Pediatricians Have Important Role in Talking About Substance Use, Experts Say

Alarming data on fentanyl, including the synthetic opioid's staggering presence in counterfeit pills and contribution to overdoses among young people, continue to emerge, as do questions about the role of physicians in addressing the crisis.

Notably, pediatricians and other physicians who regularly provide care to children and teens are in a unique position when it comes to having conversations about the dangers of fentanyl and other drugs.

"If we look at the big picture, we are seeing, unfortunately, a rapid increase in the number of overdose deaths in adolescents," Kao-Ping Chua, MD, PhD, a pediatrician and health policy researcher at the University of Michigan in Ann Arbor, told MedPage Today. "Almost all of those overdose deaths involved fentanyl."

From July-December 2019 to the same period in 2021, median monthly overdose deaths among kids and adolescents ages 10 to 19 increased 109%, CDC researchers reported, while deaths involving illicitly manufactured fentanyls (IMFs) increased 182%. Approximately 90% of deaths involved opioids, 84% involved IMFs, and counterfeit pills were present in nearly a quarter of deaths.

"It is becoming increasingly important for primary care pediatricians to provide anticipatory guidance to adolescents at well-child visits, or really any visit, regarding the increasing dangers of using substances now," Chua said, pointing out that people don't know what they're getting.

As a result, "screening is hugely important," noted Aaron Quiggle, MD, a psychiatrist and medical director of Addiction Recovery Management Services at Massachusetts General Hospital and an instructor at Harvard Medical School, both in Boston.

This includes asking young people about whether they use substances and with what frequency, and whether they have friends or know people who do, he said, as well as offering "guidance around the fact that counterfeit pills are containing fentanyl," discussing the signs and symptoms of overdose, and what should be done in the event that an overdose occurs.

There's a gap in understanding "what the dangers of contamination are," he added.

Previously, there has been a perception that people who are dying of opioid overdoses have an opioid use disorder, "which is a tragedy itself," Quiggle said. The reality is that many young people who are dying of these overdoses don't have such a disorder.

A Growing Problem

Just this week, the National Institute on Drug Abuse reported that the number of individual pills containing fentanyl seized by law enforcement was 2,300 times greater in 2023 compared with 2017, with more than 115 million pills seized in 2023 and fewer than 50,000 in 2017.

"Drugs mixed with fentanyl are extremely dangerous, and many people may be unaware that their drugs contain it," according to the CDC. Powdered fentanyl, for instance, "looks just like many other drugs," and "is commonly mixed with drugs like heroin, cocaine, and methamphetamine and made into pills that are made to resemble other prescription opioids."

In his own practice, Chua often asks his patients whether they know what drug is killing more people their age than any other. Less than half answer correctly.

Sarah Nosal, MD, a family medicine physician in New York City and director of the American Academy of Family Physicians, has seen her conversations with patients shift over her 15-year career in the South Bronx.

In the mid-2000s, she remembers talking to her patients about fentanyl. However, at that time, the conversations were mostly about instances in which there may have been a grandparent in the home or someone near end of life, and how to safely store these medications.

Now, "the discussion has changed," she said, noting that all kids and adolescents will "pass by fentanyl in their lives," and that it has vastly "contaminated illicit substances on the street."

"You should expect that any substance is contaminated," Nosal said. "We need to have those conversations with young people."

Conversation Starters

Ultimately, there are two types of conversations that physicians have when it comes to substance use, Nosal noted. There are those with parents or guardians, explaining to them why this is an appropriate discussion. And there are those with children, which can be initiated with questions about what other kids they know are doing, and whether any kids they know have taken a pill.

As a family physician, "we see young people by themselves, as well," Nosal said, and it's important to give them the opportunity to talk about topics ranging from sex to substance use with their family doctor. In New York, this is confidential, unless patients are a risk to themselves or others.

Direct conversations with patients about substance use are usually appropriate around middle school age, she noted.

"We need to be talking to families about where our kids are going," she said. Just like asking about whether there is a firearm in the home, physicians should be asking whether families have a naloxone (Narcan) kit to reverse the effects of an opioid overdose.

Nosal herself has used a naloxone kit, which she regularly carries. "Do I think 'one pill can kill?' -- yes," she said.

Chua said he also has used the concept of "one pill can kill" with patients, though not that exact language. The message he tries to convey is that avoiding substance use altogether is the "safest path."

However, for people who are already experimenting with substances, "it really becomes a conversation about how you mitigate risks," he noted. This can include discussions about having access to naloxone, as well as avoiding mixing drugs.

It's important to emphasize that "you just don't know what you're getting these days," Chua said, without engaging "in too much fear-based messaging."

"It's more effective, sometimes, to say, 'You're a healthy person. I want to keep you healthy. And I know you want to stay healthy to achieve all the things you want to do in life,'" he explained.

Persisting Challenges

Regardless of precise messaging, experts agreed that having conversations with young patients about substance use can be difficult for a number of reasons.

Findings from a survey of U.S. pediatricians revealed that, of 474 respondents, most agreed or strongly agreed that it is their responsibility to identify substance use disorders (93.9%) and refer patients to treatment (97.4%).

However, fewer respondents felt prepared or very prepared to counsel adolescents on opioid use (48.3%) compared with alcohol (87.1%), cannabis (81.7%), and e-cigarette use (80.1%). They were also less likely to provide counseling and more likely to refer patients to off-site care for opioid use than for alcohol, cannabis, and e-cigarette use.

"I'm sure there are a lot of pediatricians who are not necessarily aware of the fentanyl issue," Chua said. "Maybe there's another group who is aware of it, but may not view it as their responsibility."

It's also possible that some physicians don't think it's a common enough issue to warrant discussions during office visits that are already stretched for time, he added. Moreover, patients may have other issues of concern and "can only retain so much."

"There are times when this type of counseling about drugs doesn't come to the forefront for various reasons, even if pediatricians believe it's important to provide that counseling," Chua acknowledged. But these conversations are essential in the context of a "general lack of pediatric specialists," especially in pediatric addiction medicine.

"You can't just assume that somebody's going to get care elsewhere," he said.

Quiggle noted that pediatricians and family medicine physicians really are at the front line for "treating mental health and substance use in this country."

Nosal pointed out that, ultimately, the things physicians want to address are "unlimited," but talking about the risks of substance use is critical.

"It's worth it," she said. "You can take a moment."

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