Youth, fentanyl, and the urgency of honest conversations

In the final episode of The Killing Drugs, host Vanda Felbab-Brown speaks with Dr. Lisa Durette and Dr. Alexis Kennedy of the University of Nevada, Las Vegas, about the impact of the fentanyl and opioid epidemics on young people. They explore risk factors leading to substance use disorders among the young, including developmental vulnerabilities, the social environment, and trauma and abuse. They discuss the challenges in identifying opioid use in adolescents, how to have conversations with young people about drugs, and the importance of community and family involvement in prevention. Finally, they explore treatment and other drug support services available to young people or their lack of, including in the juvenile justice system. 

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[music]

FELBAB-BROWN: I am Vanda Felbab-Brown, a senior fellow at the Brookings Institution, and this is The Killing Drugs. With more than 100,000 Americans dying of drug overdoses each year, the fentanyl crisis in North America, already the most lethal drug epidemic ever in history, remains one of the most significant and critical challenges we face as a nation. In this podcast and its related project, I am collaborating with leading experts on this devastating public health and national security crisis to find policies that can save lives in the U.S. and around the world.

Today, I am on the campus of the University of Nevada, Las Vegas. With Nevada experiencing also a devastating number of opioid overdoses, this crisis here has become a focal point of both research and frontline intervention. As part of the Brookings Mountain West Partnership between UNLV and the Brookings Institution, I am speaking with experts who are directly confronting the issue.

Joining me today are Doctor Lisa Durette, associate professor, Child and Adolescent Psychiatry Fellowship Program director, and chair of the Department of Psychiatry and Behavioral Health at the Kirk Kerkorian School of Medicine, and also Doctor Alexis Kennedy, professor in the criminal Justice Department at the University of Nevada, Las Vegas.

Lisa, thank you so much for joining me today.

DURETTE: Thank you for having me.

FELBAB-BROWN: And, Alexis, it’s great to have you on the show as well.

KENNEDY: Oh, it’s exciting to be able to talk about this.

FELBAB-BROWN: So, Lisa, on the show we explored various dimensions of drug use, opioid use disorders and policies to respond to them. And today on the show, with you and Alexis, we’ll be talking about young people and drugs, young people and opioids. Can you please speak to us about this? Teenage years are often the age when young people start experimenting with drugs. What are the primary risk factors that make teens and young adults particularly vulnerable to developing an opioid use disorder?

[2:17]

DURETTE: Well, I think that a lot of the risk factors that lead to the development of an opioid use disorder, which from a prevalence rate that we can measure is relatively low, although deadly if it happens, are the same risk factors that pertain to any substance of abuse.

So, you have this two-fold issue that’s happening in adolescents. First of all, in social-emotional development, adolescents are going to identify more with their peers than to their parents or other adults. And they are moving towards autonomy and trying to figure out their identity and figure out themselves. And so, depending on their peers that are surrounding them, various sociodemographic factors like the neighborhood that they’re growing up in, the school environment, are they even in school—all of those social and emotional factors can tie into the potential development of a substance use disorder.

But then we can get to the micro level about the neuroanatomy. And if we think about the way a brain develops, our prefrontal cortex, that part that helps separate us from other primates in the world, the part of our brain that deals with planning, impulse inhibition, thinking through complex problem solving, that’s one of the last parts to develop. And so, you have this adolescent who cognitively can identify ways to think through problems beyond concrete black-and-white thinking. They can have abstract thinking. So, on the surface, they might seem to have some adult-like thinking processes, that part of their brain that serves as the impulse mediator, almost that sense of brakes, is not yet well developed.

And at this early age of brain development, should the adolescent be exposed to substances of any type, because the brain is still in that developmental phase, they’re even more sensitive to or susceptible to the negative or deleterious effects of the drugs, which can then lead to further problems including substance use disorders.

FELBAB-BROWN: So, if I’m understanding correctly what you’re saying, Lisa, is that this age the addictiveness of the drugs is even greater than what would be the case with adults that have fully developed prefrontal cortex.

DURETTE: That would be correct, yes.

FELBAB-BROWN: And am I right that, it’s around the age of 30 when it’s the full development of the prefrontal cortex?

DURETTE: Closer to 23 to 26.

FELBAB-BROWN: Okay, well, that’s better for for many of us, including, of course, for dealing with opioid use disorder.

DURETTE: Yes.

FELBAB-BROWN: And, Lisa, so you started talking about why the early age is, the teenage age is particularly, vulnerable. Can you tell us about whether the risk factors in the case of opioids, fentanyl, are in any way different than in the case of all drugs. Is simply the age kind of the issue here or is there something specific to fentanyl, to synthetic opioids that makes it different than vulnerabilities related to developing a cocaine habit or meth habit?

[5:20]

DURETTE: So, you ask a really great question, Vanda. And I don’t have a direct way to answer that, but I can talk around other data that we have from national surveys. So, there are three national surveys conducted by the centers for Disease Control by the federal government through SAMHSA [Substance Abuse and Mental Health Services Administration]. And these surveys help us identify prevalence rates, the frequency of substance use in adolescents, patterns between occasional use and chronic use. And they’re administered to kids, typically in high school settings. So, our understanding of the frequency of use of any of the substances of abuse are derived from these national surveys that are happening in schools. Thus, a fallacy is oftentimes those adolescents that are engaged in heavy substance use might not be attending school.

So, at baseline we know that our data are flawed. But if you look at trends in the data, opioid use disorder is relatively low. So, if you think about high school students, the overall prevalence is estimated to be around 1 to 2%—very, very low. But of those who initiate heroin use within a period of high school, over 30% go on to have an opioid use disorder.

Let’s talk about the difference between a use disorder and using, which are two different things. So, you might go out and have a glass of wine tonight. That doesn’t mean that you have an alcohol use disorder. And so, the DSM, the Diagnostic and Statistic[al] Manual, really helps define what a use disorder is. And there are specific criteria for specific drugs, typically including things like escalating use over the course of time, engaging in behaviors that might violate the rules and regulations of society in order to get that substance, might include elements about withdrawal, and other physiologic signs of dependance. And all of the criteria entail having significant dysfunction in one’s life, be it at home, school, job, etcetera.

So, again, you can have a glass of wine, but you’re not going to have those criteria. To meet the criteria for an alcohol use disorder, you might be stealing from a store, you might get DUIs, you might have a disrupted marriage because your alcohol use got out of control.

So, now let’s extrapolate that model to an adolescent with an opioid use disorder. And you can really start to think about how difficult is it going to be to find those adolescents and to really get an honest, accurate prevalence rate? So, you know, you’re asking about risk factors that are specific to opioid use disorder. I can’t answer that so much. But we do know that some of the more high-risk risk factors, so to speak, would be working with youth who are unsheltered, who are psychiatrically ill, psychiatrically hospitalized, those in juvenile detention, which I imagine Doctor Kennedy is going to speak about, as well as those in foster care. And so, those youth have much higher risk factors for any substance use. We know that those who start with heroin or other opioids have a strong likelihood, 1 in 3, of going on to having a use disorder versus a one-time use. But we don’t have good numbers on the overall problem.

FELBAB-BROWN: This is very significant what you’re saying. So, you know, 1 in 3 developing substance use disorder from initiation, it’s a very significant number for heroin. And of course, what is so challenging about the drug market today is that it may very well be that the first substance that a young person comes in contact with, or for that matter adult, is actually fentanyl. And the DEA campaign “one pill can kill” is not an exaggeration given the enormous lethality of synthetic opioids.

We will speak certainly with Alexis about the criminal justice system, but I just want to follow up on one thing you said and to ask you specifically, what are some of the warning signs that a young person may be struggling with opioid use disorder? How would parents, educators, or peers recognize those signs?

[9:28]

DURETTE: So, looking for signs of any substance use disorder really starts by tuning into the adolescent in your life and being alert to any behavioral change. So, this behavioral change could be indicative of depression. It could be indicative of substance use. A myriad other mental health things. But things you’d look for as a change such as increased moodiness, secretive behavior, hiding things, becoming more secretive about looking on one’s cell phone or hiding information from parents, family. Getting into fights, especially for somebody that has not gotten into fights previously. Having a change in their friend group, a new friend group, or even suspicion of gang affiliation—that could be a sign of distress.

Specific to school you want to look at somebody’s grades. At least you have some quasi-objective performance data to see how they’re doing. Somebody who’s either becoming truant, skipping class, cutting class, all of those. And then arguments with authority figures, be it teachers, teachers’ aides, administrators within the school, those would all be red flags.

And then finally at home, if you have a parent, a grandparent, or any relative who is prescribed medication for a pain syndrome all of a sudden having missing pills, that could be a big risk factor, a sign. Money that’s gone missing. Somebody is going into the parent’s wallet and taking money. Smells: smells of drugs or smells of unusual substances that the parents aren’t used to. And then, of course, finding drug paraphernalia.

And I think back to my practice, I’ve had at least two or three situations of parents coming in saying, I found this pipe, or I suddenly found pieces of foil that didn’t make sense in my child’s room. What do you think it is? And I would say to the parent, what do you think it is? And I would be surprised by how reluctant the parent was to face and acknowledge that perhaps it could be substances that are being abused.

We have to be aware it is everywhere. Fentanyl and the synthetic opiates are being adulterated into some of the other drugs of abuse that we’re getting on the streets. We’ve had patients just within this past week over at the hospital that we’ve seen  who believed that they were using methamphetamine, had come in for methamphetamine intoxication, and yet their drug screens are coming up positive for fentanyl. Why? Because it’s everywhere. And beyond “one pill can kill,” things that you buy on the street can be laced. And parents need to be alert and aware to this because it’s everywhere in their kids have access.

FELBAB-BROWN: Absolutely. The mixing of drugs and synthetic opioids into literally everything these days is one of the enormous challenges of trying to reverse both substance use disorder and particularly overdose. So, those warning signs, Lisa, that you outlined are terrifically useful. And I think many of our parents, listeners, will appreciate it being able to hear this advice, including your initial point that not all use is disorder, not all use will lead to disorder. But being mindful of the risk factors.

So, you know, Alexis, Lisa already mentioned that a lot of the issues you look at are young people in the juvenile criminal system, perhaps with substance use disorder, perhaps not. How effective are we at screening for drug use among risk at youth broadly?

[12:49]

KENNEDY: I don’t think we’re very effective because we’re not really good at talking about drugs. Even people who work in juvenile justice and foster care, they wouldn’t necessarily know what a foil packet means. Or, what it means to find an empty blister pack of stuff that’s not been prescribed to a kid. Because we just, unlike other countries, we don’t have a lot of public service announcement. We don’t have a lot of honest conversation about it. And it’s kind of similar to our sex education. We’re afraid that if we talk about it, it means that we’re promoting it. And that’s absolutely not true.

So, when a kid gets in a fight at school, the first question isn’t are you also using drugs? It’s what happened? If a kid changes their friend group, parents will ask you a couple of questions about what happened, but not, you know, are you using drugs? Are they using drugs? Because it’s a difficult conversation to have. So, by not asking it we’re leaving the kids to figure it out on their own. And they’re figuring it out through social media and through a lot of misinformation. So, that lack of information isn’t protecting us, it’s harming us.

FELBAB-BROWN: And Lisa and Alexis, could I ask you for a little bit of role play? So, say that, you know, Lisa, you’re the mother having just found a foil in Alexis’s room. How would a good conversation go that would help diagnose problems and that would not just scare off the child or drive the child to denial?

[14:03]

DURETTE: Well, this is an interesting one. I think it would all come down to the relationship that the parent has with the child. But let’s pretend we have a good relationship. I might come in and say, you know, I was cleaning up the house and I found this. What can you tell me about this?

KENNEDY: I can’t believe you’re in my room. And that’s my friend’s. It has nothing to do with me. I was just holding it for her.

DURETTE: You know, I appreciate that you were holding that for your friend. When’s the last time you think your friend got high with stuff?

KENNEDY: I think most kids would stop and say, mom, I don’t want to talk about this. So, we’d have to push through and say, I don’t know, I’m not paying attention to them. Occasionally, it’s no big deal.

DURETTE: Yeah, I hear you, that’s no big deal. And I’m really worried about you. When’s the last time you got high?

KENNEDY: Uh, mom, you know, it was a while ago and I said I wasn’t going to do it again, and I won’t.

DURETTE: So, if we went into the drug test together, what would it show?

KENNEDY: I can’t believe you don’t trust me. I can’t believe we’re having this conversation.

FELBAB-BROWN: Well, thank you. And all this was great. And I, you know, again, I think that many of our parent listeners will appreciate the challenge, but also the indication that you have given in this little role play. So, thank you both very much. And obviously the goal is to be able to establish a trust relationship, I would imagine, Lisa and Alexis, including to be able to have a more honest conversation. No?

[15:22]

DURETTE: Not just establishing a trust relationship, but like Alexis said, setting expectations, the language, the shared understanding from an early phase. And other parents might skewer me for saying this, but if we look at an overall harm reduction model, being able to say to a child, you know what? I imagine at some point you might get drunk; you might get high. Because again, if we look at some of this national prevalence data amongst our 12th graders, at least 40% have tried marijuana or alcohol at least once. So, we accept that close to half have used something. And if I go in with the I would expect it’s probably happened, let’s talk about it. That might help decrease some of the stigma and the defensiveness that could come across in the conversation.

[16:09]

KENNEDY: And also, to not give up the conversation when the child pushes back. Because they’re going to do it, even when they want to talk about it and disclose, they’re embarrassed, they’re ashamed, they don’t want to admit they’ve gotten in over their head. So, it requires that discomfort of continuing and pushing them. And sometimes it’s good to come at it slightly sideways by saying, well, I know your friend, or I heard about a case of a kid at another school. And keeping them in the conversation even if they’re not participating in that moment, keeping it going, because they may come back a few hours later and say, actually, mom, I want to talk about this, or mom, I’m worried about my friend. And then the next day might be, actually, I did that too.

So, we have to keep being persistent and obnoxious because they’re going to start with a defensive position. So, we have to let them know we’re still here.

FELBAB-BROWN: Okay. Terrific. Persistency, trust, being willing to push, being willing to have the uncomfortable conversation, but also trying to reduce the stigma so that diagnoses and establishment of how worrisome or not the case is are important. And, you know, Alexis, this is just a good lead to why are young people reluctant to disclose drug use, opioid use?

KENNEDY: Well, they don’t want to get in trouble first and foremost because they feel like they’re trying to fit all these rules, and the rules keep changing. And even when kids have been in trouble for fighting or get arrested for graffiti or something else like that, no one’s asking them the extra questions or about the drug use. And if they do disclose the drug use, then they’re doubly in trouble. So, once you’ve been labeled as someone who has a drug problem, it changes the trust. It changes the conversation. It changes the way people look at them. So, they’re afraid to admit it. And if we’re not asking and following up with asking and making it a safe environment for them to disclose, they’re going to keep it to themselves so they don’t get further in trouble.

FELBAB-BROWN: So, being able to overcome the fear and, as you mentioned, establish the safe environment with at least some adults in their lives. And I would probably say perhaps also some peers in their lives. But, but certainly for young people, adults as well. So, how closely linked is drug use, Alexis, to delinquent behavior among the young?

[18:20]

KENNEDY: Well, when we look at the kids who have been arrested for various reasons that are in the delinquency system, the research shows, national research, that 84% of them are disclosing that they’ve used illegal drugs, 84% for, like, the national overview. When you look at subpopulations, like if I’m looking at trafficked children who’ve got a really robust history of abuse, their rates are even higher. They’re over in the 90%.

And it kind of makes sense. When you’re living outside of the normal path of high school or if you’re getting into trouble or you’re just trying to escape your everyday problems, turning to drugs to sort of change your state makes a lot of sense. That’s part of the adolescent experimentation, trying new things, trying to differentiate themselves from their family and their parents. And it’s the age without that prefrontal cortex where they’re going to try things and think, it’s not going to be bad for me, I’ll be fine with this.

FELBAB-BROWN: So, by the time young people end up in the juvenile justice system, arguably our society has already failed to notice some of the warning signs. And that might not be the case with everyone, but certainly at least some people that would be the case. But Alexis, can you walk us through what happens after a young person enters the juvenile justice system? What kind of treatment, care, support, or the absence of them do they receive?

[19:38]

KENNEDY: It’s interesting because they’re not consistent in screening for drug use. So, if a kid is brought in for a different crime and they’re sort of doing the intake interview trying to figure out their needs, they’re not necessarily going to ask also, are you using drugs on top of that? So, the kids, you know, they’re already in trouble, so they don’t want to disclose even more things. But we’re missing that opportunity to really screen and do intervention. So, if they have a history of running away, they may be monitored for running away. But that doesn’t mean they’re getting the treatment that they need for other issues that are going on.

So, we need to have a more holistic evaluation and approach to help people, because running away, and drug use, and truancy, and shoplifting, they’re all signs of underlying frustration, anxiety, trauma to being disconnected. And if we try and only fix one thing at a time or address one thing at a time, we’re not going to be dealing with the sort of reasons behind what’s going on.

FELBAB-BROWN: So, would it be a good idea, Alexis, to have mandatory drug testing—I’m thinking urine test, for example, or other blood tests—in the juvenile justice system?

[20:41]

KENNEDY: It would if there are services available to deal with the treatment. The other problem about disclosing treatment is that often a lot of jurisdictions don’t have drug treatment programs that are in-state. So, in Nevada, we have a history of sending our kids with drug addiction problems out of state. So, now they’re not just in trouble and being pulled out of school and being pulled out of their family, they’re being sent somewhere completely different to deal with drug issues, which may be only the symptom of the underlying disconnect and family disruption and family dysfunction, or potentially a history of abuse. So, you can’t just treat the drug addiction without treating everything else. And pulling kids out of their community and sending them away is not the most healing way to approach that issue.

FELBAB-BROWN: Absolutely. So, screening is important, but it needs to be matched with effective treatment, otherwise it might actually end up doing more harm. The issues you mentioned, Alexis, trauma, abuse, are of course a part of the larger picture of mental health. Lisa, please tell us how does mental health intersect with opioid use in young people?

[21:44]

DURETTE: Even before going to that, I do want to follow up on one of the comments you made about the out-of-state. You know, if we look at best practice standards, we have something called an Olmsted Law, which really helps frame the fact that treatment should happen in the least restrictive environment possible and should be as close to your home base as possible. And so, the concept of ripping somebody out of their familiar environment and sending them out of state is the antithesis to good care.

And when we look at treatment, which we might be getting to later, but this just made me think about it, one of the most robust evidence-based treatment models is multidimensional family therapy for treating youth with substance use disorder. And so, the idea of removing from the family system and placing somebody in a distant location takes away one of your most evidence-based effective treatment options. And it’s not just in Nevada. Other states have the same issue. We are doing such a disservice to our kids.

FELBAB-BROWN: Just to follow up on that, would it also apply then that there is evidence that treatment in the family as opposed to residential treatment, outpatient treatment, is more effective, more beneficial than in-residence treatment? Or do we not have information on this kind?

[22:57]

DURETTE: There’s not great long-term data. So, if we look at all of the data that we currently have, we know that if you’re going to select a residential treatment, having family involvement improves the success and the long duration improves a success.

There’s so many factors that work against that. We talked about the distance. Simple things like who’s going to pay for a long duration of a residential treatment? Insurers typically try and pay for things in the smallest packet possible. And yet the evidence shows the longer duration of treatment is more effective. Outpatient treatment alone may not be effective, but there’s intermediate levels of care.

So, you have outpatient over here, you have inpatient over here. But in between there’s intensive outpatient, which is a few hours, a few days a week, versus a partial hospitalization program, which might be going into treatment for the duration of a school day, five days a week. And then you go home at night to practice the skills that you learned in treatment. So, there’s lots of opportunities for treatment that don’t have to just fall into those two opposite models of inpatient versus outpatient.

KENNEDY: The other thing is you mentioned, who’s paying for it. If this kid is being sent to treatment through delinquency or through child welfare, they have limited budgets. So, part of our solutions are very much tied to who is the pushing force to move the kid from one system into a treatment system.

FELBAB-BROWN: Yeah. And absolutely, across the show we just heard so much about the fundamental importance of insurance to be able to cover treatment, mental health, substance use disorder treatment so that people can have better care in the absence or inadequate insurance rate, limitations to Medicaid being some of the core obstacles to getting more people into treatment, adult or young, at the time of the most lethal drug epidemic.

Alexis, you mentioned at one point people, young people, with trauma, victims of sexual abuse, or victims of human trafficking. I would imagine that drug use is a particularly a strong challenge among those type of victims. What can you tell us about that?

[25:04]

KENNEDY: Well, when you’re coming from any history of abuse or trauma and you don’t feel good about yourself and you don’t know how to get out of that situation, taking drugs reduces that pain. It reduces the emotional pain. It reduces the psychological pain. So, it’s actually very logical to turn to drugs to get through your day, to try and forget about what your life used to be like as opposed to where it is now. So, there’s a really logical nexus to drug use and surviving through commercial exploitation.

So, I definitely see that when I go into delinquency and compare the girls who are trading sex to survive compared to their peers who may have just been in for graffiti or delinquency or something else. The girls that have been pulled into the world of prostitution have much higher drug use rates, and they also start at a younger age. And starting at age 12 with heroin, it’s probably something to do with maybe family disruption or the abuse that they experienced. It’s actually kind of logical to take drugs to try and dull that pain.

FELBAB-BROWN: That would also be mentioned that many times that it is the traffickers that give them drugs in the first place.

KENNEDY: It does happen. But it’s also that they’re partying with older people. They’re in a room with a man who’s going to do cocaine before he pays her. So, they’re doing very grownup things in their youth bodies and surrounded by people who are being very, you know, cavalier and free with the drugs.

FELBAB-BROWN: Well, it’s just horrific situations to hear about. What kind of mental health support do young people in these circumstances get and especially if they are in the juvenile justice system? Alexis, maybe I’ll start with you.

[26:41]

KENNEDY: I wish I had better news. We are really struggling with trying to manage and contain youth, but we haven’t really gotten down to understand what the complexity of their issues are and how much help they actually need. And it’s not just the youth, but it’s also the family. You know, if we release them back to the family, a lot of times kids will not disclose their drug use because they’re afraid of getting their parents in trouble. If they got it from home, they’ve been warned by their parents don’t tell anyone that, you know, I’ve got meth in my cupboard or that we’ve got these drugs here because they’re being threatened that they’ll split up the family or that their younger siblings will suffer. So, there’s a lot of reasons to keep it secret.

And so, we have to address the entire family situation as well as all of the sort of complex issues of healing from trauma as well as healing from being in the delinquency system and labeled delinquent as well as, you know, healing the family. So, it’s a complex situation that we really haven’t got a grasp on in terms of providing services.

FELBAB-BROWN: Lisa, anything you would like to add? Mental health support, treatment in the criminal justice system?

[27:45]

DURETTE: Criminal justice system and even just in the general environment of children’s mental health, we know that adolescents who have substance use disorders almost universally have some other psychiatric or mental health comorbidity, trauma being a huge one. But other things to consider are attention deficit hyperactivity disorder. And we know that untreated ADHD is a risk factor because I already spoke about at baseline the impulsivity of an adolescent in a normal sense. But now let’s say you have attention deficit hyperactivity disorder where you have even more impulsivity, and it’s gone untreated, and you have opportunities. That’s just a set-up for the potential for substance use disorder. Not that all kids with ADHD would develop a substance use disorder, but those two factors together could predispose you.

Talking about things are so miserable with respect to trauma, I might end up using drugs—that’s also not very different from somebody, let’s say, with severe major depressive disorder, the same sort of thing. Somebody perhaps with bipolar disorder who in a manic phase of doing things to excess, having too much energy, may turn towards drugs, A, through the lens of impulsivity, but then, B, through that excess drive that they’re actively having.

Somebody with a psychotic disorder. I mean, we could talk about the chicken-egg of chronic use of cannabis might predispose you towards psychotic disorders, psychosis, schizophrenia, and at the same time having a psychotic disorder that’s untreated might predispose you towards substance use.

And so, when we think about screening in the juvenile justice population, the foster care population, but really amongst any adolescents, I would advocate as somebody who teaches childhood and adolescent psychiatry that we need to, as clinicians, learn to universally screen, to get comfortable having the conversation, to ask the questions, and then know what to do next. We know in some of our systems, we don’t have a lot of great options for what to do next. But we need to at least equip ourselves with knowing the bare minimum of what we could have at our fingertips.

FELBAB-BROWN: Lisa, let me stay with you. What about prevention? So, the 1980s programs like “Just Say No to Drugs” are widely discredited. And that has almost led to a predisposition that prevention just doesn’t work and that we should not be bothered with prevention. What’s your take on that? What are some of the most effective preventative measures that can be taken at the community level, in school, with parents, or by parents?

[30:21]

DURETTE: I think the paradigm around prevention needs to shift from, like you said, the dare to stay off drugs, say no to drugs to looking at education, awareness, and access to potential treatment throughout the lifespan. So, you might say, like, why do you think somebody in elementary school needs to go through substance use prevention? Maybe that’s not what it is. Thinking about all of those factors that could lead somebody to down the road of substance use in the elementary age, we could teach about social-emotional learning, conflict management, how to mediate conflict amongst peers, how to build a self-esteem, how to develop activities within oneself, hobbies, sports, self-competency. Because if those factors are in place, you’re later in life are going to be less apt to engage in substance use.

And then as kids move up the age ladder, taking it from the baseline of social-emotional learning to education awareness about the potential effects of drugs, how to have difficult conversations with one’s peer, because peer-to-peer confrontation might be a lot more effective than a strange adult coming in.

And strengthening those internal resources within kids and families. There’s a really great resource, it’s through the Discovery Channel and the DEA— OperationPrevention.com—and they have fantastic free resources, be it videos, curricula, etcetera that teachers, schools, families can avail themselves of that address this different paradigm around prevention that can be used.

FELBAB-BROWN: Thank you very much for pointing us toward that resource. And, Alexis, finally, in conclusion, what are some of the best approaches to keep young people out of the juvenile correction systems for issues related to substance use?

[32:12]

KENNEDY: I just think we have to take our head out of the sand and just pay attention to kids more. I mean, we’ve got so much research coming out on how much their anxiety has gone up since the pandemic. And they may think that marijuana reduces anxiety when actually it can exacerbate it. But we don’t talk about it because we think talking about it is promoting it.

We need more research on how it’s affecting people. Obviously, we can’t run research on the teenage brain, but we need to be honest about the fact that the teenage brain is different than the adult brain. And parents need to understand and teach themselves about it, and they have to be ready to have some uncomfortable conversations.

And most importantly, is to not take it personally when a child lies to you the first time you ask them about it to be persistent and to recognize that their health is more important than you being a buddy in that moment, and that they’re going to lie out of a defense mechanism. And we need to move past that and keep asking the question.

FELBAB-BROWN: Well, thank you so much, Alexis and Lisa, for, guiding us through the tough conversations that we need to have, and for the great little demo that you did about how to talk to young people about drug use. And thank you also very much for your research and your clinical work, which is so important.

[music]

DURETTE: Thank you for having us.

FELBAB-BROWN: The Killing Drugs has been a production of the Brookings Podcast Network. This is the final episode of season one. Many thanks to all my guests for sharing their time and expertise on this podcast and in this project.

Also, thanks to the team at Brookings who makes this podcast possible, including Kuwilileni Hauwanga, supervising producer; Fred Dews, producer; Gastón Reboredo, audio engineer; Daniel Morales, video editor; and Diana Paz Garcia, senior research assistant in the Strobe Talbott Center for Security, Strategy, and Technology; Natalie Britton, director of operations for the Talbott Center; and the promotions teams in the Office of Communications and the Foreign Policy program at Brookings. Katie Merris designed the compelling logo.

You can find episodes of The Killing Drugs wherever you like to get your podcasts and learn more about the show on our website at Brookings dot edu slash Killing Drugs. 

I am Vanda Felbab-Brown. Thank you for listening.