by Maia Szalavitz, author of "Undoing Drugs: How Harm Reduction is Changing the Future of Addiciton"
NY Times, November 9, 2022
I am sharing this article widely, since it is on so many parents' minds. Fentanyl is so widely available and appears to be in so many different drugs used for recreation that it is imperative we discuss this dangerous (and terrifying) drug with our children.
In September, two 15-year-old Los Angeles girls overdosed on fentanyl, one of them fatally, after they purchased what they thought were prescription opioid pills. Although most overdose deaths occur among adults, teenage opioid fatalities have doubled in recent years, even as opioid use among adolescents has plummeted.
In the age of fentanyl and other illegally manufactured synthetics, the danger associated with trying drugs is greater than ever. If these girls had each swallowed a single Percocet - what they thought they were buying - even the highest-dose pill is unlikely to have been fatal. Street fentanyl and its derivatives, however, can be dozens to thousands of times stronger than the oxycodone in Percocet. Street synthetics are typically found in drugs sold as heroin or prescription pills, but they are sometimes present in party drugs like cocaine. This has exponentially increased the risk of even one or two youthful experiments.
But in a country where teenagers are bombarded with exaggerated scare stories about all types of substances - fentanyl very much included - how can drug prevention programs cut through the noise to get their attention? Two key themes emerge in effective approaches. One is that reaching adolescents requires earning their trust by being truthful, rather than simply trying to instill fear. The second is that school-based programs must recognize that not all drug use can be prevented. Instead of focusing only on abstinence, they aim to prevent the highest-risk behaviors and address the personal and environmental factors most likely to lead to addiction.
Some argue that teaching anything beyond "Just say no" condones drug use and that sharing ways to reduce risk only encourages teenagers to get high. But as with the debate over sex education, there is little evidence that providing accurate information in an appropriate context increases problematic behavior. Given the toxicity of the drug supply, we must protect young lives by targeting the factors that cause the most harm. Popular 20th century drug programs - like DARE and Just Say No - tried to frighten teenagers away from illegal drugs with exaggerated horror stories, despite research showing that fear tactics are ineffective in changing adolescent behavior.
Today there is greater recognition of the need for accuracy over hype. New videos and radio spots from the Ad Council, which has been making public service announcements for the government and nonprofits since the 1940s, confront the dangers new reality directly. They feature former drug dealers - not cops- speaking plainly about fentanyl. They also provide information on how to reverse overdoses with the opioid antidote, naloxone. "It goes back to making them aware of the real risks and challenging any sorts of beliefs they have that are not true," said Rhana Hashemi, who has helped pilot an evidence-based program called Safety First in the San Francisco Bay Area. She says teenagers are more likely to listen when they recognize they are given accurate information about genuine dangers.
Young people need to know, for example, that pills sold as prescription drugs are often counterfeit and of unknow dose and purity. In this sense, rainbow fentanyl might actually be less risky, because much of it looks like legitimate medication. Ms. Hashemi said that she always stresses that abstinence is the safest option and that in reality, most teenagers abstain from illegal drugs. (Many earlier programs erred by inadvertently reinforcing the idea that everyone is doing it and were associated with increased drug use in some studies.) But she also provides information on harm reduction. This can include using tests that can detect fentanyl before taking any pill or powder not prescribed by a doctor, never using alone and having naloxone nearby.
When Ms. Hashemi presents this approach, she said, a common response is for students to recognize how serious the danger is and decide in that light of the effort needed to reduce risk, using isn't worth it right now. For those who aren't deterred, however, the hope is they are armed with ways to protect themselves. These outlying teenagers are the group at highest risk of experimentation and addiction. Protecting them requires understanding why they seek drugs to begin with and offering alternative ways to meet their psychological and social needs.
Research suggests that those at greatest risk for addiction often have outlying temperaments that can be visible as early as preschool - extreme recklessness, for example, or severe anxiety. These differences may reflect a predisposition toward mental illness, which raises addiction risk. Another risk factor for addiction is the experience of childhood trauma, particularly early repeated trauma, neglect and loss. In 2016, I wrote about a program called PreVenture, which targets problematic coping strategies by teaching children better ways to manage their particular temperaments. By acting early, the program aims to prevent predisposition from becoming disorders and obviate the desire to use drugs to self-medicate. Programs like PreVenture that teach self-regulation and coping skills have been shown to have lasting effects, unlike those that focus only on refusing drugs.
"The target is to delay onset and reduce experimentation, as well as reduce heavy, frequent use," said Patricia Conrod, a professor of psychiatry and addiction at the University of Montreal who developed PreVenture. It is a school-based program that uses a personality test to direct kids toward personally relevant workshops but does not label them; the teenagers are simply invited to participate in seminars that teach ways to optimize their unique temperaments. For example, adolescents who frequently report higher levels of hopelessness, are more likely to use drugs to lift their moods, even if they don't have diagnosable depression. PreVenture teaches cognitive behavioral techniques that can help relieve depression, such as learning to recognize that self-perception ("Everyone hates me") is often inaccurate. This can help improve both mood and motivation to withdraw socially or seek escape. Research on PreVenture found that it reduces the risk that teenagers will develop severe symptoms of depression by around 25 percent. It works similarly on other traits and cuts alcohol and other drug use.
In the long term, effective addiction prevention requires social change to prevent or at least intervene early in childhood trauma, creating communities conducive to mental heath with safe, nurturing schools, stimulating extracurricular activities and access to comprehensive health care. But first, we need to keep young people alive, and that means having uncomfortable, honest conversations about the dangers of drugs and the ways to minimize the risk for those who use them.
No one has yet found a way to eliminate youthful risk-taking and impulsiveness - which is probably for the best, because these can also drive learning and creativity. We can, however, reduce the odds that the unwise things kids do will kill them.