"Do you think I can snowboard tonight?" Sam asks Dr. Medina. "I totally think you can snowboard tonight," Dr. Medina says reassuringly. Sam is going with a new buddy. Making new friends and cutting ties with his former social circle of teens who use drugs has been one of the hardest things, Sam says, since he entered rehab 15 months ago. "Surrounding yourself with the right people is definitely a big thing you want to focus on," Sam said. "That would be my biggest piece of advice."
As part of his pediatric practice, Dr. Safdar Medina
treats opioid use disorder. During a recent appointment at a clinic in
Uxbridge, Mass., Medina switched a teenage patient's buprenorphine
prescription to an injectable form and checked in about his school and
social life.
Martha Bebinger/WBUR
A 17-year-old boy with shaggy blond hair steps onto the scale at Tri-River Family Health Center in Uxbridge, Massachusetts.
After
he's weighed, he heads for an exam room decorated with decals of
planets and cartoon characters. A nurse checks his blood pressure. A
pediatrician asks about school, home life and his friendships.
This story was produced in partnership with KFF Health News.
This looks like a routine teen check-up, the kind that happens in
thousands of pediatric practices across the U.S. every day – until the
doctor pops this question.
"Any cravings for opioids at all?" asks Dr. Safdar Medina. The patient shakes his head, no.
"None, not at all?" Medina says again, to confirm.
"None," says the boy named Sam, in a quiet but confident voice.
We're only using Sam's first name because he could face discrimination in housing and job searches based on his prior drug use.
Medina is treating Sam for an addiction to opioids. He's
prescribed a medication called buprenorphine. It curbs cravings for the
more dangerous and addictive opioid pills. Sam's urine tests don't show
any signs of the Percocet or Oxycontin pills he was buying on Snapchat,
the pills that fueled Sam's addiction.
"What makes me really proud of you, Sam, is how committed you are to getting better," says Medina, whose practice is part of UMass Memorial Health.
Are pediatricians an untapped resource to fight addiction?
The American Academy of Pediatrics recommends offering buprenorphine to teens addicted to opioids. But only 6% of pediatricians do, according to survey results.
In fact, buprenorphine prescriptions for adolescents were declining as overdose deaths for 10-19-year-olds more than doubled. These overdoses, combined with accidental opioid poisonings among young children, have become the third leading cause of death for U.S. children.
"We're really far from where we need to be and we're far on a couple of different fronts," says Dr. Scott Hadland, chief of adolescent medicine at Mass General for Children, and co-author of the study that surveyed pediatricians about addiction treatment.
That
survey showed that many pediatricians don't think they have the right
training or personnel for this type of care — although Medina and other
pediatricians who do manage patients with an addiction say they haven't
had to hire any additional staff.
Some pediatricians responded to the survey by saying they don't
have enough patients to justify learning about this type of care, or
don't think it's a pediatrician's job.
"It's
seen as something that's a very specialized area of medicine and
therefore people are not exposed to it during routine medical training."
Camenga
and Hadland say medical schools and pediatric residency programs are
adding information to their curricula about substance use disorders,
including how to discuss drug and alcohol use with children and teens.
The main culprits are fake Xanax, Adderall or Percocet pills laced with the powerful opioid fentanyl. Nearly 25 percent of recent overdose deaths among 10-to-19-year-olds were traced to counterfeit pills.
"Fentanyl and counterfeit pills is really complicating our efforts to stop these overdoses," says Dr. Andrew Terranella,
the CDC's expert on adolescent addiction medicine and overdose
prevention. "Many times these kids are overdosing without any awareness
of what they're taking."
Terranella says pediatricians can help by stepping up screening for — and having conversations about — all types of drug use.
He
also suggests pediatricians prescribe more naloxone, the nasal spray
that can reverse an overdose. It's available over the counter, but
Terranella, who practices in Tucson, Arizona, says a prescription may
carry more weight with patients.
Trying out different prescription methods
Back
in the exam room, Sam is about to get his first shot of Sublocade, an
injection form of buprenorphine that lasts 30 days. Sam's switching to
the shots because he didn't like the taste of Suboxone, oral strips of
buprenorphine that he was supposed to dissolve under his tongue. He was
spitting them out before he got a full dose.
Many doctors also prefer the shots because patients don't have to
remember to take them every day. But the injection is painful. Sam is
surprised when he learns that it will be injected into his belly and
will take 20-30 seconds.
"Is it almost done?" Sam asks, while a
nurse coaches him to breathe deeply. When it's over, the staff joke out
loud that even adults usually swear when they get the shot. Sam says he
didn't know that was allowed. He's mostly worried about any residual
soreness that might interfere with his evening plans.
"Do you think I can snowboard tonight?" Sam asks Dr. Medina.
"I totally think you can snowboard tonight," Dr. Medina says reassuringly.
Sam
is going with a new buddy. Making new friends and cutting ties with his
former social circle of teens who use drugs has been one of the hardest
things, Sam says, since he entered rehab 15 months ago.
"Surrounding
yourself with the right people is definitely a big thing you want to
focus on," Sam said. "That would be my biggest piece of advice."
Buprenorphine wasn't offered earlier
For
Sam, finding addiction treatment in a medical office jammed with
puzzles, toys and picture books is not as odd as he thought it would be.
He's come to this appointment with his mom, Julie. She says
she's grateful the family found a doctor who understands teens and
substance use.
Before coming here, Sam had seven months of
residential and outpatient treatment — without ever being offered
buprenorphine to help control cravings and prevent relapse. Only 1 in 4
residential programs for youth offer it. When Sam's cravings for
opioids returned, a counselor suggested Julie call Dr. Medina.
"Oh
my gosh, I would have been having Sam here, like, two or three years
ago," Julie says. "Would it have changed the path, I don't know, but it
would have been a more appropriate level of care for him."
Some parents and pediatricians worry about starting a teenager on buprenorphine, which can produce side effects
including long-term dependence. Pediatricians who prescribe the
medication weigh the possible side effects against the threat of a
fentanyl overdose.
"In this era, where young people are dying
at truly unprecedented rates of opioid overdose, it's really critical
that we save lives," says Hadland, chief of adolescent medicine at Mass
General for Children. "And we know that buprenorphine is a medication
that saves lives."
Addiction care can take a lot of time for a
pediatrician. Sam and Dr. Medina text several times a week. Medina
stresses that any exchange that Sam asks to be kept confidential is not
shared.
Medina says treating a substance use disorder is one of the most rewarding things he does.
"If
we can take care of it," he says, "We have produced an adult that will
no longer have a lifetime of these challenges to worry about."
This story comes from NPR's health reporting partnership with WBUR and KFF Health News.
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