Adolescent Vaping: Recognizing Addiction and Understanding ...

Adolescent Vaping: Recognizing Addiction and Understanding ...

Adolescent Vaping: Recognizing Addiction and Understanding Treatment and Referral Protocols in Primary Care December 13, 2019 D R. LU CI E N G O N ZAL E Z , AD O L E S C E N T AD D ICT IO N M E D I C I N E S P E C I A L I S T , U N I V E R S I T Y O F M I N N E S O TA , A N D C H A I R O F T H E A A P C O M M I T T E E O N S U B S TA N C E U S E A N D

PREVENTION D R S . A N N E G R I F F I T H S A N D N A N D I N I K ATA R I A , P E D I AT R I C P U L M O N O L O G I S T S AT C H I L D R E N ' S R E S P I R AT O RY & CRITICAL CARE SPECIALISTS E R I C D I C K , LO B BY I S T F O R T H E M I N N E S O TA C H A P T E R O F T H E A M E R I C A N A C A D E M Y O F P E D I AT R I C S Pediatric Vaping Aerosol Inhalation Lucien Gonzalez MD MS, FAAP

Joint MNAAP and MMA Webinar 13 December 2019 Disclosure Information Joint MNAAP and MMA Webinar Pediatric Vaping 13 December 2019 Lucien Gonzalez MD MS, FAAP

Disclosure of relevant financial relationships: I have no financial relationships or other conflicts of interest to disclose I will be discussing investigational or off-label use of medications or other treatments Objectives As a result of this activity, participants will be able to describe how electronic drug delivery devices work

understand the impact of nicotine on developing brains and bodies name strategies for incorporating vaping questions into substance use screening and brief intervention name major pharmacological and psychotherapeutic interventions for nicotine use disorder identify resources to support cessation Minnesota Student

Survey 2019 https://www.health.state.mn.u s/data/mchs/surveys/mss/sta tewidetables/statetablesbygr ade19.pdf Youve Come A Long Way, Baby 2016

1982 This is a drug delivery device Due to ethical restraints, it is unlikely that there will ever be definitive studies that fully quantify the effects of nicotine on

the developing human brain Nicotine is a cognition chemical Nicotine use disorder risk Transition to/combined use of combustible cigarettes Other substance use risk

Smoking cessation tool Respiratory risk Cardiovascular risk ? Cancer risk ? Altered neurodevelopment ? Please get substance use out of social history

John R. Knight, MD Boston Childrens Hospital, 2018. Reproduced with permission from the Center for Adolescent Substance Use and Addiction Research (CeASAR), Boston Childrens Hospital. www.crafft.org

The 5 As of Smoking Cessation Ask about use Advise to quit Assess readiness to quit Assist in quit plan Arrange follow-up 17. National Advisory Committee on Health and Disability. Guidelines for Smoking Cessation, Revised 2002. Wellington, New Zealand: National Advisory Committee on Health and Disability (National Health Committee); May 2002.

18. US Public Health Service. Treating tobacco use and dependence--clinician's packet. A how-to guide for implementing the Public Health Service clinical practice guideline. 2003. www.surgeongeneral.gov/tobacco/clinpack.html. The 5 Ds of Managing Cravings Delay increase interval between hits Drink Water keep your mouth busy Do Something Else distract yourself Deep Breathe use relaxation techniques Discuss Your Feelings call a friend, use quit

line 17. National Advisory Committee on Health and Disability. Guidelines for Smoking Cessation, Revised 2002. Wellington, New Zealand: National Advisory Committee on Health and Disability (National Health Committee); May 2002. 18. US Public Health Service. Treating tobacco use and dependence--clinician's packet. A how-to guide for implementing the Public Health Service clinical practice guideline. 2003. www.surgeongeneral.gov/tobacco/clinpack.html. The 5 Rs of Promoting Readiness Relevance what makes quitting important Risk what negative experiences have you had

Rewards what benefits gained by quitting Roadblocks what are the barriers Repetition repeat efforts at each encounter 17. National Advisory Committee on Health and Disability. Guidelines for Smoking Cessation, Revised 2002. Wellington, New Zealand: National Advisory Committee on Health and Disability (National Health Committee); May 2002. 18. US Public Health Service. Treating tobacco use and dependence--clinician's packet. A how-to guide for implementing the Public Health Service clinical practice guideline. 2003. www.surgeongeneral.gov/tobacco/clinpack.html. Wheeler KC, Fletcher KE, Wellman RJ, Difranza JR. Screening adolescents for nicotine

dependence: the Hooked On Nicotine Checklist. J Adolesc Health. 2004;35(3):225-230 Nicotine Replacement Therapy Consider for adolescents who are daily users; those with moderate to severe level of physical dependence Preferred options: Patch, gum, lozenge Less preferred options: Inhaler, nasal spray

NRT Patch: Daily use 1+ pods -1 pod Few hits Dose 21 mg

14 mg 7 mg (remove at bedtime) Based on adults, 8-10 weeks is ideal. If start with 21 mg patch, use for 4 weeks, then 14 mg patch for 2 weeks, then decrease to 7 mg patch NRT

Gum: Daily use 1+ pod < 1 pod Dose 4 mg 2 mg

Based on adults, about 12 weeks is ideal. One piece Q1-2 hours x 6 weeks, then 1 piece Q2-4 hours x 3 weeks, then one piece Q4-8 hours for 3 weeks then discontinue. NRT Lozenge: Time to 1st Use < 30 min after waking > 30 min after waking

Based on adults, 12 weeks is ideal Weeks 1-6: 1 lozenge Q1-2 hrs Weeks 7-19: 1 lozenge Q2-4 hrs Weeks 10-12: 1 lozenge Q4-8 hrs Dose 4 mg 2 mg

Psychotherapeutic Interventions Currently no evidence-based options For teen smoking, modest effects of smoking cessation programs, school-based (Project EX), and school nurse delivered smoking interventions Decreased smoking in teens enrolled in txtmessage delivered, peer network program Resources

AAP Richmond Center https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Pa ges/Electronic-Nicotine-Delivery-Systems.aspx Supports Outside the Office The Truth Initiative: https://truthinitiative.org/thisisquitting and

Text DITCHJUUL to 88709 SmokeFreeTeen: https://teen.smokefree.gov/quit-vaping Project ECHO Extension for Community Healthcare Outcomes 1. AAP Pediatric Substance Use (SBIRT) ECHO (recruiting next cohort NOW, deadline 12/18/2019)

https://www.surveymonkey.com/r/SBIRTECHO2) 2. AAP E-cigarette ECHO (cohort recruitment expected as early as January 2020) 3. Pediatric Nicotine ECHO through UMN Department of Psychiatry and Behavioral Sciences (Minnesota only, recruitment February 2020) Clinical Evaluation for

EVALI Nandini Kataria, MD | Anne Griffiths, MD Pediatric Pulmonologists | Childrens Respiratory & Critical Care Specialists & Childrens Minnesota Cough, chest pain Respiratory Symptoms

Clinical Clinical Present Presentati ation on Gastrointestinal

Symptoms Constitutional Symptoms Exertional and non-exertional dyspnea/shortness of breath Hemoptysis

Abdominal pain, nausea, vomiting, diarrhea Decreased appetite Fever, chills Weight loss Fatigue, headaches, dizziness Oxygen saturation <95%

Physical Exam Tachycardia, Tachypnea +/- Fever Algorithm for Diagnosis and Management of EVALI

Symptom and substance use history Abnormal chest imaging Elevated inflammatory markers (CRP/ESR/WBC) Diagnosi s Neutrophil predominance

Evaluate for concomitant infection Respiratory viral panel, Influenza, Mycoplasma Endemic infections +/- Transaminitis Consider selective toxicology testing and/or bronchoscopy

Considerati ons for Outpatient Manageme nt Oxygen saturation >95% in room air

No comorbidities that may compromise pulmonary reserve Reliable access

to care 24-48 hours following presentation Strong social support in place Reporting to MDH Report any suspected cases

Call 651-201-5878. Fax a Vaping Initial Case Report Form (PDF) to 1800-267-1058. Use the online Vaping Initial Case Report Form. Hold earliest clinical samples Blood Urine BAL Thank you! Questions?

2018 Drs. Carlos Galliani, Damon Olson, Robyn Reed, Peter Helseth, Pathology, Childrens MN Dr. Megan Dishop, Pathology, Phoenix Childrens Hospital Dr. Melinda Pierce, Endocrinology, Childrens Minnesota Dr. Susan Sencer, Hematology Oncology, Childrens Minnesota Community Pediatric Hospitalists and Emergency Department Physicians

Ruth Lynfield, Terra Wiens, Nate Wright, Stacy Holzbauer, Jason D, Minnesota Department of Health Dr. Travis Olives, Emergency Medicine Toxicology, Hennepin Healthcare, Minnesota Poison Control System Dr. Sakina Naqvi, Adult Pulmonology, Health East Medical System Dr. David Segal, Lung Injury Clinical Response Group, Centers for Disease Control and Prevention 38

2020 Minnesota Legislature Tobacco, E-cigarettes & Vaping December 13, 2019 Eric Dick MNAAP Lobbyist Tobacco & Vaping at the Minnesota State Capitol

Tobacco 21 Includes all tobacco products & e-cigarettes Passed the House in 2019; Awaiting action in the Senate Vaping Education Requirement Tobacco & Vaping at the Minnesota State Capitol Flavor Bans

Tobacco flavoring (including menthol) E-cigarette flavors Prior authorization requirements for certain cessation products Inaction at the Federal Level T21 bill pending in the US Congress No significant action re: e-cigarettes

Be an Advocate! You Have a Unique & Powerful Voice As advocates for your patients you have advantages: Credibility and expertise Motivated by profession ethics, not financial interest Compelling personal experience with patients Call. Write. Email. Use Social Media.

Legislators want to hear from you YOU are the expert, and they need your expertise Tips: Keep it positive Keep it simple, avoid medical terminology Tell personal story Its okay if you disagree, but be respectful Form a relationship become a resource

Questions & Discussion [email protected] THANK YOU/QUESTIONS

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