Sex, Drugs & Science

Scott Hadland

July 01, 2020 Valerie Earnshaw & Carly Hill Season 1 Episode 5
Sex, Drugs & Science
Scott Hadland
Chapters
Sex, Drugs & Science
Scott Hadland
Jul 01, 2020 Season 1 Episode 5
Valerie Earnshaw & Carly Hill

Dr. Scott Hadland is a pediatrician and addiction specialist at Boston Medical Center and Boston University School of Medicine. Valerie and Carly talk with him about the importance of treating addiction during adolescence, medications for opioid use disorders, and associations between the pharmaceutical industry's opioid marketing and physicians' opioid prescribing. Valerie and Carly debate whether pharma has a hit out on Scott and nominate Scott for an official science superhero cape and magic policy wand. 

How does Harry Potter fit into the mix? Listen in to find out.

Read more about Scott’s work here: https://www.bumc.bu.edu/care/faculty/scott-hadland/
Read about Scott's work on prescription marketing and overdose deaths at NYT: https://www.nytimes.com/2019/01/18/health/opioids-doctors-overdose-deaths.html 
Follow Scott on Twitter: @DrScottHadland 

Show Notes Transcript

Dr. Scott Hadland is a pediatrician and addiction specialist at Boston Medical Center and Boston University School of Medicine. Valerie and Carly talk with him about the importance of treating addiction during adolescence, medications for opioid use disorders, and associations between the pharmaceutical industry's opioid marketing and physicians' opioid prescribing. Valerie and Carly debate whether pharma has a hit out on Scott and nominate Scott for an official science superhero cape and magic policy wand. 

How does Harry Potter fit into the mix? Listen in to find out.

Read more about Scott’s work here: https://www.bumc.bu.edu/care/faculty/scott-hadland/
Read about Scott's work on prescription marketing and overdose deaths at NYT: https://www.nytimes.com/2019/01/18/health/opioids-doctors-overdose-deaths.html 
Follow Scott on Twitter: @DrScottHadland 

Valerie:

I'm Valerie Earnshaw.

Carly:

I'm Carly Hill.

Valerie:

And this is Sex, Drugs and Science.

Carly:

Today's show is with Dr. Scott Hadland. Scott is a pediatrician and an addiction specialist at Boston Medical Center at Boston University School of Medicine.

Valerie:

Scott, you're actually our second Canadian that we're talking to on this show. So we're really excited because it's really reaffirming my stereotypes that Canadians are both like, super generous with their time and kind, but then also like super smart.

Scott:

And if you could see, if you could see us, you could see that we smile a lot.

Valerie:

Yeah, for sure. Yeah. And actually, so our first Canadian was Carmen Logie. I think she might've had like a Northern lights, zoom background going. So she was like peak Canadian.

Scott:

I love it. I love it.

Valerie:

Yeah. And then you're also a pediatrician and, you know, after working at Boston children's for a few years, my stereotype about pediatricians are that they're just like the absolute nicest of a clinician. So it's like, you've got the Canadian plus pediatrician. I just feel like you can't score any nicer on the, on the charts.

Scott:

It's a double hit.

Carly:

That's going to be the title of this episode... is like, "The Nicest Doctor in the World".

Valerie:

Well, okay. So in addition to all the nice stuff, you're also triple board certified. So, general pediatrics, adolescent medicine, and addiction medicine. Now someone who is zero board certified, that sounds like a lot of boards to be certified in. Is that, would that be accurate?

Scott:

Uh, it's a fair number of boards, and it's a lot of money.

Valerie:

Ah, okay.

Scott:

A lot of standardized testing, a lot of, annual upkeep, a lot of annual professional fees. So...

Valerie:

Oh yeah. I didn't even think about that. Okay. Fair. Yeah. That's fair. So I was wondering how does the pediatrician get into addiction medicine? I think for some folks, this might seem like an unusual or a surprising combination.

Scott:

Yeah, it's a, it is pretty rare combo. But one that's becoming more common, and I can talk about that in a second. My own personal path is that, um, my interest in substance use actually came first. So when I was a medical student, I spent a summer between my first and second years of medical school in Northern Thailand, working with people who inject drugs. And, I, I loved the opportunity and this was sort of super imposed on me having grown up in Vancouver, Canada, which, is the, uh, epicenter of the national, heroin and injection drug use epidemic. Now sort of the heart of our fentanyl overdose related crisis, and sort of having grown up in that environment and then having the opportunity to, to dive deep and work closely with people who inject drugs. That really inspired in me, a lot of excitement for working in this field. And so, pretty early on in my medical education, I knew I wanted to work in the area of substance use. I saw it as a real opportunity to, to bring medicine in a sort of social justice oriented framework, to traditionally underserved population. But then when I went through my medical clerkships, I realized that I love working with kids. And the way that those two things came together was that I realized that actually a lot of the, the substance use behaviors that we worry about as clinicians, the very things that put people at risk for HIV and hepatitis C and other adverse health outcomes, those behaviors all start in adolescence. And so I saw this opportunity to, work with people who use substances, who are an underserved group, and work with adolescents who are also relatively underserved in the world of medicine and sort of bring these two things together. And that's how I sort of chose this path. And so, my path was that I, did a residency in pediatrics and, and a chief residency in pediatrics after which I, I pursued training subspecialty training in adolescent medicine. And, and, spent some of that time focused on addiction medicine and became board certified in that area as well. And actually this, this intersection of pediatrics and addiction medicine, is one that's becoming increasingly common. So there's, you know, for a long time, there were only really a handful of pediatricians with an interest or expertise in addiction, and that's really actually started to grow. And what we're seeing now is for example, at Boston Children's Hospital, there's now, um, what was the nation's first pediatric focused addiction medicine fellowship. And you're starting to see that more of these are popping up across the country.

Valerie:

That's amazing. And that's where we met was, at Boston Children's Hospital. And I think we met through that adolescent substance abuse program with the wonderful and terrific, Dr. Sharon Levy, over there.

Scott:

That's right. That's right. And I actually, I think, our sort of academic interests really came together around, your work in stigma, recognizing that at least from my perspective, the, it really became unavoidable. Your work really became unavoidable for me because adolescents in healthcare really experienced a lot of stigma. People who use substances experience an enormous amount of stigma in healthcare. And again, when you bring these two things together, you sort of have this population that's highly stigmatized and very underserved.

Valerie:

Yeah, for sure. And what was really interesting to me with the adolescent story is that it's like, it's very much more of a whole family issue, you know, both with the, the stigma that people are experiencing and, you know, also with the treatment that they access, it's, it's definitely like a whole family affair. Which is, I feel is a little bit different from adults.

Scott:

That's right. Yeah. In fact, most addiction treatment models have been built for adults. I think our work as pediatricians is to make the, these treatment models now developmentally appropriate to make them youth friendly and to make them family centered when we do have family members involved in the treatment of a young person. And that means, tackling stigma on a lot of different levels as well.

Valerie:

Yeah. So what are some ways that you think about sort of tailoring these treatment options for adolescents and what, and maybe what do the treatment options look like?

Scott:

Well, much of my work and, the focus of my funding from the National Institutes of Health really focuses on primary care based addiction treatment. So the sort of traditional or conventional approach has been that, addiction treatment really happens outside of primary care, right? Like if a teenager were to prevent, uh, present to his pediatrician, say a 17 year old struggling with addiction, goes in with his parents to the pediatrician and says like, "Hey, I've been struggling with opioids. I need help,". The, the, the traditional approach would be that the pediatrician would say, "Okay, great, I've got this, you know, addiction treatment program, um, out in the community that I'm going to send you to, you'll go for detox and then you'll go and stay there in residential treatment for awhile,". And, uh, and the pediatrician really doesn't sort of take on any aspect of that, that care. And what we've found is that for adults with addiction, they really do many people do have a preference for receiving their addiction treatment in primary care from their trusted provider is in a setting with which they're familiar, right alongside all their other medical problems, physical or mental health problems. And, you know, teens have very close relationships with their pediatricians who have often known them for a great many years. And, in part that's why often families don't think to bring a young person to a pediatrician they're often sort of worried that a pediatrician will sort of be disappointed or let down.

Valerie:

Oh, wow. That's, that's kind of heartbreaking. We can't tell Dr. Hadland what's going on.

Scott:

Right, right.

Valerie:

Yeah. But it makes sense. I mean, pediatricians are like part of your community and, um, yeah, I could definitely imagine people being worried about what they'll think. And they, you know, they know they have these like long standing relationships to your families. Like, I think that my, my pediatrician saw, like all of my siblings and my mom knew them for years because she was a nurse in the community, so. Okay. Yeah. I could definitely imagine people.

Carly:

I stayed with mine until I was 21. And they were like, "Dude, if you can go get a drink at the bar, you have to leave the pediatrician's office,". It's like, I guess that's fair. But it is like I had, you know, they were the only doctor, you know, the only practice I ever saw my whole life, but you're exactly right. It would make sense, but I also probably would be like, "I don't want to tell them, I don't want them to be disappointed,".

Scott:

Right. Yeah. I mean, it's, it's, it's really tricky. And all of this really boils down again to, to stigma... That there's so much stigma around substance use and around addiction, that people don't feel like they can bring this to a, to a doctor who's known them since they were a baby. Anyway, the, you know, where I was headed with all of this is that, there's really an opportunity here for young people, who might otherwise be sent to an addiction treatment program out in the community where they don't know anybody and where they're going to be treated alongside older adults who have been injecting heroin for a couple of decades. There's an opportunity to, to bring that treatment into the pediatric medical home and say, "No, let's actually provide this treatment in primary care again from a trusted provider who I've known all these years and who knows me inside and out and, um, uh, and get into this place where I'm comfortable and where, um, you know, I, uh, I know the space and I know how to get here, and I know how to park here, and I know how to take the bus here. And I know what to expect when I walk in these doors, it's much less intimidating,". And so, this has really been, much of my work is to figure out how are the, what are the ways that we can adapt the sort of primary care based treatment models to make them youth friendly? I think Valerie, one of the questions that you had asked are like, what are the ways in which we had that we do that? And you know, I think, uh, it's, um, we're still learning that we're doing a lot of research around this right now, actively, as I, as I say this, um, like I've got a team that's actively investigating this by talking to families and to youth and to experts. And I think the things that we're learning are not huge surprises. And yet I think that they're going to be really critical in improving our clinical models. They include things like, you know, you need to have drop in hours, you need to be sort of ready and available to help provide treatment to a young person when they want it, because treatment often happens on the terms of a young person and...

Valerie:

Like everything else for young people?

Scott:

Yeah. They're interesting.

Valerie:

Yeah.

Scott:

Openness and ability to get treatment at any given point in time could, could wane from one moment to the next. And so you really sort of need to be prepared. You may need to have flexible hours, like in the evening, you know...Young people are supposed to be in school for most of their day, and they're not supposed to be at the doctor's office business hours. You may need weekend hours for the same thing, same reason. You, may need to be prepared for the fact that young people may want to get treatment without their parent involved. And how do you navigate those issues and how do you make sure that a young person is safe? If they don't have parental involvement, you need to know how to involve the parent. When the young person does want them involved, what are the ways of which a parent can help support a young person's recovery, and set some limits and expectations around where they are, who they're spending time with, what they do, where the money comes from, how that money is spent, when people are spending, when young people spend time together. And how do you support parents to be able to sort of institute those limits to help keep a young person safe? So there's lots of different considerations, and you see, you can see pretty quickly how this work becomes really different and unique for young people compared to older adults.

Valerie:

Can we talk for a minute about what some of the treatment, you know, what some of the treatment options typically look like? So, you know, for talking about medications for opioid use disorders...what do those medications include?

Scott:

Well, there's, there's three US Food and Drug Administration approved medications for the treatment of opioid use disorder. And these same three medications are used to treat adults and are also available to young people, but there's some, some quirks and some unique limitations that affect the access of young people, to these medications. But the first medication, and probably the most commonly used one is, a medication whose trade name is Suboxone. Its generic name is buprenorphine. And, it's what we call a partial opioid agonist, meaning that, if, if a young person is either experiencing withdrawal symptoms because they've been using opioids, or if they're experiencing cravings for opioids, because they've been using them for such a long time and have started to struggle with addiction, what buprenorphine does is it binds to the opioid receptor and it sort of gives a little bit of an effect at, at the receptor, to help address that withdrawal or those cravings.

Valerie:

Okay. And those, sorry, Scott, those cravings can be really intense, right? Like, and they can include like lots of GI upset, these intense biological cravings. Like you could get headaches, like the, a lot of what some of these medications are doing are just trying to keep people like semi-human during this period of, you know, coming off of using opioids.

Scott:

Yeah, that's right. I mean, you can add if you really wanted to, to engage in, in, in support or counseling or therapy, um, to help address your addiction. It'd be really hard to do it if you were experiencing a lot of these physical symptoms that you've mentioned and these physical symptoms of withdrawal, and then also if you're experiencing intense cravings, if like from one moment to the next, all you can do is think about, you know, the next time that you're going to use substances. Or if every time you pass, you know, a certain part of your neighborhood where you've used in the past or where, you know, people who have used or where you've met up with your dealer, it's going to be really hard to sort of get by moments, moments in your recovery...if you're constantly sort of experiencing those, those cravings for triggers. And so buprenorphine is as a, as an opioid that binds to the receptor, and, and does so in a sort of safe, predictable and long acting way, unlike heroin and short acting opioids, which are what people misuse, is actually a very effective treatment. And the data really do support that there were clinical trials showing that these are effective. This is an effective medication, including among young people. The second medication that's FDA approved is methadone and methadone is also an opioid agonist. It's a very effective treatment and back. Some studies really suggest that it's probably the single most effective treatment for opioid addiction and, and saves lives. Quite frankly, it's been associated with improvements in mortality, across studies. What's difficult about methadone is that access to methadone for teenagers under the age of 18 is exceptionally limited in the United States. Federal policies dating back to, I believe about the 1960s really dictate the teenagers...if they want to go on methadone, have to have, two quote unquote, "failed attempts at treatment", that didn't involve medication. So as a young person, required to try treatment, have it not work out. And then if you, that happens twice, then you can then go and get methadone for your treatment.

Valerie:

So, sorry, this is actually like, I didn't, I didn't know about this and this is I'm having a mind blown moment right here. So first off our rules about methadone access for young people were created in the sixties. Okay. So that's so that's, that's an interesting thing right there. And then B, a failed treatment attempt can be death. So we're like willing to sacrifice like two failed attempts that could lead to death before someone, before a young person can have access to the thing that we know is most effective for treating an opioid use disorder?

Scott:

Yeah. And effective at preventing mortality.

Valerie:

Oh my gosh. Okay.

Scott:

You have to experience the bad outcome, twice, essentially experience mortality. Twice before you can get the effect of treatment and potentially mortality reducing medication. Yeah.

Valerie:

Okay. Well, that's, that's something. Okay.

Scott:

Incredibly backwards.

Valerie:

Incredibly backwards.

Scott:

I think stigma underlies these policies. And, you know, even if a young person surpass that barrier where they've had to failed, and I hate using that word but failed, this is actually the language that's used treatment episodes, and then is ready to go out and find a methadone treatment. They then have to find a methadone treatment program that's willing to take on someone under the age of 18 and practically, that doesn't exist. We did a study in 2018 looking at Medicaid programs across 11 States and found that, um, over a period of two years leading up to that study, that, exactly zero adolescents across those 11 states had gotten methadone, as well opioid use disorder. So you can see just how exceptionally high that barrier is.

Valerie:

I think I'm so interested in this because Carly and I collect data in a methadone clinic, and I should really clarify that, but by saying Carly and I mean, Carly collects our data in a methadone clinic. So we have a lot of, you know, we have a lot of experience with what that looks like. I mean, people come in either every day, as, you know, the further they go, it might be once a week to maybe once a month to pick up their medication. And, it's just, it's, there's so many people getting this care and there are definitely challenges to that. But you know, when, as we were talking to people, so many people talked about how it saved their life, it's allowed them to live a life. And so just to think that, this medication and that is effective for people that zero less than had access to it across all these States. So, okay. So that's really striking, but I think that you were only through, I only let you get through two of the three options before I derailed us

Scott:

Well I was a little long in getting through the first two, so...

Valerie:

No, no, take your time.

Scott:

The third one is a very different medication and that's naltrexone. Naltrexone is actually an opioid antagonist, which is what makes it different and the antagonist binds to the opioid receptor, but then it has no effect and it blocks, it blocks the receptor so that no other opioids can bind to it. And so someone who is taking naltrexone, um, if they use heroin or another opioid, that heroin or opioid won't be able to break through and bind to the receptor and have an effect because it will be blocked by the medication. And that, that really is part of the mechanism of this medication. Naltrexone is that it's, it's, um, not perfectly but largely, blocks someone from being able to experience the, the effects of using, um, an opioid. Naltrexone for a great many years was only available as a pill, and it still is a once daily pill, um, available that some patients choose to take. But actually is, um, uh, has been available since, um, I believe 2000, um, as a shot. And that shot is called Vivitrol and it's a shot that's given every, um, every month, and stays in the body for, for that period of time and blocks the ability of opioids to come in. It may also have some, um, through some unique, neuro pharmacologic properties. It may actually also block cravings to some extent, but by and large its main mechanism of action is that it's preventing someone from experiencing the high of an opioid. Interestingly, it's a medication that, is used very commonly or relatively more commonly in young people than it is in older people. And I think that's because there's this idea that if you give someone a medication that prevents them from getting high, that's somehow better than giving them buprenorphine or methadone, which are medications that act on the opioid receptor and have an effect. They're agonists and people feel better about using naltrexone for that reason. But the truth is actually it hasn't been studied very effective, very extensively among people under the age of 18 and is not actually FDA approved for people that are under the age of 18 , unlike Suboxone, which is FDA approved for 16 and up.

Valerie:

So for the, so that sounds like another stigma issue at play. And when we, so one of the things that we're looking at, or maybe the primary thing we're looking at is people's disclosure experiences. And we have found it's, it's interesting when people disclose different types of medications and they, you know, they explain what those medications do, that people do have different types of reactions to them. We still get a lot of, you're replacing one drug for another when people are disclosing just methadone and a little bit more support when they're disclosing one of these other options.

Speaker 3:

Yeah, yeah. It received that play at all the time. And we see it on a lot of different levels with adolescents. I mean, there's a lot of stigma around these medications just to begin with, um, for all the reasons you said. You know, there's this perception that if you take Suboxone or you take methadone, you're just, you know, trading one addiction for another. But of course that's not accurate. Addiction is not just use of a substance, but a lot of problems in your life, negative consequences resulting from the use of that substance. And in fact, methadone and buprenorphine help people get rid of life problems from their addiction. And so, their use in and of itself is not addiction because their use actually results in improvements in people's lives, which is this sort of antithesis of addiction. But so adolescents experience that sort of general stigma around these medications that exist, whether, you know, you're a 17 year old struggling with opioids or a 65 year old struggling with opioids, but they get it on a lot of different levels too, because they also get it from family members and parents who carry that stigma and sort of, um, pass that messaging on to them and say, you know, I don't want you on, I don't want you to trading one addiction for another. Um, and then they hear it from trusted adults in the community. And so I have a lot of patients who, might go to a Narcotics Anonymous or Alcoholics Anonymous to get support out in the community. And they get matched with, with a peer who is in recovery and that person didn't use medications and doesn't want them to take medications and gives them again, further messaging as somebody who's trusted, gives them further messaging that they shouldn't be on medication. And so, I spent a lot of my time as a, as a clinician, trying to reorient that framework around medications and talking to parents and other trusted adults to explain to them the rationale behind these medications and help them understand the data that underlies their advocacy.

Valerie:

I'm seeing Carly smile because we have gotten an earful going on to community settings, and advertising for our study and, you know, in recovery settings and sharing with people, um, that we've tested this among, you know, folks who are accessing methadone and then, you know, we get an ear full from people from other recovery communities telling us about how terrible methadone is. So it's been, we've had a little bit of a wild ride with that. You know, and we're aware that the scientists coming in, so I'm sure it's like, you know, it's a pretty muted conversation that people are trying to have with us.

Scott:

Yeah.

Valerie:

Yeah. So I'm sure that the, you know, the, the physicians you're trying to get to prescribe these medications probably have, you know, like no biases and misinformation about it. It's probably just like super easy sailing with them, right. To get them to, to get them, to try to prescribe these in office settings. How, how's that looking for you?

Scott:

You know, it's interesting. I, I'm of a couple of minds about this. On the one hand, I think in an ideal world, every pediatrician would be prepared to treat any person with addiction who walks into their doors. Um, you know, I think of addiction treatment as part of our expected skillset. Just as any pediatrician should be able to treat asthma, any pediatrician should be able to recognize diabetes, any pediatrician should be ready to recognize and treat addiction. Unfortunately, you know, that traditionally hasn't been the case. And so I think part of our workforce development is to try to, work, to introduce these concepts into residency training even earlier on into medical school training. And then also to provide sort of, helpful continuing medical education for people who are already in practice to help them develop and maintain these addiction treatment scales. You know, I think that's a bit of an idealized approach, cause that's certainly is not going to happen overnight. And so I think a, a helpful middle ground would be that, you know, not every pediatrician needs to be able to do this, but what if, you know, just one pediatrician, in every practice could do this, wouldn't you just have sort of one champion, right. And we do this for other conditions too, right? Like in every practice, yeah we can all do a little bit of asthma management, but there's often one person who is able to, to, to work with, the patients whose asthma is really severe and really complex and, and may need sort of more advanced treatment. And so one middle ground, again, might be just to say like, can we identify that champion for addiction treatment in every practice. And then at least, you know, everybody's got somewhere to turn. And so, whether our workforce development results in, you know, scenario number one or scenario number two, you know, I'd be, I'd be delighted with either outcome, but regardless there's a lot of workforce development to make that happen. As you, as you sort of suggested, there is a lot of stigma, even in our own medical practice among pediatricians, um, around treating youth with addiction, there's a lot of people go into pediatrics because they want to take care of kids.

Valerie:

Yeah, like bandaids and lollipops, right? So what am I doing with these? Yeah.

Scott:

There's a very specific feel to pediatric practice that brings us all a lot of joy. And I think in a lot of people's traditional notions of pediatrics and what the practice should look like. It doesn't include teenagers who inject drugs. But it's, it's, it's part of our practice, nonetheless. And, you know, this is a primary public health crisis across the United States and we all sort of need to do our part. And this is, this is a part that pediatricians need to play. They need to recognize and, and, and address addiction.

Valerie:

I mean, can pediatricians prescribe opioids to youth?

Scott:

Absolutely. With little to no training.

Valerie:

Oh, okay. So pediatricians can prescribe opioids and then there's some like queasiness around prescribing, you know, the medications for opioid use disorders, if those were to develop. Okay.

Scott:

Well, yes, there is queasiness, but it's not all born out of, um, pediatricians', stigma. You know, Suboxone is a, and we haven't talked about this. Suboxone has medication that requires for physicians an eight hour training and special certification from the US Drug Enforcement Agency before you can prescribe it. So, whereas any of us can prescribe oxycodone and, and, medications that can contribute to opioid addiction with little to no training. We need eight hours of training to be able to prescribe the medication that can treat opioid addiction.

Valerie:

Yeah. And I'd really love to see how many people can get any clinician to do eight hour trainings. I mean, that's a high bar. So we were at a meeting in January and it was interesting the, with the addiction and the pain community. And there was a lot of buzz around this. And I think I, as a, you know, as a social scientist, didn't quite understand the uproar until I looked into it a little bit afterwards. Cause there were a lot of people, you know, the conversation was why, why what's what's wrong, we need better access. And then the clinicians are in the room or were like get rid of this eight hour training and you'll have lots more prescribing a play. Was that your read on the conversation?

Scott:

Yeah. Yeah. And that's, that's my personal stance. So there's, the, the DEA waiver to prescribe Suboxone is called the X waiver. And it's called that because when you, when you get this waiver, the first letter of your, DEA number, which we all need to prescribe controlled substances, um, turns to an X the letter, it was, it becomes an X.

Valerie:

Really? So you're like, so that's a real stigma thing. So you've got like a mark on you.

Scott:

Well, you know, it's really interesting. There is, there is something to what you just said. You know, I get called by pharmacies. Sometimes they will say like, you know, "I'm not, I can't accept your X DEA number. I want your other one,". There's, there's a lot of different sort of, issues that come up, first getting the waiver and then second of all sort of having it. And so that's why, what you'll hear if people will sort of, um, uh, and this trends on Twitter, people will say, "We need to X the X waiver we need to get rid of it,", and that's where that comes from. But it, it really is a waiver that is difficult to get, that sort of, that training that's required. It just, the symbolism behind requiring so much training for a single medication, I think creates a lot of stigma around the medication and makes a lot of people put their hands up and say like, "I don't want to go through that training. I don't see those patients. Why would I go sit through an eight hour training," is the sort of response that I'll often hear from people. And, and it really has meant that the workforce available to prescribe buprenorphine across the country is really limited, as a result. And in fact, at a recent check and, and, conversation that I had with one of the organizations that leads all these trainings, um, in fact that the foremost organization that leads these, these waiver trainings, when I asked, you know, what percentage of people who take your course are pediatricians. The answer as of 2019 was 2% meaning one in 50 people that they train, to prescribe buprenorphine is actually a pediatrician, just showing the extent to which, you know, my entire workforce is really on the sidelines of this, this public health crisis.

Valerie:

And just to kind of come back to that idea a little bit. I mean, so many of our substance use disorders are adolescent or young adult onset. Like people start using these substances when they're young and then they continue, you know, the substance use disorders will worsen if they're not sort of, you know, addressed in pediatric settings or when they're young.

Scott:

Yeah. I, you know, the, the data, the national data tell us that, um, every, among all adults with a substance use disorder, nine out of 10 of them first starting using before the age of 18.

Valerie:

No, really? Nine out of 10... Is that all subs like, so opioid use disorders included and...?

Scott:

Yeah, that's looking at a sort of like a broad look at all substance use disorders. If you told them "When was the first time you used?" they'll tell you that their substance use first began before the age of 18, really highlighting the extent to which substance use is a, is a pediatric onset condition. Opioid use among teens is quite a bit more rare, and has actually been on the decline in recent years. And so if you ask all people with opioid addiction, "What was the very first time you used an opioid?" About one third will say that it happened before the age of 18. And about two thirds, they'll say that it happened before the age of 25. And to be clear, there are a lot of people in their early to mid twenties who were still seeing pediatricians too.

Carly:

Not alone.

Scott:

Exactly. So again, this is, this needs to be in our wheelhouse.

Valerie:

So Scott, you know, in talking to you, it's really striking me that moving, treatment for substance use disorders into, you know, office based settings to pediatricians has a lot of challenges. So you've got these policy issues, you've got this X, you got the parent issues, the training issues. So it, it feels like there's like a lot in the mix. And I know that your, your K award is really focused on interventions to improve that. So how do you, like, what threads do you try to pull on? What, what do you try to do, you know, when you're thinking about interventions to address this, to try to move the needle and get, and just get started?

Scott:

Well, very fortunately I, uh, all on its own, the needle is moving a little bit already and a lot of this is born out of the recognition that, you know, we were in the middle of a national crisis. You know, COVID-19 aside the sort of...

Valerie:

Well, it's only going to get worse than COVID-19 right. I mean, yeah.

Scott:

Exactly, exactly. The very immediate crisis is actually exacerbating our sort of longer standing crisis, you know, our opioid overdose crisis. But, I think a lot of pediatricians have sort of recognized this as an issue and, um, you know, particularly with, you know, each year more and more new pediatricians enter the field and the vibe of pediatrics is shifting. And we're, we're really seeing that young pediatricians in particular, as well as older pediatricians who just want to do the right thing are increasingly taking on mental health as part of their own practices, increasingly taking on addiction as part of their own practices. And so, you know, when I, when I go around the country and I talk to, pediatricians, I'm actually finding people are sort of naturally gravitating towards this, this work out of a recognition that this system is a necessity. So some of the groundwork is already laid. And you know, if I find myself having to convince people, I try to convince them with data and with stories. And, um, uh, and so, uh, you know, I think some of the data that we've already talked about, including our nine out of 10 number, um, for teens, starting with substance use before subsequently developing an opioid or a substance use disorder further on down the road, that's, that's really compelling data that I think can be convincing the pediatricians. And then I think some of the stories that, that I can share from my own practice and that other pediatricians can share with other pediatricians from their own practices can be really illuminating. I remember, the very first time I, as a pediatrician treated a young person with opioid use disorder in my own primary care practice.

Valerie:

Oh, wow.

Scott:

It was a, it was a 17 year old young man who, had long struggled with, um, uh, some, some, um, difficulties with anxiety. And, uh, after he had appendicitis, he received, opioids for his pain and just really found that the opioids were really made him feel different and really sort of addressed his anxiety in a way that obviously opioids, can do, but are not meant to do. And that's how we started struggling with, with, with oxycodone for the first time. And it, and it just, I will always remember for as long as I'm a pediatrician that day, that addiction treatment and pediatric primary care came together under one roof. Because, when I walked into the exam room to meet the 17 year old young man for the very first time, um, he was sitting there reading a Harry Potter book and, uh, while experiencing opioid withdrawal. And I, that was the moment for me that it all crystallized, and I really saw these, these, these two things could come together.

Valerie:

Yeah. So that, so now that story time, we were doing interviews when I was at Children's and the way that it came together for me was that we were interviewing young people who are in recovery. So a broad spectrum, and we were interviewed one young man. He was like 16, who was in recovery from an alcohol use disorder. And we were asking him about his experiences. And I think it was like towards the end of summer. And he was telling us, and it was like the best. It was just the best. I mean, he was like, my, "My friends have been so supportive of me all summer. We have been having adventures going on, hikes, doing all sorts of non alcohol related things,". You could tell that he was probably of the like high school strata that would usually be having these like big drinking parties all summer. And it was just the fact that he said that his, his group of like 16 and 17 year old friends were hiking mountains and going on adventure. It's my, I think my heart just like left out of my body, talking to him. It was just the most adorable.

Scott:

Yeah, absolutely. Absolutely. And it really highlights why, physicians who have expertise in these developmental considerations are so needed, to take this work on.

Valerie:

Okay. So if, if we can all pretty much agree that pediatricians are the superheroes of your story, maybe we can transition over to pharmaceutical companies. You know, maybe I won't go too far, but transition over to pharmaceutical companies because you have gotten some really nice attention for your work looking at, pharmaceutical industries, marketing of opioids, and also stimulants. And I was wondering if you could talk a little bit about that, including I was interested to read even just like what, what pharmaceutical industry marketing even looks like?

Scott:

Yeah. Well, if I can take it back to the origin of this research, this is always a really, sort of nice, story for me personally. Um, uh, I have a good friend who's, uh, who's a researcher I'll leave, I'll leave this person's name out of the podcast, just in case they don't want to mention, but this person is a researcher who does a lot of work in the area of opioid related overdose and this person and I are old friends and we were getting together one day over breakfast. And this person said to me that they had experienced, they had submitted a paper for publication in a journal and had received really negative reviews on the paper where the reviewer was sort of calling into question everything that this person had done in their research. And, and the reviewer's name was known. That's not always true when a few manuscripts, but in this case, um, it was known who the reviewer was. And, uh, my friend looked up this reviewer, turned out that this reviewer had received hundreds of thousands of dollars in opioid related marketing. There was actually an entire newspaper article written about this because, um, this particular doctor, uh, not only had gotten hundreds of thousands of dollars of marketing, but actually had sort of flattered a little bit by buying big fancy cars and ultimately was arrested, for their over prescribing of opioids is sort of serving as a pill mill doctor.

Valerie:

Oh my God. Were they, were they, arrested before they did the peer review or after, or...?

Scott:

This would have been after. I think it's probably hard to do peer review from incarceration.

Valerie:

Yeah, yeah, yeah. Okay. So super concerning. Okay.

Scott:

Anyway, this friend and I over breakfast, that's where we develop this idea of like, wow. Like "We should really understand the extent to which the opioid industry might be influencing physicians' prescribing behavior,". Um, and to what extent is the sort of practice of medicine, um, or do we have a conflict of interest amid this again, like critical public health crisis? And so that's really what led me to, to venture into, um, a database called the, sort of colloquially known as the, The Sunshine database...

Valerie:

Ah, okay.

Scott:

Based on the Sunshine Act, but it's, it's a database called the Open Payments database, um, put out by the Centers for Medicare and Medicaid services. And they basically systematically track and have tracked, since, mid 2013, every single interaction between a drug company and a doctor whose value is worth more than $10. And so anytime a doctor gets a gift from a drug company valued at more than $10, gets travel paid for, gets, um, speaker sphere on our area, a consulting fee or what's most common, a meal from a drug company, that all gets documented. And, the nature of that interaction is documented. So we know, what was the sort of monetary value of that interaction? What medications were discussed? What was the drug company, where did this take place on what date did it take place? And, again, sort of like, you know, it was a meal, was it a gift? What was it? And, um, and so there was, you know, all of a sudden, um, when this idea came to us to, to look into, um, physicians who might've received payments from drug companies, it was now a new database with which we could study this. And so we systematically went through and understood, the extent to which doctors, were getting payments from drug companies. And actually our first paper showed that between the years of 2013 and 2015, really at a time of accelerating drug overdose deaths in this country, including many from prescription opioids, about one in 13 doctors across the US had actually gotten some kind of marketing for an opioid. And if you looked at family physicians who were really providing the bulk of primary care across the country, that number rose to one in five.

Valerie:

Oh my God. So I... One in 13, one in five. I really thought that by 2013 it would be much less frequent than that, that there would be more recognition. Cause I feel like there's been a buzz since the 2000s that mark, you know, pharmaceutical marketing around opioids is really problematic. And so to hear that you have one in 13 and as high as one in five that's, that seems surprising to someone not in the field.

Scott:

And that we, we did a couple of followup studies. One study that we did a year after that original study, that got a lot of attention. We looked at doctors who prescribed opioids under the Medicare part D program. And what we found is that doctors who got any marketing related to opioids in 2014 subsequently went on in 2015 to prescribe more opioids. And they really did so in a, in a dose dependent way. So that the more of these payments or more of this marketing that you got really, the more opioids you subsequently prescribed.

Valerie:

I was looking at this graph this morning and telling Carly about it cause it's like the prettiest graph. Cause it has like, I think the, on the, um, on the X axis, right, it has like number of meals. And then on the Y axis, it has like a melon of prescribing and it's like, you couldn't have made up a better graph for yourself. Like it almost looks like the data has to be fake. So, right. So you had this idea over breakfast and then you stumble upon like the perfect data set that's already been collected for you, which is surprising that that even exists with that level of detail. I mean, that's kind of amazing. And then you crunch the numbers and you, you look at the graph and do you have one of these moments? Like "I can't believe I was right,". Cause sometimes when I'm right, I'm like, I'm surprised. I have to just say I'm like surprised when I'm right. And I'm surprised when I'm wrong. I'm just like, I'm always surprised to see what happens. So you see this perfect graph and what did you think?

Scott:

Yeah, well, I, you know, I have to, I have to sort of, confess and come clean in that. I wasn't the first person to think of, you know, looking at payments as an exposure and then prescribing these an outcome. And we were really using another paper that had come before us. It was exceptionally well done, kind of as a model. And they were looking at different medications all together. They were looking at some of the most prescribed brand name drugs in Medicare part D, so it was different from opioids. And I had seen it in their paper that, you know, there was a clear association there. And so I wasn't surprised that we saw it with opioids, but you're right after we produced the figure, I really did say out loud exactly what you had just said. Like, if I, if you would ask me to create this figure, like to make up a figure, this is what it would look like. You know, it would look like this line. And so, it was really, it was really pretty astounding to have a figure that was just so dramatic. So as I said, sort of like such a dose response association.

Valerie:

I think that's just a really neat example of how science can work though. You know, seeing how these things work in other areas and then trying it out in this, you know, in the field of opioid research and seeing that it does work or it does hold up. So I think that's really neat.

Scott:

Yeah. There are a couple, there are a couple things that I feel like whenever I talk about this research, I, I, I really want to get out though. Because I think it'd be easy to label me as sort of like anti pharmaceutical industry warrior...

Valerie:

Carly and I had this whole conversation about wondering if you're safe from the pharmaceutical industry. We were like, "Do they know where he lives? Does he have a fake, like Instagram account?"...

:

Walking around with a hit out all day?

Scott:

I don't think I'm important enough for them, or as much as, you know, my research may have gotten some attention. I don't think it's sort of...

Valerie:

I don't know, Scott. You're a BFD. I feel like, you know, maybe.

Scott:

I don't know if I'm BFD enough that they know where I live or care where I live. My life has never been threatened. And I, I, you know, I think, um, one criticism that, that comes up, when I talk about this work is the pharmaceutical industry, the pharmaceutical industry needs to market their product. You know, physicians need to know about these. And in fact, in doing so they're often educating physicians, right? They're often showing positions like, "Hey, this is how this medication is used. These are some side effects you might expect,". And so, so their interactions can be helpful. I think the couple of caveats that I would place on that though, are that, first of all, it's probably different for opioids, right? Like I think that if pharmaceutical industry, if the pharmaceutical industry wants to market anti-hypertensives and get doctors to prescribe more blood pressure medications that may have a net positive, public health benefit, right. It probably costs us a lot of money because there are new fancy medications and probably way more expensive than the cheap old generics that worked just as well, if not better. But you know, they, you can make sort of a public health argument. In that case, I think here it is very clear that there's a national effort right now that is, it is geared at reducing excessive and inappropriate opioid prescribing. And so that's why I think actually the answer needs to be different for opioids, that it really should be that we should be thinking about limits on pharmaceutical marketing when it comes to opioids in a way that we may not choose to for other medications. The other thing that I would say is that, sort of like to counter my own counterpoint, about, about pharmaceutical companies providing sort of continuing medical education and helping to support doctors in learning, you know, I really think, I actually believe very strongly in a lot of people agree with me that that education should come from non-biased sources, from sources that don't stand to make money, through that education. And so yes, I believe pharmaceutical companies can play a role in education. No, I don't think they should routinely.

Valerie:

Okay. That's fair. Well I'm glad that we got the sort of balanced conversation in, but I also, you know, one of the other findings that I wanted to ask you about from this line of research was that, so not only were you finding that, either two physicians or in areas where more marketing is happening, that more prescribing is happening, but you actually also found that there's more opioid related deaths in those, in those places. So that, that seems to be a pretty big finding. So for those you can, it looks like you worked with that same data set, and then you layered in depth data, and then you looked nationally, right? I look at, this is another example of some, like, really pretty figures that you had in one of your papers with graphs of, places where there's more marketing along with places where there's more prescribing and places where there's more depth and like all of the hot zones sort of overlapped.

Scott:

Yeah, this, this was a paper that probably got our group the most attention. It was really covered, covered heavily. And the New York Times, Washington Post and a lot of different outlets, was on NBC News at Night. And, and, so got a lot of attention because it really does sort of demonstrate this link between marketing and overdose deaths. It also, for me as a, as a researcher, was sort of a riskier paper to put out there because I, more than any other paper that I've gotten, it was the sort of, one that I got the most criticism and heat for. And the criticism was like, you know, this is not cause and effect. You can't demonstrate cause and effect when you're looking at these like very equallogic data, all that you know, is how much marketing is going into a particular county and whether or not there are elevated deaths in that county one year later. And you can't say that one caused the other, we tried to do some analyses to sort of like demonstrate that causal pathway a little bit better. We actually looked at the extent to which marketing, um, was associated with those overdose deaths and the extent to which that relationship was actually sort of mediated or, or has it as an intermediary, the amount of opioid prescribing in that particular county. So we did some things to try to address that, but at the end of the day, I mean, I agree. I can't say that this was caused in a fact, this is, you know, this is an association, but you know, where stand on this is that let's imagine for a second that I got it all wrong. And, the association actually happened in reverse, right. That, that there were already overdose deaths present in these counties. And then the drug companies came in and started marketing heavily. Well, is that appropriate?

Valerie:

Yeah.

Scott:

What we saw were that counties with some of the highest overdose deaths in our country, we're also the counties that drug companies were marketing heavily. And that's, that's not good either. And so no matter which way you spin it, this was a really concerning association. And so I do stand by the work, even though boy, there are some times where I cite my own work and will cite this paper and then, you know, submit one of, you know, submit a manuscript for review and a reviewer will say like, "That paper was controversial. You should remove it from your list of references,". That is actually...

Valerie:

Wow. That's wild. I feel like you're doing good work.

Carly:

Yeah.

Valerie:

So you've got pushback from reviewers. Do you get, did you get pushback and other ways? I mean, I I've, I feel like lately in the last couple of years, I've, I'm starting to get more like random trolling, like emails and pushback of people picking up my work. And on one hand, that's distressing to get those emails. Then on the other hand, it's like maybe I've leveled up in some sort of way, professionally. So like you get some pushback from reviewers. Did you get it, you know, in other sort of routes as well?

Scott:

A little bit, I think, um, you know, I, I sort of, I'm a, I'm a physician practicing at a, at an academic institution in the liberal Northeast. And so I think I haven't come across, you know, colleagues who have really sort of called my work in a question. I think, I think there were a lot of people that felt it was a little bit bombastic to be sort of reporting on an association between marketing and overdose deaths. And I think that's probably the major sort of heater critic criticism that I got. But you know, if such as an association exists, I think there is sort of a responsibility for us as a profession to, to reflect on it and sort of, at least consider it, it might be a real cause and effect, relationship and, and consider whether there are things that we need to be addressing in terms of conflicts of interest.

Valerie:

I mean, it's certainly passed like the common sense, you know, test, you know, so if it passed, you know, it passes the common sense test then, um, it's interesting that there's so much kind of pushback and resistance to it, for sure. Yeah. Yeah. And that, isn't kind of interesting to think about it. If you're getting, if you get a little bit of pushback or heat in Boston, imagine what you would get in a, in a different location.

Scott:

Absolutely.

Valerie:

Yeah.

Carly:

Well, so, and I have another question, too. So do you, I don't, I'm not really familiar with how, the pharmaceutical companies would like go about targeting, um, you know, physicians and how that, what that interaction looks like, but does, did you notice that publishing this paper had any impact on that? Like, did you all of a sudden get people like, "You know what, we're not going to that guy to see if he wants to, you know, start prescribing X, Y, and Z," you know, whatever...

Valerie:

We're not going on a date with this pharmacy...

Carly:

No food for this guy. Let me tell you what.

Scott:

Well, you know, we, a lot of us working in academic institutions already sort of have limitations on the interactions we're allowed to have with drug companies. And so, you know, you can check my name in that database. I'm not in there. I double check every once in awhile. You know, cause you sort of never know when this stuff might sneak into your life, you know, someone hands you a sandwich, you gotta remember that sandwich came from. But, no, I, that, that isn't something, that happened, but it did sort of, um, did receive a number of, um, state attorneys, general, and other sort of, lawyers and attorneys who were involved in some of, um, some of the, sort of like many ambient opioid related drug manufacturer cases that are going on...still reach out to me for opinions, thoughts, comments. And so that was really interesting cause you know, part of what we do is, in, in our line of work is to try to do work that's impactful. And so I think a neat thing for me was to observe the ways in which something that I had published. You could draw a direct line between that and some response that might have a public health effect through litigation. I think one important distinction I always had to draw is that a lot of the opioid manufacturer lawsuits have really been centered around like agregious marketing practices, right? Like, you know, I think of, for example, Insys pharmaceuticals, which was a major source of a lot of the marketing that we saw in our studies.

Valerie:

Yeah. They were like 50% or something, right?

Scott:

Yeah.

Valerie:

I picked up on them.

Scott:

About half they... Either years of 2013 and 2015, if I'm remembering that, right. I might be off a little bit in my timeframe, but, you know, they had this egregious practice of, basically cutting doctors, huge checks, for appearance sort of quote unquote "speaking TVs". They would say like, "Oh, you spoke about this medication. And so, let's cut you a big check,". And they also had an incentive structure for their pharmaceutical reps where if a pharmaceutical rep could get a doctor to A prescribe to a new and B prescribe to a preexisting patient higher and higher doses then they would get larger and larger bonuses, there was a bonus built around like getting drug reps to get more people on opioids and get people on higher doses of opioids. So some of these marketing practices were egregious and as it turns out like quite illegal in some cases, and, and that is what has gotten the bulk of attention. I always have to be clear that the work that we did was actually focused on often the very legal, practice of drug companies, just buying a doctor, a meal and boring and mundane as that sounds, that actually has the much bigger public health effect across the country. Again, if we assume that the association that we observed was cause and effect, you know, we really found that, um, this effect that exists is probably a very subtle one, but it's widespread it's happening all across the country, too. As I said, one in 13 physicians and a small effect spread over many, many doctors actually has a huge potential effect across the country.

Valerie:

For sure. So Scott, you know, since you're a solutions person, if you could wave your magic wand, what do you, what would you do to try to make some headway here?

Scott:

Well, as, as, as, as a Harry Potter fan, I would love to do a lot of different things. But I think my solution to this would be, would be threefold. I think, one, physicians would self-regulate. I think that physicians would stop and sort of reflect on their own practices, and understand the extent to which their behavior might be influenced by marketing, recognizing that that effect may be subtle and difficult to sort of, tend to really piece apart. I think, we as sort of organizations need to self regulate. So I think, you know, everybody from the large academic hospital in Boston that employs thousands of doctors, down to the sort of like smaller primary care practice that only has three physicians, needs to have some rules around what are the interactions that they have with drug companies. And I think quite honestly, the more restrictive, the better, I think the approach that many academic hospitals would take, have taken a sort of saying, "We don't allow any marketing on our premises," is probably the right one. And so I think smaller practices might choose to adopt similar policies for themselves. And then I think the third approach probably does need to be, federal state or local policy that actually limits the extent to which doctors can interact with pharmaceutical companies. And so actually there have been some States that have taken this on New Jersey a couple of years ago, introduced legislation to limit the dollar amount of marketing that a doctor to get into here, but they set that dollar cap really high. They said that any amount over $10,000 was too much. Well, what we found in our study is that like the vast, vast, vast, vast majority of marketing that takes place across the country is on the order of like $10, $20 or $30. Because, and so, you know, in my, my sort of like dream policy would be that you don't just limit the dollar amount. Cause actually I do think we should limit the dollar amount cause it's pretty egregious. I think for physicians to be taking tens, if not hundreds of thousands of dollars and pharmaceutical money for their own sort of personal manifests. Um, but also there would be limits on the number of times that a doctor can interrupt, interact with a drug company in a given year because as you and I had, as we've just discussed a few minutes ago, there really does seem to be this dose response association where the more meals you get, the more interactions you have, the more you appear to go on to prescribe the following year.

Speaker 2:

Well, Scott, well, um, we should let you get along with the rest of your day and get back to all of this really important science. I think that Carly and I's homework is to get you a magic wand, to get you a superhero cape. And, you know, I just want to say, I feel like the science that you're doing is, is really tough. You know, like working with adolescent substance use disorders, trying to investigate what's happening with pharmaceutical industries and marketing. And, I think that in part, you know, we've been talking about how there's not a lot of people who do this, and I think not a lot of people do this cause it's like really, really hard work. And couldn't be more grateful that you are out there in your superhero cape, soon with your wand, doing it. And, it's really important. I think it's making a really big difference cause I think you're making a big difference when you start to get pushback from people, we wanted to recommend people to find your website on Boston University because there's great detail about you there to go check out the co-edited book that came out in, was it 2019 or 2018 on adolescent substance abuse?

Scott:

Yeah, that was last year. Yeah, yeah.

Valerie:

Yeah. Okay. So you got this great co-edited book that folks could go and read more about some of these things. And then of course they could follow you on Twitter at Dr. Scott Hadland. Is there any other places that folks should look to?

Scott:

Well, you can creep on my Facebook, but I think I've got my privacy settings up.

Valerie:

Okay. Well that's good. Cause we got to like, hold off the pharmaceutical.

Scott:

Well, thank you both. It really is an honor to, first of all, be asked and then second of all, I'm like a total delight to get to talk to you about all this stuff. So I really appreciate it.

Carly:

Yeah. Likewise, thank you very much.

Valerie:

Carly. I find myself in the position of needing to walk something back on this episode once again. So I characterized pharmaceuticals as villains and pediatricians as superheroes in this episode. And I'll just put it out into the universe that that may have been a little too like black and white that I, you know, certainly there are superhero folks working in pharmaceuticals and there are surely villains working in, pediatrics. But I think that I did that maybe cause I'm watching too many superhero shows on Netflix during quarantine.

Carly:

You know, I think our listeners will forgive you, particularly all the big pharma listeners that we have out there.

Valerie:

Oh yeah, for sure. All right. Well, we talked about trying something new today. The undergrads who are helping us with the podcast gave it a listen and then they flagged a few things that they had questions about that they thought, you know, other listeners might also have questions about. So we're going to review those after, you know, after our episode starting today and you know, if it goes well, we'll keep doing it. So the main thing that they wanted a little bit more detail about was substance use among adolescents. So I pulled some 2018 data from the National Survey on Drug Use and Health, which is run every year to estimate how many people essentially in the US might be using substances different types. So they have categories, age categories in this report for 12 to 17 year olds, 18 to 25 year olds and then 26 and older. So they found that in the past year that 12 to 17 year olds, 9% of them had reported alcohol use, 4.7% reported binge drinking use. So that 4.7, you know, percent of youth reporting binge drinking. I'm going to say that some of them probably do need some sort of intervention if they're engaging in binge drinking, that's kind of a red flag for an alcohol use disorder, for sure.

Carly:

Right.

Valerie:

For illicit drug use it's 16.7% of adolescents. So it's actually higher than, uh, alcohol use. So that's 4.2 million adolescents. We will note though that this includes marijuana use. So 12.5% of that 16.7 were reporting marijuana. I mean, they may have also been using other substances, but I think a big chunk of that illicit drug use group has probably marijuana use for all opioid misuse among adolescents. It's actually 2.8% of adolescents. So that's um, 699,000. So if you think about that, like if you're, if you're in a high school or you have kids in your high school, that's more than a hundred students, that there's probably a handful of students at that school who are misusing, or misusing opioids. And it also means that, you know, if you know, a hundred like young people, that some of them might be misusing opioids.

Carly:

Yeah. I think it, I, I can definitely say from my own experience, I think that it, it starts a lot younger than a lot of, parents are inclined to believe. So I think, you know, having someone like Scott doing this work, who's, you know, a pediatrician that can, you know, sort of knows what to look for and knows how to treat it and start those conversations is super important because like you said, you know, even if you know, it just think about your high school class, that's a handful of people, which is probably a handful more than a lot of us thought, you know, were in our class that were struggling with some sort of substance use disorder.

Valerie:

Yeah. That's a really great point. Carly, and I think what's also striking for me is that it's 2.8% of adolescents. And it only goes up to 5.6% among 18 to 25 year olds. And then back down to 3.6% among 26 and older. So, you know, the stats actually for 12 to 17 are not that different from the stats for 26 and older. We really, you know, need to pay attention to this group.

Carly:

Right. And, you know, going back on some older data. So for everyone that just listened to the podcast, uh, Scott had this, you know, has a lot of really great work, but at one paper in particular, I found this statistic from 2012, which I thought was really jarring. And so, you know, in the among youth age 12 to 17, there were 1 million persons or 4.2% of that age group who needed treatment for an illicit drug use problem in 2012. But of this group only 121,000 received treatment at a specialty facility, which meant that 920,000 youths who needed treatment did not receive it. And that, that statistic is just staggering.

Valerie:

Yeah. Can you imagine this with like cancer? Like if there were 1 million kids with cancer and then we only got 11.6% of those kids into shape, can you imagine the number of lemonade stands that an outcry that there would be about, um, that like as a health problem and a real, like a real health emergency that these young people are experiencing.

Carly:

Right. And you know, that makes me think of, you know, the other take home from this episode for me was when Scott was talking about the story where, you know, it really clicked for him where this child is in his waiting room and he comes in and the kid is reading Harry Potter and is coming to him for, you know, some help with his substance use disorder. And it's like, you know, it's something that I think a lot of I'm sure all of the listeners can relate to like either themselves or some other kid that they know who, you know, really was into Harry Potter and read all the books and all the things like that. And so that's such a relatable thing, but we don't think about, you know, kids that age struggling with substance use disorders and, and, you know, like Scott was saying, it's like, but that was the moment where it clicked for me that there has to be, there has to be, you know, this shift in, in getting the world of pediatrics to understand that this is, you know, for, to get the world pediatrics to first recognize that it's a problem. And then B to help them sort of navigate, like what, what does that look like? What does that care look like? And how can we provide it adequately?

Valerie:

And I think it's so great that we have Scott out there sharing that story, because if we think back to Carmen's episode and she talked a lot about like the power of storytelling and just like telling this story and humanizing who these kids are, like, why wouldn't you want to get treatment for kids who are reading Harry Potter and their doctors? It's like, you know what I mean? I think it's just, that story is really powerful. And I also, like, I think I've thought about that like every day since we talked to him.

Carly:

Me too well, it's like the, the point that like, you know, someone that is as young as, you know, I say that like, I don't read Harry Potter all the time, but like someone that's that young reading, Harry Potter, like we just, you know, healthcare providers, especially pediatricians, I think, you know, they, they just see the kid reading Harry Potter and Scott's asking them to say no, look at the whole person and like help them, you know, help that kid who is reading Harry Potter navigate, you know, you have to, you have to stay with them. You have to be their, their pediatrician and carry them through, you know, all aspects of their life. And I think that for a lot of pediatricians, they just don't think that this is a, a real thing. But you know, like I said, it starts young. People are in high school, kids are trying stuff and figuring stuff out and it's important to stay on that and help them navigate through that phase of life.

Valerie:

Yeah Carly, beautifully put. Thank you to the Stigma and Health Inequities Lab at the University of Delaware, including Natalie Brousseau, Saray Lopez and Alyssa Leung. Thank you to Christina Holsapple who edited the episode.

Carly:

And I'm going to say special shout out to Valerie, who was kind enough to research this episode while the undergrads were on break ,and as always thank you to city girl for letting us use your music.

Valerie:

And thanks to all of you for listening.