Talking To Teens: Expert Tips for Parenting Teenagers

Andy: Talk to me a little bit about this, what got you so interested in opioid, in the opioid crisis? Why did you do all this research and write this book Ending the Crisis?

Holly: Ending the Crisis, this book is really the heartfelt effort of a number of us at Opioid Stewardship Program that came together and recognized that we have a problem, and if we thought we had a problem a couple of years ago, it's only been magnified since COVID.

I grew up in the world of addiction, my parents are both responsible for starting a drug rehab program up in Minnesota, and there wasn't a day that went by when I didn't hear a heartfelt story from someone who was living that life. And what surprised me by that world of addiction is how many came from what we would consider affluent and/or well-educated families that got roped up in opioid crisis problems. It was shocking, it's not just people living on the street. And so with that, I took that knowledge base, entered the world of medicine, became more involved, got my addiction medicine subspecialty, and really use all of those skillsets in continuation to really help America understand what role we play in ending America's opioid crisis.

Andy: I love that, I think this is something that really just touches all strata of society, and a lot of parents are really worried about the teenagers getting into really dangerous drugs that can be really, we hear about kids overdosing on fentanyl, and things like that, but also my mom's a medical malpractice attorney and she deals a lot with doctors and really high functioning people who are super successful and are also struggling with opioid addiction. And I think it's just something that really touches people at all walks of life, and that's really, I think, important to talk about.

Holly: It's so true, and Andy, I might have a number of titles of positions associated with me, but the heart of this book is a mom who's scared to death about her three little girls. I have a one, a three, and a five-year-old, and 50% of the world's fentanyl is trafficked through my home state of Arizona. If these drugs stay within my borders, they are in my kids' lunches because a family member didn't put it in the right plastic baggy when they sent the lunch to school with their kid, it's in the cannabis my kids might experiment with right outside my front door. It's a scary world. This is the first time I went trick-or-treating, Andy, with Narcan or Naloxone, the opioid rescue medication, in my back pocket. There's something wrong with our world if we as parents feel like we're in that desperate of a situation.

Andy: You talk about this crisis, or this epidemic. Can you talk a little bit about that, you have some charts and some statistics here in the book, there's some graphs that were surprising and shocking to me, including this one on page 27 about the increase in opioid related deaths, that we see some steady increase over the past 20 years in prescription opioid deaths, but really this purple line of synthetic opioid overdose deaths, starting in 2014 and just climbing really off the charts, is something that's really scary to me.

Holly: Absolutely. To better understand why we're in the current crisis that we're at, which is well over a hundred thousand deaths related to drug overdoses each year, and almost a million marks since the late 1990s for total overdose deaths related to opioids, you have to go back to our root causes, and that really started back in the 1990s when there was this over-prescribing by physicians that was running rampant through the communities. Physicians, many of them well-meaning, were handing out opioids inappropriately to our teens, to adults. In fact, by 2015, one out of every three American adults had received an opioid prescription.

We recognized, back in about 2012, that we were way over-prescribing, and many of the individuals that went on to use our opioids ultimately became dependent on then, and then of course became addicted. So we stopped, or I shouldn't say stopped, but discontinued our rampant prescribing practices by 2012, and on those graphs you're going to see a tapering, or a plateau, of prescriptions, with pretty much steady improvements since then. But you know what happened to overdose deaths? They skyrocketed. 2012 to 2015 we see what we call the heroin epidemic, when lives lost started taking this heightened trajectory upwards, and then around 2015 or so, that's when the synthetic opioids hit the market.

Fentanyl and a number of analogs that are produced in illicit environments, no pharmaceutical company oversight, you don't really know what you're getting in these compounds, which could be one of other 30 compounds that are just like fentanyl, and when those hit the streets, that's when everything spiraled out of control. You might remember, Andy, back in that probably 2016 to 2018 timeframe, States wisened up, and there was mass campaigns across America to start really reigning in overprescribing, reigning in how we manage opioid use disorder and identifying, putting limitations on prescriptions, fight all of those interventions. You know what happened to overdose deaths? They worsened. 30% increase in overdose deaths in 2020, another 15% in 2021. Who knows what 2022 will look like. But you're absolutely right, what we thought would be the solution is anything but, we're still in crisis mode.

Andy: And why is that? Why is it that not all this efforts, and all this media and attention that's going towards this, how's it getting worse still?

Holly: I believe, and as my colleagues do at Mayo Clinic, in our Opioid Stewardship Program, we've been marketing our campaigns to the wrong population. For so long there's been this over-dependency that the government will regulate us out of this crisis, or physicians will prescribe us out of this crisis, or drug treatment programs will treat us out of this crisis, or rehabilitate us out, and the reality is that's not the party that's affected. At the end of the day there is a very personal responsibility on the part of every parent that's listening, on the part of every teen, on the part of every person that ever comes across an opioid along the cascade of their use, to use them wisely, store them safely, know their potential toxicities, and then have the information necessary to get out of the crisis, addiction patterns, things like that, if they come across them.

That, Andy, is why we wrote this book. It is the first and only book on the market that talks a person through all of the things I mentioned about how to use opioids safely when they are and aren't appropriate, and then how to manage things like overdoses, addiction, how to find a treatment program, how to navigate the insurance industry, what is standard of care, how do you analyze what a good treatment program is, how do you help friends and family from a very personal level get out of this crisis?

Andy: So, what exactly is an opioid, and there's a difference between opiates and opioids, and I didn't quite really understand any of this until I read your book, and why do those two words exist, and why do we have to know both of them?

Holly: We in the world of medicine like to be nuanced in our terminology. For the everyday user of opioids, it will make no difference to them. An opiates is an opioid. Opiates historically have referred to anything that comes from its parent compound, which is the poppy plant, interestingly enough, many of which are grown in Afghanistan and then shipped over. Opioids are derived synthetically, so we make them in a lab, essentially. But all of them can lead to the same potential toxicities, though varying degrees.

Andy: Okay, yes. And you talk about how, I guess there's different, all of these drugs can be taken orally or intravenously or snorted through the nose, I guess. But yeah, what are some of these diagrams in here on how these affect the body or get into the bloodstream, how does that work?

Holly: Yeah, so opioids can enter into the body through many different routes. The way they come into the body will impact their risk of addiction, how high of a high a person can get, how risky they are to take, meaning toxicities like over-sedation and difficulty breathing. When they're made in pharmaceutical companies they undergo rigorous testing to find out which route is safest to use, and so you'll see many opioids are taken traditionally in the oral route, when they're given outpatient, and they undergo something called first pass metabolism, which essentially changes that compound to something else and then allows it to slowly go across to the different parts of the body that are responsible for binding to the receptors and having their point of action.

Whenever somebody changes that route, especially without a prescribers regulation, you greatly increase the risks associated with that drug. So for example, if someone were to take oxycodone and shoot it up, they find syringes lying around, and it goes straight across the blood, straight into the brain by passing that blood-brain barrier, as we call it, the high is very high, but the risk of over-sedation and overdose is tremendous. Same thing goes for snorting it or inhaling it. This is why it's so key to only take drugs as prescribed.

Andy: So, can you talk just a little bit about overdose, or how does overdose really even happen, and what are the risks, or what increases the risk of that?

Holly: So an opioid overdose occurs when there is over sedation and the person literally forgets to breathe. Now when taken as an opioid from a prescriber, meaning an appropriate route, at the right dose, through the right route, at the right location and timing of when it's supposed to be given, for the right indication, by the right person, the risk of experiencing an overdose is very low. But when taken outside of any of those parameters, this is why it's the number one cause of death in adults under age 45.

The risk can be high, and so when someone experiences an overdose, sometimes what you'll see is that they'll be stuporous, or less able to converse, they'll become very sleepy, they'll start becoming cold, you might hear funny breathing sounds, they may become unresponsive. All of those are emergency signs to call 9-1-1. That is your first step, and then the next step is to get a bottle or a vial of Naloxone, the opioid rescue medication, and deliver it according to the instructions.

Andy: You break down in the book how to recognize and respond to overdoses, which I think would be really just important for everybody to understand, but especially parents of teenagers, and having one of those kits on hand, and understanding how to use it, and understanding how to recognize overdose, would be really, I think, worthwhile.

Holly: 100%. I think what most people don't know is that almost all 50 states now have standing order prescriptions, or some formulary of that, where essentially you don't have to go to a provider, your prescriber, to get a vial of Naloxone, you can actually go through a local pharmacy where a state run prescription system allows you to request the prescription, and it's delivered right to you. I did that for my own family, we've got Naloxone sitting in our house and we don't have opioids. It's so key.

When I was working with my little three-year-old at the park the other day, this was probably two years ago, we had a situation where kids were screaming at the other end of the park, and I grabbed my three-year old's hand, we raced over, and they're lying on the floor. Right behind the bathrooms was probably a 12, 13 year old, blue, had been experiencing with drugs with his friends, and had 9-1-1 not been activated and had EMS not showed up literally minutes within my arrival, that boy would be dead.

And my little girl watched this, and I didn't have Naloxone on me. There is such a great purpose to keep Naloxone on our persons, and I would encourage every person in our audience, especially if there's opioids in your house, go down, get some Naloxone. The intranasal version is pretty cheap, most insurances cover it, and quick and easy to deliver.

Andy: And that's like you're going to just shoot it up someone's nose, and even if they're passed out like that, it still is going to be effective?

Holly: It is, as long as there's active circulation in the body that is going to allow that medicine to go where it needs to go to resuscitate. And the drug is interesting, any opioids that are bound to their receptors causing that over-sedation get kicked off by Naloxone, and then Naloxone binds to it, holds it tight and doesn't activate it. You go through pretty bad withdrawals in that moment of awakening. It's always a medical emergency because with synthetic opioids like Fentanyl it can take a couple doses now of Narcan or Naloxone to get someone back, so key to call 9-1-1.

Andy: What is central sensitization?

Holly: Central sensitization, we're transitioning to the topic of chronic pain, and chronic pain, I think it's very important to understand, is very different from acute pain. Acute pain serves a purpose, and we all have it because it protects. Acute pain occurs when you get an injury, or you undergo a procedure, and it's there to tell you, oh my gosh, I've been injured as a body, I need time to heal. Don't do this, don't do that. It's an instruction manual, and what's so frustrating is the American mentality that there's a pill for that. There's a pill to get us out of these limitations, and unfortunately what happens all too often is that we push beyond our limitations and we start developing that cycle of chronic pain greater than 45 or 90 days of ongoing, almost daily pain, is a disease to itself, and it serves really no natural purposes of protection.

Chronic pain can lead to many other features, one of which is called central sensitization. Say that word twice, right? It's essentially when the brain starts developing internal networks and pathways that amplify the pain signal without external stimuli. It's essentially a rewiring of the brain. And so some features of it include when someone touches something, or gets touched, that's not painful and they perceive it as pain, or when you and I get touched by something that should be a one or two out of pain, and they experience an eight or 10 out of pain. It's a horrible cycle to be in, and my heart goes out to those people that struggle with it.

The most important thing to know, Andy, about this situation is that chronic pain in general does not respond to opioids. There was a nice study done a couple years ago that showed that 79% of American adults believe the indication for opioids is chronic pain, and it couldn't be more reversed. Opioids actually make chronic pain worse in most situations.

Andy: Interesting. And it's pretty easy to think, hey, wow, I have this pain that doesn't go away, so I need some strong painkillers for that, but it's really interesting learning about actually how that works in the brain and that sometimes that's not the answer.

Holly: What happens is when we take opioids with chronic pain, those opioids hijack the system temporarily. And you're going to see, for many people who get started on opioids for chronic pain, it's the most relief they've had in a long time, just for the first couple weeks. But then the opioids start to have their effect, and the brain is remodeled by the opioids themselves. Day after day, week by week, they turn what should be dirt roads that connect different parts of the brains into four-lane freeways, and as it rewires the brain it actually increases the sensitization of the brain to painful stimuli. You get something called opioid induced hyperalgesia. In some patients you require higher and higher doses to get the same effect as you develop tolerance, and what we end up with is all of the toxicities, none of the relief, and the sense of dependency that in many times turns full addiction. Not worth it.

Andy: You talk a lot about that in the book, and what to do instead of using opioids when there's chronic pain like that. I'm really interested in how to spot opioid use disorder, and what really leads to that, and how to notice when that's happening.

Holly: So, I think, for every parent listening, the number one thing they're probably scared of, is my kid at risk for an overdose or addiction? And it's a scary question out there, I face it every day myself with my own kids. Opioid use disorder, also synonymous with addiction, is going to occur somewhere between 3 to 20% of individuals that ever touch an opioid. That's a study by the American Medical Association. And we recognize there's many risk factors that set a person up for addiction. Not everyone's going to be that 20%, and not everyone's going to be that three.

Risk factors include younger age of use, a history of addiction or experimentation with other substances, and that's our kids, that's cannabis, that's tobacco, touching even what we call lightweight substances like that can be a risk factor. If our kids have mental health disorders, so depression, anxiety, bipolar, schizophrenia, any of these, certainly big risk factors for developing dependency and chronic use of opioids. Other things, if they live with chronic pain, if they've been in and out of the medical system. I hear horror stories from parents whose kids have struggled with cancer and they're survivors, they've done amazing making it through some of the hardest diagnosis, and the medical system has, in essence, propagated them through the addiction life cycle and they come out dependent on these medications. There's many risk factors just like that really make us want to use these drugs appropriately and safely in every population.

Addiction or opioid use disorder is going to have some mainstream features and it's going to look different in younger or early users than it is in later users. But things I would say every parent should watch out for, early signs might be a bit more withdrawn, spending time with friends that you don't necessarily think are the best influences on your kids, have a history of substance abuse, patterns of behavior in the household, such as being a bit more secretive, not as open. If at any time at the dinner table you're noticing that they're not necessarily paying as much attention, not engaged with schoolwork as much, having trouble at school, these can be early features.

As the life cycle of addiction progresses it'll become much more prominent, and this is when you see them stealing. This is when they're gone long hours, they're not coming home. This is when you find frank evidence in the house in underwear drawers, or sock drawers, of syringes or drug paraphernalia. All of those can be things that you can look out for, and I actually encourage parents to screen for on a regular basis because this is such a prevalent problem.