RICK WEISS: Hello, everyone. Welcome to SciLine’s media briefing on substance use and misuse among U.S. teens. I’m SciLine’s director, Rick Weiss. And for those not familiar with us, SciLine is a philanthropically funded, editorially independent free service for journalists and scientists based at the nonprofit American Association for the Advancement of Science. Our mission is pretty straightforward. It’s just to make it as easy as possible for reporters like you to get more scientifically validated evidence into your news stories. And that means not just stories about science but any story that can be strengthened with some science, which means, in our view, just about any kind of story you can think of. Among other things, we offer a free matching service that helps connect you to scientists who are both deeply knowledgeable in their field and are vetted to be excellent communicators. We make those available to you on deadline. Just go to sciline.org, click on I need an expert, and while you’re there, check out our other helpful reporting resources.
Couple of quick logistical details before we start. We have three panelists today who are going to make short presentations of up to seven minutes each before we open things up for Q&A. To enter a question either during or after their presentations, just hover over the bottom of your Zoom window, select Q&A and enter your name, news outlet and your question. If you want to pose your question to a specific panelist, be sure to note that. A full video of this briefing should be available on our website by tomorrow and a timestamped transcript soon after that. But if you’d like a raw copy of the recording more immediately, please just submit a request with your name and email in the Q&A box, and we can send you a link to the video, the raw video, by the end of today. You can also use the Q&A box to alert us of any technical difficulties.
OK, I’m not going to give full introductions to our speakers. Their bios are on the SciLine website. I’m just going to tell you that we will hear first from Dr. Lindsay Squeglia, who is an associate professor in psychiatry and behavioral sciences at the Medical University of South Carolina and who will focus on cannabis, with particular attention to the effects of today’s especially potent blends on the adolescent brain. Second, we’ll hear from Dr. Deepa Camenga, an associate professor of emergency medicine and a board-certified physician in pediatrics and addiction medicine at Yale University, who will focus on the latest research on vaping of nicotine and other substances. And third, we’ll hear from Dr. Scott Hadland, who is a pediatrician and chief of adolescent and young adult medicine at Mass General for Children, and—sorry, Mass General Hospital for Children and Harvard Medical School, who will focus on opioids and youth. OK, let’s just get started. And over to you, Dr. Squeglia.
Cannabis and the teen brain
LINDSAY SQUEGLIA: Hi. Sorry about that. I’m having an issue with my mouse. But thank you guys so much for having me here today. I am very excited to be talking to you all about cannabis and the teen brain. So, not surprisingly, cannabis, alcohol and other substance use is typically initiated during adolescence, and we see rates of use increasing throughout adolescence into young adulthood. And the three most commonly used substances during this period of time are alcohol, cannabis and e-cigarettes. And today I’m going to be focusing on cannabis, but our other fantastic speakers will be talking about e-cigarettes and also opioids. And interestingly, likely due partially to the effects of legalization, cannabis legalization in the U.S., we’ve seen this pretty dramatic decrease in perception of harm among adolescents. So, in the early ’90s, about 80% of youth viewed regular cannabis use, so about weekly cannabis use, as something that would be harmful to your health. Only 1 in 5 youth report that cannabis would be harmful to your health now. So, we’ve seen this really dramatic decline in perception of harm. And this is coming at a time when the products that are available are very different than the products that were available just 10, 20 years ago.
So, I’ll talk mostly about two different constituents within cannabis. So, THC is the part of cannabis that gets you high. It’s the psychoactive part of cannabis. And then there’s cannabidiol, or CBD, which potentially has therapeutic effects. So, you know, you’ve probably heard about CBD through its FDA approval for treating pediatric seizures, and it has been looked at as a treatment for many other psychiatric and medical disorders. And so over the past several years, we’ve seen a pretty dramatic increase in the amount of THC in cannabis products relative to the amount of CBD in cannabis products. And so, when I’m talking to parents and youth about potency of cannabis products these days, I use the analogy with alcohol. So, it would be, you know, the difference of drinking a pint of beer versus a pint of vodka, right? So, back in the ’80s, ’90s, there were THC levels typically in 5 to 10% in cannabis products. Now you can easily access products that have 80, even 90% THC levels. So, there is this proliferation of these really high-THC concentration products out there.
And so why do we care about that? We care about that because adolescence and young adulthood is a time when the brain is undergoing just this significant amount of neural development. And while adolescents may often look like adults, their brains are not at adult levels until about mid-20s. So, this is something that car insurance companies figured out way before neuroscientists did because we know that you can start renting cars at age 25, when your frontal lobe is fully developed. So, we—the brain doesn’t change in size. So, it’s not like your brain is growing during adolescence, but there is a decline in gray matter, which are your neurons in your brain, so your brain cells, where thoughts, feelings and emotions are happening, and an increase in white matter in helping normal brain development. And white matter are the tracks in the brain that connect the different gray matter regions. And so, I always explain this as like the superhighways in the brain. And during adolescence and young adulthood, these superhighways are getting paved. So, as you can see from the video, not all regions of the brain are developing at the same time. And we know that in adolescent brains, the reward centers of the brain are developing before the cognitive control center. So, the reward centers are more like adult reward centers of the brain before these cognitive control centers come on board. And so, a lot of people will use the analogy of adolescents having fully developed gas pedal, not fully developed brakes.
So, there are multiple studies that have been done. This is one of the most famous studies. It was done in New Zealand, looking at how cannabis use affected the developing brain. And they looked at IQ, and IQ is a really stable indicator of intelligence across the lifespan. Your IQ doesn’t really change much over the lifespan. And in people that they followed for 30-plus years, they found that people who were not using cannabis over this time, they increased their IQ by one point, so really, basically, stayed the same over that 30-year period, whereas people who used cannabis during adolescence in particular showed an eight-point decline in their IQ levels. So, heavy cannabis use during adolescence was related to a decline in IQ. And interestingly, this wasn’t the fact for adults. So, if someone waited until they were an adult to use cannabis, they didn’t see similar declines in IQ. And there is a really great meta-analysis that was put together several years ago. A meta-analysis means that you take a ton of different studies and add them all together to see what the effects are. And what this found was that in adolescents and young adults who used cannabis, they showed poorer performance on tasks of learning, processing speed, memory, inhibition and attention. So, overall, cannabis was affecting cognitive functioning in youth using. And we’ve also done studies where we looked at the structure of the brain. So, like I talked about, those white matter tracts that are connecting different regions of the brain, kids who used cannabis during adolescence, their white matter tracts weren’t getting paved at the same level. So, that could be related to the slower processing speeds that we see, the less efficient processing of information in the brain that we see in adolescents who use cannabis heavily.
And there was another great meta-analysis put together a few years ago, again, a bunch of studies adding together, where they found differences in the way that the brain was activating during certain tasks that they did in the scanner. So, there was more activation in kids using cannabis in certain regions of the brain, like the putamen and the inferior parietal gyrus, where these are areas of the brain that are involved in memory and integration of a lot of information and have been implicated in addictive processes. So, this was, like, a really, really brief overview. I could have talked to you all for, like, an hour-plus about all of this. But overall, in cannabis use, specifically during adolescence, we see poorer cognitive functioning. We see less efficient white matter structures in the brain. And we see this increased activation. So, we interpret it as this, like, compensatory effect where brains are having to work a little harder to keep up in kids who are using cannabis versus not. And we did a review last year where we saw that co-use had the most pronounced effects. So, usually kids that are using cannabis are also using other substances, particularly alcohol. And those two things together show even poorer outcomes in youth brain development. So, that is all I have for you guys today. I’m really happy to take questions at the end.
RICK WEISS: Great. Thank you, Lindsay. Not a lot of great news there about using cannabis in adolescence, but I’m sure we’ll get to talk in the Q&A about what the implications of all that are for what seems like a much higher use level going on in society today. Let’s move on at this point over to Dr. Deepa Camenga.
DEEPA CAMENGA: All right. Well, also, thank you for having me join today. My name is Deepa Camenga. As was said, I am an addiction medicine specialist and a pediatrician. So, I treat teens and young adults with a variety of substance use disorders, including vaping addiction. And one of the ways—vaping is very prevalent in this country among youth today, and one of the ways that the scientific community monitors the extent of the public health impact of vaping is through national surveys. And one of the surveys that we often look at is the National Youth Tobacco Survey. And this survey is conducted annually, and it collects data from U.S. high school and middle school students. When we look at the 2021 data, we see that a sizable number of youth or high school and middle school students are vaping. More than 2 million reported that they currently used e-cigarettes. So, that’s about 11% of high school students and 2.8% of middle school students.
RICK WEISS: Deepa, I just want to interrupt you because I’m not seeing your screen-share, and I think you are trying to share.
DEEPA CAMENGA: I’m sorry about that. I am. This is—now can you see it?
RICK WEISS: Yes.
DEEPA CAMENGA: Well, there you go. So—again, sorry about that. So, this is data from the National Youth Tobacco Survey. And so as I was saying, 11% and 2%. And as it was reported in the press, these numbers were lower than the peak rates we saw in 2019, where the rate of e-cigarette use among high school students was around almost 27%. But the scientific community is interpreting this data with caution—the data suggesting that rates of e-cigarette use are declining. And there are two reasons for this, which I’m going to highlight here. The first is when reporting on survey data, it’s important to understand how the data were collected. And as you know, in 2021, we were in the middle of the pandemic, and many high school and middle school students were learning from home. So, in this survey in particular, half the kids who reported on e-cigarette use were taking the survey from home. And we know that when teens report on behaviors, they tend to underreport it if they’re around their parents. So, we are, you know, really looking towards the next year of data collection with caution because we’re not really sure exactly if rates will rebound or stay the same as we emerge out of the pandemic. So—but another reason that we are concerned and continue to be concerned about e-cigarette use—and again, this is data from the National Youth Tobacco Survey—is because youth report using e-cigarettes not just for curiosity and fun, but the primary reason they’re reporting using it is to relieve stress, anxiety and depression symptoms. And the second-highest reasons is because it feels good, and it provides a high. But the reason this is of concern is because, as you know, we are experiencing a public health emergency around the mental health of youth and teens in this country. And as you can see here, the more untreated or undertreated symptoms—such as stress, anxiety and depression—we’re concerned that kids will continue to use e-cigarettes to self-treat these symptoms.
Now, e-cigarettes have been around for more than a decade now, and the evidence continues to accumulate regarding their health effects. The data is pretty good in showing that nicotine exposure during adolescence—much in the same way that cannabis exposure during adolescence—affects brain health and specifically, as Dr. Squeglia mentioned, changes the wiring in the brain, the reward pathways related to addiction. Nicotine vaping is increasingly being shown to adversely impact lung health, as well, especially among teens. And it’s associated with symptoms such as asthma and—wheezing and diseases such as asthma. It also—vaping or using any substance, really, in your teenage years increases the risk that you would try another substance. So, a person who vapes and starts with vaping has a higher risk of eventually trying other substances such as cannabis or alcohol. And several studies have shown that nicotine vaping is associated with an increased chance or likelihood of initiating combustible tobacco product use. And that increases your risk by 3 1/2 to about four times. And this is of great concern because we know of the multiple adverse effects of cigarette smoking. Dr. Squeglia described some of the health effects related to brain health and cannabis vaping. I’d also like to highlight that e-cigarettes or those devices are used also for delivering cannabis. And cannabis vaping has been—was associated with EVALI [E-cigarette or Vaping Use-Associated Lung Injury] or the outbreak of severe lung disease in 2019 to 2020. It also has been shown to be linked with developing symptoms of psychosis. And psychosis is a serious mental health condition wherein a young person may experience symptoms of delusions or paranoia. And we know that people vape—when they vape cannabis, they use very high THC concentrates. And that in particular has been linked with an increased risk of developing psychosis, trying other substances as well and developing an addiction.
So, what are the messages, I think, that the science is supporting now for the public? We know for young people and people across the life span that not using tobacco or being tobacco-free is the healthiest choice. Nicotine use during the teen years can lead to nicotine addiction, and that is because the teens have developing brains. The science is mounting showing that ingredients in e-cigarettes can be harmful to the lungs. Vaping is a harmful way to manage anxiety, depression and stress, and that is because of its effects on the brain and the lung and other parts of the body. For teens, e-cigarettes should not be used as a substitute for cigarettes. We know of no healthy use level of e-cigarette use for children and adolescents. And vaping is still a serious public health threat. All right. Well, thank you very much.
RICK WEISS: Great. Thank you, Dr. Camenga. And let’s cover our third topic with Dr. Scott Hadland.
Teen opioid use
SCOTT HADLAND: Great. Thanks, everyone. So, as Rick had introduced me earlier on, I am head of adolescent medicine at Mass General and Harvard Medical School and, in my clinical work, take care of young people who struggle with substances. And a big proportion of our population that we work with is young people that struggle with opioids, which we hear a lot about in the news. And I’m hoping to shed a little bit of light on the ways in which this national overdose crisis and problem with opioids nationally affects the teen population because I think that gets much less coverage in the media. So, just a quick primer—what are opioids? Well, first of all, they’re a mainstay of medical practice. They’re not always needed in the treatment of pain, but they’re extremely effective for the treatment of severe acute pain. They can help people with chronic pain function in life as well. And we know a lot about prescription painkillers. They’ve been in the media a lot because of pharmaceutical companies having marketed them very heavily. And some medications that I think are common to people that you may have heard of include oxycodone, which often goes by the brand names Percocet or OxyContin, and hydrocodone, which often goes by the brand name Vicodin, as well as morphine. Even fentanyl, which we hear a lot about in our public discourse right now—and I’ll talk about it more in this presentation—is also medically prescribed in certain conditions. But opioids sold on the illicit market that are the opioids that are really fueling the overdose crisis right now are heroin and fentanyl. And to be very clear about the fentanyl involved in the overdose crisis right now, this is fentanyl that’s illicitly manufactured outside of the United States, imported into the country and then introduced into the drug supply. So, this is not fentanyl that’s being prescribed by doctors. And this fentanyl contamination is rampant. It’s mixed in with other substances that people buy on the market, including cocaine—is commonly tainted with fentanyl. And many of the pills that people buy on the street that they perceive to be an opioid prescribed by a doctor are actually counterfeit pills that contain fentanyl and are billed as being something else, like an opioid or even another medication like Xanax, which is a common medication that people will try to buy on the street.
So, let me highlight for you what’s been going on in youth overdose death rates. This is a study that came out, actually, just a few weeks ago that really kind of shook the landscape of how we think about overdoses here in the United States. Just to orient you to the figure, the horizontal axis here is year, going from 2010 on the left up to 2021 on the right. So, these are brand-new data from the post-COVID era, which is this dotted line here. And the vertical axis is the death rate. And what I really want to highlight is that, for overdoses—these are overdose deaths occurring among teenagers in the United States—you can see just this enormous upswing caused by illicit fentanyl. And don’t worry about the second part of that that says and synthetics. That’s just a word that the Centers for Disease Control uses. What you can see is that there has been a massive, huge, more than triple, uptake—uptick, rather, in the number of overdoses in this country in teenagers, and it’s fueled by fentanyl. But that’s not the full story. And I think this is important to know as well. Here’s another study that our group did—same national Centers for Disease Control data. This figure runs from 1999 on the left all the way out to—the most recent year we had here was 2018. And these are overdoses, but they’ve been broken down into overdoses that involve opioids alone, which is this gray-blue line, and then overdoses that involve opioids plus something else in that teenager. And what you can see is that as of 2017, it’s actually more common for teenagers to overdose on opioids plus something else and not opioids alone. And what are those other things? No. 1, it’s cocaine. No. 2, it’s benzodiazepines. Those are medications like Xanax that I mentioned before. And No. 3, it’s methamphetamine or more commonly just called meth. So, this is really an overdose crisis fueled by a lot of drugs at the same time.
I want to clarify a couple of things. I’ve been talking about overdose, which is strictly speaking, not the same thing as addiction. Addiction is when somebody struggles and uses a substance over and over compulsively. And it’s important in this case because given the lethality of fentanyl, one single counterfeit pill could kill a young person. And I don’t say that to be alarmist. It really is potentially contributing to some of what we’re seeing in the upswing in overdose deaths. And I want to be clear that not every teen who overdoses has addiction. They might just be trying opioids for the first time or may have only tried a handful of times. But many teens who overdose do have underlying addiction. And that’s important to note because I don’t know that that always gets the full attention it should. And in fact, across this country, there are 1.6 million youth who have addiction, and very few of them actually get treatment for it. What are some risk factors for addiction? Well, use of other substances like nicotine, alcohol or cannabis all predisposes to opioid addiction. Earlier age of first use of substances—so one thing that Dr. Camenga and I are always doing in our work, and I know because we talk about this commonly, is trying to delay the onset of somebody’s first substance use, to try to get teens who might otherwise start at age 14 or 15 to delay it until they’re older. Untreated mental health problems, most commonly depression, anxiety and history of trauma, are linked to addiction. And then a family history of addiction, and that’s addiction to any substance. In fact, most commonly, the addiction that a parent will have is a problem with alcohol in a young person who has addiction to opioids.
So, what are some final recommendations for reporters? We’ll flesh this out a little bit more, hopefully, in the Q&A afterwards. But my two tips for you are these—to put together a good story that’s compelling and will convince policymakers, you should tell the stories of teens and families that have been affected by this crisis. And I see this done really well by you all all the time. And I really want to sort of encourage you to keep up that good work. And at the same time, though, I encourage you to avoid the simple narrative. I think back to when we were earlier on in this crisis and we heard a lot of stories of the 17-year-old football player who was doing fine in life until the day that they were prescribed an opioid for the first time, and that set them on the pathway to addiction. The story is often a lot more complex, often involves other underlying addictions, other mental health problems. And I would just encourage you all to really sort of understand that this is a complex problem that isn’t just about the drugs but really involves a lot of interpersonal and personal factors that sometimes get short shrift in coverage. So, thank you.
What is being done well in press coverage of these issues, and where is there room for improvement?
RICK WEISS: Great reminders there and a great segue to the first question I want to ask all of you while reporters submit their questions. A reminder to reporters—you can use the Q&A icon at the bottom of the screen to submit your questions. Let us know if you want to direct it to one in particular. But let me just go around the horn first, as I traditionally do in these briefings, and ask each of you first to direct something to the reporters who are with us today, in terms of something you see in the way these topics are being covered today that you think is being done well or something that you’re a little bit unhappy with as a professional and wish the media would sort of take a different bent on or a different approach to. And I’ll head around in the same order here, Dr. Squeglia first.
LINDSAY SQUEGLIA: Thanks. Those other talks were really excellent. So, I really enjoyed hearing them. And I think one of the things that journalists are doing well is that they’re covering these topics, and they are focusing on adolescents and young adults and appreciating that this is a development—addiction in general is a developmental disorder that starts quite early. And so I’ve really appreciated seeing coverage of this from adolescent and young adult perspective. Room for improvement—I would say the language being used. As scientists, we’re—and clinicians, we’re really trying to help destigmatize substance use disorders, and there has been really good destigmatization in depression and anxiety, those worlds, where people are more comfortable talking about it as a psychological disorder, where in the substance use field I still feel like you see these snippets of it being, like, a moral disease and a moral disorder and people just need to quit. And using terms like addict still are really common, or alcoholic, those terms are still really common. And I see them in a lot of pieces trying to cover substance use disorders. So, just trying to have more compassion and using person-first language when talking about substance use disorders I think can go a really long way in helping us to destigmatize substance use disorders.
RICK WEISS: Deepa Camenga.
DEEPA CAMENGA: I agree with what Lindsay, Dr. Squeglia, said as well around language. Regarding vaping, I think I’ve followed the press and reporters as they’ve been covering how tobacco products have been regulated in this country, and the different laws and things that are happening around the FDA and their regulation of e-cigarettes and other tobacco products. And I really think they—it’s a very complex and difficult topic. But I think especially, you know, over the years, the reporting has been excellent and helping the public understand the challenges in appropriately regulating these products for public health and also always highlighting the risks to youth if tobacco products are widely available. And public health messaging is, you know, confusing. You know, things I think might be covered more in the discourse in this country in general—we always—we’re—we as a society focus a lot on reacting to problems. But there is a whole science base around prevention. And it’s—there’s so many challenges around prevention, but really, for teens, it’s so important that communities have access to prevention. And there’s so many challenges as to how to get evidence-based prevention strategies into communities. It’s not just teaching curriculums in the schools. It involves businesses. It involves laws. It involves parents. And I think, you know, more stories highlighting how powerful that can be when it’s done right and the challenges in really taking a prevention-oriented attitude towards youth substance use could be helpful.
RICK WEISS: That’s a really interesting point. I think it’s a challenge, frankly, from the news point of view because news is so wedded to something that happened, you know, at least good or bad. And prevention is hard to fit into that model in the same way that public health generally is often a hard thing to cover in the news because when it’s being done well, there’s nothing to write about. And yet the reason things are going well is because people are working very hard at public health all the time—so tough call on news coverage. But I appreciate that emphasis. Scott Hadland.
SCOTT HADLAND: Yeah, I agree with everything that’s been said. And I think what I’m seeing increasingly is exactly what I was just asking for in my last slide, and that is more sort of rich reporting around the underlying causes of overdose and addiction and not pointing simply to the bad drug that caused this but understanding that use of substances happens in a context. And for teens, that context is complex, often has a lot of contributing factors. And trying to capture that in the reporting, trying to understand if a teen may have had other mental health problems, how they may have been interacting with their family, some of the struggles they may have had seeking treatment and being unsuccessful in doing so—I’m seeing a lot more of that in reporting. And I’m really thankful for it because that’s what drives the policy—is understanding what our barriers are for families.
An area of improvement—I actually, independently, without consulting with Deepa beforehand, had the exact same thought. And to just build on what she said and sort of lay out an analogy, the way that we think about overdose in this country is—would be equivalent to if we just sat around waiting for everybody to have a heart attack, and that’s the moment at which we intervened. We talk about the overdose crisis as though it’s this thing that happens at the last moment when somebody finally overdoses. We don’t spend nearly enough time talking about the upstream factors; that, for a young person who’s struggling with addiction, the very roots of the addiction that they’ll have later on in their teenage years are often formed during their early life years if they have a parent who may have substance use and may have been unable to access treatment and may not have been a reliable parent or may have, you know, contributed to a chaotic upbringing; that young people who struggle with mental health problems often go months to years without getting them treated and that contributes to addiction; that there are all these upstream things. Not even to, like, say the least of—I truly believe that our state has failed us in providing young people and families the basics that they need in terms of income, housing, food; that all of these things create a context in which addiction occurs. And so we shouldn’t be surprised that when we look at a map and we see that the areas of the country that have been hardest hit by addiction are those that have struggled in terms of socioeconomic status and income and poverty and struggled in terms of housing, have struggled in terms of education, unemployment—that these are the places hardest hit by addiction, which we talk about as being a disease of despair. It happens in these places that are not sufficiently served. It happens in this very rich context. And I think that’s a story that has critical policy implications that we need to keep hammering home for policymakers.
When reporting on any treatment program, are there any specific benchmarks, standards, or certifications to look for?
RICK WEISS: Very interesting answer and something that I think news organizations need to struggle with—to devote the resources to covering those kinds of stories. You know, it’s not a one reporter one day doing that kind of story. That’s something you need to devote resources to over some time. We have a question here that I think all three of you might want to weigh in on. It’s from Anna Boiko from KUOW, Seattle, NPR. And they write that our audience is hungry for information about how they can help family members with addiction. When reporting on any treatment program specifically, are there any good benchmarks, standards or certifications to look for to make sure it’s actually a good treatment program? One of you want to start with that? I can—Lindsay, do you want to—do you have anything to say on that?
LINDSAY SQUEGLIA: Yeah. I sent in the Q&A the link to NIAAA’s treatment finder. And so this is NIH-supported, and the focus is on alcohol but substance use treatment in general. And people can go there to find evidence-based treatment. I think this is a really, really important point and great question because it is so hard to find services right now in particular. And even when you identify certain providers based—like, depending on insurance and things like that, it can be really difficult. So—and there’s just a infiltration of nonevidence-based treatments out there that are—it’s honestly horrifying, some of the things that people are touting and taking so much money from very vulnerable people and families who just want help—and putting them through not evidence-based treatment. So, I really like that as a starting point, and it is NIH-supported.
RICK WEISS: Deepa, anything to add there?
DEEPA CAMENGA: I think SAMHSA also has a treatment locator resource. I think when talking about teens and substance use in this country, we have a workforce shortage, an extreme workforce shortage, meaning professionals—there are very few professionals who are trained to provide evidence-based services for teenagers struggling with addictions. And it’s very unfortunate. It’s extremely unfortunate. So, I feel for families. And I myself have trouble finding treatment for my patients. It’s—we really lack in that area. I think really trying to look for treatment programs that focus on young people is something that parents really should do. There are some programs which are—you know, they say they do everything, but you really want to make sure they have experience working with teens in particular.
RICK WEISS: And SAMHSA is the Substance Abuse and Mental Health [Services] Administration, I think is part of Health and Human Services, for those unfamiliar with that. Scott, anything to add on criteria to look for as people think about programs?
SCOTT HADLAND: No, I actually put the SAMHSA link in the Q&A, too, so that folks can see it. It’s a fantastic resource. No, I agree. I would just, you know, really caution everybody that there’s a lot of predatory treatment out there. I have had families who struggled so much to find treatment and ultimately, like, expended their entire 401(k) savings paying for, you know, out-of-pocket private wilderness retreats for their kids that didn’t use any evidence-based strategies. And so—but unfortunately, there’s not really a lot of gold standard sort of certification. Even, you know, some of the treatment programs that you’ll find in the SAMHSA or NIAAA treatment locator have some concerning features. They’re not all high quality. Not all of them are pursuing evidence-based strategies, especially when it comes to teens. And so I think for you as reporters, one thing that you can do is partner with us to help understand—if you’re sort of trying to understand whether a particular treatment modality is actually effective or not, we are happy to help you navigate the evidence base and understand, you know, what’s been proven, what hasn’t been, because unfortunately, there is not a gold standard that you can just look to. You sort of have to do your research. And that’s hard on families. And we’re here to help you, too.
Is E-cigarette or Vaping Use-Associated Lung Injury still a problem, or is it gone?
RICK WEISS: OK. Good warnings. Question here from Carla Johnson at Associated Press for Dr. Camenga, what is happening with EVALI now? Is it still a problem, or is it gone?
DEEPA CAMENGA: Excellent question. I looked at the literature to see if there was any data, surveillance data available on EVALI during 2021, 2022. And there hasn’t—because the CDC stopped formally collecting data in February 2020, right for the pandemic, we don’t have ongoing surveillance data, but I will tell you this. So, I speak very often with a lot of professional organizations, with pulmonologists, with ICU doctors who take care of teens. And there is some suspicion in the field that there are still cases happening because they are having teens present with a severe lung injury, and they use e-cigarettes, and they’re not testing positive for COVID or other infections. They’re not clear as to what is doing that. So, I’m expecting—I mean, this is anecdotal from providers and physicians who are providing care, but I’m expecting now that we will start seeing more literature on this, now the pandemic—we’re opening up a little bit. And we’re starting to realize that there are other things that we’re seeing in the hospital that we need to continue to monitor.
In adults, cannabis is sometimes used as a medical treatment for pain or other health challenges. Is it ever considered an appropriate treatment for teens?
RICK WEISS: Great. Thank you. Question for you, Dr. Squeglia. In adults, cannabis is sometimes used as a medical treatment for pain or other health challenges. Is it ever considered an appropriate treatment, medically speaking, for teens? It certainly seems to be popular.
LINDSAY SQUEGLIA: And I think this goes back to what I was talking about, like, the different constituents in cannabis where there’s the THC that gets people high. There’s the cannabidiol that has had more therapeutic effects. There is so little quality research in this area. In general, just, like, taking cannabis off—like, getting cannabis—however you would get cannabis and smoking it, it’s very unlikely that that is going to be an effective treatment. I’ve seen people use, like, that—like, had patients before who’ve used, like, cannabis as treating their COPD. And like, obviously, smoking a product is not going to help with your COPD. So, it’s really important that when we talk about using cannabis as a therapeutic, that we’re specific about which constituents. So, yes, there’s some interesting preclinical and even early-stage clinical evidence suggesting that cannabidiol specifically could be therapeutic and have therapeutic effects. But even that—like, the CBD products that are publicly available—there’s so—it’s not regulated, and so there’s so much variability where some of the products—they will test it in labs, and it’s actually not CBD at all. Or the percent CBD that they say it is—it is not that at all. So, there needs to be standardization and there needs to be just a mindfulness that when you use the word cannabis, there’s so many constituents, and we need to make sure that we are very specific about what we mean by that and using it as a treatment. But there’s so much more room in the area of using CBD for psychiatric disorders where there isn’t a lot of high-quality data yet.
Are there differences in trends around teen addiction and overdoses, versus adult?
RICK WEISS: It sounds like a lot of the same problem that Scott was talking about where you just don’t always know what you’re getting—obviously, a problem with street drugs. And we do have a question for you, Scott, from Anastassia Gliadkovskaya from Fierce Healthcare—are there differences in the trends around teen addiction and overdoses versus adults, for instance, more co-use or less prescription opioids or something else?
SCOTT HADLAND: This is a really good question. And this is sort of the crux of what has gone on with the opioid-related overdose crisis and the way in which it has evolved. Earlier on in the crisis, youth were much more likely to start with prescription opioids and sort of have this pathway where maybe they progressed from pills to heroin to maybe even injecting heroin. And sort of there was this slow onwards trajectory as they kind of intensified in their substance use. That was different from adults who often were already well-established in their substance use—may have been using heavily, may have been using multiple substances. We’ve now, though—and this is what these new studies have really shown us from the CDC. We’re now at a point in the crisis where youth look a lot like adults in terms of how they overdose, what they’re overdosing on. And at this point, three-quarters of all youth overdoses involve fentanyl, and that’s something that is true of adults, as well. A majority of youth overdoses involve multiple substances. That’s true of adults, as well. Those substances are commonly stimulants like cocaine or methamphetamine or a benzodiazepine pill like Xanax. That’s also true for adults. And so the crisis has really become one that looks very similar for youth in adults in a way that it didn’t used to.
How does heavy cannabis use after age 25 affect the brain?
RICK WEISS: Great. Question for Dr. Squeglia. You showed data about negative effects on the brains of heavy cannabis use during adolescence. Is there similar evidence of effects of heavy use after 25? It sounded like from that one study, maybe not?
LINDSAY SQUEGLIA: You know, there’s a lot of variable data out there on the effects of cannabis use on the adult brain because mostly people who are using during adulthood had used during adolescence as well. But more data are coming out as legalization occurs in states where people who are adults who have never used cannabis before are starting to use cannabis. So, there are studies that are ongoing that are going to help answer that question. But I think it gets back to also the potency of cannabis products, and how our newer, really high potency THC products affecting brains that are already adult-level developed? I think that’ll be really an interesting question. But the research is still ongoing in that area.
Are certain demographics more at risk for using vaping as self-medication for anxiety or depression?
RICK WEISS: Question for Dr. Camenga. You talked about anxiety relief as a key reason that many teens vape. Are there any particular subgroups among adolescents, age demographics that are most at risk for this behavior?
DEEPA CAMENGA: That is a great question. Maybe I am not aware if the—so it’s—I mean, what it shows is the people who vape are more likely depending on the measurement to be—come from a little bit higher socioeconomic status communities. The disparity between racial groups is changing over time, but it is still more prevalent in teens who are white, although Black and Hispanic youth are increasingly having higher rates. So, in terms of using it as self-medication for depression or anxiety, I have not yet seen the literature looking at particular subgroups for which this is prevalent. I think it gets at what Scott said. You know, those who have underlying stressors in their life due to their social environment, underlying trauma or family history—they are more likely to be primed to use these substances to help relieve symptoms of anxiety, depression or stress.
RICK WEISS: Scott, any…
DEEPA CAMENGA: I don’t know. Is anyone else aware of data showing that, more specifically the subgroups?
RICK WEISS: Yeah. Scott, you had mentioned family history. And I don’t know. Is that considered to be something genetic or environmental, or what’s the connection? What’s thought to be the connection there?
SCOTT HADLAND: I think, as with all things, it’s complicated. I think—we think about it as being a combined risk factor, that there do seem to be some genetic variants that are passed on in families that are linked to certain types of addiction, particularly opioid addiction, but that the context in which young people grow up is also very important and that families that have somebody struggling with substance use, you know, create a context that may put a young person at risk for substance use. I want to be very clear that the cycle of addiction can very much be broken when people get the treatment and resources that they need to thrive.
What are some red flags or concerning practices that should be watched for when selecting treatment programs for youths?
RICK WEISS: Great point. So, the follow-up question here from Anna Boiko at KUOW, Seattle, NPR—this references something you said, Scott, but any of you might want to weigh in on this. What are those red flags? This is, again, about, you know, making decisions about treatments. What are those red flags and concerning practices in treatment programs for youth that Dr. Hadland mentioned? Can you be more specific about what to watch out for? It’s also wondering here about whether Alcoholics Anonymous or Narcotics Anonymous is considered to be an evidence-based practice or not.
SCOTT HADLAND: I can take that first question. For me, the No. 1 thing I look for in a predatory treatment program for teens is a high out-of-pocket cost. That private pay only at a hefty fee is usually a bad sign. They will often use therapies that involve sort of removing a young person from their environment as a way to stop that person from using—so, you know, having them go to a retreat in the wilderness in Utah or go to a horse ranch in Arizona or, you know, something that brings them out of their usual context. And so it’s not surprising that they stop using because they’re out of their usual context. And then what we most commonly see is that when they get back to their previous life, all the same stressors, triggers that may have prompted them to use in the first place are still there. So, that is a common sort of red flag—the idea that you pay a lot out of pocket to transport your child somewhere else.
RICK WEISS: Anyone else—Lindsay?
LINDSAY SQUEGLIA: Yeah. I would also say, you know, there are certain keywords that you might want to ask about or inquire. If you look on the website where they talk about using maybe cognitive behavioral therapy, that’s a good thing. That’s evidence-based. Or acceptance and commitment therapy—there’s some good substance use disorder treatment literature looking at that now. Motivational interviewing is another term. Family therapy—if they incorporate the family as part of the treatment, particularly for adolescent substance use disorders because the most well-intentioned parent—if they’re not getting the same information as the child, they can start accidentally reinforcing some of the undesirable behaviors if they’re not involved in treatment as well. So, I would totally agree with Dr. Hadland and what he said. But also, there are some key terms of evidence-based treatments that you can look for—and then calling them up and asking them, like, what does a day in treatment look like, or, what does a session look like? What kind of things do you incorporate into treatment—and looking for some of those evidence-based treatments.
RICK WEISS: Great. Deepa, anything to add there?
DEEPA CAMENGA: I agree with that as well, completely. And if your child—if a child has a—which we didn’t discuss. Many of the children have both a mental health disorder and a substance use disorder—many. We call that dual diagnosis. So, if your child or your teen is in that situation, it’s important that you have people who are trained in psychiatry, psychology, formally trained to diagnose and treat the mental health issues that co-occur with substance use disorders as well.
Is there evidence that the mode of cannabis consumption or frequency of use during adolescence can affect potential harms?
RICK WEISS: Lindsay, a question for you. In terms of the potential harms for teens from cannabis use, does mode of consumption matter—for example, smoking versus vaping versus edibles? And does more frequent use during adolescence equal greater harm?
LINDSAY SQUEGLIA: This is such a great question, and it gets at the fact that quantifying cannabis use is really, really hard for us. It’s very different than alcohol. So, alcohol—we can say, oh, you drank this product. We know exactly what percent ABV it is. You had X number over a period of time. We can figure out their blood alcohol content. With cannabis, it is so hard because even if they’re getting it from a dispensary that says it’s x-percent THC and x-percent CBD, it’s often not accurate, like, even from dispensaries. So, it is really, really, really hard to quantify cannabis at that level. And we have so many restrictions on research, cannabis-related research, because it’s still not federally legal. So, it’s so hard to do a lot of the research. There are several teams in Colorado where they actually—to get around this because you can’t give someone cannabis legally and get federal dollars—that you can’t get cannabis products that they would actually use, right? So, there is NIDA-available cannabis products that are, like, still 5%, 7% THC. So, what they do is they have a van that they go around to people’s homes. They ask the person to go inside, use cannabis how they normally would, come out to the van, and then they do cognitive testing or other kind of, like, behavioral testing with them to try to get around that. And so—but that’s with adults still. So, with adolescents, it’s really, really difficult to quantify, to understand exactly, like, the potency levels and how that’s affecting them.
What is one key take-home message for reporters covering substance use and misuse among U.S. teens?
RICK WEISS: Well, that’s unfortunate. If we are looking for evidence-based solutions to this problem, it sounds like it’s pretty hard to get the evidence. I know this has been an issue for a long time in this community, so perhaps we’ll see some progress there. I know that we’re getting close to the top of the hour. I know that Scott, in particular, you’ve got a hard stop. You’ve got patients to see. So, I want to take these last couple of minutes to just ask each of you for a little take-home message. If there’s one thing you want reporters to walk away with today, something they might want to quote or just focus their stories around, I’m going to go around and do that. Before I do that, I just want to remind reporters who are on the line, as you leave at the end of the briefing, you will see a very brief survey pop up. It takes about 30 seconds to answer it, but it gives a lot more value than 30 seconds’ worth to us as we decide how to run these briefings and keep them helpful to you. So, please take that extra half-minute as you leave to fill out that survey. But let me just go around and give each of our speakers an opportunity to say one thing, you know, that you really want to make sure that reporters get as we close out this briefing today. And I’ll start with you, Lindsay.
LINDSAY SQUEGLIA: Yeah. Something that I always like to remind parents is that most kids who use cannabis or alcohol or even e-cigarettes, they don’t go on to develop problematic use, which is a good thing, right? But there are a subsample of kids who do end up using problematically. And cannabis can be addictive. I think a lot of people consider cannabis as something that—you know, that’s not a drug that you can get addicted to. But there is—there are cannabis use disorders. And there are kids who really struggle with cannabis use. Most kids don’t, but there are some kids that do. So, it’s important to have really good evidence-based treatments for those kids who are struggling with cannabis and other substance use disorders.
RICK WEISS: Great. Thank you. Scott, I’m going to go to you second in case you need to actually drop off in our last minute. But go ahead.
SCOTT HADLAND: Yeah. This is a little bit in the weeds, but I want to go back to this idea of prevention. You know, we are still very reactive in our approach to the overdose crisis. We are really focused on things that are important—treatment, harm reduction, trying to get the drugs off the streets. But the real solution to getting out of this is going to be for us to take a 10- to 20- to 30-year view of the horizon and think about how do we protect the kids who are being born today from struggling with addiction and having an overdose down the road? And this is really close to me right now because I recently had a patient die, and it struck me that this patient died during the opioid overdose crisis. They died during a time when we knew overdose deaths were rising, and their entire life was played out against the backdrop of this now two-decades-long crisis. And we need to look ahead at the long view here if we’re going to solve this.
RICK WEISS: Sobering summary. Thank you. And Deepa.
DEEPA CAMENGA: I think one thing is really helping to report on and educate the public about what addiction is. It is a brain disease. It is treatable, and it’s preventable. And people—working with patients and families, there’s a—there’s not a lot of knowledge as to how to know if one is developing an addiction, the signs and symptoms—early signs and symptoms that might indicate that your child or you might be struggling or on your way to developing an addiction and just, you know, providing that education. It’s a brain disease. It’s treatable. It’s preventable as well. I think just continuing to do that would be very helpful.
RICK WEISS: Fantastic. I want to thank our three expert guests today for really incredibly clear and concise and really useful information today in today’s briefing. Thanks to all the reporters who joined us today. Please check out our Twitter feed at @RealSciLine. Check out our website at sciline.org. And stay tuned for our next media briefing coming up. Thanks, everybody. Really appreciate all your time and work today. So, long.