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Dr. Joseph Lee: Focusing on teen opioid use helps limit adult addiction

“The teen and young adult years are when addiction really begins,” Dr. Lee said. “We can’t lose sight of that if we want to make a difference.”

It has to start somewhere. It’s true that white, middle-aged male Minnesotans are most likely to die of an opioid overdose, but if we want to truly stem the tide of addiction and death, Dr. Joseph Lee, medical director for youth continuum at Hazelden Betty Ford Foundation, believes that we need to set our sights on the young.

“The teen and young adult years are when addiction really begins,” Lee said. “We can’t lose sight of that if we want to make a difference.”

A spokesperson for the American Academy of Child and Adolescent Psychiatry, Lee explained that youth drug use is too often overlooked, or dismissed as developmentally appropriate experimentation. He wants us to shift the way we think about drug use and the young.

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“If we don’t invest money in prevention and early intervention,” Lee said, “we are just waiting for a new crop of young people to incubate in the school system. We have to put the priority on youth intervention, before a new, highly addictive drug comes along. Then we will regret the mistakes we made in the past.” 

Earlier this week, Lee and I talked about the importance of identifying and treating problem drug use in younger populations. He told me that he believes early intervention can save many lives.  

MinnPost: The stereotypical person battling opioid addiction is middle-aged. Are teens also addicted to opioid-based drugs?

Dr. Joseph Lee: Yes. Substance-use disorders are developmental disorders. That’s not up for debate. People develop substance-use disorders at all ages, but if you really look at the patterns of addiction, more than likely those patterns start in adolescence and young adulthood. Studies will tell you that the greatest amount of experimentation with substances happens in the 20s. Even with opioid use, this begins in the teens and then progresses through the early 20s.

In my work, I see a growing number of teens addicted to opioids. I believe that any highlight on adolescence and opioid addiction is really important because this is a problem that doesn’t always get discussed. Of course, I’m a child psychiatrist so I’m biased, but this is a real problem and there is a need to focus on the distinct issues that affect people in their teens and early 20s around addiction treatment. It is not a one-size-fits all situation.

Most addiction professionals have been trained in the adult model of care, but they don’t really have training on how to work with teens and the systems that surround them.

MP: What do you mean by “systems?” And why does this make a difference in treatment methods?

JL: Adult addiction care is very focused on the individual, but in order to be impactful, teen addiction care should be very connected to the many communities that support teens, like families, schools, sports and clubs. The best addiction care for teens and young adults is developmentally sensitive.  We see addiction as a family disease.

MP: Can you explain why that is important?

JL: A lot of young people and young adults fall through the cracks in a traditional medical model. Pediatricians are trained to identify and treat typical diseases of the young, like asthma. Internal medicine physicians deal with diseases of later adulthood like heart disease or obesity.

Unfortunately, mental health and substance use disorders occur in the gap between those two specialties.

Joseph Lee, M.D.
Joseph Lee, M.D.

You might have an individual who is technically an adult because they are 18 years old, but in no other way do they function as an adult. For young people, maintaining sobriety means reintegrating into their social life and family relationships. We have to find a way for young people to engage in pro-social activities to replace their drug use.

At Hazelden Betty Ford, we emphasize development and families. We realize that young people don’t exist in a vacuum. Adult addiction care can be overly sterile. In that way the other players are not as involved as they should be. That involvement is a big part of delivering evidence-based care. We develop a style that fits each young person and addresses his or her individual needs.  

A good example is we use medications like Suboxone and injectable Naltrexone to treat opioid dependence, but young people sometimes struggle with compliance and their families can get confused about the importance of these medical treatments. It really takes a family approach to make sure that all the right stakeholders are involved in the care of a young person.

MP: How are teens gaining access to opioid medications?

JL: The way teens get their hands on opioids is really quite varied. Often they get access through their parents’ prescription pain medications, or they get some from friends at school who have access to their parents’ medication.

I know of other examples: Say a teen gets his wisdom teeth taken out and he is prescribed oxycodone for the pain. He has some left over and he starts using it later. Or a kid’s grandmother has hip surgery and she goes to visit her and take some of her pain meds. When it comes to prescription drugs, most kids are getting them from friends and family members. But the older they get, the more access young people have to different avenues for getting these substances.

MP: Are many teens and young adults making the transition to heroin?

JL In the past, you’d see a more gradual progression to heroin addiction, but due to increased access, can now see big jumps possession of this drug. Now I see more kids jumping to heroin before trying other substances.

MP: I thought the typical user profile was a person who loses their access to prescription pain medications, and they turn to heroin because it is an opioid that’s freely available. It’s a last-ditch situation.

JL: Heroin use is not always an act of desperation. Sometimes it’s just economics. You can by .1 gram of heroin for 10 bucks.

MP: Earlier in our conversation, you said that the problem of opioid abuse in young people isn’t discussed enough, that you’d like to sharpen the focus on this age group. Why?

JL: I believe this is a serious, chronic public health issue. If you were to study the age when people develop serious substance-use disorders, you would see that it is the late teens and early adulthood. So we need to address this issue when people are young, before their abuse it hits a peak.

Compare youth addiction to any other chronic medical condition, say, like diabetes: A public health worker would say that we need to address this disease in young people, to get ahead of the problem and help them develop the resources needed to fight it. They’d say that we need to connect with young people before they get older and their disease hits a peak — or a point where it’s hard to turn back.

Too often we wait until people are middle aged or older to treat them for substance-use disorders. Then they die. If we could address substance use at younger ages, we’d save a lot of lives.

MP: Why do you think adults avoid addressing addiction in young people?

JL: I think it’s just ignorance. A lot of people who use substances in their youth don’t get addicted.  A lot of people go through a stage in their adolescence and early 20s when they take risks with substances, they binge drink or use marijuana. But they don’t get addicted. So when they get older and their substance use has gone down, they witness that kind of behavior in a young person and they think, “It’s not a big deal. I went through that phase.” Because of that attitude, older people don’t always take substance use or abuse seriously when they see it in the young people in their lives.

MP: How can you tell the difference between a young person who is experimenting with substances and one who is likely to be addicted?

JL: On the surface, these behaviors look fairly similar. But the use pattern and psychology are not the same. If you look at the data, the people who are at high risk for problematic drug use have plenty of red flags and warning signs before they are addicted. There are a lot of kids you can pick out who have high risk factors prior to their starting using substances.

Young people at higher risk for addiction exhibit certain behaviors, including an increased likelihood of risk-taking impulses. Young people who are more likely to use substances tend to be more inclined toward risk taking. They are less daunted by consequences and have a harder time learning from their mistakes. They may be a more wired for thrill seeking, less likely to delay gratification.

MP: Are boys more likely to be addicted than girls?

JL: Girls aged 12-17 struggle with substance use just as much as boys. When kids get older, substance use tends to shift in a 2-1 proportion in favor of males. But we are now seeing a real increase in alcohol use in females.

There is a actually a lot of research going on right now on identifying high-risk youth or high-risk families, but compared to other disease models, we don’t invest the resources we should be investing.

MP: What should we be doing to keep young people from getting addicted?

JL: A lot of prevention and early intervention should be going on in schools and primary-care clinics. There’s research that shows that prevention programs of all kinds can prevent or reduce a number of issues in young people, including down-the-road behavior problems, dropouts and substance use. It is a fairly cheap and easy way to reach young people early on. We also need to develop better screenings so we can identify those at greater risk of addition. And we need to implement brief intervention strategies that can be used while people are still young.

Prevention science is a lot more sophisticated than DARE.  That’s not what happens. If you go to the National Registry of Evidence-based Programs and Practices (NREPP), you will find a ton of evidence-based prevention and early intervention models that can be used in a school system or primary care settings for kids. These aren’t fool-poof. They’re not huge. But they are easy to do.

Our leaders have to have the courage to make an investment in our children that may not bear fruit right away.

MP: Can early opioid use affect a young person’s physical development?   

JL: When young people decide they want to stop using substances, they are usually going to quickly bounce back physically. But early use can point to much larger problems down the road.

Sometimes the highest risk people start using at a very young age. It’s like when a serious heart condition appears in a young person: It’s unique, but it happens, and we have to address that issue right away in order to help that person continue to live a healthy life.  

MP: When is it time for a young person to seek help for substance use?

JL: We need to recognize that young people can be facing true substance-use disorders and addiction. Something like 1.3 to 2 million kids between the ages of 12 and 17 have a substance use disorder. We as a society are all wrapped up in worrying about end-point disease systems. We wait until we see end-point symptoms of an addiction until we intervene. And that can be too late.

When people start using drugs when they are young, they may be tipping their hand. We need to respond at that point. When we are working with young people and high-risk families, we’ve started turning away from the concept of  “rock bottom.” A young person doesn’t have to hit rock bottom to seek help: The disease just slowly takes over every aspect of their life until it crowds everything else out.

I don’t know the last time I’ve talked to a young person about “rock-bottom” anything. We want to get in there and act before a young person hits that point. Do I have to have a heart attack before I realize I need to lose weight?