating a 16-year-old with buprenorphine for addiction recovery. I'd like to ask my co-presenters, they're not my co-presenters, because I'm not presenting, sorry, the case presenters to go ahead and come on up, and we also have three discussants. So I am going to be, I'm going to introduce you, and if you wouldn't, because you're the chairperson, I'm also going to introduce our discussants. So the clinical case conference is on integrative approaches. By the way, I'm Ellen Edens, and I'm from Connecticut, West Haven, VA. Integrative Approaches to Adolescent Addiction Psychiatry, a Case Study on Treating a 16-Year-Old with Buprenorphine for Addiction Recovery. I am very happy to introduce Dr. Lorelei Sorollo-Rivera. She was born and raised in Puerto Rico and brings a strong sense of community and resilience to her medical journey. She is starting an addiction medicine fellowship and provides street medicine to underserved populations in Savannah, Georgia, where she is addressing mental health and addiction issues. Collaborating with the local behavioral health unit, she offers vital support to those at risk of incarceration. She is an awardee of the AAAP John Renner Travel Award for 2024, so congratulations, and we certainly are very glad to have her with us today. She's going to be presenting a case along with Zulemae Vallier, and then I'm going to present the case discussant. So the way this is going to go is we're going to present a case, and then we've come up with some objectives that we have asked our discussants to address. So Dr. Amy Ewell is a child and adolescent psychiatrist, as well as an addiction psychiatrist. She's Vice Chair of Addiction Psychiatry and Associate Professor at Boston University Chobanian and Avedisian School of Medicine, sorry. We have asked Dr. Ewell to summarize the standard of care treatments of opioid use disorder in children and adolescents, including medications. Then we have Dr. Mark Fishman, who is an addiction psychiatrist and medical director of Maryland Treatment Centers. He's a member of the psychiatry faculty at Johns Hopkins University School of Medicine, and his clinical specialties include treatment of drug-involved and dual-diagnosis youth, opioid addiction in adolescents and adults, and addiction with co-occurring psychiatric disorders. And we've asked Dr. Fishman to address the objective that by the end of this session, we will be able to appreciate the complexities and tensions between family involvement, developmental stages, and autonomy in substance use disorder and treatment for adolescents. So welcome, thank you for coming. And then last, but certainly not least, Dr. Brady Heward is an assistant professor at the University of Vermont Larner's College of Medicine, and is a clinical instructor at the Yale School of Medicine. He specializes in addiction psychiatry and child and adolescent psychiatry, as well. He works clinically at the Addiction Treatment Program at University of Vermont Medical Center, and on the Child and Adolescent Inpatient Psychiatry Unit at CVPH. We've asked Dr. Heward to compare and contrast treatment approaches for trauma in adolescents versus adults, kind of compare and contrast. So welcome, and thank you all for being here. They're going to share their thoughts, and then there's going to be time to ask questions about the clinical case, so that we can learn from both our experts and our discussants, and also from the case presentation. Turn it over to you. All right, thank you, Dr. Hayden. Hello, AAAP. It is very exciting to be here. My name is Loreliz Arroyo, and I am an addiction medicine fellow in Savannah, Georgia. And this is Dr. Zuleybe Vajablas. She is a child and adolescent psychiatry fellow in Savannah, Georgia, as well. Thank you, Dr. Yoel, Dr. Heward, and Dr. Fishman. I really appreciate the discussion. All right, let's get started. So our case is of a 16-year-old patient currently being treated for buprenorphine for addiction recovery. Okay? And I am... So let's start with the disclosures. We have no financial disclosures right now. And for our case overview, we are going to talk about the limitations in the treatment of a 16-year-old patient with severe substance use disorder and pour insight into his illness. And for our objectives, like Dr. Edens has summarized, we want you guys to feel comfortable treating, or at least somewhat comfortable treating a 16-year-old patient and minors for substance use disorder. Okay? And I will hand this gadget to my colleague over here. Okay. Hello, everyone. I'm a little bit shy of the microphone, so I'm going to try not to be too close. Okay. So I'm going to start with the case presentation. So the chief complaint was, I was referred, history of present illness. This is a 16-year-old patient with a history of opioid, alcohol, cannabis, and sedative substance use disorder who was referred by his pediatrician to establish care after unintentional overdose. This patient was receiving overuse disorder treatment by primary care. However, after experiencing the overdose, he was referred to our care. Now, just to give a little bit of background, prior to his referral, father found this patient unresponsive due to ingestion of benzodiazepine and opioids. And I did not talk about the gunshot wound, but we will address that a little bit later. I know it's a little bit different. Now, once this patient had that overdose, he spent two to three days in the emergency department, you know, being treated for his overdose, and then he was admitted to the crisis stabilization unit where he spent two or three days. And from there, he was transferred to a residential facility. It was a 30-day residential facility, but he actually only spent five days. Per this facility preferences, the patient was tapered off the buprenorphine. And as a result of this, he started to have significant bowel incontinence, which led to him being truant from school, and actually after dropping off. His dad or parent, after seeing this, he gave the patient some leftover buprenorphine to kind of help him with the symptoms. And that's kind of what speed up him coming to the office because they came in requesting to be continued on a buprenorphine treatment. Now, Doctora, we're just going to talk more about the substance use history. All right. So, bear with us. It's quite lengthy. In terms of his opioid use, some of the risk that he has experienced is overdose and withdrawal symptoms. His first use of the drug started when he was around 14 years old and later escalated to smoking black tar heroin, using pills, fentanyl. Most of his use occurs alone. He obtains his substances from mail service, from his work route. He works in sanitation and from the homeless population. He has not used IV drugs. For his treatment episodes, he's been treated for withdrawal management, residential treatment, and medications for opioid use disorder. For effects of use, he's had pain relief and decreased anxiety. And for his period of abstinence, he's had about six months of complete abstinence with buprenorphine combination product. And his return to use, as with any other drugs as well, is due to accessibility, intoxication with other substances, and anxiety. For his alcohol use, some of the risks include respiratory depression, withdrawal symptoms, and violence and slash legal charges. He initiated this as well around age 14 and later escalated to about six or eight shots of vodka daily. Treatment episodes include multiple hospitalizations for withdrawal management, residential treatment, and for his anxiety. His effects of use include to relieve some of the anxiety and the insomnia, and some legal charges after attacking his father due to being intoxicated at the time. Period of abstinence, six months occurred due to the patient being on probation. After this, he spent some time in jail and later on probation was having anger management classes. And his return to use occurred, again, due to accessibility and intoxication with other substances. His cannabis use, the risks include irritability with withdrawal and increased anxiety. Initiated around 14 years old as well, and you probably can see there's a trend here at 14 years old. And his pattern of use is currently about one or two joints every night. He uses alone at home. And his treatment episodes include supportive therapy and residential treatment. Effects of use include decreased anxiety and insomnia, and abstinence about six months, and return to use due to accessibility as well. And for his benzodiazepine use, some of the risks include respiratory depression, life-threatening withdrawals. This time, his initiation happened around 15 years old because his anxiety was not taken seriously. His pattern of use included using quinazepam, diazepam, and oprazolam, up to like 40 milligrams of oprazolam a day. He also buys etizolam online. This is not approved in the United States for anxiety. And he usually buys this from the dark web. Treatment episodes, multiple hospitalizations, and effects of use is to relieve anxiety. Regarding his gunshot wound trauma, that happened at 14 years old, and again, abstinence for about six months, and return to use due to anxiety and accessibility. For some of his treatment history, he has been treated with multiple medications before coming to us, actually, including some mood stabilizers, SSRIs, SNRIs, gabapentin for gaveling, and for psychotherapy, he's had mostly supportive therapy before coming to us. And outpatient treatment has been mostly outpatient treatment. The patient, most of the time, declines to go to residential treatment facilities. Okay. So for his past psychiatric history, like we mentioned, he has the use disorders mentioned before. He also has a history of PTSD related to trauma. At 14 years old, he received a gunshot wound while playing with a friend, and this resulted in hand and knee injury, and he needed surgery for this. So after that, he had some neuropathic pain. For medication trials, he has tried a very long list of medications, so we just summarized saying SSRIs, SNRIs, TCAs, and gabapentin. No history of suicide attempts or self-harm. For hospitalizations, I think we have heard that he has multiple hospitalizations in different facilities and levels of care. For his past medical history, he has a history of hypertension and the neuropathic pain after the gunshot wound. For his social history and family history, his highest level of education is the 10th grade. That's the last grade he completed. He lives currently with his mother, but his father has full custody, and he works. He's employed in sanitation. For his family history, his mother has a history of major depressive disorder, anxiety, and substance use. Not disclosed to us what the substance is. And his father has a history of alcohol use disorder. For his mental status examination, the patient initially, his appearance was disheveled and restless. His speech was normal, raised, and slurred due to intoxication. He wasn't happy about being here, but he's all right. His ethic was congruent at the time, although displeased, for sure. Thought process linear and goal-directed. And thought content was mostly main topics around pain, anxiety, and insomnia. No suicidal or homicidal ideation. No perceptual disturbances. And he was not observed for responding to external stimuli. His memory function was intact, memory intact, and insight and judgment is poor. And for his review system, his anxiety and his trauma was the major topic around here. His anxiety was always reported as excessive worrying, restlessness, and just failure to relax, and trauma, experiencing the traumatic event by being shot, and with chronic dysfunction, thoughts, avoidance of environmental triggers. His depression and mania and psychosis, he denied any symptoms for this. And for his assessment and plan, we have diagnosed him with opioid use disorder, sedative hypnotic and anxiolytic use disorder, alcohol use disorder, all severe, with his cannabis use disorder moderate, and PTSD. For his assessment, the patient was found to have uncontrolled anxiety in the context of substance use, trauma, and social stressors. Substance use complicated by poor insight and judgment with chronic risk of overdose. And for his plan, we have some medication management. We have a lot of motivational interviewing to do, some parental support. Child protective services were informed in this situation for a bunch of incidents that happened during that time. And we wanted him to engage in some individual and group therapy, some residential treatment, and intensive outpatient services. He declined all of those services at the time. We're near the end, I promise. So this is just a little bit of an overview of the treatment course. It just goes a little bit back to before we met him, but not when his use started. So just on the first box, that's his residential treatment. That's when he had the overdose, had the CSU stay, and went to the residential treatment where he was tapered off the buprenorphine. And then when we met him outpatient, basically that was, I mean, he already had restarted opioid medicine, but that was the intention of that referral. But then quickly after, he returned to drinking heavily and started using heroin. So he himself self-referred to the CSU. So he decided that he wanted to go in for withdrawal management. That's the second box. So in the CSU, he had the withdrawal management of the alcohol and heroin, but he also had significant agitation due to the intoxication. At that time, he was diagnosed with bipolar disorder while he was intoxicated, and he was started in multiple psychotropic medications. They did continue his buprenorphine treatment at that time, and then he returned to outpatient. When he was with us, we started to see that escalate at use. He started to show to our appointments more and more intoxicated each time, but he was still functional. And I say that because he was still showing up to work on time. He was doing all of his appointments. He was doing all the other things, but when he got home after work, then he would use basically. And there were no pressuring safety concerns. So at this point, his family decided to do an order to apprehend to get him to the CSU for an evaluation. And that's the last box that we have in this image. And this particular CSU admission for withdrawal management was different because it was in-house. So we were able to actually manage his withdrawal, and we did it symptom-based rather than just giving a taper. And we learned a lot of things during this time. So at this point, we also offered him long-acting injectables, buprenorphine products. He declined, and we found other barriers in the treatment. Even when we were trying to refer him at this time to residential facilities, the facilities were rejecting him or refusing due to acuity or just his low motivation to actually engage in treatment. Okay. Case highlights. Those two slides were just a summary of what I said. So case highlights. We do have this adolescent male with multiple substance use disorders, including opiates, alcohol, and benzos, with a history of overdose. He does have significant childhood trauma, including the gunshot wound at 14. He also has a complicated home with, you know, consequences due to his use, like his probation, but also kind of unstructured family dynamics between mom and dad. Mother is unhoused, which led to the CBS report, and that's why they were involved. But dad was too strict, so he didn't want to be with father. He also had the diagnosis of bipolar disorder during intoxication, which was another barrier. And he often declined all treatment recommendations, but still showed up to all the appointments, so that was still, you know, something in our favor. And then, of course, we also have the barrier of meeting treatment locations that were available to treat the complexity and the perceived low motivation of this patient. And that's it. Thank you. So, now we're going to enter some of the discussion topics. Some of the questions that we've had and we wanted to discuss is, you know, how to empower parents to create harm reduction strategies within their own house, besides having just multiple naloxone kits. How to create consequences for minors that are oppositional, unable to lose housing, or connections created with a family and friends. And our first discussion topic is, you know, just to help us summarize standard of care treatment for opioid use disorders in children and adolescents, including medications, harm reduction strategies. All right. And Dr. Yoel will help us with that. Thank you for this opportunity to talk about this case. I think this is obviously a complicated adolescent case, an adolescent who's at very high risk for a fatal overdose, and also at really high risk to not be engaged in outpatient care. So, the fact that he is coming to care is really important and would really, you know, kind of focus on that as a strength. And sometimes, you know, Mark's going to talk about family engagement, but sometimes you do need to really emphasize that to the family as well. You know, like they don't have to come to treatment appointments. And so, it is, even though the family may perceive that they're not making changes, or other people on the treatment team may perceive they're not making changes, the fact that they're coming to treatment is really important. Because it's going to be hard to support them in making a change or helping them stay safe if they're not coming to treatment. And that's often where I'm kind of starting when I'm working to engage these youth in care, is kind of what's bringing them to treatment, and what are, you know, what's their goal. And so, it's not uncommon for these kids to come in and say, I was referred, you know, but they still came. And so, I really try to get to, like, you know, what's important to them, and why are they coming to treatment, and try to align the things that we're working on in terms of their treatment plan with their goals. Another piece of things is just working to keep them safe. And so, you know, really do try to engage in discussing harm reduction with them around all the different substances that they might be using. And, you know, this can be hard to navigate sometimes with families, which I'll leave to kind of Mark to discuss when you're kind of, but it's really around, like, you know, you are, you're going to, you're still drinking, you're still using opiates, you're still using benzodiazepines. There are risks. Even though you don't want to stop your use of those, maybe you don't want to have to go to the emergency room. Or maybe you don't want to have to be reincarcerated. So what can we do to decrease your risk of going to the emergency room? What type of alcohol are you consuming? Can we start to count how many drinks that you're having? Can we start to drink water when you're drinking alcohol? All these harm reduction things, I do really try to discuss with youth and bring into their care. One of the things that would be making me very anxious when I'm sitting with him in the office is the fact that he's often using alone. And so we'd want to explore that further and try to understand that behavior, since that puts him at really high risk for overdose. We do now have these phone lines that people can call for safe spotting or to call and have someone stay on the line with you while you're using. I do find it is hard to get kids to still call. And if I have someone who's willing to entertain the thought of using this resource, we'll call with them in the office so they can experience what it's like to call and can really have more information to help them make that decision to call and have more support. Do also talk to them about naloxone and often try to give it to them in hand, since they may be a little bit ambivalent about this. May not want to have to talk to an adult at the pharmacy. So even though we do have often standing orders for naloxone in pharmacies or it's available over the counter, I do think it can be hard for adolescents to navigate that conversation in terms of asking for the medication. And then also, they may not prioritize spending money out of pocket for naloxone versus other expenses. Do where it's legal to use fentanyl test strips and talk to kids about how to use fentanyl test strips. They tend to be pretty engaged in the idea of doing that. And then this patient has no history of intravenous drug use, which seems kind of miraculous. And so would be kind of also curious about that and be thinking about potentially anticipatory guidance around safe intravenous use. And then I think kind of also really considering, you talked a little bit about how they were accessing the substances they were using in terms of sometimes ordering it over the internet or potentially getting it from people experiencing homelessness. But that's often another thing I'll really focus on in terms of decreasing risk with adolescents is how are they accessing these substances and then how are they also paying for them. And so this individual does have a job and so maybe he's spending the money from employment to purchase the substances, but have seen an escalation in risky behaviors with kind of all these new ways to engage to get money. So like over the internet, so selling pictures, doing other kind of high risk things or kind of engaging in risky relationships with people in order to access substances. And so again, really have a goal when trying to engage a youth like this with many different risk factors, have a goal of just helping them stay engaged and then decreasing their risk. And so as we think about standards of care for an opioid use disorder, now that we have him coming to the office consistently, really it's recommended by adolescent society. So specifically the Society of Adolescent Health and Medicine and also supported by the American Academy of Pediatrics as well as the American Academy of Child and Adolescent Psychiatry to be discussing medications for opioid use disorders with youth and their families and offering these medications. Buprenorphine is the only medication that FDA approved for someone under the age of 18 and is approved for people 16 and above with an opioid use disorder, moderate to severe. But it would help kind of push us all to remember that we're often in psychiatry prescribing medications off-label and that this is kind of definitely a situation where off-label use potentially of naltrexone extended release or buprenorphine extended release can be very much indicated. I think sometimes people tend to freeze, at least the child psychiatrists that I work with in thinking about the idea of using medications for an opioid use disorder with someone under the age of 18. Unfortunately, these kids are not immune to the adverse consequences of opiates just because they're young. And so we're still at really high risk for overdose and these medications are life-saving and important to be prescribing to youth. One issue that comes up a lot when working with youth is adherence to medication. And so as I was hearing you talk about his insomnia and anxiety and pain, it was making me kind of question, is he taking the buprenorphine 16 milligrams per day consistently? And so I will spend a lot of time during my appointments, often most of the appointment, really getting into the details of how many days a week are you remembering to take your medication? How exactly are you taking it? And I think with adults, especially with adults with a history of multiple treatment episodes, they know how to take buprenorphine sublingually. With kids, they kind of give you the perception that they know how to take it, but they often don't know how to take it. They're putting it on their tongue, they're swallowing it. I mean, they're not doing sublingual administration. And so really kind of, again, getting into these basics and these kind of detailed kind of things can make a big difference in terms of making sure that they're taking the medication as prescribed and that they're receiving the medication. Often will involve families to help with monitoring how someone's taking their medication. This can get kind of tricky when someone's initiating buprenorphine, especially out of office, because it may be hard for the adolescent to be fully forthcoming with myself or with their parent about when their last opiate use was. And so we try not to get into like with the parents about like time since last opiate use and try to more focus on opioid withdrawal symptoms and kind of talking to them about the importance of having opiate withdrawal symptoms before starting the medication. You know, just logistically, at least in my practice, we're not able to do in-office start to buprenorphine, but have other colleagues who work with adolescents who really prioritize doing in-office starts for someone for their first treatment with buprenorphine because they really want to make sure that this is a positive experience for the youth because if a youth experiences something that's not positive, that, you know, they may not come back to see you for six months, they may not be willing to give that medication another try. So these are some of these things, I think, to be kind of considering when you're thinking about medication for abuse disorders for youth. But let's see. The other piece when thinking about this case was just the importance of taking the medication as prescribed and messaging with the adults and the parent, you know, to really call if you have questions about the dosing of the medication and trying to emphasize kind of using us for guidance when they're taking the medication. The other thing I will note is that parents often are, you know, so anxious, and I don't mean to kind of steal Mark's thunder, but that, you know, when they're coming to the office, you may give a very in-depth explanation about how these medications work and have just, you know, found that often parents don't retain any of that information because they're so anxious about this and so anxious about kind of helping to keep their adolescents safe. And so have found that it's helpful to revisit when things have stabilized, you know, how these medications work, kind of what kind of our thoughts are around the medication because it's just hard for kids and for parents to retain that information when they're first coming into care. And then treatment should, you know, ideally be multimodal, but youth may not be initially interested in therapy or other supports when they're first coming to treatment. And so really important to be flexible with this patient population in particular, and, you know, work to build their motivation over time to be engaging with other recovery supports. And then, you know, here with a room of adult addiction psychiatrists, you know, really just want to kind of implore you to kind of, to think about treating 16-year-olds and 17-year-olds. Access is very, very challenging for this patient population. As kind of noted, I think, in one of the slides, residential programs rarely continue or initiate treatment for medication for abuse disorders with adolescents. And a recent study that was published in 2023 found that only 10% of adolescent residential treatment programs that work with adolescents with an abuse disorder initiate buprenorphine and offer ongoing treatment. So 10%. And then as we think about kind of overall access on an outpatient basis, we'd love to kind of see a show of hands as we think about buprenorphine for adolescents. Do you think that prescribing kind of between 2015 and 2020, did it stay the same in terms of the number of prescriptions for buprenorphine for adolescents? Did it increase? How many people think it increased? So unfortunately, it decreased. And so, you know, a study that was published in 2023 that looked at buprenorphine dispensing trends found that the proportion of adolescents prescribed buprenorphine decreased by 45% between 2015 and 2020, in comparison to a 47% increase in the proportion of buprenorphine prescriptions for people ages 20 and over. And so this is your call to action to kind of think about, are there any 16 or 17-year-olds that you can consult on or support in treatment? And with that, I will turn it over to Dr. Fishman. All right. Well, great case. It's so thought-provoking. And, Amy, I totally agree with everything you said, and I just want to say it one more time and maybe even more strongly in terms of the standard of care for the use of MOUD in young people. Everybody here knows it's the standard of care across the lifespan. That's no different for young adults, no different for adolescents, and not just those 16 and up, but also those under 16, like this young person. And it being off-label makes no never mind. It's the right thing to do. It's where the evidence is. It's where all the professional societies have endorsed. We've got the evidence. There's no reason to suppose a fail-first standard, give them a try of non-medicine, psychosocial-only treatment first, and then see if they die and then treat them. That's the wrong order in which to do it. There's no reason to superimpose predetermined arbitrary specific limits of the duration of treatment in the same kind of way. That doesn't mean, and this is a developmental issue both for families and adolescents, that when they come in and they say, I'm not taking that medicine for the rest of my life, you stupid doctor. I never said that. That's not what I'm saying. We're just talking about for now. We'll talk about getting off of it later. We're just talking about stabilizing it. But again, standard of care, full stop. All right, so with that, I was charged with talking about three topics, I guess, developmental vulnerability, autonomy, and family, and I'm gonna do them in that order. So one of the first things that's obvious to everybody is that adolescents are not just short adults, so we're thinking about developmental stage. It's not just a presupposed or arbitrary chronological age, right? It extends to some extent across young adults, but we're talking about minors for the moment. And one of the things that's central in the features of this case that's so typical of adolescent OUD cases is that the trouble doesn't usually begin with first initiation of opiates. Certainly it accelerates and it exacerbates, but like in this case, there tends to be, in the vast majority of cases, progression and loss of control with pre-opioid substances, right? And for adolescents, those typically are alcohol, cannabis, and nicotine. And so we wanna think about the arc of SUD writ large, of which OUD is a particularly malignant advanced form, having its roots in the vulnerability of loss of control of other substances, and that was here in this case. Another issue is thinking about what the engagement is likely going to be for a young person in any kind of treatment. Certainly, as we see in this case, and as you mentioned, Amy, for OUD treatment, but for adolescent diabetes, for any case, young people don't wanna think of themselves as sick. That is so normative developmentally. I'm not a sick person, why should I need to take medicines? Taking medicines is a sign of being a sick person, a crazy person, that's not me, why would I do that? And to be involved in a steady utilizer of the healthcare delivery system is just not a kid thing. And so you gotta take that into account, and you gotta not presuppose adherence, in fact, just the opposite, you gotta presuppose waxing, waning motivation. One day they'll be really for it, and the next day they'll be, this doesn't make any sense to me. I'm either because I want to continue to use, or because I don't wanna continue to use, but I don't need your stinking medicine, or your stinking treatment. So I've got this, and that's another normative feature, right, of adolescent development, is I'm 14 and I'm all grown up, and you can't tell me what to do, and neither can my mom, so don't be surprised. Now, as we talk about autonomy, by the way, these are issues that are not foreign to us across the whole lifespan, right, thinking about, well, what kind of autonomy do patients present with, and where's the discrepancy between their sense of perception of autonomy, and how really capable they are of good, independent, health-directed judgment in the midst of this illness? And that's true across the lifespan, but it's even more true of adolescence, where it is developmentally normative to have this pushback about accelerated autonomy, because I'm all grown up, and this kind of normative transition from adolescence to young adulthood to autonomous, independent adulthood, where it is part of growing up that we want from adolescence to work hard on being all grown up, except when they have this illness that doesn't work necessarily quite as good as we'd like them to. So what's the approach is kind of rolling with it, and recognizing it, and not fighting it, and not stern lecturing, I'm the doctor, as all of you know who are using MET and MI kinds of techniques, but even more so with young adults, and anticipating the SAS, and embracing and leaning into the SAS. I mean, how many of you treat adolescence? Maybe not many, but how many of you, well, some, oh yeah, how many of you have parented adolescence? How many of you have been adolescent? Yeah, right, so you know what this is like, and having the sense of having some fun with it, and some give and take with it, and being able to, as I say, take the SAS and interact, and that's just okay, but never forgetting that these issues of developmental vulnerability will be forward, even when you think that now they're getting it, and now they're motivated. Yeah, just wait five minutes, and it'll all be topsy-turvy, and that's not because they're bad people, or because you're a bad doctor, it's just because that's what it's like. So, I think the issue of addressing autonomy is not one necessarily of creating false dichotomies. That is, we don't have to have a battle about who's in charge. I mean, patients are always in charge. They're gonna vote with their feet, and do what they want, and that's even more so true for adolescence, but I tend to take a parentalistic approach, and we'll talk about that when we talk about family involvement, but that doesn't mean I'm necessarily commanding, and assuming that because I give health instructions, they're gonna be followed. It's that I assume that I've got something to say, and some expertise, and I'm gonna try to work on engagement, but engagement's gonna be more important than expertise in the long run, and I've gotta be persuasive, and I've gotta get buy-in, but I'm gonna do so from a perspective of being able to make a clear recommendation, but not being naive enough to say that just because I make that recommendation, it's automatically gonna be followed, and that's just like being a parent, isn't it? Walking the tightrope of making clear prescriptions of what we think is helpful, and good for a young person's trajectory of functional maturation, but not necessarily naively expecting that they're gonna do what we say, or half of what we say, or a tenth of what we say, but that we remain the voices in their heads of guidance, and be the grown-up in the room the best we can, right? So for families, unfortunately, in my view, and I'm a big advocate for family involvement, just as Amy, you said you were, I think that we talk about addiction as a family disease in general, but mostly that's lip service, and I don't think we generally do a good job at any point in the lifespan, but especially for young people, so, so important, and almost always, there is something that is of great benefit that you can get from the involvement of family. Sometimes they're a pain. Sometimes they're counter-messaging. MOUD is not real recovery. I'll learn them to behave better. I'll show you what's, okay, yeah, they can misbehave, but mostly they are forces for good and for health, and besides, it's the family they've got, and they're gonna be around long after we're gone, right? So investing in what families can bring, and it's normative in terms of raising kids and the health behavior of kids, and if you think about what we do for really young kids, like when a five-year-old has otitis media and doesn't wanna take the stupid pink medicine, that's Mom 101, right? A truculent, irritable, young person who can't appreciate how to utilize healthcare services. Now, when they're five, you can put them in a basket hole and squirt them with pink medicine, right, but can't do that necessarily with a 150-pound 19-year-old, but it's the same concept. What am I gonna do as a mom, as a dad, as a grandma, as a auntie, whatever, to be able to use my parentalistic persuasion-love connection to try to make things go better for a young person who thinks they're all grown up, but maybe really isn't, especially in the throes of this terrible illness, and improve adherence to medicine, improve adherence to treatment, and the goal is to try to have a collaboration with the family in such a way that they become champions for better treatment outcomes, that they become champions for better treatment adherence, that they become champions for particularly medication adherence, and as you said, that often takes a lot of coaching and a lot of education, because they weren't born knowing about buprenorphine or even about opioid addiction. They don't know, so you gotta assume they don't. You gotta do a lot of education. You gotta do a lot of persuasion, especially when there's misinformation and prejudice about the medicines, especially for young people, and that means taking some extra time. I like to meet with families and young patients, both separately and together, each individually, with slightly different agendas and different kinds of coaching, and then bring them together, because any communication skill enhancement you can deliver or coach on contributes to kind of the ecological change in the family system that hopefully gets better even without you, but maybe it works, maybe it doesn't, but it's always worth a try, and thinking about the particular goal of medication adherence, that's gonna be a thing that adults are gonna be better at in general than kids. Again, it's not just about OUD. It's about child with diabetes or whatever, so adults, moms, dads, other family members, caregiving adults are gonna be able to get the concept of medication as a vehicle for utilization of medical services and treatment, and you gotta train them on the taking of this particular medicine and how it works. One thing I liked about the vignette of family involvement in this case is that one of the parents, I think it was dad, maybe, who got the kid back on buprenorphine from a supply. Am I advocating for non-medical prescription of medicines that happen to be sitting in the medicine cabinet? No, but he had been prescribed before. It had helped. Maybe the current treatment team wasn't doing, let's at least do something until I get them back to the new treatment team, and mostly that's a force for good, but they need coaching, so for example, supervising medicine. I've seen so many parents who say, yeah, I supervise the medicine. I make sure he takes it. Yeah, what does that mean? That means I check that it's in his medicine cabinet. Or I put it on the kitchen table after I go to work so that when he wakes up at noon with his breakfast cereal, he'll see it there. And I assume it goes in him. No, no, so what does it actually mean to supervise sublingual buprenorphine? You've got to watch it under, you know, all the things that you guys know. And that requires effort. Some families can do it. Some can't. Some families have lots of other kids and three jobs and a lot of chaos and maybe not stable housing. So it doesn't work in every situation. But that's the aspirational goal, is to try to make them champions. And it's sometimes three steps forward and two steps back. Maybe it's usually three steps forward and two steps back. But that's okay. It's a marathon, not a sprint. And thinking about where are the other tension points. So one of the things you see with families is they want you to fix them. Here, have my kid and fix them. And no, you're saying, but you've got to be involved in this process, mom, dad, auntie. And what's it going to be? And they also lose sight of their treatment priorities. Like can't you get him to clean his room? Well, we're going to pick one or two treatment goals for this next week and you pick. Right? Is it going to be fentanyl overdose prevention or is it going to be cleaning their room? I'm exaggerating, but you get the point. You've got to focus them on the long game for priorities. And that's part of the work of doing this family coaching that I think is so essential to the treatment of young people with SUD and especially OUD. So I guess there's a question sometimes about what about confidentiality? That is an issue somewhat of autonomy and how you do these cases. And once again, I don't think that false dichotomies are helpful to us. That is, can you tell, can you not tell? I think that it's really about getting to yes. So we want to think about open communication, brokered by us. Mom, you're going to have to trust me, I'm going to, you're not going to get all the gory details. Kid, I'm going to keep your secrets, but I'm also going to call the cavalry when I need to. What are the rules of the road and of open communication? Let's get the releases signed up front and it doesn't have to be legalistic. You guys just tell me what it's going to be. And we can usually get to yes. You're rarely in a position of having to say, I'm going to snitch on you behind your back whether you like it or not. You almost never need to do that and that's not good practice. Let's do it collaboratively. Let me coach you on how you can talk to your family and earn some parent points while we're at it. Disclose from a position of strength and with my support. And so again, I think universally getting to yes. It's so rare that you can't, that maybe you can't do that today. Maybe that's an aspirational goal, maybe it takes time, but it's about getting to yes. And then one last plug on the medication, which is a relatively new phase in our appreciation of the role of MOUD in the treatment of adolescents, is the potential upside of extended release buprenorphine. And in cases like this one where adherence has been an issue, as in maybe most cases of adolescent OUD that I've treated, the potential for an adherence benefit of monthly injectable buprenorphine, if they've had a good pharmacological response to buprenorphine, is your treatment of choice. And the same might go for extended release naltrexone if that's the pharmacological treatment of choice. So it's a relatively new uptake in the adolescent population in the few places where people have tried it. We don't really have the data yet. We've got some case series and maybe stay tuned for a study in the CTN next year, fingers crossed. But the notion that if you can get it paid for, and in my state I'm just being able to convince the state Medicaid authority, I've got to fight for every case and fuss and moan and write letters, but I can get it sometimes, or most times now. And I think the practitioners around the country who have had some initial experience are all very enthusiastic about response to both of the commercially available formulations, the Bruxade and the Sublocade, for young people as having that adherence advantage. So to the extent that you're willing to stick a toe in this water, do it. It's very rewarding work. And I'll just mention there are at least three case reports of Sublocade with adolescents under the age of 18. And so if you're kind of needing to kind of pull out something to talk to Medicaid with or whatnot, again, there are at least three, and hopefully more. And that's how I've done a lot of my fighting, you know. And there's a couple of case series I think in press now, or at least under review. So stay tuned for even more ammunition if you're up for the fight. All right. Well, thank you. I'll turn it over to you. All right. Is this working? I've got two that work. All right. Yeah. So I have been tasked with talking more about the trauma and less about the substance use, which I think in this case, as we see in many cases of adolescents, they are co-occurring. And often kids that we're treating with serious OUD have pretty significant trauma histories. This is a complicated case. And I think Amy had mentioned that, and Mark as well. There's a lot going on here. And I think, as Amy mentioned, really starting out with aligning with the patient's goals can be really important. And the patient may be coming in not interested in working on their substance use, but really focused on their trauma. And I think through motivational interviewing and talking with the patient, that's a way to really align the two. Because we know that the treatment for a co-occurring trauma and or PTSD and substance use, really the evidence is supporting treatment of both at the same time. I think in addition to kind of aligning with the patient's goal, as Amy said, often our goal is, and Mark, it's a long-term goal with this patient. There's a lot to cover, a lot to work on from a substance use standpoint and from a mental health and PTSD standpoint. And so success may be less in seeing significant changes in between sessions and more in having the patient come for the second or the next session. And so really resetting our own goals as well and not getting frustrated or upset when we don't see the change that we hope for in our patient. I wanted to highlight, in thinking about trauma and treating trauma in adolescence, just a couple of differences or kind of uniquenesses about treating youth. The first, and Mark just talked about this very well, is the idea of thinking about confidentiality and consent to treatment. States have different laws on what adolescents can consent to. And the confidentiality is often associated with what they can consent to. I think it's extra complicated with medical records because the adolescent may not consent to disclose certain information about their trauma to parents, and parents may have access to their medical record. And so we need to be having those discussions with adolescents as well. In addition to consent and confidentiality, I think another aspect of treating adolescents with trauma histories is we're often making mandated reports to CPS. And that is a part that needs to be discussed openly with our patients and with their families because they are going to be impacted by that. And that's just part of the job and part of what we are mandated to do. Going on to a kind of a second difference in really thinking about treatment of trauma and PTSD in adolescence. So in adolescence, as is the case with adults, really psychotherapy is the mainstay for treatment for treating PTSD. And the treatment modality that has the most evidence is trauma-focused cognitive behavioral therapy. Other therapeutic modalities that we use in adults, including EMDR, prolonged exposure, other narrative-driven therapies, also have significant evidence base. And there's a number of different types. In terms of psychopharmacology, there's less evidence supporting that, but there are some trials that point to effectiveness from some psychopharmacology, including SSRIs. Most of the data is with sertraline. Alpha-2 agonists, both guanfacina and clonidine, have some evidence supporting a decrease in nightmares and hyperarousal symptoms. Prazosin, there's a limited evidence base in adolescence as well. And there is even some evidence for other things like second-generation antipsychotics. But overall, I think that the messaging is that it's psychotherapy and the treatment of PTSD in adolescence. In thinking about trauma-focused CBT, it's unique in that family plays a central role. And really, you're doing psychoeducation not only to the kid, but also to the parents. And then after psychoeducation, you're really spending time with the parent, focusing on parenting strategies, including things like raising your kid, selective attention towards the kid, behavioral charts, contingencies, and reinforcement of positive behaviors. And then you're teaching the whole family relaxation skills, affect regulation, and then working through the trauma narrative with the kid. So again, as kind of has been a theme, family is an integral part of treating PTSD in kids. The third thing that I really want to emphasize, and probably my last point before we turn it over to other questions, is in thinking about trauma in adolescence, and especially in this case, sometimes the trauma diagnosis in the DSM of an exposure to actual or threatened death, serious injury, or sexual violence is only part of the picture. And we really need to be considering what's going on overall and what are the other trauma and stressors in this team that are going to get in the way of treatment. So in this case, if we focus too much on patching the literal gunshot wound in this figurative boat, we're missing a lot of cracks and holes that are going to sink the boat as well. And I think some of those things that I saw in this case were things that are consistent with ACEs, so Adverse Childhood Experiences. So a father that has alcohol use disorder, parents that are divorced, a mother I think also had some substance use disorder, mental illness in the mother with anxiety and depression. These are other things that are really important to be paying attention to as we try to treat the trauma of the child. So if we're going to be treating this child, is the father's alcohol use disorder under control? What stage of recovery are they in? Are they, have they been referred to treatment? The father also has a very authoritarian style, it sounds like, and is very strict, driving the kid from leaving that house and going to stay in the car with the mother. So how can we help support the father in developing new tools to be a warm, authoritative parent and not so much an authoritarian parent? Thinking about also the mother who's experiencing homelessness, how do we support the mother? What referrals can we put in place for the mother? How can we also help support her mental health? This kid's not going to get better without supporting the family dynamic as well, and we really need to be thinking about family systems in general. I think there's a number of other things that you can think about from that perspective as well. Sometimes parents are just not up to the challenge, and how do we build resilience by finding other mentors that can really support this kid, whether that's at school, at work, in the community at large? What other pro-health activities can we get this kid involved in as well? So really kind of thinking, this kid has had a major trauma that does meet criteria for PTSD, but there's a lot of other stressors that if we don't address those, it's going to be incredibly hard to treat both the substance use and the PTSD from that gunshot wound. I'll leave it at that. All right. Thank you so much. We will open the discussion now for some questions. Thank you for your presentation. I'm an addiction psychiatric fellow at UCSD. I'm Dr. Jo. I have two questions. The first one is that there are a lot of differences between adult and teenagers, adolescents, because their brain is not matured yet, and there are a lot of things to be done in their brain, such as pruning. And also psychologically, they are in, actually, we've all gone through that kind of thing. They have to be independent, but they are not to be fully independent like adults. And also socially, they are in the jungle. For example, in middle school, they are mean to each other, and also they are very clique, and under a lot of pressure, they have to achieve something. They have to do something, tasks in their life. So my question is that, what is the key difference in treating substance use disorder in adolescence compared to adult? That is my first question. And the next one is that I've seen that many parents are reluctant to start medication in their children, because they believe they can affect it badly to their children's brain, the growing brain. So is there any unique tips that you deal with such a situation? Well, I'll talk for a minute about educating parents about medicines. You're absolutely right that parents may be reluctant about medicines, whether MOUD or any medicines, and a skeptical stance is generally healthy. So one thing I do is I applaud them for their concern and their prioritization of safety and thinking so much about the side effect and risk benefit, but then you educate them about risks without medicine and what we know about the evidence that is both health-preserving and life-saving, and that we've got considerable experience with looking at outcomes. And so far, you know, knock wood, we have not seen any signal whatsoever of safety concerns based on chronological age. Not to say that these are not medicines with side effects, because Tylenol has side effects. As do these medicines, but there are not specific safety signals based on age. So it didn't have to be that way, but it does happen to be that way. And so let's give it a try, Mom and Dad. You can always stop if there are side effects. You can always revisit your risk-benefit analysis collaboratively with me. I so appreciate your being involved with this, but my strong recommendation is let's give it a go. Thank you. And for the first question? Yeah, I think for the first question, which I tried to emphasize, it's just like the amount of flexible, how flexible you need to be with adolescents. I really can't kind of understate that. Like you just, and I think that is a difference with adults and just having flexible treatment systems for youth. They may not, you know, kind of come every week at 9 a.m. like and be there on time and like with a smile. They may kind of show up. Because all the adult patients are always right on time with a smile. They do more often than the kids. But you know, it's not atypical to have like someone coming every like four months to see me, you know, until then it's like then it's every two months and then every month. But sometimes in some clinics they'll say you need to have a full new re-evaluation if it's been three months since you were last, you know, there's all these kind of arbitrary rules. And so I think just again trying to be as flexible as possible with this patient population and then involving families. But other things, I don't know if you guys have other things. You know, I agree with all of that. And you know, we think all the time about motivational enhancement approaches. It's about meeting people where they are. And it's the same idea except adolescents are a different place where we're meeting them. But it's the same dimensional developmental issue across the lifespan. Another funny kind of thing is that as flexible as we are, and I totally agree with you, on and off and on and off and sideways and backwards. One of the things we also have in our repertoire is what I call this kind of parentalistic approach, which is interwoven with flexibility is clear directiveness. You know, which is to say this is what I'm recommending you do. Now I may be flexible in the implementation. I may not raise a fuss when it doesn't go well. An example might be in a transition from SL to XR in somebody who's having adherence difficulties. I've had some success recently saying, you got to get the shot. I don't want to get the shot. No, you got to get the shot. Mom, tell him he's got to get the, you know, that kind of thing. Again, willing to be flexible in that approach. It's not the end of the world. I'm not going to cut your head off if it doesn't go. But I'm pretty directive about that. Thank you for your answers. Yeah. I really highly appreciate it. I think I can apply some of those tips in my practice. Thank you. Hi. So Bessel van der Kolk, as I'm sure everybody knows here, has suggested we need other tools to deal with trauma in adults. And he suggests psychedelic-assisted therapy to be one of those tools. And we know psychedelic-assisted therapy can be a very powerful tool for PTSD in adults. Has that therapy ever been considered for adolescents? Certainly not my area of expertise. I know of no evidence. And I would be very, very worried about the potential harm profile of those kinds of treatments based on what we know from non-medicinal use in the field by adolescents of a whole variety of hallucinogenic drugs that usually lead to pretty bad consequences. So my IRB would say no way, Jose. And I would vote that way, too. But listen, we learn by science. And I guess it's an open, empiric question. We'd want to see the strong adult data first, right? Thank you. You're more expert in this field. No, not in that field. Yeah, I don't know. I mean, so much of the data comes from adults first. So I think that's a reasonable feedback in most of the things we do in child psychiatry off-label, most of the pharmacology and other things, because we are relying on adult data. Will you please say something about multifamily therapy and how families can get support and learn from other families in a multifamily environment? That's a great comment. I love that modality and have had considerable success. The idea of there's certainly a big advantage to professional family interaction, but there's a big advantage to family-to-family peer interaction, as you suggest. They can help each other with lived experience. They can cry on each other's shoulders. They can talk about successes and failures. And they've been there in a way that we haven't necessarily. And all the families who've attended are, we do one virtually, because we found that even pizza won't get people to actually show up to these things. But with Zoom, you know, you reduce a barrier. And we've had pretty good, steady attendance at a telehealth family support. And we've used a family peer facilitator, and we've used a therapist facilitator, been kind of practicing with both methods. I don't know what's right, what's wrong, but I'm for it. It has not been studied, best I know, but I'm a big advocate, and I think the families I've talked to really get a lot out of it. Thank you. And there are some alternatives to Al-Aman. So I think one challenge with Al-Aman with kind of sending parents is that kind of diverse group of ages that people are seeking support from, and so there are some more kind of parent-focused, peer-led support groups that are out there. A word about that, Al-Aman has had a rich tradition of helping a lot of people and also has been a conduit to other mutual self-help kinds of tools. But for those of you who know, one of the at least more orthodox core principles of Al-Aman has been stop enabling. And when families hear stop enabling, whether it's what we intend or it's not what we intend, what they hear is it's your fault, and that's not necessarily a great message. The other thing that you will sometimes hear in Al-Aman approaches or Al-Aman-like approaches is disengage, let them reach rock bottom, and that will motivate them to eventually be treatment-seeking, yikes. And to disengage and to allow people to have natural consequences, which could include pretty serious natural consequences, including overdose and death, worries me. And as you've heard all three of us talk about, would much more advocate a constructive engagement approach rather than a disengagement approach. I think you can do much more with love and connection than you can with distance and disengagement. Anyway, that's my editorial. Yeah, no, I mean, I think we use the phrase like engage with love, and really we want the rock bottom to be that they missed an exam or lost their job, kind of lost their job, not that they overdosed and were unresponsive for 10 minutes or things like that. And I think one thing about this case is the dad did find his child unresponsive after an overdose, and just the trauma associated with that for families. I think it's a huge trauma, and it's a hard thing to talk about as a parent, and so that's where these parent peer support groups can be really helpful. Thank you, Dr. Arroyo-Rivera and Dr. Valleblas. A couple questions about the case. The first is, were abnormal symptoms of anxiety present before the gunshot wound trauma? No, not. Afterwards, he started having a little bit of social anxiety, and I assume that that is related to the trauma itself. He didn't feel safe anywhere he went, so it's very interesting. He doesn't share a lot about what happened before that as well, so I assume a little bit that it's on purpose, like he's fixated on the gunshot wound being the issue that we're not treating. An easy explanation. I would wonder if it's the correct explanation. The next question is, the bipolar disorder diagnosis, was that made in the middle of withdrawal or after withdrawal was sufficiently behind him so that he was at least coherent and had some access to his memories? I want to go back to the first question real quick. The gunshot wound exacerbated some anxiety symptoms, but after that was that he started presenting with the insomnia and more of the anxiety and kept reporting that he wanted more medication to treat his pain, so that was kind of noble. His first use of Benzos when he bought them and tried them, and this was great for my anxiety, was 15, so there was like a year where that anxiety started building up. Now for the second question, he was actually diagnosed with the bipolar disorder when he was intoxicated, so that's why we say questionable. We don't have that, we've seen and evaluated him, any evidence to say that he has true bipolar disorder. Anxiety is a symptom that has many causes, as the whole room knows, and I don't think more needs to be said other than the interaction is important. I have a question for the panelists. Should buprenorphine-resistant facilities be licensed by our states, and should they be paid by insurance companies, including public insurance? Should they even exist without buprenorphine? Wow, well, you know, listen, standards of care change in mysterious ways, and we certainly want it to be the universal response that people use modern, evidence-informed, effective treatments, and we think of bed-based care as doing crisis stabilization, but its best thing is preparing people for enduring outpatient care, where the rubber hits the road, people don't get fixed in rehab, contrary to Hollywood's expectation, and that's no different for kids, and thinking about the whole concept of a level of care called detox is problematic in this era for OUD. We should instead be thinking of bed-based care as MOUD initiation centers, rather than detox centers. I don't know how important the language is, but you raised a good point that we should have pressures from payers, from regulators, from licensors. I'm not a governmental specialist, so I don't know how that's going to happen, but we sure hope it happens quicker than it is happening. I was just going to say, I think clearly that's the evidence base. The reality of adolescent residential care is that there isn't enough. I live in Vermont. If we want anyone to go to residential care, they have to go to Massachusetts, and many ... Massachusetts is a nice place. Yeah, and there's only one. I mean, there's one that takes Medicaid, so ... And it's challenging, and depending on the state, I mean, you can involuntarily admit someone into a residential program, an adolescent, and some parents go down that route as well, and many of those programs are not using a lot of pharmacology and other evidence base as well. So I think residential treatment in general for adolescents is something that needs to be expanded, and the evidence base really needs to infiltrate all of it. And in pure numbers, this applies more to older people in the lifespan than it does to adolescents. The same issue pertains for our adult patients. What are we doing about a legacy industry that hasn't caught up? It's a big problem. And I would just say that a lot of you oversee ... Insurance companies are involved in some of these policy things at a state level, and so hopefully you'll leave this session kind of wondering, oh wait, what do we do for our 16, 17-year-olds, or 14, 15-year-olds? During the last session about kind of correctional care, you did hear a lot about Massachusetts has been really aggressive in implementing medication for opioid use disorders for adults in a carceral system. We're really still struggling to implement that in the Department of Youth Services, and so our kind of adolescents who are in custody aren't getting medication for their OUD, and so really for all of you that have influence, to kind of use your influence to be curious and kind of advocate for change in terms of how we're supporting adolescents with a substance use disorder within whatever system you have influence over. And one more thing in response, even though I'm not an advocate specialist, one thing I'll say in terms of what each of you can do, to the extent you have influence over institutions, change them, but to the extent that you're practicing in the community, choose who you refer to. You have a lot of power in terms of when you need to send your patients to a higher level of care, you can support certain institutions and not others. Or no options at all, and then you're in trouble, too. But I think that is, there's advocacy, there's a lot of things that we need to do on that front to really expand the evidence-based residential care, and building that evidence base is huge, too. Okay, we have a question over here. Yeah, Mike Dawes from Boston Medical Center, BU, VA Boston. I'm just wondering, with the panel, curious to think in terms of how contingency management, since it's a theme of the conference, might be used in this particular case and similar cases. Yeah, not well studied, but it makes a ton of sense. I've had some small venturing into that by using contingency management with the target behavior of medication adherence. And so some of the work my group's done has been primarily in young adults, but we've just started some pilot work in adolescents where MOUD adherency, the receipt of an XR dose or of sublingual dosing, is rewarded through contingency management incentives. I can't distinguish the effectiveness of that component of the multi-component intervention, family intervention, assertive outreach, and other things, but intuitively some proportion of the adolescents and their families report that it's impactful. To disentangle that component will require future studies, but I think it's a compelling idea. Those of you who were at the symposium yesterday know that we're still limited in implementation, but it should definitely be studied in young people, both with the target behavior of medication adherence and with the target behavior of negative urines. And it hasn't necessarily been studied either, but like thinking of parents as the way, the bridge to enforcing or engaging in contingency management could be really powerful. So if we don't have the funding to be able to do that, maybe the parents do. And so how can we help them engage in that as well and engage in that level of treatment? And Alan Bundy's group in Vermont, for example, has published on contingency management and parentally implemented contingency management in adolescent cannabis use. I really can't under-emphasize also positive reinforcement and then kind of talking to families about positive reinforcement. And again, because I think we all, you know, as clinicians and the family, like, you know, these kids have a life-threatening illness. So of course they should come to their appointment, right? But I really do try to encourage parents to think about, like, they made an active choice to come to the appointment with you. And so, you know, do you have time or the resources to stop at Dunkin' Donuts for their favorite coffee on the way home or, you know, kind of, and I always really am like, you know, deliberate in, you know, thanking kids for coming. Like, you know, I know it was hard today, like it's raining and snowing and modeling for the family. So, so really can't under, there's a lot of kind of, kind of stress within these family systems when a kid is struggling at this level. And so, you know, reminding the parents and supporting and modeling positive reinforcement is really important. Yeah. And of course that's not the same as formal, protocolized, strict operant conditioning principles, CM, as studied, but it's a very similar idea. And when you talk to parents, they often say, well, I'm not made of money. Why do I have to bribe them into being good? And you reframe that. No, bribing is rewarding people for doing bad things. This is rewarding people for doing good things. By the way, you're not made of money. I'm not asking you to give them hundreds of dollars, but aren't there things in your family that you do? And is it going to Dunkin' Donuts? Is it making a nice meal? Is it going on family outings? Is it letting them use the car? Is it spending time? Is what, whatever you do in your family, do that, but now link it explicitly to concrete treatment goals. Oh, I see. And sometimes you can make some progress that way. And also, I think, in emphasizing that, also emphasizing that this is not about punishment. And so often families get stuck in that punishment kind of mentality, and we really want to change that into positive reinforcement. All right. We've got a question over here. Mona Saman from the Boston VA, PTSD. So I was just wondering about this adolescent's history before 14. And in addiction psychiatry, we usually focus on the history of the substance use and when it started. And I'm wondering, in this case, if it's very important to know as much as we can about before, how this adolescent functioned before, and especially his strengths and his value system, and what he values, and what motivated him, and how did he cope before. Because if we don't know what his strength was, then we don't know what to work with, what to target to motivate him to get into treatment. Because we know all what went wrong, but we know nothing about what went right and what could go right. Agreed. Very important. Oh, over here. I have two questions. One was asked by a neighbor sitting next to me. As adult psychiatrists, does our malpractice cover treating a 16-year-old? Does anybody know that? In terms of, okay. I mean, that's a good question to ask your malpractice curator. I mean, I think in some institutions, you are getting credentialed to see an adolescent, and that's a box you're checking. But I would encourage you to ask. And I don't know that... We'll have to ask the forensicologists who were at the symposium before. Maybe they know more about this. I don't know a lot about what are the guardrails of scope that an insurance carrier will fuss at you about. I mean, don't do cholecystectomies in your psychiatric practice. They will fuss at you about that. Such a shortage of clinicians who work with children in many areas of the state. I think we're lucky, Carol, in New York and in Boston. But even in these locations, it's still really hard to access care with a child-trained clinician. Well, I mean, apropos, this is still part of the first question, sorry, of what Petras was telling us yesterday, try to get more general psychiatrists to do addiction work. Here, you're encouraging general psychiatrists to do more child work. And it did occur to some people, what is our liability, especially when things go south? The second question also has a forensic bent in the theme of today. And that is about adolescent autonomy versus parental rights and physician duty in the sense that when you see an adolescent and they say, don't tell my parents that I'm using, that you're putting me on a controlled substance, that I'm having gender-affirming healthcare. I mean, these are questions, what is our duty obligation legally as well as ethically of informing parents when treating an adolescent? Well, my view on that, as I alluded to before, is not create what I consider to be a false dichotomy there. So I say, listen, this is what we do. It is standard we involve your parents. We will try to get to yes, but we'll do so under circumstances that don't undermine you, that I appreciate your concerns. If there are particular safety or privacy issues that you think ought to be off the table, let's negotiate that. They don't have to know everything. And it doesn't have to happen today. It will never happen behind your back without you knowing. Let's figure out ways that you can do this disclosure. I'll do it with you together. We can coach it. But yeah, we ought to involve the caring and loving adults in your life because they'll help you. They'll make it better. Now, if it turns out in the minority of cases where those adults are so toxic that it's dangerous to the kid, all right, that's a different story. But that's rare. That's rare. Mostly. Go ahead. That's the approach I might take, you know, when I'm trying to involve a family member or spouse when treating an adult. But I don't know what my, so there is the option. Your hope is to get to yes, you're saying, Mark, but you might not get to yes. Might not, but so rarely, so rarely. And if there's imminent risk, I will tell a person, listen, I think you're at risk of dying. I'm going to have to tell your family. Let's do that together. No, you can't. I'm a lawyer up on your behind. That rarely happens. But there are some, some times where I say, I'm going to have to do this. I hope you'll do it with me. But on one hand, I can count the number of times. Yeah, I can also count, like, on one hand, the number of times. And one of those times was a 15-year-old that had returned to intravenous use. And, you know, we, like, shared that concern with her. Like, we do need to pull in your mom. And, you know, we are going to be recommending a higher level of care again. And, you know, she was not happy about it in the moment. But when she returned to see us a month later, was like, I totally, I get it. Like, you know, I get where you're coming from. And I understand that. And then I think a part of this is also- And sometimes even then, I'm glad you did. Yeah, yeah, yeah. It's building that trust. So maybe, like, we start with the release information that's around, like, treatment attendance, right? And then kind of build up as we're building trust with the adolescent or a young adult to kind of a more broader release information. Thank you. And the statutes do indicate that we can disclose based on that risk of imminent risk. And that there are certain requirements for doing that. And you can only disclose if you feel like it's going to actually improve or decrease that risk. And so there's a number of things that do allow us to make that disclosure. But once again, I think think clinically, not legally. Yeah. Most of the time adolescents that I work with, if I just say we're involving your parents and we can keep some of this stuff just between us, they're totally fine with that. They're not very versed in the confidentiality rules. It's hard enough for us to keep on top of it. And everyone's often living together. And so it's like a known thing that, you know, that kind of there is cannabis use or there is opiate use or there's been a change in behavior that suggests substance use. A narrative that is often helpful is you're going to get busted anyway. So why not turn this to your advantage and win the points here and think of all. And by the way, I can run interference with you. My mom's a nag. She doesn't know. She just. But what if I can get her off your case? And then you demonstrate that a little bit. You said what to my mom? And now you've got engagement points, too. But again, if they can feel empowered to be able to disclose in a way that spins it to their positive outcome from a position of strength, that can persuade a lot of young people, not all of them, but a lot of them. Just to make a general comment and then see what's your feedback on this. We are all aware of adverse childhood experiences. And this case is so stimulating about what happened at the age of 14, gunshot wound. We don't really know the details about that. Parental separation, broken home, genetics about his drug abuse problem. Of course, we didn't know all the details about uncles, aunts, grandparents. So there's so much to know about this case. My question, not really a question. I just want to make a comment that this is so much psychopathology. And we are discussing just treatment of an adolescent. But I can see so much vulnerability lifelong for this young man. So I think we should be treating, planning, where is he going? It's not just diagnosing and treating symptoms. It looks like we have to have a functional outcome in mind talking about treatment of such patients. Thank you all so much. I think this was absolutely fabulous. And congratulations for a case very well presented. So this is really wonderful. I think it's lunchtime. Thank you all very much. Thank you.

adolescent addiction

substance use disorder

buprenorphine

opioid use

trauma-focused therapy

harm reduction

medication-assisted treatment

family engagement

adolescent-specific services

contingency management

long-term recovery

functional outcomes

co-occurring disorders