On December 18, at our Chayeinu event, we had the privilege to hear Rabbi Yaakov Horowitz speak with parents in our community on having an ongoing dialogue with their children about alcohol and drug use. During the talk, he shared a story about a conversation he had with a policeman who had responded to an overdose in the Jewish community. While the Rabbi expressed some surprise that the opioid crisis was now taking Jewish lives, the policeman reminded him that there is no good reason for Jews to be immune, because substance use and abuse is a human problem.
Paths to Addiction
How does the opioid crisis, a human problem, take hold in our Jewish community? While there are many paths to addiction, opioid addiction usually emerges as a continuation of substance use that starts in middle or high school. Through a combination of simple curiosity, sensation seeking, and peer pressure, some kids will start to drink alcohol, often introduced by an older sibling or friend from school. While most drinking is done in secret (e.g., in cars or at parties), some of it is quite public, revealed at shalom zachars, kiddushes, and weddings. Many children also start vaping in middle school, usually unaware of the abuse potential of nicotine. Hanging around other teenagers who drink or vape, it is an easy progression to more powerful drugs like marijuana, which is relatively easy to obtain and is often used by at least one other kid in the group. In fact, one of the unfortunate consequences of the push to legalize marijuana is that teenagers generally hold favorable views about this drug.
Most teenagers who smoke marijuana will not progress to more dangerous drugs, though some will. Those more likely to use drugs like cocaine or opioids have vulnerabilities that increase the appeal of these substances. These vulnerabilities include a family history of substance use, frequent childhood misbehavior or rule breaking, untreated (or under-treated) disorders like ADHD, depression, or anxiety, and/or a history of trauma. Teenagers who have developed another substance use disorder (nicotine, alcohol, marijuana) are also highly vulnerable to using additional classes of drugs.
We should remember that intoxication from some drugs can be very rewarding to kids with health vulnerabilities. For a child with ADHD, for example, smoking a cigarette, which has powerful stimulant properties, can bring a certain mental sharpness and clarity. Children who have anxiety may experience considerable relaxation after smoking marijuana. Acute marijuana or cocaine intoxication can lift the spirits of a child who is depressed. While it is certainly true that the long-term use of these substance impairs thinking, increases distress, and triggers mental health and medical problems, how many vulnerable teenagers are willing to forgo immediate relief for future benefits?
Teenagers who progress from alcohol and marijuana to opioids usually start by taking prescribed drugs like Vicodin or Percocet. These drugs are often found in medicine cabinets, and are relatively easy to attain illegally. Those who like the analgesic effects of opioids and start to use the drug more frequently are susceptible to developing a physical addiction that includes tolerance to the drug and withdrawal symptoms during days that they abstain. Because these drugs can be expensive, teenagers may start to opt for more cost-effective options, like heroin and fentanyl, which might lead to an overdose. Using opioids in combination with alcohol or other drugs also increases the risk of overdose. What is particularly scary is that even if a teenager is able to stop using an opioid, a relapse to the drug can be deadly, because the teenager often resumes using the same previous dose of the drug after losing tolerance to its effects.
What Can Parents Do?
What can parents do to reduce the likelihood of their child experiencing an opioid overdose?
• Seek treatment: The most important thing parents can do is to help their children seek treatment for conditions that make them vulnerable to addiction. Disorders like ADHD, depression, and anxiety are highly treatable and often respond well to a combination of medications and counseling. Comprehensive and sustained treatment can protect children from developing a substance use disorder. Starting early is important because it can take up to a year to find the right combination of medications and for counseling to exert an effect on behavior. The best starting point for seeking treatment is to speak with the pediatrician, who often has good recommendations for other doctors and therapists in the community. Insurance companies can provide a list of covered services.
• Talk to children: Parents should have an ongoing discussion with their children about the dangers of alcohol and other substances. The daily news cycle provides multiple inroads to potentially difficult conversations. Those who joined us at the Chayeinu event had the opportunity to hear Rabbi Horowitz discuss some good ways to begin these conversations, though there are also many excellent sources online to help parents with this ongoing task. Parents should be educated on the effects of different substances of abuse to be able to provide correct information.
• Express expectations: Parents should articulate clear expectations that their children should not drink or use drugs until they become an adult. Despite these expectations, teenagers will often choose to try out different substances, and children should be encouraged to talk with their parents about these experiences. These last two statements are not a contradiction but an acceptance that, despite the best attempts to encourage your children to abstain, teenagers face a considerable amount of peer pressure that motivates alcohol and drug use. The unfortunate reality is that we must assume that at every party there will be at least one kid who is drinking or using drugs. At the very minimum, children should know never to enter an automobile if the driver is under the influence, and that they should always call their parents rather than ride with an intoxicated driver.
• Keep the home safe from drugs: Parents must keep the home safe. This means that drugs like sedatives (e.g., Xanax, Klonipin) and opioids (e.g., Percocet, Vicodin) should not be easily accessible to children. Parents with teenagers who have started to use drugs should keep Narcan in the house. This opioid-antagonist and overdose-reversal drug that can be easily attained at the pharmacy. Parents should also model healthy alcohol consumption by not becoming drunk in public.
• Find the right therapist: For those teenagers who have developed a substance use disorder, we must treat it as a health problem and help them seek treatment. The most important thing to do is to find a therapist with experience in treating teenagers with addictions, who can create a healthy therapeutic relationship with the child and help navigate the recovery process. The therapist becomes a kind of “quarterback” who can provide referrals to other resources as necessary. For example, the therapist can refer the child to a psychiatrist or another professional for treatment of co-occurring psychiatric conditions, or to a specialized substance-use treatment facility to help children detoxify from drugs and receive addiction-specific counseling. It is not enough to refer teenagers to a fancy and expensive substance-use disorder treatment program and expect that the problem will go away. It usually won’t. Substance use disorder is often a chronic and relapsing disorder, much like other psychiatric conditions. Teenagers will almost always require ongoing care, which will include counseling and medications.
• Work with the school: Treating addiction as a health problem also has important implications for how parents should support their children within our school systems. For example, a child who is vaping nicotine at school is breaking established rules. However, we should consider that children who have a nicotine use disorder may find it quite difficult to stop on their own. Given these circumstances, it is not sufficient to simply punish the child by suspending him from school. Parents can use this type of incident as an opportunity to help the child receive an assessment for substance use disorder and other mental health conditions. If the teenager is already receiving treatment, this might be a time to intensify care and address co-occurring disorders, which may be untreated or significantly under-treated.
• Join with the community: Finally, I believe that parents should be less tolerant of teenagers drinking at simchas. We need to help our children understand that it is not acceptable to drink or vape. Once children turn 21 years old, an age when their brain is more fully developed and they can more meaningfully grasp the consequences of drug use, they can make their own choices about whether to drink or smoke. The research is clear that when teenagers understand the real and potential consequences of substance use, they are less likely to use alcohol or drugs and are less likely to develop substance use disorders based on recreational use.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine.
