Scott Hadland: Pediatrics & Addiction Medicine

Dr. Scott Hadland is a pediatrician and addiction specialist at Boston Medical Center and Boston University School of Medicine. Valerie and Carly talk with him about the importance of treating addiction during adolescence, medications for opioid use disorders, and associations between the pharmaceutical industry's opioid marketing and physicians' opioid prescribing. Valerie and Carly debate whether pharma has a hit out on Scott and nominate Scott for an official science superhero cape and magic policy wand. 

How does Harry Potter fit into the mix? Listen in to find out.

Read more about Scott’s work here: https://www.bumc.bu.edu/care/faculty/scott-hadland/
Read about Scott's work on prescription marketing and overdose deaths at NYT: https://www.nytimes.com/2019/01/18/health/opioids-doctors-overdose-deaths.html 
Follow Scott on Twitter: @DrScottHadland 

Episode Transcript

Valerie (00:08):
I'm Valerie Earnshaw.

Carly (00:09):
I'm Carly Hill.

Valerie (00:10):
And this is Sex, Drugs and Science.

Carly (00:13):
Today's show is with Dr.
Scott Hadland.
Scott is a pediatrician and anaddiction specialist at Boston
Medical Center at BostonUniversity School of Medicine.

Valerie (00:30):
Scott, you're actually our second Canadian that we're
talking to on this show.
So we're really excited becauseit's really reaffirming my
stereotypes that Canadians areboth like, super generous with
their time and kind, but thenalso like super smart.

Scott (00:49):
And if you could see, if you could see us, you could see
that we smile a lot.

Valerie (00:52):
Yeah, for sure.
Yeah.
And actually, so our firstCanadian was Carmen Logie.
I think she might've had like aNorthern lights, zoom background
going.
So she was like peak Canadian.

Scott (01:03):
I love it.
I love it.

Valerie (01:05):
Yeah.
And then you're also apediatrician and, you know,
after working at Bostonchildren's for a few years, my
stereotype about pediatriciansare that they're just like the
absolute nicest of a clinician.
So it's like, you've got theCanadian plus pediatrician.
I just feel like you can't scoreany nicer on the, on the charts.

Scott (01:26):
It's a double hit.

Carly (01:28):
That's going to be the title of this episode...
is like,"The Nicest Doctor inthe World".

Valerie (01:35):
Well, okay.
So in addition to all the nicestuff, you're also triple board
certified.
So, general pediatrics,adolescent medicine, and
addiction medicine.
Now someone who is zero boardcertified, that sounds like a
lot of boards to be certifiedin.
Is that, would that be accurate?

Scott (01:54):
Uh, it's a fair number of boards, and it's a lot of money.

Valerie (01:57):
Ah, okay.

Scott (01:58):
A lot of standardized testing, a lot of, annual
upkeep, a lot of annualprofessional fees.
So...

Valerie (02:04):
Oh yeah.
I didn't even think about that.
Okay.
Fair.
Yeah.
That's fair.
So I was wondering how does thepediatrician get into addiction
medicine?
I think for some folks, thismight seem like an unusual or a
surprising combination.

Scott (02:21):
Yeah, it's a, it is pretty rare combo.
But one that's becoming morecommon, and I can talk about
that in a second.
My own personal path is that, um, my interest in substance use
actually came first.
So when I was a medical student,I spent a summer between my
first and second years ofmedical school in Northern

(02:41):
Thailand, working with peoplewho inject drugs.
And, I, I loved the opportunityand this was sort of super
imposed on me having grown up inVancouver, Canada, which, is the
, uh, epicenter of the national,heroin and injection drug use
epidemic.

(03:02):
Now sort of the heart of ourfentanyl overdose related crisis
, and sort of having grown up inthat environment and then having
the opportunity to, to dive deepand work closely with people who
inject drugs.
That really inspired in me, alot of excitement for working in
this field.
And so, pretty early on in mymedical education, I knew I

(03:24):
wanted to work in the area ofsubstance use.
I saw it as a real opportunityto, to bring medicine in a sort
of social justice orientedframework, to traditionally
underserved population.
But then when I went through mymedical clerkships, I realized
that I love working with kids.
And the way that those twothings came together was that I

(03:48):
realized that actually a lot ofthe, the substance use behaviors
that we worry about asclinicians, the very things that
put people at risk for HIV andhepatitis C and other adverse
health outcomes, those behaviorsall start in adolescence.
And so I saw this opportunity to, work with people who use
substances, who are anunderserved group, and work with

(04:10):
adolescents who are alsorelatively underserved in the
world of medicine and sort ofbring these two things together.
And that's how I sort of chosethis path.
And so, my path was that I, dida residency in pediatrics and,
and a chief residency inpediatrics after which I, I
pursued training subspecialtytraining in adolescent medicine.

(04:33):
And, and, spent some of thattime focused on addiction
medicine and became boardcertified in that area as well.
And actually this, thisintersection of pediatrics and
addiction medicine, is onethat's becoming increasingly
common.
So there's, you know, for a longtime, there were only really a
handful of pediatricians with aninterest or expertise in

(04:54):
addiction, and that's reallyactually started to grow.
And what we're seeing now is forexample, at Boston Children's
Hospital, there's now, um, whatwas the nation's first pediatric
focused addiction medicinefellowship.
And you're starting to see thatmore of these are popping up
across the country.

Valerie (05:14):
That's amazing.
And that's where we met was, atBoston Children's Hospital.
And I think we met through thatadolescent substance abuse
program with the wonderful andterrific, Dr.
Sharon Levy, over there.

Scott (05:26):
That's right.
That's right.
And I actually, I think, oursort of academic interests
really came together around,your work in stigma, recognizing
that at least from myperspective, the, it really
became unavoidable.
Your work really becameunavoidable for me because
adolescents in healthcare reallyexperienced a lot of stigma.

(05:47):
People who use substancesexperience an enormous amount of
stigma in healthcare.
And again, when you bring thesetwo things together, you sort of
have this population that'shighly stigmatized and very
underserved.

Valerie (05:58):
Yeah, for sure.
And what was really interestingto me with the adolescent story
is that it's like, it's verymuch more of a whole family
issue, you know, both with the,the stigma that people are
experiencing and, you know, alsowith the treatment that they
access, it's, it's definitelylike a whole family affair.
Which is, I feel is a little bitdifferent from adults.

Scott (06:20):
That's right.
Yeah.
In fact, most addictiontreatment models have been built
for adults.
I think our work aspediatricians is to make the,
these treatment models nowdevelopmentally appropriate to
make them youth friendly and tomake them family centered when
we do have family membersinvolved in the treatment of a
young person.
And that means, tackling stigmaon a lot of different levels as

(06:43):
well.

Valerie (06:45):
Yeah.
So what are some ways that youthink about sort of tailoring
these treatment options foradolescents and what, and maybe
what do the treatment optionslook like?

Scott (06:56):
Well, much of my work and , the focus of my funding from
the National Institutes ofHealth really focuses on primary
care based addiction treatment.
So the sort of traditional orconventional approach has been
that, addiction treatment reallyhappens outside of primary care,
right?

(07:16):
Like if a teenager were toprevent, uh, present to his
pediatrician, say a 17 year oldstruggling with addiction, goes
in with his parents to thepediatrician and says like,"Hey,
I've been struggling withopioids.
I need help,".
The, the, the traditionalapproach would be that the
pediatrician would say,"Okay,great, I've got this, you know,
addiction treatment program, um,out in the community that I'm

(07:39):
going to send you to, you'll gofor detox and then you'll go and
stay there in residentialtreatment for awhile,".
And, uh, and the pediatricianreally doesn't sort of take on
any aspect of that, that care.
And what we've found is that foradults with addiction, they
really do many people do have apreference for receiving their
addiction treatment in primarycare from their trusted provider

(08:03):
is in a setting with whichthey're familiar, right
alongside all their othermedical problems, physical or
mental health problems.
And, you know, teens have veryclose relationships with their
pediatricians who have oftenknown them for a great many
years.
And, in part that's why oftenfamilies don't think to bring a

(08:24):
young person to a pediatricianthey're often sort of worried
that a pediatrician will sort ofbe disappointed or let down.

Valerie (08:31):
Oh, wow.
That's, that's kind ofheartbreaking.
We can't tell Dr.
Hadland what's going on.

Scott (08:37):
Right, right.

Valerie (08:37):
Yeah.
But it makes sense.
I mean, pediatricians are likepart of your community and, um,
yeah, I could definitely imaginepeople being worried about what
they'll think.
And they, you know, they knowthey have these like long
standing relationships to yourfamilies.
Like, I think that my, mypediatrician saw, like all of my
siblings and my mom knew themfor years because she was a

(08:59):
nurse in the community, so.
Okay.
Yeah.
I could definitely imaginepeople.

Carly (09:02):
I stayed with mine until I was 21.
And they were like,"Dude, if youcan go get a drink at the bar,
you have to leave thepediatrician's office,".
I t's like, I guess that's fair.
But it is like I had, you know,they were the only doctor, you
know, the only practice I eversaw my whole life, but you're
exactly right.
It would make sense, but I alsoprobably would be like,"I don't
want to tell them, I don't wantthem to be disappointed,".

Scott (09:23):
Right.
Yeah.
I mean, it's, it's, it's reallytricky.
And all of this really boilsdown again to, to stigma...
That there's so much stigmaaround substance use and around
addiction, that people don'tfeel like they can bring this to
a, to a doctor who's known themsince they were a baby.
Anyway, the, you know, where Iwas headed with all of this is

(09:43):
that, there's really anopportunity here for young
people, who might otherwise besent to an addiction treatment
program out in the communitywhere they don't know anybody
and where they're going to betreated alongside older adults
who have been injecting heroinfor a couple of decades.
There's an opportunity to, tobring that treatment into the

(10:04):
pediatric medical home and say,"No, let's actually provide this
treatment in primary care againfrom a trusted provider who I've
known all these years and whoknows me inside and out and, u
m, u h, and get into this placewhere I'm comfortable and where,
u m, you know, I, u h, I knowthe space and I know how to get

(10:25):
here, and I know how to parkhere, and I k now h ow to take
the bus here.
And I k now what to expect whenI walk in these doors, it's much
less intimidating,".
And so, this has really been,much of my work is to figure out
how are the, what are the waysthat we can adapt t he sort of
primary care based treatmentmodels to make them youth
friendly?
I think Valerie, one of thequestions that you had asked a

(10:46):
re like, what are the ways inwhich we had that we do that?
And you know, I think, u h,it's, u m, we're still learning
that we're doing a lot ofresearch around this right now,
actively, as I, as I say this, um, l ike I've got a team that's
actively investigating this bytalking to families and to youth
and to experts.

(11:07):
And I think the things thatwe're learning are not huge
surprises.
And yet I think t hat t hey'regoing to be really critical in
improving our clinical models.
They include things like, youknow, you need to have drop in
hours, you need to be sort ofready and available to help
provide treatment to a youngperson when they want it,
because treatment often happenson the terms of a young person a

(11:30):
nd...

Valerie (11:30):
Like everything else for young people?

Scott (11:33):
Yeah.
They're interesting.

Valerie (11:34):
Yeah.

Scott (11:35):
Openness and ability to get treatment at any given point
in time could, could wane fromone moment to the next.
And so you really sort of needto be prepared.
You may need to have flexiblehours, like in the evening, you
know...Young people are supposedto be in school for most of
their day, and they're notsupposed to be at the doctor's
office business hours.
You may need weekend hours forthe same thing, same reason.

(11:58):
You, may need to be prepared forthe fact that young people may
want to get treatment withouttheir parent involved.
And how do you navigate thoseissues and how do you make sure
that a young person is safe?
If they don't have parentalinvolvement, you need to know
how to involve the parent.
When the young person does wantthem involved, what are the ways

(12:19):
of which a parent can helpsupport a young person's
recovery, and set some limitsand expectations around where
they are, who they're spendingtime with, what they do, where
the money comes from, how thatmoney is spent, when people are
spending, when young peoplespend time together.
And how do you support parentsto be able to sort of institute
those limits to help keep ayoung person safe?

(12:41):
So there's lots of differentconsiderations, and you see, you
can see pretty quickly how thiswork becomes really different
and unique for young peoplecompared to older adults.

Valerie (12:52):
Can we talk for a minute about what some of the
treatment, you know, what someof the treatment options
typically look like?
So, you know, for talking aboutmedications for opioid use
disorders...what do thosemedications include?

Scott (13:06):
Well, there's, there's three US Food and Drug
Administration approvedmedications for the treatment of
opioid use disorder.
And these same three medicationsare used to treat adults and are
also available to young people,but there's some, some quirks
and some unique limitations thataffect the access of young
people, to these medications.
But the first medication, andprobably the most commonly used

(13:29):
one is, a medication whose tradename is Suboxone.
Its generic name isbuprenorphine.
And, it's what we call a partialopioid agonist, meaning that,
if, if a young person is eitherexperiencing withdrawal symptoms
because they've been usingopioids, or if they're
experiencing cravings foropioids, because they've been

(13:50):
using them for such a long timeand have started to struggle
with addiction, whatbuprenorphine does is it binds
to the opioid receptor and itsort of gives a little bit of an
effect at, at the receptor, tohelp address that withdrawal or
those cravings.

Valerie (14:06):
Okay.
And those, sorry, Scott, thosecravings can be really intense,
right?
Like, and they can include likelots of GI upset, these intense
biological cravings.
Like you could get headaches,like the, a lot of what some of
these medications are doing arejust trying to keep people like
semi-human during this periodof, you know, coming off of

(14:27):
using opioids.

Scott (14:29):
Yeah, that's right.
I mean, you can add if youreally wanted to, to engage in,
in, in support or counseling ortherapy, um, to help address
your addiction.
It'd be really hard to do it ifyou were experiencing a lot of
these physical symptoms thatyou've mentioned and these
physical symptoms of withdrawal,and then also if you're
experiencing intense cravings,if like from one moment to the

(14:51):
next, all you can do is thinkabout, you know, the next time
that you're going to usesubstances.
Or if every time you pass, youknow, a certain part of your
neighborhood where you've usedin the past or where, you know,
people who have used or whereyou've met up with your dealer,
it's going to be really hard tosort of get by moments, moments
in your recovery...if you'reconstantly sort of experiencing

(15:13):
those, those cravings fortriggers.
And so buprenorphine is as a, asan opioid that binds to the
receptor, and, and does so in asort of safe, predictable and
long acting way, unlike heroinand short acting opioids, which
are what people misuse, isactually a very effective
treatment.

(15:34):
And the data really do supportthat there were clinical trials
showing that these areeffective.
This is an effective medication,including among young people.
The second medication that's FDAapproved is methadone and
methadone is also an opioidagonist.
It's a very effective treatmentand back.
Some studies really suggest thatit's probably the single most
effective treatment for opioidaddiction and, and saves lives.

(15:57):
Quite frankly, it's beenassociated with improvements in
mortality, across studies.
What's difficult about methadoneis that access to methadone for
teenagers under the age of 18 isexceptionally limited in the
United States.
Federal policies dating back to,I believe about the 1960s really
dictate the teenagers...if theywant to go on methadone, have to

(16:21):
have, two quote unquote,"failedattempts at treatment", that
didn't involve medication.
So as a young person, requiredto try treatment, have it not
work out.
And then if you, that happenstwice, then you can then go and
get methadone for yourtreatment.

Valerie (16:41):
So, sorry, this is actually like, I didn't, I
didn't know about this and thisis I'm having a mind blown
moment right here.
So first off our rules aboutmethadone access for young
people were created in thesixties.
Okay.
So that's so that's, that's aninteresting thing right there.
And then B, a failed treatmentattempt can be death.

(17:04):
So we're like willing tosacrifice like two failed
attempts that could lead todeath before someone, before a
young person can have access tothe thing that we know is most
effective for treating an opioiduse disorder?

Scott (17:19):
Yeah.
And effective at preventingmortality.

Valerie (17:22):
Oh my gosh.
Okay.

Scott (17:24):
You have to experience the bad outcome, twice,
essentially experiencemortality.
Twice before you can get theeffect of treatment a nd
potentially mortality reducingmedication.
Yeah.

Valerie (17:36):
Okay.
Well, that's, that's something.
Okay.

Scott (17:40):
Incredibly backwards.

Valerie (17:40):
Incredibly backwards.

Scott (17:43):
I think stigma underlies these policies.
And, you know, even if a youngperson surpass that barrier
where they've had to failed, andI hate using that word but
failed, this is actually thelanguage that's used treatment
episodes, and then is ready togo out and find a methadone

(18:03):
treatment.
They then have to find amethadone treatment program
that's willing to take onsomeone under the age of 18 and
practically, that doesn't exist.
We did a study in 2018 lookingat Medicaid programs across 11
States and found that, um, overa period of two years leading up
to that study, that, exactlyzero adolescents across those 11

(18:29):
states had gotten methadone, aswell opioid use disorder.
So you can see just howexceptionally high that barrier
is.

Valerie (18:38):
I think I'm so interested in this because Carly
and I collect data in amethadone clinic, and I should
really clarify that, but bysaying Carly and I mean, Carly
collects our data in a methadoneclinic.
So we have a lot of, you know,we have a lot of experience with
what that looks like.
I mean, people come in eitherevery day, as, you know, the
further they go, it might beonce a week to maybe once a

(19:00):
month to pick up theirmedication.
And, it's just, it's, there's somany people getting this care
and there are definitelychallenges to that.
But you know, when, as we weretalking to people, so many
people talked about how it savedtheir life, it's allowed them to
live a life.

(19:20):
And so just to think that, thismedication and that is effective
for people that zero less thanhad access to it across all
these States.
So, okay.
So that's really striking, but Ithink that you were only
through, I only let you getthrough two of the three options
before I derailed us

Scott (19:41):
Well I was a little long in getting through the first
two, so...

Valerie (19:42):
No, no, take your time.

Scott (19:44):
The third one is a very different medication and that's
naltrexone.
Naltrexone is actually an opioidantagonist, which is what makes
it different and the antagonistbinds to the opioid receptor,
but then it has no effect and itblocks, it blocks the receptor
so that no other opioids canbind to it.
And so someone who is takingnaltrexone, um, if they use

(20:06):
heroin or another opioid, thatheroin or opioid won't be able
to break through and bind to thereceptor and have an effect
because it will be blocked bythe medication.
And that, that really is part ofthe mechanism of this
medication.
Naltrexone is that it's, it's,um, not perfectly but largely,
blocks someone from being ableto experience the, the effects

(20:28):
of using, um, an opioid.
Naltrexone for a great manyyears was only available as a
pill, and it still is a oncedaily pill, um, available that
some patients choose to take.
But actually is, um, uh, hasbeen available since, um, I
believe 2000, um, as a shot.

(20:50):
And that shot is called Vivitroland it's a shot that's given
every, um, every month, andstays in the body for, for that
period of time and blocks theability of opioids to come in.
It may also have some, um,through some unique, neuro
pharmacologic properties.

(21:12):
It may actually also blockcravings to some extent, but by
and large its main mechanism ofaction is that it's preventing
someone from experiencing thehigh of an opioid.
Interestingly, it's a medicationthat, is used very commonly or
relatively more commonly inyoung people than it is in older

(21:32):
people.
And I think that's becausethere's this idea that if you
give someone a medication thatprevents them from getting high,
that's somehow better thangiving them buprenorphine or
methadone, which are medicationsthat act on the opioid receptor
and have an effect.
They're agonists and people feelbetter about using naltrexone

(21:54):
for that reason.
But the truth is actually ithasn't been studied very
effective, very extensivelyamong people under the age of 18
and is not actually FDA approvedfor people that are under the
age of 18, unlike Suboxone,which is FDA approved for 16 and
up.

Valerie (22:12):
So for the, so that sounds like another stigma issue
at play.
And when we, so one of thethings that we're looking at, or
maybe the primary thing we'relooking at is people's
disclosure experiences.
And we have found it's, it'sinteresting when people disclose
different types of medicationsand they, you know, they explain
what those medications do, thatpeople do have different types
of reactions to them.

(22:33):
We still get a lot of, you'rereplacing one drug for another
when people are disclosing justmethadone and a little bit more
support when they're disclosingone of these other options.

Speaker 3 (22:44):
Yeah, yeah.
It received that play at all thetime.
And we see it on a lot ofdifferent levels with
adolescents.
I mean, there's a lot of stigmaaround these medications just to
begin with, um, for all thereasons you said.
You know, there's thisperception that if you take
Suboxone or you take methadone,you're just, you know, trading
one addiction for another.
But of course that's notaccurate.

(23:05):
Addiction is not just use of asubstance, but a lot of problems
in your life, negativeconsequences resulting from the
use of that substance.
And in fact, methadone andbuprenorphine help people get
rid of life problems from theiraddiction.
And so, their use in and ofitself is not addiction because

(23:28):
their use actually results inimprovements in people's lives,
which is this sort of antithesisof addiction.
But so adolescents experiencethat sort of general stigma
around these medications thatexist, whether, you know, you're
a 17 year old struggling withopioids or a 65 year old
struggling with opioids, butthey get it on a lot of
different levels too, becausethey also get it from family

(23:51):
members and parents who carrythat stigma and sort of, um,
pass that messaging on to themand say, you know, I don't want
you on, I don't want you totrading one addiction for
another.
Um, and then they hear it fromtrusted adults in the community.
And so I have a lot of patientswho, might go to a Narcotics
Anonymous or AlcoholicsAnonymous to get support out in

(24:12):
the community.
And they get matched with, witha peer who is in recovery and
that person didn't usemedications and doesn't want
them to take medications andgives them again, further
messaging as somebody who'strusted, gives them further
messaging that they shouldn't beon medication.
And so, I spent a lot of my timeas a, as a clinician, trying to

(24:36):
reorient that framework aroundmedications and talking to
parents and other trusted adultsto explain to them the rationale
behind these medications andhelp them understand the data
that underlies their advocacy.

Valerie (24:50):
I'm seeing Carly smile because we have gotten an earful
going on to community settings,and advertising for our study
and, you know, in recoverysettings and sharing with people
, um, that we've tested thisamong, you know, folks who are
accessing methadone and then,you know, we get an ear full

(25:12):
from people from other recoverycommunities telling us about how
terrible methadone is.
So it's been, we've had a littlebit of a wild ride with that.
You know, and we're aware thatthe scientists coming in, so I'm
sure it's like, you know, it's apretty muted conversation that
people are trying to have withus.

Scott (25:31):
Yeah.

Valerie (25:32):
Yeah.
So I'm sure that the, you know,the, the physicians you're
trying to get to prescribe thesemedications probably have, you
know, like no biases andmisinformation about it.
It's probably just like supereasy sailing with them, right.
To get them to, to get them, totry to prescribe these in office
settings.
How, how's that looking for you?

Scott (25:54):
You know, it's interesting.
I, I'm of a couple of mindsabout this.
On the one hand, I think in anideal world, every pediatrician
would be prepared to treat anyperson with addiction who walks
into their doors.
Um, you know, I think ofaddiction treatment as part of
our expected skillset.
Just as any pediatrician shouldbe able to treat asthma, any

(26:16):
pediatrician should be able torecognize diabetes, any
pediatrician should be ready torecognize and treat addiction.
Unfortunately, you know, thattraditionally hasn't been the
case.
And so I think part of ourworkforce development is to try
to, work, to introduce theseconcepts into residency training
even earlier on into medicalschool training.

(26:40):
And then also to provide sort of, helpful continuing medical
education for people who arealready in practice to help them
develop and maintain theseaddiction treatment scales.
You know, I think that's a bitof an idealized approach, cause
that's certainly is not going tohappen overnight.
And so I think a, a helpfulmiddle ground would be that, you

(27:03):
know, not every pediatricianneeds to be able to do this, but
what if, you know, just onepediatrician, in every practice
could do this, wouldn't you justhave sort of one champion,
right.
And we do this for otherconditions too, right?
Like in every practice, yeah wecan all do a little bit of
asthma management, but there'soften one person who is able to,
to, to work with, the patientswhose asthma is really severe

(27:27):
and really complex and, and mayneed sort of more advanced
treatment.
And so one middle ground, again,might be just to say like, can
we identify that champion foraddiction treatment in every
practice.
And then at least, you know,everybody's got somewhere to
turn.
And so, whether our workforcedevelopment results in, you know

(27:50):
, scenario number one orscenario number two, you know,
I'd be, I'd be delighted witheither outcome, but regardless
there's a lot of workforcedevelopment to make that happen.
As you, as you sort ofsuggested, there is a lot of
stigma, even in our own medicalpractice among pediatricians,
um, around treating youth withaddiction, there's a lot of

(28:11):
people go into pediatricsbecause they want to take care
of kids.

Valerie (28:16):
Yeah, like bandaids and lollipops, right?
So what am I doing with these?
Yeah.

Scott (28:21):
There's a very specific feel to pediatric practice that
brings us all a lot of joy.
And I think in a lot of people'straditional notions of
pediatrics and what the practiceshould look like.
It doesn't include teenagers whoinject drugs.
But it's, it's, it's part of ourpractice, nonetheless.

(28:42):
And, you know, this is a primarypublic health crisis across the
United States and we all sort ofneed to do our part.
And this is, this is a part thatpediatricians need to play.
They need to recognize and, and,and address addiction.

Valerie (28:56):
I mean, can pediatricians prescribe opioids
to youth?

Scott (29:00):
Absolutely.
With little to no training.

Valerie (29:02):
Oh, okay.
So pediatricians can prescribeopioids and then there's some
like queasiness aroundprescribing, you know, the
medications for opioid usedisorders, if those were to
develop.
Okay.

Scott (29:14):
Well, yes, there is queasiness, but it's not all
born out of, um, pediatricians',stigma.
You know, Suboxone is a, and wehaven't talked about this.
Suboxone has medication thatrequires for physicians an eight
hour training and specialcertification from the US Drug
Enforcement Agency before youcan prescribe it.

(29:35):
So, whereas any of us canprescribe oxycodone and, and,
medications that can contributeto opioid addiction with little
to no training.
We need eight hours of trainingto be able to prescribe the
medication that can treat opioidaddiction.

Valerie (29:53):
Yeah.
And I'd really love to see howmany people can get any
clinician to do eight hourtrainings.
I mean, that's a high bar.
So we were at a meeting inJanuary and it was interesting
the, with the addiction and thepain community.
And there was a lot of buzzaround this.
And I think I, as a, you know,as a social scientist, didn't

(30:13):
quite understand the uproaruntil I looked into it a little
bit afterwards.
Cause there were a lot ofpeople, you know, the
conversation was why, why what'swhat's wrong, we need better
access.
And then the clinicians are inthe room or were like get rid of
this eight hour training andyou'll have lots more
prescribing a play.
Was that your read on theconversation?

Scott (30:34):
Yeah.
Yeah.
And that's, that's my personalstance.
So there's, t he, the DEA waiverto prescribe Suboxone i s called
the X waiver.
And it's called that becausewhen you, when you get this
waiver, the first letter ofyour, DEA number, which we all
need to prescribe controlledsubstances, u m, turns to an X

(30:58):
the letter, it w as, it becomesan X.

Valerie (31:00):
Really?
So you're like, so that's a realstigma thing.
So you've got like a mark on you.

Scott (31:06):
Well, you know, it's really interesting.
There is, there is something towhat you just said.
You know, I get called bypharmacies.
Sometimes they will say like,you know,"I'm not, I can't
accept your X DEA number.
I want your other one,".
There's, there's a lot ofdifferent sort of, issues that
come up, first getting thewaiver and then second of all

(31:27):
sort of having it.
And so that's why, what you'llhear if people will sort of, um,
uh, and this trends on Twitter,people will say,"We need to X
the X waiver we need to get ridof it,", and that's where that
comes from.
But it, it really is a waiverthat is difficult to get, that

(31:47):
sort of, that training that'srequired.
It just, the symbolism behindrequiring so much training for a
single medication, I thinkcreates a lot of stigma around
the medication and makes a lotof people put their hands up and
say like,"I don't want to gothrough that training.
I don't see those patients.
Why would I go sit through aneight hour training," is the
sort of response that I'll oftenhear from people.

(32:13):
And, and it really has meantthat the workforce available to
prescribe buprenorphine acrossthe country is really limited,
as a result.
And in fact, at a recent checkand, and, conversation that I
had with one of theorganizations that leads all
these trainings, um, in factthat the foremost organization

(32:34):
that leads these, these waivertrainings, when I asked, you
know, what percentage of peoplewho take your course are
pediatricians.
The answer as of 2019 was 2%meaning one in 50 people that
they train, to prescribebuprenorphine is actually a
pediatrician, just showing theextent to which, you know, my

(32:55):
entire workforce is really onthe sidelines of this, this
public health crisis.

Valerie (32:59):
And just to kind of come back to that idea a little
bit.
I mean, so many of our substanceuse disorders are adolescent or
young adult onset.
Like people start using thesesubstances when they're young
and then they continue, youknow, the substance use
disorders will worsen if they'renot sort of, you know, addressed
in pediatric settings or whenthey're young.

Scott (33:21):
Yeah.
I, you know, the, the data, thenational data tell us that, um,
every, among all adults with asubstance use disorder, nine out
of 10 of them first startingusing before the age of 18.

Valerie (33:34):
No, really?
Nine out of 10...
Is that all subs like, so opioiduse disorders included and...?

Scott (33:40):
Yeah, that's looking at a sort of like a broad look at all
substance use disorders.
If you told them"When was thefirst time you used?" they'll
tell you that their substanceuse first began before the age
of 18, really highlighting theextent to which substance use is
a, is a pediatric onsetcondition.
Opioid use among teens is quitea bit more rare, and has

(34:02):
actually been on the decline inrecent years.
And so if you ask all peoplewith opioid addiction,"What was
the very first time you used anopioid?" About one third will
say that it happened before theage of 18.
And about two thirds, they'llsay that it happened before the
age of 25.
And to be clear, there are a lotof people in their early to mid
twenties who were still seeingpediatricians too.

Carly (34:23):
Not alone.

Scott (34:26):
Exactly.
So again, this is, this needs tobe in our wheelhouse.

Valerie (34:30):
So Scott, you know, in talking to you, it's really
striking me that moving,treatment for substance use
disorders into, you know, officebased settings to pediatricians
has a lot of challenges.
So you've got these policyissues, you've got this X, you
got the parent issues, thetraining issues.

(34:53):
So it, it feels like there'slike a lot in the mix.
And I know that your, your Kaward is really focused on
interventions to improve that.
So how do you, like, whatthreads do you try to pull on?
What, what do you try to do, youknow, when you're thinking about
interventions to address this,to try to move the needle and

(35:13):
get, and just get started?

Scott (35:16):
Well, very fortunately I, uh, all on its own, the needle
is moving a little bit alreadyand a lot of this is born out of
the recognition that, you know,we were in the middle of a
national crisis.
You know, COVID-19 aside thesort of...

Valerie (35:31):
Well, it's only going to get worse than COVID-19
right.
I mean, yeah.

Scott (35:35):
Exactly, exactly.
The very immediate crisis isactually exacerbating our sort
of longer standing crisis, youknow, our opioid overdose
crisis.
But, I think a lot ofpediatricians have sort of
recognized this as an issue and,um, you know, particularly with,
you know, each year more andmore new pediatricians enter the
field and the vibe of pediatricsis shifting.

(35:57):
And we're, we're really seeingthat young pediatricians in
particular, as well as olderpediatricians who just want to
do the right thing areincreasingly taking on mental
health as part of their ownpractices, increasingly taking
on addiction as part of theirown practices.
And so, you know, when I, when Igo around the country and I talk
to, pediatricians, I'm actuallyfinding people are sort of

(36:19):
naturally gravitating towardsthis, this work out of a
recognition that this system isa necessity.
So some of the groundwork isalready laid.
And you know, if I find myselfhaving to convince people, I try
to convince them with data andwith stories.
And, um, uh, and so, uh, youknow, I think some of the data
that we've already talked about,including our nine out of 10

(36:41):
number, um, for teens, startingwith substance use before
subsequently developing anopioid or a substance use
disorder further on down theroad, that's, that's really
compelling data that I think canbe convincing the pediatricians.
And then I think some of thestories that, that I can share
from my own practice and thatother pediatricians can share
with other pediatricians fromtheir own practices can be

(37:03):
really illuminating.
I remember, the very first timeI, as a pediatrician treated a
young person with opioid usedisorder in my own primary care
practice.

Valerie (37:15):
Oh, wow.

Scott (37:15):
It was a, it was a 17 year old young man who, had long
struggled with, um, uh, some,some, um, difficulties with
anxiety.
And, uh, after he hadappendicitis, he received,
opioids for his pain and justreally found that the opioids
were really made him feeldifferent and really sort of

(37:38):
addressed his anxiety in a waythat obviously opioids, can do,
but are not meant to do.
And that's how we startedstruggling with, with, with
oxycodone for the first time.
And it, and it just, I willalways remember for as long as
I'm a pediatrician that day,that addiction treatment and

(37:59):
pediatric primary care cametogether under one roof.
Because, when I walked into theexam room to meet the 17 year
old young man for the very firsttime, um, he was sitting there
reading a Harry Potter book and,uh, while experiencing opioid
withdrawal.
And I, that was the moment forme that it all crystallized, and

(38:21):
I really saw these, these, thesetwo things could come together.

Valerie (38:27):
Yeah.
So that, so now that story time,we were doing interviews when I
was at Children's and the waythat it came together for me was
that we were interviewing youngpeople who are in recovery.
So a broad spectrum, and we wereinterviewed one young man.
He was like 16, who was inrecovery from an alcohol use

(38:49):
disorder.
And we were asking him about hisexperiences.
And I think it was like towardsthe end of summer.
And he was telling us, and itwas like the best.
It was just the best.
I mean, he was like, my,"Myfriends have been so supportive
of me all summer.
We have been having adventuresgoing on, hikes, doing all sorts

(39:12):
of non alcohol related things,".
You could tell that he wasprobably of the like high school
strata that would usually behaving these like big drinking
parties all summer.
And it was just the fact that hesaid that his, his group of like
16 and 17 year old friends werehiking mountains and going on
adventure.
It's my, I think my heart justlike left out of my body,

(39:34):
talking to him.
It was just the most adorable.

Scott (39:37):
Yeah, absolutely.
Absolutely.
And it really highlights why,physicians who have expertise in
these developmentalconsiderations are so needed, to
take this work on.

Valerie (39:54):
Okay.
So if, if we can all pretty muchagree that pediatricians are the
superheroes of your story, maybewe can transition over to
pharmaceutical companies.
You know, maybe I won't go toofar, but transition over to
pharmaceutical companies becauseyou have gotten some really nice
attention for your work lookingat, pharmaceutical industries,

(40:18):
marketing of opioids, and alsostimulants.
And I was wondering if you couldtalk a little bit about that,
including I was interested toread even just like what, what
pharmaceutical industrymarketing even looks like?

Scott (40:31):
Yeah.
Well, if I can take it back tothe origin of this research,
this is always a really, sort ofnice, story for me personally.
Um, uh, I have a good friendwho's, uh, who's a researcher
I'll leave, I'll leave thisperson's name out of the
podcast, just in case they don'twant to mention, but this person

(40:52):
is a researcher who does a lotof work in the area of opioid
related overdose and this personand I are old friends and we
were getting together one dayover breakfast.
And this person said to me thatthey had experienced, they had
submitted a paper forpublication in a journal and had

(41:14):
received really negative reviewson the paper where the reviewer
was sort of calling intoquestion everything that this
person had done in theirresearch.
And, and the reviewer's name wasknown.
That's not always true when afew manuscripts, but in this
case, um, it was known who thereviewer was.
And, uh, my friend looked upthis reviewer, turned out that
this reviewer had receivedhundreds of thousands of dollars

(41:38):
in opioid related marketing.
There was actually an entirenewspaper article written about
this because, um, thisparticular doctor, uh, not only
had gotten hundreds of thousandsof dollars of marketing, but
actually had sort of flattered alittle bit by buying big fancy
cars and ultimately was arrested, for their over prescribing of

(42:01):
opioids is sort of serving as apill mill doctor.

Valerie (42:04):
Oh my God.
Were they, were they, arrestedbefore they did the peer review
or after, or...?

Scott (42:11):
This would have been after.
I think it's probably hard to dopeer review from incarceration.

Valerie (42:17):
Yeah, yeah, yeah.
Okay.
So super concerning.
Okay.

Scott (42:19):
Anyway, this friend and I over breakfast, that's where we
develop this idea of like, wow.
Like"We should really understandthe extent to which the opioid
industry might be influencingphysicians' prescribing
behavior,".
Um, and to what extent is thesort of practice of medicine,

(42:41):
um, or do we have a conflict ofinterest amid this again, like
critical public health crisis?
And so that's really what led meto, to venture into, um, a
database called the, sort ofcolloquially known as the, The
Sunshine database...

Valerie (42:56):
Ah, okay.

Scott (42:58):
Based on the Sunshine Act, but it's, it's a database
called the Open Paymentsdatabase, um, put out by the
Centers for Medicare andMedicaid services.
And they basicallysystematically track and have
tracked, since, mid 2013, everysingle interaction between a
drug company and a doctor whosevalue is worth more than$10.

(43:21):
And so anytime a doctor gets agift from a drug company valued
at more than$10, gets travelpaid for, gets, um, speaker
sphere on our area, a consultingfee or what's most common, a
meal from a drug company, thatall gets documented.
And, the nature of thatinteraction is documented.
So we know, what was the sort ofmonetary value of that

(43:43):
interaction?
What medications were discussed?
What was the drug company, wheredid this take place on what date
did it take place?
And, again, sort of like, youknow, it was a meal, was it a
gift?
What was it?
And, um, and so there was, youknow, all of a sudden, um, when
this idea came to us to, to lookinto, um, physicians who

(44:06):
might've received payments fromdrug companies, it was now a new
database with which we couldstudy this.
And so we systematically wentthrough and understood, the
extent to which doctors, weregetting payments from drug
companies.
And actually our first papershowed that between the years of
2013 and 2015, really at a timeof accelerating drug overdose

(44:27):
deaths in this country,including many from prescription
opioids, about one in 13 doctorsacross the US had actually
gotten some kind of marketingfor an opioid.
And if you looked at familyphysicians who were really
providing the bulk of primarycare across the country, that
number rose to one in five.

Valerie (44:45):
Oh my God.
So I...
One in 13, one in five.
I really thought that by 2013 itwould be much less frequent than
that, that there would be morerecognition.
Cause I feel like there's been abuzz since the 2000s that mark,
you know, pharmaceuticalmarketing around opioids is
really problematic.
And so to hear that you have onein 13 and as high as one in five

(45:09):
that's, that seems surprising tosomeone not in the field.

Scott (45:13):
And that we, we did a couple of followup studies.
One study that we did a yearafter that original study, that
got a lot of attention.
We looked at doctors whoprescribed opioids under the
Medicare part D program.
And what we found is thatdoctors who got any marketing
related to opioids in 2014subsequently went on in 2015 to

(45:39):
prescribe more opioids.
And they really did so in a, ina dose dependent way.
So that the more of thesepayments or more of this
marketing that you got really,the more opioids you
subsequently prescribed.

Valerie (45:52):
I was looking at this graph this morning and telling
Carly about it cause it's likethe prettiest graph.
Cause it has like, I think the,on the, um, on the X axis,
right, it has like number ofmeals.
And then on the Y axis, it haslike a melon of prescribing and
it's like, you couldn't havemade up a better graph for
yourself.

(46:12):
Like it almost looks like thedata has to be fake.
So, right.
So you had this idea overbreakfast and then you stumble
upon like the perfect data setthat's already been collected
for you, which is surprisingthat that even exists with that
level of detail.
I mean, that's kind of amazing.
And then you crunch the numbersand you, you look at the graph

(46:33):
and do you have one of thesemoments?
Like"I can't believe I wasright,".
Cause sometimes when I'm right,I'm like, I'm surprised.
I have to just say I'm likesurprised when I'm r ight.
A nd I'm surprised when I'mwrong.
I'm just like, I'm alwayssurprised to see what happens.
So you see this perfect graphand what did you think?

Scott (46:48):
Yeah, well, I, you know, I have to, I have to sort of,
confess and come clean in that.
I wasn't the first person tothink of, you know, looking at
payments as an exposure and thenprescribing these an outcome.
And we were really using anotherpaper that had come before us.
It was exceptionally well done,kind of as a model.
And they were looking atdifferent medications all

(47:08):
together.
They were looking at some of themost prescribed brand name drugs
in Medicare part D, so it wasdifferent from opioids.
And I had seen it in their paperthat, you know, there was a
clear association there.
And so I wasn't surprised thatwe saw it with opioids, but
you're right after we producedthe figure, I really did say out
loud exactly what you had justsaid.

(47:28):
Like, if I, if you would ask meto create this figure, like to
make up a figure, this is whatit would look like.
You know, it would look likethis line.
And so, it was really, it wasreally pretty astounding to have
a figure that was just sodramatic.
So as I said, sort of like sucha dose response association.

Valerie (47:50):
I think that's just a really neat example of how
science can work though.
You know, seeing how thesethings work in other areas and
then trying it out in this, youknow, in the field of opioid
research and seeing that it doeswork or it does hold up.
So I think that's really neat.

Scott (48:05):
Yeah.
There are a couple, there are acouple things that I feel like
whenever I talk about thisresearch, I, I, I really want to
get out though.
Because I think it'd be easy tolabel me as sort of like anti
pharmaceutical industrywarrior...

Valerie (48:22):
Carly and I had this whole conversation about
wondering if you're safe fromthe pharmaceutical industry.
We were like,"Do they know wherehe lives?
Does he have a fake, likeInstagram account?"...

(48:35):
Walking around with a hit out all day?

Scott (48:37):
I don't think I'm important enough for them, or as
much as, you know, my researchmay have gotten some attention.
I don't think it's sort of...

Valerie (48:44):
I don't know, Scott.
You're a BFD.
I feel like, you know, maybe.

Scott (48:47):
I don't know if I'm BFD enough that they know where I
live or care where I live.
My life has never beenthreatened.
And I, I, you know, I think, um,one criticism that, that comes
up, when I talk about this workis the pharmaceutical industry,
the pharmaceutical industryneeds to market their product.
You know, physicians need toknow about these.

(49:09):
And in fact, in doing so they'reoften educating physicians,
right?
They're often showing positionslike,"Hey, this is how this
medication is used.
These are some side effects youmight expect,".
And so, so their interactionscan be helpful.
I think the couple of caveatsthat I would place on that
though, are that, first of all,it's probably different for

(49:30):
opioids, right?
Like I think that ifpharmaceutical industry, if the
pharmaceutical industry wants tomarket anti-hypertensives and
get doctors to prescribe moreblood pressure medications that
may have a net positive, publichealth benefit, right.
It probably costs us a lot ofmoney because there are new
fancy medications and probablyway more expensive than the

(49:51):
cheap old generics that workedjust as well, if not better.
But you know, they, you can makesort of a public health
argument.
In that case, I think here it isvery clear that there's a
national effort right now thatis, it is geared at reducing
excessive and inappropriateopioid prescribing.
And so that's why I thinkactually the answer needs to be

(50:13):
different for opioids, that itreally should be that we should
be thinking about limits onpharmaceutical marketing when it
comes to opioids in a way thatwe may not choose to for other
medications.
The other thing that I would sayis that, sort of like to counter
my own counterpoint, about,about pharmaceutical companies

(50:36):
providing sort of continuingmedical education and helping to
support doctors in learning, youknow, I really think, I actually
believe very strongly in a lotof people agree with me that
that education should come fromnon-biased sources, from sources
that don't stand to make money,through that education.
And so yes, I believepharmaceutical companies can

(50:57):
play a role in education.
No, I don't think they shouldroutinely.

Valerie (51:01):
Okay.
That's fair.
Well I'm glad that we got thesort of balanced conversation
in, but I also, you know, one ofthe other findings that I wanted
to ask you about from this lineof research was that, so not
only were you finding that,either two physicians or in
areas where more marketing ishappening, that more prescribing

(51:23):
is happening, but you actuallyalso found that there's more
opioid related deaths in those,in those places.
So that, that seems to be apretty big finding.
So for those you can, it lookslike you worked with that same
data set, and then you layeredin depth data, and then you
looked nationally, right?
I look at, this is anotherexample of some, like, really
pretty figures that you had inone of your papers with graphs

(51:46):
of, places where there's moremarketing along with places
where there's more prescribingand places where there's more
depth and like all of the hotzones sort of overlapped.

Scott (51:58):
Yeah, this, this was a paper that probably got our
group the most attention.
It was really covered, coveredheavily.
And the New York Times,Washington Post and a lot of
different outlets, was on NBCNews at Night.
And, and, so got a lot ofattention because it really does
sort of demonstrate this linkbetween marketing and overdose
deaths.

(52:18):
It also, for me as a, as aresearcher, was sort of a
riskier paper to put out therebecause I, more than any other
paper that I've gotten, it wasthe sort of, one that I got the
most criticism and heat for.
And the criticism was like, youknow, this is not cause and
effect.
You can't demonstrate cause andeffect when you're looking at

(52:39):
these like very equallogic data,all that you know, is how much
marketing is going into aparticular county and whether or
not there are elevated deaths inthat county one year later.
And you can't say that onecaused the other, we tried to do
some analyses to sort of likedemonstrate that causal pathway
a little bit better.
We actually looked at the extentto which marketing, um, was

(53:03):
associated with those overdosedeaths and the extent to which
that relationship was actuallysort of mediated or, or has it
as an intermediary, the amountof opioid prescribing in that
particular county.
So we did some things to try toaddress that, but at the end of
the day, I mean, I agree.
I can't say that this was causedin a fact, this is, you know,
this is an association, but youknow, where stand on this is

(53:26):
that let's imagine for a secondthat I got it all wrong.
And, the association actuallyhappened in reverse, right.
That, that there were alreadyoverdose deaths present in these
counties.
And then the drug companies camein and started marketing
heavily.
Well, is that appropriate?

Valerie (53:49):
Yeah.

Scott (53:49):
What we saw were that counties with some of the
highest overdose deaths in ourcountry, we're also the counties
that drug companies weremarketing heavily.
And that's, that's not goodeither.
And so no matter which way youspin it, this was a really
concerning association.
And so I do stand by the work,even though boy, there are some

(54:13):
times where I cite my own workand will cite this paper and
then, you know, submit one of,you know, submit a manuscript
for review and a reviewer willsay like,"That paper was
controversial.
You should remove it from yourlist of references,".
That is actually...

Valerie (54:29):
Wow.
That's wild.
I feel like you're doing goodwork.

Carly (54:33):
Yeah.

Valerie (54:35):
So you've got pushback from reviewers.
Do you get, did you get pushbackand other ways?
I mean, I I've, I feel likelately in the last couple of
years, I've, I'm starting to getmore like random trolling, like
emails and pushback of peoplepicking up my work.
And on one hand, that'sdistressing to get those emails.
Then on the other hand, it'slike maybe I've leveled up in
some sort of way,professionally.

(54:56):
So like you get some pushbackfrom reviewers.
Did you get it, you know, inother sort of routes as well?

Scott (55:04):
A little bit, I think, um, you know, I, I sort of, I'm
a, I'm a physician practicing ata, at an academic institution in
the liberal Northeast.
And so I think I haven't comeacross, you know, colleagues who
have really sort of called mywork in a question.
I think, I think there were alot of people that felt it was a

(55:25):
little bit bombastic to be sortof reporting on an association
between marketing and overdosedeaths.
And I think that's probably themajor sort of heater critic
criticism that I got.
But you know, if such as anassociation exists, I think
there is sort of aresponsibility for us as a
profession to, to reflect on itand sort of, at least consider

(55:48):
it, it might be a real cause andeffect, relationship and, and
consider whether there arethings that we need to be
addressing in terms of conflictsof interest.

Valerie (55:56):
I mean, it's certainly passed like the common sense,
you know, test, you know, so ifit passed, you know, it passes
the common sense test then, um,it's interesting that there's so
much kind of pushback andresistance to it, for sure.
Yeah.
Yeah.
And that, isn't kind ofinteresting to think about it.
If you're getting, if you get alittle bit of pushback or heat

(56:18):
in Boston, imagine what youwould get in a, in a different
location.

Scott (56:22):
Absolutely.

Valerie (56:23):
Y eah.

Carly (56:23):
Well, so, and I have another question, too.
So do you, I don't, I'm notreally familiar with how, the
pharmaceutical companies wouldlike go about targeting, um, you
know, physicians and how that,what that interaction looks
like, but does, did you noticethat publishing this paper had
any impact on that?
Like, did you all of a suddenget people like,"You know what,
we're not going to that guy tosee if he wants to, you know,

(56:45):
start prescribing X, Y, and Z,"you know, whatever...

Valerie (56:51):
We're not going on a date with this pharmacy...

Carly (56:51):
No food for this guy.
Let me tell you what.

Scott (56:55):
Well, you know, we, a lot of us working in academic
institutions already sort ofhave limitations on the
interactions we're allowed tohave with drug companies.
And so, you know, you can checkmy name in that database.
I'm not in there.
I double check every once inawhile.
You know, cause you sort ofnever know when this stuff might
sneak into your life, you know,someone hands you a sandwich,

(57:17):
you gotta remember that sandwichcame from.
But, no, I, that, that isn'tsomething, that happened, but it
did sort of, um, did receive anumber of, um, state attorneys,
general, and other sort of,lawyers and attorneys who were

(57:39):
involved in some of, um, some ofthe, sort of like many ambient
opioid related drug manufacturercases that are going on...still
reach out to me for opinions,thoughts, comments.
And so that was reallyinteresting cause you know, part
of what we do is, in, in ourline of work is to try to do
work that's impactful.

(58:00):
And so I think a neat thing forme was to observe the ways in
which something that I hadpublished.
You could draw a direct linebetween that and some response
that might have a public healtheffect through litigation.
I think one importantdistinction I always had to draw
is that a lot of the opioidmanufacturer lawsuits have

(58:22):
really been centered around likeagregious marketing practices,
right?
Like, you know, I think of, forexample, Insys pharmaceuticals,
which was a major source of alot of the marketing that we saw
in our studies.

Valerie (58:39):
Yeah.
They were like 50% or something,right?

Scott (58:41):
Yeah.

Valerie (58:42):
I picked up on them.

Scott (58:43):
About half they...
Either years of 2013 and 2015,if I'm remembering that, right.
I might be off a little bit inmy timeframe, but, you know,
they had this egregious practiceof, basically cutting doctors,
huge checks, for appearance sortof quote unquote"speaking TVs".

(59:05):
They would say like,"Oh, youspoke about this medication.
And so, let's cut you a bigcheck,".
And they also had an incentivestructure for their
pharmaceutical reps where if apharmaceutical rep could get a
doctor to A prescribe to a newand B prescribe to a preexisting
patient higher and higher dosesthen they would get larger and

(59:27):
larger bonuses, there was abonus built around like getting
drug reps to get more people onopioids and get people on higher
doses of opioids.
So some of these marketingpractices were egregious and as
it turns out like quite illegalin some cases, and, and that is
what has gotten the bulk ofattention.
I always have to be clear thatthe work that we did was

(59:50):
actually focused on often thevery legal, practice of drug
companies, just buying a doctor,a meal and boring and mundane as
that sounds, that actually hasthe much bigger public health
effect across the country.
Again, if we assume that theassociation that we observed was
cause and effect, you know, wereally found that, um, this

(01:00:13):
effect that exists is probably avery subtle one, but it's
widespread it's happening allacross the country, too.
As I said, one in 13 physiciansand a small effect spread over
many, many doctors actually hasa huge potential effect across
the country.

Valerie (01:00:30):
For sure.
So Scott, you know, since you'rea solutions person, if you could
wave your magic wand, what doyou, what would you do to try to
make some headway here?

Scott (01:00:40):
Well, as, as, as, as a Harry Potter fan, I would love
to do a lot of different things.
But I think my solution to thiswould be, would be threefold.
I think, one, physicians wouldself-regulate.
I think that physicians wouldstop and sort of reflect on
their own practices, andunderstand the extent to which

(01:01:05):
their behavior might beinfluenced by marketing,
recognizing that that effect maybe subtle and difficult to sort
of, tend to really piece apart.
I think, we as sort oforganizations need to self
regulate.
So I think, you know, everybodyfrom the large academic hospital
in Boston that employs thousandsof doctors, down to the sort of

(01:01:27):
like smaller primary carepractice that only has three
physicians, needs to have somerules around what are the
interactions that they have withdrug companies.
And I think quite honestly, themore restrictive, the better, I
think the approach that manyacademic hospitals would take,
have taken a sort of saying,"Wedon't allow any marketing on our

(01:01:48):
premises," is probably the rightone.
And so I think smaller practicesmight choose to adopt similar
policies for themselves.
And then I think the thirdapproach probably does need to
be, federal state or localpolicy that actually limits the
extent to which doctors caninteract with pharmaceutical

(01:02:09):
companies.
And so actually there have beensome States that have taken this
on New Jersey a couple of yearsago, introduced legislation to
limit the dollar amount ofmarketing that a doctor to get
into here, but they set thatdollar cap really high.
They said that any amount over$10,000 was too much.
Well, what we found in our studyis that like the vast, vast,

(01:02:33):
vast, vast majority of marketingthat takes place across the
country is on the order of like$10,$20 or$30.
Because, and so, you know, in my, my sort of like dream policy
would be that you don't justlimit the dollar amount.
Cause actually I do think weshould limit the dollar amount
cause it's pretty egregious.
I think for physicians to betaking tens, if not hundreds of

(01:02:55):
thousands of dollars andpharmaceutical money for their
own sort of personal manifests.
Um, but also there would belimits on the number of times
that a doctor can interrupt,interact with a drug company in
a given year because as you andI had, as we've just discussed a
few minutes ago, there reallydoes seem to be this dose
response association where themore meals you get, the more

(01:03:16):
interactions you have, the moreyou appear to go on to prescribe
the following year.

Speaker 2 (01:03:23):
Well, Scott, well, um, we should let you get along
with the rest of your day andget back to all of this really
important science.
I think that Carly and I'shomework is to get you a magic
wand, to get you a superherocape.
And, you know, I just want tosay, I feel like the science
that you're doing is, is reallytough.

(01:03:44):
You know, like working withadolescent substance use
disorders, trying to investigatewhat's happening with
pharmaceutical industries andmarketing.
And, I think that in part, youknow, we've been talking about
how there's not a lot of peoplewho do this, and I think not a
lot of people do this cause it'slike really, really hard work.

(01:04:05):
And couldn't be more gratefulthat you are out there in your
superhero cape, soon with yourwand, doing it.
And, it's really important.
I think it's making a really bigdifference cause I think you're
making a big difference when youstart to get pushback from
people, we wanted to recommendpeople to find your website on

(01:04:26):
Boston University becausethere's great detail about you
there to go check out theco-edited book that came out in,
was it 2019 or 2018 onadolescent substance abuse?

Scott (01:04:37):
Yeah, that was last year.
Yeah, yeah.

Valerie (01:04:39):
Yeah.
Okay.
So you got this great co-editedbook that folks could go and
read more about some of thesethings.
And then of course they couldfollow you on Twitter at Dr.
Scott Hadland.
Is there any other places thatfolks should look to?

Scott (01:04:53):
Well, you can creep on my Facebook, but I think I've got
my privacy settings up.

Valerie (01:04:57):
Okay.
Well that's good.
Cause we got to like, hold offthe pharmaceutical.

Scott (01:05:04):
Well, thank you both.
It really is an honor to, firstof all, be asked and then second
of all, I'm like a total delightto get to talk to you about all
this stuff.
So I really appreciate it.

Carly (01:05:13):
Yeah.
Likewise, thank you very much.

Valerie (01:05:26):
Carly.
I find myself in the position ofneeding to walk something back
on this episode once again.
So I characterizedpharmaceuticals as villains and
pediatricians as superheroes inthis episode.
And I'll just put it out intothe universe that that may have
been a little too like black andwhite that I, you know,
certainly there are superherofolks working in pharmaceuticals

(01:05:49):
and there are surely villainsworking in, pediatrics.
But I think that I did thatmaybe cause I'm watching too
many superhero shows on Netflixduring quarantine.

Carly (01:06:02):
You know, I think our listeners will forgive you,
particularly all the big pharmalisteners that we have out
there.

Valerie (01:06:10):
Oh yeah, for sure.
All right.
Well, we talked about tryingsomething new today.
The undergrads who are helpingus with the podcast gave it a
listen and then they flagged afew things that they had
questions about that theythought, you know, other
listeners might also havequestions about.
So we're going to review thoseafter, you know, after our
episode starting today and youknow, if it goes well, we'll

(01:06:32):
keep doing it.
So the main thing that theywanted a little bit more detail
about was substance use amongadolescents.
So I pulled some 2018 data fromthe National Survey on Drug Use
and Health, which is run everyyear to estimate how many people
essentially in the US might beusing substances different

(01:06:53):
types.
So they have categories, agecategories in this report for 12
to 17 year olds, 18 to 25 yearolds and then 26 and older.
So they found that in the pastyear that 12 to 17 year olds, 9%
of them had reported alcoholuse, 4.7% reported binge

(01:07:14):
drinking use.
So that 4.7, you know, percentof youth reporting binge
drinking.
I'm going to say that some ofthem probably do need some sort
of intervention if they'reengaging in binge drinking,
that's kind of a red flag for analcohol use disorder, for sure.

Carly (01:07:27):
Right.

Valerie (01:07:28):
For illicit drug use it's 16.7% of adolescents.
So it's actually higher than,uh, alcohol use.
So that's 4.2 millionadolescents.
We will note though that thisincludes marijuana use.
So 12.5% of that 16.7 werereporting marijuana.

(01:07:49):
I mean, they may have also beenusing other substances, but I
think a big chunk of thatillicit drug use group has
probably marijuana use for allopioid misuse among adolescents.
It's actually 2.8% ofadolescents.
So that's um, 699,000.
So if you think about that, likeif you're, if you're in a high

(01:08:10):
school or you have kids in yourhigh school, that's more than a
hundred students, that there'sprobably a handful of students
at that school who are misusing,or misusing opioids.
And it also means that, youknow, if you know, a hundred
like young people, that some ofthem might be misusing opioids.

Carly (01:08:30):
Yeah.
I think it, I, I can definitelysay from my own experience, I
think that it, it starts a lotyounger than a lot of, parents
are inclined to believe.
So I think, you know, havingsomeone like Scott doing this
work, who's, you know, apediatrician that can, you know,
sort of knows what to look forand knows how to treat it and
start those conversations issuper important because like you

(01:08:50):
said, you know, even if youknow, it just think about your
high school class, that's ahandful of people, which is
probably a handful more than alot of us thought, you know,
were in our class that werestruggling with some sort of
substance use disorder.

Valerie (01:09:03):
Yeah.
That's a really great point.
Carly, and I think what's alsostriking for me is that it's
2.8% of adolescents.
And it only goes up to 5.6%among 18 to 25 year olds.
And then back down to 3.6% among26 and older.
So, you know, the stats actuallyfor 12 to 17 are not that

(01:09:24):
different from the stats for 26and older.
We really, you know, need to payattention to this group.

Carly (01:09:31):
Right.
And, you know, going back onsome older data.
So for everyone that justlistened to the podcast, uh,
Scott had this, you know, has alot of really great work, but at
one paper in particular, I foundthis statistic from 2012, which
I thought was really jarring.
And so, you know, in the amongyouth age 12 to 17, there were 1

(01:09:52):
million persons or 4.2% of thatage group who needed treatment
for an illicit drug use problemin 2012.
But of this group only 121,000received treatment at a
specialty facility, which meantthat 920,000 youths who needed
treatment did not receive it.
And that, that statistic is juststaggering.

Valerie (01:10:14):
Yeah.
Can you imagine this with likecancer?
Like if there were 1 millionkids with cancer and then we
only got 11.6% of those kidsinto shape, can you imagine the
number of lemonade stands thatan outcry that there would be
about, um, that like as a healthproblem and a real, like a real

(01:10:37):
health emergency that theseyoung people are experiencing.

Carly (01:10:40):
Right.
And you know, that makes methink of, you know, the other
take home from this episode forme was when Scott was talking
about the story where, you know,it really clicked for him where
this child is in his waitingroom and he comes in and the kid
is reading Harry Potter and iscoming to him for, you know,
some help with his substance usedisorder.
And it's like, you know, it'ssomething that I think a lot of

(01:11:03):
I'm sure all of the listenerscan relate to like either
themselves or some other kidthat they know who, you know,
really was into Harry Potter andread all the books and all the
things like that.
And so that's such a relatablething, but we don't think about,
you know, kids that agestruggling with substance use
disorders and, and, you know,like Scott was saying, it's
like, but that was the momentwhere it clicked for me that

(01:11:23):
there has to be, there has tobe, you know, this shift in, in
getting the world of pediatricsto understand that this is, you
know, for, to get the worldpediatrics to first recognize
that it's a problem.
And then B to help them sort ofnavigate, like what, what does
that look like?
What does that care look like?
And how can we provide itadequately?

Valerie (01:11:43):
And I think it's so great that we have Scott out
there sharing that story,because if we think back to
Carmen's episode and she talkeda lot about like the power of
storytelling and just liketelling this story and
humanizing who these kids are,like, why wouldn't you want to
get treatment for kids who arereading Harry Potter and their
doctors?
It's like, you know what I mean?

(01:12:03):
I think it's just, that story isreally powerful.
And I also, like, I think I'vethought about that like every
day since we talked to him.

Carly (01:12:10):
Me too well, it's like the, the point that like, you
know, someone that is as youngas, you know, I say that like, I
don't read Harry Potter all thetime, but like someone that's
that young reading, HarryPotter, like we just, you know,
healthcare providers, especiallypediatricians, I think, you
know, they, they just see thekid reading Harry Potter and

(01:12:31):
Scott's asking them to say no,look at the whole person and
like help them, you know, helpthat kid who is reading Harry
Potter navigate, you know, youhave to, you have to stay with
them.
You have to be their, theirpediatrician and carry them
through, you know, all aspectsof their life.
And I think that for a lot ofpediatricians, they just don't
think that this is a, a realthing.
But you know, like I said, itstarts young.
People are in high school, kidsare trying stuff and figuring

(01:12:53):
stuff out and it's important tostay on that and help them
navigate through that phase oflife.

Valerie (01:13:00):
Yeah Carly, beautifully put.
Thank you to the Stigma andHealth Inequities Lab at the
University of Delaware,including Natalie Brousseau,
Saray Lopez and Alyssa Leung.
Thank you to Christina Holsapplewho edited the episode.

Carly (01:13:16):
And I'm going to say special shout out to Valerie,
who was kind enough to researchthis episode while the
undergrads were on break,and asalways thank you to city girl
for letting us use your music.

Valerie (01:13:26):
And thanks to all of you for listening.