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Advancing Addiction Treatment for Youth: Q and A with Addiction Psychiatrist Dr. Marc Fishman

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Marc Fishman, MD, is an addiction psychiatrist and a member of National Council’s Medical Director Institute. He is the Medical Director of Maryland Treatment Centers, a regional behavioral healthcare provider, which offers programs for residential and outpatient treatment of drug-involved and dual-diagnosis adolescents and adults and a faculty member of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.

Your work has focused on youth and adolescents. Why is it important to focus on young people?

Substance use disorders are a pediatric, developmental problem. The occurrence of substance use and problem use peaks in young adulthood. If we understand addictions as an adolescent or pediatric problem, then we can accurately change our approach to research and clinical practice, and most importantly our policy and service delivery. Think of what this country did with HIV in the course of addressing a new devastating epidemic — we changed our focus and resource allocation to mount a massive response on both prevention and treatment. We should be doing that for this problem.

We live in a culture that strongly endorses and markets intoxication – particularly with substances like alcohol and cannabis. This leads to a decrease of the perception of risk or harm among youth, parents, caregivers and the broader population. The medicalization and legalization of cannabis has a huge influence on young people who are most vulnerable to developing a harmful addiction.

I work in Baltimore, which has long been a capital of heroin use. At our center, we have been treating youth with opioid use disorders for a long time. It came as no surprise that they have higher severity than youth using other substances — with lower rates of response to treatment, greater relapse and a less enduring response to treatment, and that is frustrating.

Within an environment of limited specialty providers, what services would you like to see more primary and behavioral health care organizations offer?

It begins with general behavioral health taking on addiction as a part of the mission. Behavioral health providers also ought to think seriously about whether opioid treatment has a place in their system. Maybe adolescent treatment is too sub-specialized for many generalists to take on, but at least adult treatment ought to be on the menu. People with substance use disorders are already in your clinics, so why not? Even if behavioral health providers can’t take on subspecialty treatment themselves, it’s important to develop collegial relations and referral relationships with local providers and be able to coordinate care. Primary care providers can work with specialists, refer patients back and forth and we need to do that better.

We must improve capacity, but there is so much more work to be done.

How do you involve family in treatment and why is that important?

Families may be involved in different ways. They are often confused or unsure of how to proceed. It is important to invite families to be involved from day one. Are they dropping their child off? Invite them inside. Ask them questions about their expectations and what they would like to know about treatment. Empower them to have a plan and think through the what-ifs – like a missed appointment or a missed dose of medication, or a relapse. A parent may be used to hearing “you need to stop enabling,” and in fact what parents hear is “it’s my fault, I have caused this.” We have to be sympathetic to this and engage parents in a meaningful way so they know they can set limits and move forward in a way that is engaging and constructive, rather than dismissive. This kind of communication is compelling and helpful for parents and families.

We prescribe the relapse prevention medications buprenorphine and extended release naltrexone. We have evidence that medications are more effective than no medications and we know from 60 years of research and clinical practice how effective it is for adults. Now, how do we adapt them to developmentally informed ways for youth? We don’t know that one medication is better than the other for youth, but we try to work strategically to learn which may be better for a particular patient at a particular time. In my experience, parents can approach the medication as a concrete aspect of treatment they can help their child manage. We’re researching models to encourage parents to know more and take more responsibilities in collaboration with their child and the treatment team.

What can/should behavioral health providers do to improve continuity of care for young people with addiction?

 Addictions treatment is a marathon, not a sprint. Twenty-eight days of rehab as a one size fit all “cure” does not work without ongoing continuing care. On the other hand, residential treatment is enormously important for some high-severity youth, and there is not enough of it available. That’s not huge news in the adult treatment community, but it’s relatively radical in treatment of youth.

As a co-editor for the American Society of Addiction Medicine’s (ASAM) Criteria I have a special interest in the field’s efforts to develop a treatment matching approach specifically for youth and adolescents.  There is still no clear consensus on models of treatment for youth, especially youth with opioid addiction. We must take what we know about adult treatment models and adapt them to be developmentally friendly for youth, thinking carefully about how to adapt, modify and implement models to sustain effectiveness for youth and their families. It’s important for us to move from a surgical, discrete episodic approach to a longitudinal, continuous, enduring engagement model.

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