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After writing several previous newsletters on the stunning rise in opioid overdoses in the US, including among adolescents, I thought it was worth taking a look at what happens after an overdose, particularly for adolescents.
I talked to Dr. Sivabalaji Kaliamurthy about what he’s encountering. A child and adolescent addiction psychiatrist who is board certified in general psychiatry, child psychiatry and addiction psychiatry, Kaliamurthy is also the director of the addiction clinic at Children’s National Hospital in Washington, DC.
He told me that his clinic, which he set up in early 2022, has gone from getting one or two opioid use referrals per month to eight or more per month now, a year later.
He particularly wanted to discuss some major news: The opioid overdose antidote naloxone, sold as Narcan, got approval from the US Food and Drug Administration on March 29, the day we talked, to be sold over the counter.
Excerpts from our conversation, edited for flow, are below.
View Narcan as a fire extinguisher to have on hand
WOLF: What is your reaction to Narcan being available over the counter?
KALIAMURTHY: When I do an evaluation (of a patient), regardless of the substance use, you’re always talking about naloxone, brand name Narcan. …
The message that I present parents with is always that it’s kind of like having a fire extinguisher at home. You hope you never need to use it, but you’re glad that you have it if you need to use it.
Access is important. There are some controversies around increasing access to naloxone and fears that this may encourage more substance use. We have scientific research looking into this very specific question.
And overall, there’s one study that came out this month that found that across 44 states where they increased access to naloxone for adolescents, it did not increase the rates of substance use in this population. And in some states, it actually decreased opioid use among adolescents. …
The FDA approved the over-the-counter sale of naloxone, specifically the brand Narcan, because of how easily it can be administered. Naloxone also comes in other formulations, like injections, but Narcan is a nasal spray. We’re hoping that it will be out later this summer.
The challenge remains how much is it going to cost? On average, it can cost anywhere between $50 to $100 right now. If it becomes over-the-counter, we don’t want insurances to stop covering [it].
It will be interesting to see how the manufacturer goes about introducing it over the counter.
An antidote, not a treatment
WOLF: You said it’s like a fire extinguisher. Should everybody have it, or just people whose kids have demonstrated addictive behavior?
KALIAMURTHY: Everyone should have it. Naloxone is not a treatment; it is more of an antidote. It reverses opioid overdoses, and the person who has the opioid overdose is never the one who’s going to use it somewhere in the community.
The view from one hospital
WOLF: I’ve reported on a surge in overdoses. What are you seeing at Children’s?
KALIAMURTHY: We are seeing an increase in the number of kids presenting to the hospital after experiencing an opioid overdose, and in general, opioid overdose deaths in the DMV (Washington, DC, Maryland, Virginia) region have significantly increased in the last two years. That aligns with a national trend we are seeing with regards to opioid overdoses.
WOLF: Is there a profile for who these kids are? Do they share any traits?
KALIAMURTHY: Yes. Let me talk about the kids we do see for opioid-related concerns first.
At Children’s National, children often present after experiencing an overdose or having a medical complication because of using these M30, or the fake Percocet pills. We’ve had kids come in following conditions such as preliminary hemorrhage, where they were bleeding into their lungs, and overdose is not the only concern.
Apart from that, we also have had kids presenting actively using these pills. They haven’t overdosed yet but they’re asking for help to stop using these pills.
Some things that we have noticed, and this is the trend across the DMV region … the kids who are presenting to treatment, these are kids who are motivated to stop – they predominantly identify as Hispanic in ethnicity. Most of them have Medicaid for insurance.
A lot of them, you know, they come to us – the average age is about 16, 16½ and their first use of opioids, these pills, was about a year ago. So the average first use was about 15 to 15½ years of age. They are really struggling, and they want to get better.
From cannabis to crushing fake pills
KALIAMURTHY: Another common trait: cannabis use is quite common in this population. Pretty much every patient that I’ve come across started off around age 12 using cannabis products. This includes the flower and bud, vapes or edibles. Soon they transition to using the M30 pills.
There are various different reasons, one of which is just access. A lot of other kids are using it. They’re using it in schools. They try it, they like it, and then it escalates and they stop using other substances.
Most of these kids start off with crushing and try it nasally by snorting it and then they transition to smoking. What they do is they put these pills on a piece of aluminum foil, heat it up and inhale the fumes that come up. We haven’t had anyone come in who reported using any of these pills intravenously.
Their first pill might be fentanyl
WOLF: How is treatment for adolescents different than treating adult users who are seeking help?
KALIAMURTHY: We have to take into consideration their developmental age and the psychological development that’s happening in adolescence, which is very different from adults.
Oftentimes, this is the first point of entry into opioid use for these kids. Fentanyl, which is one of the most powerful opioids of abuse out there, is the first point of entry into opioid use for these children.
Where for adults, they might have been prescribed pain medications. Or they might have started on opioids through other routes and might have used less potent products before transitioning to fentanyl.
Adolescents today want help
KALIAMURTHY: Historically, adolescents were not always the most motivated to seek treatment for substance use. What we would see was they would start off with experimenting, there would be a problem, it would take a few years and they’re adults by the time they’ve entered treatment and they’re trying different things to treat themselves before they enter treatment.
With adolescents, now we are seeing that they can tell that they need help, and they are motivated and they are entering treatment.
We have to take into account the presence of parents or guardians, how the school system interacts with them, what else do they do in their communities. There’s an increased association of violence and legal trouble that some of these patients end up in that we need to address while treating them. And these are some differences when it comes to treating adolescents versus adults.
There isn’t enough available treatment
WOLF: One local community’s opioid response coordinator stressed to me that lack of availability of treatment is a real problem. Is that something that you agree with?
KALIAMURTHY: Absolutely. That is a real problem at this point, because there is a huge discrepancy between the number of kids who need treatment and the available resources.
The challenge is we can limit access and prevent these kids from getting the pills. But then you have a huge population of kids who are dependent on these pills, who can’t tolerate withdrawal symptoms, who have what we call opioid use disorder. That is going to perpetuate the problem if we’re not treating them. We need to do more in terms of increasing access to care for these kids.
How treatment works for adolescents. And where it’s lacking
WOLF: Can you illustrate that capacity issue for me, through numbers or data? Or is it more anecdotal?
KALIAMURTHY: Treatment is across different realms.
For example, when a child is using these pills, and they have a problem with substance use, they need to go and be evaluated by a professional who has expertise in both addressing and evaluating mental health and addiction problems. And we don’t have very many people being able to do that.
The first response
KALIAMURTHY: The first-time response is usually a counselor or social worker, sometimes physicians.
But generally, there’s very little expertise in the pediatric health space with regards to addressing substance use-related problems. Screening is the point of entry.
KALIAMURTHY: Then, say they need detox beds. Once they’ve entered treatment, we want to help them get through those initial days when their body is kind of adjusting to not using these pills, and we refer to that as detox.
At Children’s National Hospital, when the kids come to the emergency room, we are not able to admit them for detoxes all the time. Sometimes we do end up admitting them.
This depends on the availability of beds. The number of pediatric beds is very small to begin with. And beds may not always be available when somebody presents to the emergency room detox.
And then there’s who is on call? Who’s available to treat these kids? I spoke about the lack of expertise in general, across the pediatric health space, so all that will determine whether a child is able to get access to detox services.
That’s the detox part of treatment, which can be anywhere between two to five days.
Detox doesn’t always mean somebody needs to be admitted. I also do outpatient detox where we are helping kids stop by providing them with medications and guiding their parents or guardians and the child on how to go through detox.
KALIAMURTHY: Once you go through detox, depending on the extent of the problem, a child may require admission to a rehabilitation facility for anywhere between a month to six months.
When we look at the number of facilities in the DMV region that provide this kind of rehab, I don’t think Virginia has any, DC doesn’t have any, Maryland has two. One is Sandstone Treatment Center, which is a private institution. The other is a treatment center, which is closer to Baltimore. There’s a limitation on who they can take.
WOLF: Let me interrupt you. In a region that has millions of people, there are only two facilities that will take adolescents for one to six months’ treatment for substance use?
KALIAMURTHY: Yes. For substance use.
The system wants to help, but there are challenges
WOLF: Is that just a function of there’s more demand for those kinds of facilities among older people who are more likely to face addiction problems? Is that something the system is pivoting to address right now?
KALIAMURTHY: It’s unclear. The system wants to help, but the challenge is historically adolescents are not always the most eager and motivated to get help.
When we look at treatment programs, that didn’t exist in the past. They often relied on the judicial system, where some of these kids might have been mandated to treatment.
Now we know that substance use disorders are chronic disorders and mandates don’t always work. Courts have stopped mandating treatment, because it’s like you mandate it for a month and then they come out and then what happens? There’s a lot of issues with mandating treatment.
Now, most of the programs that were present prior to the pandemic also shut down during the pandemic because the needs also declined.
This is not financially lucrative. That’s one reason why they’re having a huge issue with finding systems and having the county or the state take over with regards to creating the system.
WOLF: I cut you off there. You were moving from the one-to-six-month facility to the next step in the process.
KALIAMURTHY: So the next step is really engaging these kids in treatment. Not all kids require one to six months. Some kids might be OK with just completing detox and engaging in regular outpatient level of care. This might involve what we call intensive outpatient combined with medication.
Which is where I would come in. A lot of what I do is provide medications for addiction treatment. These medications, the first part is for the detox to help with the child’s symptoms, but once you go through withdrawals, you can still have significant cravings to go back to using.
The challenge, again, is the number of facilities. There are more options for intensive outpatient, but again, they are packed. The wait times to get in are longer now, and some of them are just virtual-only options, which may be good for some kids, but some kids might need more inpatient help.
KALIAMURTHY: After this step, we have regular outpatient therapy and recovery support services, which is also lacking.
The recovery support services are services which help kids get back on track academically. Catch up with your credit, get up on your grades and form a healthy, functioning resume. Get help finding part-time jobs. Keep these kids engaged in activities outside of school so that they are less likely to go back to the path that they were on which led to the substance use.
Message to parents
WOLF: What’s your message to parents who are trying to keep an eye on their kids?
KALIAMURTHY: Let’s look at the national-level data that we have collected up to 2021. Substance use is actually on the decline.
Which is interesting because what is happening is that even though substance use among kids is on the decline – that’s both in middle school and high school – the substances that kids are using have become so much more potent.
Take cannabis, which if you measure the potency by the percentage of THC content, has gone up significantly. The average THC percentage in the ’60s and ‘70s was like 2-5%. And now it’s like 20-25%. And kids are more likely to use what they call the concentrates, which is like 80% or more THC.
When I talk to parents, the first thing I’m telling them about is the landscape of different substances that are out there, and kids are more likely to start off with cannabis or alcohol before they transition to the M30 pills.
Parents can control what their children see them do
KALIAMURTHY: If you think about modifiable and non-modifiable risks, some risks just cannot be changed. These are things like genetics, family history and also if a child has a history of any traumatic experiences. Those are not things you can necessarily change. There are modifiable risk factors, like if a child has ADHD, they’re more likely to be at risk for developing substance use problems.
If there are untreated mental health conditions, such as depression, anxiety, they’re more likely to have problems. We know that. The kids who identify as LGBTQ+, they also tend to have more risk factors in terms of initiating substances that transition into a problem.
But also, we need to rethink how families address substances in the household. Kids learn by modeling they see from adults in their life and also the direct conversations we have. What are their values as a family around use of substances? These are not just legal and illegal – all substance use can have some harm. And early initiation is going to lead to more likelihood of having a problem.