Hi, everyone, and welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share their expertise on a very important topic, preventing and addressing substance use in youth and young adults with type 1 diabetes. We're glad you're here. I'm Etta Cengiz, I'll be moderating today's webinar. To share a little bit about myself, I'm a professor of pediatrics at the University of California, San Francisco, UCSF. I'm a Benioff UCSF professor in children's health and the cross-bay director of the UCSF Pediatric Diabetes Program. I'm a pediatric endocrinologist by training, and my research focuses mostly on diabetes technology, insulin action, and I've had a chance to work and publish with experts in the fields regarding substance abuse on diabetes management to improve outcomes for people with diabetes who are navigating the complexities of diabetes. So we'll spend the next hour together by following the agenda on the screen. We'll be using interactive features during today's session. In the chat box, we'll send you important links and information throughout today's session. We also want you to engage. We will have two poll questions pop up during the presentations. Please keep an eye out for them. We will use Zoom Q&A at the end of the presentation for panel questions, and if you think of a question as our presenters speak, use the Q&A box on your control panel to type your questions. You can join us next month on February 11, 2025, for the next installment in the hands-on webinar series. You can easily register scanning the QR code, the link in the chat box, and ADA is seeking members who are interested in being involved in the ADA's interest group leadership team, specifically early career representatives. Scan the QR code for more information. Play a key role in shaping the next wave of diabetes leaders. Now I'd like to introduce the panelists for today's webinar. We have Dr. Alyssa Roberts, who's an assistant professor. She's an attending pediatric endocrinologist at Seattle Children's Hospital, and she's a faculty member at the University of Washington. Her work focuses on diabetes, particularly in adolescents, mental health, and psychosocial concerns. She contributes to the Search for Diabetes in Youth Study, and serves as the co-PI for the Type 1 Diabetes Exchange QI Collaborative. She's passionate about medical education. She directs the pediatric endocrine rotation at Seattle Children's, and she's active on the Pediatric Endocrine Society's Education Committee. In outside work, she enjoys family time with her husband and three young children. And our second panelist, Dr. Rachel Wasserman, PhD, is a licensed clinical psychologist and associate professor at Western Michigan University, Homer Stryker MD School of Medicine in Kalamazoo, Michigan. As a behavioral scientist, Dr. Wasserman applies psychosocial factors salient to adolescence and emerging adulthood to develop novel measures and behavioral interventions that aim to reduce the emotional burdens of young people living with a chronic medical condition, and prevent or reduce unhealthy risk-taking behaviors, such as alcohol use. So now at this time, I'd let our panelists introduce themselves and state their disclosures. Hello, my name is Alyssa Roberts, and I have no relevant disclosures. Hi, my name is Rachel Wasserman, and I'm an employee at Western Michigan School of Medicine, and have support from the ADA for research. Okay, well I'm very excited to be here and present on this topic that I am very passionate about. So thank you for the organizers of this webinar and thank you to my colleagues who are presenting with me today. So the first part of this presentation that I will be giving, I will discuss two kind of key substances, alcohol and cannabis, mainly because these are the two substances that are most widely used and that we have the most data on and most literature on. And I'll speak about how use of these substances can impact diabetes management and glucose levels in someone with type 1 diabetes. I will also spend some time talking about the prevalence of use in both youth with type 1 diabetes and the young adult population. I will then pass the baton to Dr. Wasserman, who will give the second half of this webinar, and she will dive into screening, prevention, and how to address substance use in youth and young adults with type 1 diabetes. As was mentioned, we will save the Q&A to the end, but feel free to start putting questions in the kind of Q&A box as you come up with them, but we will address all of those at the end of both presentations. So first speaking about alcohol in the setting of diabetes. So the primary concern with alcohol ingestion is the risk and heightened risk of hypoglycemia. Now hypoglycemia occurs when blood glucose drops below a level of 70 and can present with symptoms of slurred speech, confusion, dizziness, impaired coordination that if left untreated can then progress to loss of consciousness, seizure, and even death. So very concerning as an acute potential complication. Alcohol consumption seems to increase the risk of hypoglycemia in a few different ways. One is in a direct way, a direct impact on the liver in that it seems to inhibit gluconeogenesis. It also can decrease awareness of hypoglycemia due to some of the symptoms of ingestion. And then there also seems to be an impairment of the counterregulatory hormone response to hypoglycemia. Now what is important to understand is that this risk of hypoglycemia does not just occur at the time of drinking or when feeling the acute kind of symptoms of intoxication. This risk actually persists for up to 24 hours after consuming alcohol. This figure is from a great study that was published that looked at 16 people with type 1 diabetes who were wearing CGM and had them drink a beverage on two separate occasions separated by a two-week period. One of the occasions they drank orange juice and the other they drank orange juice that had alcohol in it as well. And this figure represents the difference in mean interstitial glucose after alcohol ingestion compared to the placebo. And what we see is that at most time points for 24 hours after drinking, the mean interstitial glucose is lower. Also in this study, they found that people reported more episodes of hypoglycemia occurring after the alcohol ingestion. And this is especially important given that oftentimes alcohol ingestion occurs in the evening prior to going to bed. And so this heightened risk of hypoglycemia can really occur at the time of someone sleeping where they can be less likely to detect that hypoglycemia. So really important concept to understand. Now there are other things that can occur with alcohol ingestion that can also exacerbate that risk for hypoglycemia. One of which is oftentimes physical activity such as dancing or walking can accompany alcohol drinking. And physical activity also increases the risk of hypoglycemia during the physical activity. But similarly, you can have that risk for up to 24 hours with kind of a delayed second peak of hypoglycemia. So these two things, drinking alcohol and increased physical activity, can really compound each other and have an increased risk of hypoglycemia later on. There also is a thought that potentially glucagon may not be as effective in the setting of alcohol ingestion given that you can have hepatic glycogen depletion. Now I will say the literature doesn't necessarily demonstrate that this is the case. There aren't a lot of studies out there looking at this. And one that I could find did show that there was still a response to glucagon in the setting of alcohol ingestion. So the way I use this clinically is I discuss that it is best to really prevent getting to the point of severe hypoglycemia because there is this concern. But it is more of a theoretical concern. So if someone were to have a severe hypoglycemia episode following alcohol ingestion, they still should direct someone to use glucagon in that scenario. So not hold off on glucagon in that even if there is a partial response to glucagon, that can be really effective in reversing some neuroglycopenic symptoms. So definitely still worthwhile using. But just another reason why measures should be taken to prevent hypoglycemia in the setting of alcohol ingestion. So knowing that alcohol and consuming alcohol does increase the risk of acute complications of hypoglycemia and severe hypoglycemia in the setting of type 1 diabetes, do people with diabetes still drink? The answer is yes. And I'll show you some data on that in the next few slides. But we do know that in general, especially in the kind of adolescent, young adult period, risk-taking behaviors such as substance use definitely escalate. And that this is the case in youth and young adults with type 1 diabetes as well. So a lot of what we should focus on is how to do this safely. So looking at the data that we have. So in youth, looking at alcohol consumption rates. So this study looks at youth with type 1 diabetes. The black bars are the youth with type 1 diabetes. And the white are their peers. The x-axis is grade level, not age, to be noted. So as you can see, in terms of alcohol consumption, at the younger grades, so 8th, 9th, 10th grade, rates of alcohol use does seem to be lower in those with type 1 diabetes compared to peers. But once you get to the older grades, 11th and 12th grades, it really is similar to their peers. Another study looking at this found that in 100 youth with type 1 diabetes, past year alcohol use was reported in over one-third of participants. And then binge drinking was reported in almost half of participants, or of those who reported drinking. So definitely something that is occurring in youth with type 1 diabetes and something to be concerned about. So here we are at our poll question. So true or false, binge drinking in adults is defined as five or more drinks in a male or four or more drinks in a female over a two-hour period. So I'll give Laura a chance to pull up the poll mechanism, and then if everyone could state their response. And Laura, just let me know when I should, oh, there we go. Okay, so it looks like we have a nice response here. So about 68% of people listening to this said true and 33% false. So yeah, it sounds like maybe some kind of mixed responses. Let's see. Try to progress my slide here. There we go. So the answer is true, but it's a true but. So there's a bit of a caveat. So it's true in adults, that is the definition, but that definition changes when we look at youth. So here on this slide, I have the definition of binge drinking in youth and given metabolism and the size of youth, that it does require less drinks to kind of meet that binge drinking definition in the younger population. All right. So looking now at the young adult population, because most of the literature kind of separates youth out from young adults. So the Search for Diabetes in Youth study looked at around 600 young adults with type one diabetes. And the mean age in this group was relatively young, so 21 years. And in this group, over half reported past month alcohol use and almost a third reported binge drinking. This study also found that males seem to consume more frequently, more drinks at once and more likely to be binge drinkers compared to females. And then in adjusted models, binge drinkers were older, had a higher parental education and were more likely to be current or former tobacco users. And this study did not find an association of alcohol use with hemoglobin A1C or with rates of severe hypoglycemia. However, the absolute number of severe hypoglycemia events were quite low. So it likely wasn't powered to find a difference in that. There's also data in young adults from the T1D Exchange. So this paper looked at almost a thousand adults. This had a slightly higher mean age of 38 years. And they found in this slightly less young adult group that past month use of alcohol was a little bit higher than the younger adults and binge drinking was slightly lower. They also looked at other substance use in this paper. As you can see here, rates of other substance use are also quite substantial. So now that we have data to suggest that, yes, alcohol can result in hypoglycemia, but those youth and young adults with type 1 diabetes are drinking alcohol, what do we do about this? Especially in the clinical setting, how do we address this? So in terms of recommendations around how to drink safely, the ADA has some great recommendations and kind of user-friendly areas on their website. I think Laura will put in the chat. And a lot of these guidelines I use in the clinical setting to really talk to my youth and young adults about how to consume alcohol in a safe environment. So one major part of these recommendations is to never drink on an empty stomach. So always drinking alcohol following a robust meal and making sure to have plenty of snacks when drinking. It's also recommended that they not cover the carb content in the alcohol itself and maybe being more conservative with other pieces of the meal around the alcohol ingestion. Staying hydrated, having a method of carefully monitoring blood glucose, both during and then following alcohol consumption is particularly overnight given that risk that was discussed and then having a more robust target to give more of a buffer overnight given that risk of hypoglycemia. I also really recommend making sure that you're wearing a medical alert ID because oftentimes the symptoms of alcohol intoxication can really look similar to the symptoms of hypoglycemia and both of those can be confused. And it's important to understand that a low blood sugar needs to be treated if that's what's going on. I also recommend that youth and young adults make sure that somebody in the group that they are with when they're drinking is aware of their diagnosis of diabetes and also knows what to look for in terms of the symptoms of hypoglycemia and how to treat, particularly how to get glucagon if needed. So really important to have that as a kind of safety net when drinking alcohol. So shifting gears now away from alcohol to cannabis which is kind of emerging as much more common and prevalent at least from what we've seen clinically especially given the legalization in many states. So in terms of how cannabis can impact blood glucoses directly, the jury's still out in terms of if there's any direct impact of cannabis on glucose metabolism and glucose in that it does seem to cause more insulin resistance in some tissues, but then more insulin sensitivity in other tissues. So it's really unclear. It definitely does not have the same kind of profound direct effects that alcohol does. However, what we do see is it can cause hyperglycemia in general due to the appetite stimulation that often goes with cannabis use. You also can have impaired judgment in the setting of cannabis use and this can result in insulin emission which can result in hyperglycemia also can cause incorrect dosing of insulin which can cause both hyper and also hypoglycemia depending on which direction this goes. And looking at one study that looked at adolescents with type one diabetes, almost a quarter of these adolescents reported prior cannabis use. All of them were aware that they should monitor their blood glucose while consuming cannabis, but not all did. And then about 14% forgot to take insulin when they were under the influence of cannabis. So this can be a issue. And then the same study that was presented earlier looking at rates of alcohol use in youth with type one diabetes also looked at marijuana use and found that almost a quarter of participants endorsed past year marijuana use and then 17% endorsed past four week marijuana use. And of note, this paper was published in 2015 and marijuana has become legal in many more states since that date. And so likely a lot of these rates are continuing to increase as access becomes a lot easier and just the ability to get it. So looking at the young adult population, so Search for Diabetes in Youth looked at this in the adolescent young adult population both with type one and type two diabetes. And they found that 19% of type one diabetes participants were current cannabis users and 19% who were not current users were former users. So that's 40% with some sort of marijuana exposure. And in type two diabetes, these rates were similar. The rates of complications were looked at as well. And in type one diabetes, former or current cannabis users had a higher odds of DKA in the prior 12 months. And then current users did have a higher hemoglobin A1c. The T1D Exchange also looked at this, a cannabis use in their registry. And they found in their adult population that cannabis use was associated with a twofold increase in risk for DKA in adults with type one diabetes. So definitely seems to be a risk of higher A1c and then DKA in those with type one diabetes. So this brings me to some of the key tips from this portion of the presentation. You can read them here. And with that, I will let Dr. Wasserman take the reins and go into the second part of this presentation. Thank you for your attention. Thank you, Dr. Roberts, for that excellent part of the presentation. Today, I'm going to pick up where Dr. Roberts left off and talk more about the behavioral aspect of substance use and risk-taking behavior in general in adolescents and young adults, and then how that might apply to those with type 1. The main objective of my part of the presentation is to talk about evidence-based strategies for preventing and addressing substance use in youth and young adults with type 1 diabetes. To talk about youth and young adults with type 1 diabetes, first, I'd like to pull from what we know just generally about adolescents and young adults. In general, whether or not they have a chronic illness, because there's so much more research being done and has been done in this area for the general population. We're going to start off with a poll. This area for addiction began using substances, tobacco drugs or alcohol, before the age of 18 years old. Is that true or false? Once you lock in your vote, then we should be able to see the results. Okay, so overwhelmingly, most believe that that's true, right, that in the U.S., 9 out of 10, so 90% of adults who meet criteria for addiction began using substances in adolescence, and you are correct. Yes, that is true. There we go. Okay, so yes, the vast majority of adults with a substance use disorder or addiction who qualify for addiction started using substances in adolescence. So among people in the U.S. who use substances, most start in adolescence. And if a person's risk for developing that of those who abstain until age 21. So what this indicates is really the importance of identifying early substance use and trying to delay the onset of substance use for adolescence. So just to kind of go over some general review of some of what Dr. Roberts covered, but again, this is just talking about youth in general, not necessarily those with diabetes. But substance use rates in general are relatively stable. Cigarette use has declined, but vaping and e-cigarette use and marijuana use have increased. And also with the vaping, there's some research that suggests that there's some confusion sometimes even about what's in the vape, and that some adolescents may not even realize that what they're vaping is tobacco or marijuana, for example. Also, substance use is typically initiated in adolescence, as we had talked about before. Typically, the most common like first substances to be used are tobacco, alcohol and marijuana. And as the true false poll indicated, adults are much more likely to develop a substance use disorder if these substances are initiated in adolescence, especially if they're earlier in adolescence. So what are some risk factors that can lead to adolescent substance use? We can kind of break this down into different areas of individual familial and social risk factors. So as Dr. Roberts went over already, males tend to have higher rates of substance use. That was true in the studies that she covered as well. Also, early trauma exposure, so adverse childhood experiences, things like exposure to violence can be or abuse can be a risk factor for later substance use. Prenatal exposure to drugs and alcohol, co-occurring psychopathology, so like depression, anxiety. Oftentimes, people will use substances as a way of coping with those depression or anxiety symptoms, and then sleep problems as well. In terms of familial risk factors, family history of substance abuse or addiction is a risk factor. Parental behavior, their behaviors around alcohol use, how much they use, and then also their attitudes towards alcohol or other substance use. So, for example, if they allow their adolescent or underage people to be drinking at family gatherings. And then parental neglect or limited supervision can also be a risk factor. In terms of social risk factors, if peers are using, that's a risk factor. Also, in the peer literature, they break it down into different aspects of how peer relationships can affect substance use. So there's a selection of who the person is selecting to associate with. Socialization of how much the other peers, what they're doing is influencing that person. And then social norms is kind of the expectation or the belief of the person in terms of how much other people, how often other people are using. If an adolescent is in a romantic relationship, that's also a risk factor for using substances. And then media and social media influences can also increase substance use. Okay, so what are some models that we can pull from the adolescent decision making research to kind of better understand why a person, especially a young person, might take risks, engage in mistaken behavior, or even substance use behaviors? So there's two models that I'd like to talk about today. The first is this idea of executive functioning development. So what we know about adolescent brain development in particular is that the prefrontal cortex, which is the area in the front of the brain, is most responsible for higher level cognitive tasks. We also call it executive functioning skills, things like organizing, planning, problem solving, and it also helps to control impulses as well. And we know that the prefrontal cortex is one of the last areas of the brain to mature. So these are things that adolescents are still, these are skills that adolescents are still developing. And the other thing about executive functioning skills is that there are what we call cool executive functioning skills, and these are executive functioning within a cool environment. What I mean by that is that one that is not very high in emotional or social intensity. So, for example, this could be like at home or in the doctor's office, hopefully where someone is relatively calm and there's not a lot of pressure to act in a certain way and the emotions are not running high. So these are the kind of like optimal executive functioning skills, and we know that these, again, are still developing in adolescents. And then hot executive functioning is this idea that, yes, these are, that executive functioning skills can be optimal in cool settings, but when someone is in a situation that is hot or highly emotional. So, for example, at a party, at a concert, that those are places where emotions are running high, where there's a lot of social pressure around that planning the same skills. So the same executive functioning skills of planning, organizing, problem solving actually occur in different areas of the brain than they do when someone is in a cool environment. And there's some research to indicate that these hot executive functioning skills or being able to use these skills in hot environments actually takes longer to develop even than just the cool executive functioning skills on their own. So how does this apply to adolescents and risk taking behavior? So, again, if we think about the doctor's office as a potentially cooler environment, right, there's not peers, there's no social pressure, or less, I should say, less social pressure, and hopefully emotions are lower, that a person, you know, a young person might say, no, of course, I'm not going to drink. Of course, I'm not going to use drugs. Of course, I'm not going to, you know, I'm not interested in any of those things. However, in, and they might be able to tell you, sorry, in that doctor's office, like their plan for being able to abstain, you know, from those things. However, when they're in a hot environment, like if they go to a concert later that week, you know, with friends, with peers, that those same, the same process of thinking through how they might abstain or how they might say no or reasons why they might say no to using substances, that their brain is actually going to process those questions differently in that concert context than when they were in the doctor's office. Okay. So that's the first model that I like to draw from. And then the second model that I'd like to discuss and kind of draw from to, again, explain these like risk taking behaviors, is something called the behavioral willingness model. And it's this idea that the risk taking behavior all the way at the right here. So whether that's, you know, engaging in substance use, it could be any risk taking behavior, right, like engaging in a fight, or sexual risk taking behavior, that there's this idea that we have like behavioral intention. So this is what someone has an idea of what they set out to do, what they plan to do. So an adolescent might say, for example, I have no intention of drinking at any point in life, or I have no intention of drinking at this party that I'm going to go to on Friday. That's their intention. And that's one way that an adolescent might decide to take a risk. So they might say, you know, actually, I'm going to go to this party, and I do plan on having a drink at this party. And then that's one way of getting to the risk taking behavior. Another way is this idea of behavioral willingness. And this model, what I like about it is that it captures what I think happens more often, especially for that initiation of substance use in the behavioral willingness. So this is if they're in the situation, would they be willing to engage in that behavior? If they go to the party, not really having an intention to drink, but if someone hands them a drink, would they then, are they willing to take the drink and drink it? And the idea of this model is that it's really both of these pathways that can lead to risk taking behavior, not just the intentions of the person. And then in terms of what can go into either the intentions or the willingness, is this idea of perceived vulnerability. So how susceptible am I as a person to bad things happening if I were to engage in, you know, in drinking this, this drink of alcohol? And then norms, like what are other people my age doing in terms of the risky behaviors? That can influence both intentions and behavioral willingness. And then risk prototypes. This is this idea of what would someone who drinks, what kind of person is, is that person, someone who drinks? This idea, an image, or a model of the type of person who engages in either alcohol use or other risky behaviors, that that can lead to this idea of, or to the pathway of willingness. So these, I think the importance of this model is that the two circles on the left are potential areas of intervening. Like these are factors that we could potentially intervene on, and that would affect both behavioral willingness and behavioral intention. So how can we give more accurate information, for example, about someone's risks of bad things happening? So, for example, a risk of hypoglycemia after drinking alcohol, specifically for youth with diabetes, and also more accurate norms. A lot of adolescents think that everyone is drinking. And actually, the data shows that most adolescents and adults are not. So these are, these are ways that we could intervene in order to prevent both someone's intentions and also their willingness to engage. alcohol store, or asking someone to purchase alcohol for them, versus going to a party and the alcohol being there. One, going to the store would be the intention, like I'm intending to engage, I want, I'm seeking out a drink in order to engage in that alcohol use, versus willingness, I happen to be in this situation, and so then I'm willing to engage in this behavior. Okay, so main takeaways from these two models, and then we'll apply it more specifically to how we can then focus on preventing substance use. Main takeaways are two main goals for addressing substance use in youth, like adolescents and adults. One, delaying the initiation of substance use, because that can reduce risk for later developing substance use disorders. And then second, reducing rates of use, so how often they're using, and then using a harm reduction approach to try to reduce the harms associated with substance use. So if they are using, are they then being, using it in a way that they're preventing some of the potential harms. Number two, context is absolutely important. What an adolescent is able to think through and plan out and process in a low stakes, kind of like emotionally calm environment is a lot different than how they might, the decision that they might make in a hot environment. And that I think is very hard sometimes for parents, especially to understand when they believe, you know, oh, my child would never, you know, my teen would never do that. They may talk through and demonstrate how responsible they are in a cool environment, but it can be hard to take those same skill sets and use them in an environment where they're with their peers and when emotions are running high. So then, number three, takeaway is that prevention is key. Willingness to engage in a behavior is just as important as the intent. And then four, perceived vulnerability and norms are drivers for both pathways. So we could potentially do a lot of work in preventing substance use if we focus on those two for prevention efforts. So what do we know about what works for preventing substance use in teens? One, identify use as soon as possible. Again, trying to catch it early. Educating about risks and consequences. And this is more so in a calm way, not necessarily trying to instill fear, but really to provide education. And then three, educating about normative data. So the fact that most adolescents and adults don't use alcohol or other drugs. Four, confidential communication and active listening. So creating a safe space for the adolescent to feel like they can open up about these behaviors, which sometimes they could feel judged about. Five, brief interventions with motivational interviewing, which we don't have time to go into that today, but motivational interviewing is a set of skills and strategies for talking about these types of risky behaviors in particular and trying to move adolescents to the point of wanting to wanting to have motivation to abstain or to reduce harms related to these types of risky behaviors. And then embellishing the family and having the family more involved. Usually this can be beneficial for adolescents. They show, for example, that having family dinners together is a protective factor against adolescent substance use and substance use disorders. However, of course, you know, that takes clinical judgment and knowing this particular situation and that not all families are a safe space. And then addressing mental health concerns because they often do coexist. The anxiety, depression, or symptoms can coexist and be often even a reason for engaging in substance use. And then referral to a specialist for problematic use. So all of these earlier tips or strategies really can be helpful in identifying and screening for and then even preventing substance use or even preventing some of the harms associated with some who are maybe like experimenting or not using to a level of addiction or substance use disorder, like we're qualified for substance use disorder. But once an adolescent kind of gets to that point where it has become an addiction or qualifies for a substance use disorder, then really a referral to a specialist is the most effective way of helping that adolescent. And then what do we know what doesn't work? Well, one, just saying that abstinence is the only way or encouraging abstinence only by saying, you know, well, I'm not engaging in conversations if the teen is, you know, asking for education or asking for strategies or information to help manage their substance use behavior. And just saying, and not giving that education, but just saying, no, we recommend that you don't drink, period. Threats and scare tactics we also know are not effective. Shaming and blaming. Again, this could potentially, you know, cause the adolescent to not feel like they're in a safe place where they can talk about these behaviors. Ignoring family dynamics because the family system is so important, especially in adolescence. Again, that lack of confidentiality. So being very clear from the beginning about limits and boundaries of confidentiality. So that way, if you do have to break confidentiality, the adolescent is prepared ahead of time and doesn't feel like they can't trust the person that they're talking with. And then treating substance use in isolation. So this is in reference to, for example, not addressing, you know, depressive symptoms or anxiety symptoms, but really targeting just the substance use. And then one single conversation, we know that this is, it's likely that one conversation or one, you know, class assembly is not going to prevent someone to, or reduce someone's substance use in the long term. Okay. So how might we integrate these strategies specifically for youth with type 1 diabetes? I'm going to go over this real fast. This is really more so for reference, but the ADA guidelines and standard of care do talk about screening for substance use, eliciting a history of use, and then discouraging specifically like electronic cigarette use or marijuana use. And then also in the, and it's in various places in the child standard, child and adolescent standards of care, and then also in the adult chapter. And then SAMHSA, there's lots of really great resources for implementing evidence-based practices for screening and preventing different kinds of substance use for adolescents. And these are really excellent resources and toolkits if you're interested in implementing these kinds of interventions that have been evidence-based. And then just one thing I wanted to introduce is this idea that has been used in general primary care for pediatrics and is recommended by the American Academy of Pediatrics, but I don't think has been implemented really in specialty care clinics, is this idea of screening brief intervention and referral to treatment. It's kind of a model for how to identify and provide brief intervention for adolescents regarding substance use. And it's the idea that you screen all patients and ask using validated screening tools, whether they're using or whether their friends are using. And then based on that score, there's an algorithm for whether there's further screening or brief intervention or a referral to treatment. And there's a reference here, the website through the American Academy of Pediatrics where there's more information about this particular model. So key tips and takeaways from my part of the talk today, abstinence-only approaches are known to be ineffective, that things that are effective are education, brief interventions, family involvement, all these things can reduce substance use, but for substance use disorders and addiction, they often really need more of a specialist referral. And adolescence is a vulnerable time for initiation of substance use and substance use disorders. So it makes prevention and early identification really crucial for this age range and this developmental stage. The SBIRT model is an example that integrates evidence-based substance use identification and treatment into pediatric care. It's possible it could benefit youth with type 1 diabetes, but again, there's not a lot of literature or examples of that yet. So thank you very much for your time and attention. We'll go to questions. Thank you. So remember these five hands-on takeaways from today's panel. I'm gonna leave it on the screen slide up for a little bit so you get a chance to read. And for those who joined a little later who'd like to come back and watch our webinar again, it's gonna be, the recording is gonna be available on the Institute of Learning site, I think in about a week. So you can always come back and watch these great presentations from the site. I'd like to thank our panel, Dr. Westerman and Dr. Roberts for these excellent presentations today. They were very informative, engaging. Again, I learned a lot and I'm pretty sure you learned a lot too. If you have any questions, if you haven't already done so, please ask your questions in the Q&A box. And I'll see you in the next webinar. Thank you. I'm gonna ask your questions to today's presenters by typing them in the QA box on Zoom. And we already have some questions. So I'm just gonna go ahead and start with our first question. And this would be both for Dr. Roberts and Dr. Westerman because we need a psychologist and a clinician diabetologist perspective for this question. So how about recommendations of having conversations for patients who are admitted to the hospital? Because at the clinic as clinicians, we don't have a lot of time. Unfortunately, we have such a short time to address so many things, but often we admit them in DKA and then that's when substance use comes out. So what are your thoughts? And I'd like to start with Dr. Roberts and then Dr. Westerman. Yeah, I can answer part of this, but yeah, I definitely would like to get Dr. Westerman's thoughts on this as well. This is a question that's near and dear to my heart right now because I'm actually on service this week and we've already had a couple of patients who presented in DKA and some either overdose or substance abuse has been a part of their clinical picture, but it's very tricky. In terms of, you know, I think one thing is always having this on your radar as kind of a potential risk factor for DKA. So screening patients, so doing a urine tox screen when patients are admitted for DKA. And then at least, you know, as the, just trying to get to that as part of potentially the inciting factor to their DKA. Sometimes I'll use like the positive urine tox screen to be like, hey, we saw this on your tox screen. Like, can you tell me about, you know, what, why this or what happened and kind of use that objective evidence that they had some recent drug use as a part of that conversation. I think it gets trickier when you have a negative screen which can often happen because a lot of substances can pretty quickly be metabolized and not be detected on the urine screen. So then it's more at really trying to kind of dig at it as part of your general screening question, like doing a great heads assessment or other kind of just screening other risk behaviors. But once you've kind of determined that substance use might be a concern, I guess that's where I will have Dr. Wasserman, I mean, I know for our, we definitely rely on our social work and psychology colleagues here to help with some of that conversation once we kind of determine that there may be a concern. So I don't know, Dr. Wasserman, if you want to weigh in. Yeah, I think that's a really excellent question. And I think like Dr. Roberts mentioned, I think it's happening not just for this person, this anonymous attendee, but that this is happening in hospitals and clinics across the nation. And I think it's also something that we struggle with across the nation, that it's not, I don't know that we have like a really excellent way of connecting, not even just for diabetes, but really anyone, right? With substance use treatment at the right level, especially going from like an inpatient to another system or another setting. I do think that consulting with social work, with psychology, with your mental health supports, I think that would be fantastic, involving them on the team. And then also in terms of, like you mentioned, when they're coming in inpatient, there's a chance that you may not already have much of a relationship with that person, with that patient, with that family. And so then it can be really hard. Whereas when you're seeing them in diabetes clinic every few months, ideally, you get to know them a lot more, the rapport is already there. So I think on one hand, that can be challenging. On the other hand, it can also be an opportunity because sometimes adolescents feel like they can open up a little bit more even to people that maybe they don't already have an established relationship with. And so it could be an opportunity to have that conversation about like, well, what does substance use look like for you? Really drawing, I think in that moment, focusing on like that education piece and that harm piece, like drawing the connection between like for them, what did this mean when they use substances and how might that affect them being in the hospital in this moment? Like kind of really drawing that connection. Not in a way, again, of like trying to instill fear, but really trying to provide education about how that might affect their diabetes management and their potential health consequences. And then in terms of referral, obviously social work can be helpful with that. SAMHSA on their website, they also have a website where you can look up different substance use providers at different levels, whether it's inpatient, outpatient groups, and also for different age ranges, like for adolescents, young adults, adults. So that could be a helpful tool. And then in that SBIRT model, the referral to treatment part, that's a whole part of the SBIRT model. And so there's even training available on best practices for how to refer an adolescent and talk to the family about substance use and how to try to get them connected in the best way once they are released from the hospital. Thank you. I'm going to merge two questions. That's in the chat box, the Q&A Zoom chat box. It's regarding abstinence. And I'm going to address this question to Dr. Westermann first, and then maybe Dr. Roberts can weigh in later on. So the question is abstinence is ineffective regarding substance abuse. Is this for adults and not for adolescents? And the second part of the question is, how do you suggest handling it when families have differences of opinion about abstinence-only approaches to substance use? Those are really great questions too, yeah. I think that, so the first question about abstinence-only or abstinence as being ineffective, asking if that's more so for adults than adolescents. So I want to be clear that, especially for adolescents, we're trying to delay initiation, and of course we're going to encourage abstinence. What I'm saying is that's not effective is when we're saying abstinence-only in that that's all that we say and that's where the conversation ends, is just any conversation around alcohol or substance use being like, well, nope, just don't do it. And then the conversation ending there. The conversation ending is the part that's ineffective. If it becomes more of a conversation about, this is why we recommend abstinence. This is why we recommend not using alcohol. This is why we recommend not using substances and providing that education. That's the piece that is really important is making sure the conversation doesn't end at abstinence. And I think that when addressing that with families, I think that's a very good question. Like for example, families where alcohol use is not, or substance use is not a part of the culture, it's not a part of like, it's not a condoned behavior, that talking to parents and saying, hey, like this may never ever come up for your teen, but I want to make sure that we're providing all the information about your teen's body and diabetes and how things like substances can affect a person with diabetes. So that way they're fully informed. And even that way, they're also sharing this information potentially with other people that they know with diabetes. So the information's out there. Almost like the idea of having a fire extinguisher in the house. We don't plan that there's going to be a fire. We don't anticipate there's going to be a fire, but it's good to have that there just in case. I'll leave it at that. I'll pass that on to you, Dr. Richards. Dr. Roberts, where are you? I think you covered it. Yeah, yeah. Good, yes, thank you. Excellent answers. So another question we have is, and I think this might be a good question for Dr. Roberts. I was really impressed with the cannabis statistics you presented during your presentation. For young adults who want to use cannabis recreationally, what are some strategies for them to manage their diabetes effectively? Yeah, good question. I think monitoring blood glucose is a big part of that. And so preferably if they're on continuous glucose monitoring, that would help. And then I think the issue tends to be with kind of a lot of the grazing that can happen along with uncovered carbs, you can get just a lot of sustained hyperglycemia. And so I think for that, the closed loop systems are probably a great way to help mitigate that a bit. But if they are on MDI and not a pump CGM connected system, it's just really trying to, as much as possible, bolus for the carbs they're eating, if they remember to, or trying to like, if they're wanting to graze a lot, having more like lower, maybe lower carb options, right? Like more like have a bunch of string cheese or something that is not necessarily gonna spike you quite as high. And then in terms of the DKA risk, I think a lot of that has to do with the sustained hyperglycemia, but also the, if you miss doses, especially if you miss your Lantus or if you're on a pump, if you don't recognize that you may have like a PODS, if you don't change your site or have a PODS or something that could then lead to DKA risk. So I think that that's a little bit trickier, but kind of the same thing as we would do to have, anyone who's having trouble remembering their insulin, maybe setting an alarm on their phone that can kind of remind them to take their long-acting or change their POD site, things like that. But yeah. Thank you, Dr. Roberts. Another question we have is, I'm just gonna read the question. I used to lead conversations at camps for kids with diabetes about alcohol and substance use. And one thing that came out as a reason for their use was to escape and not have to always think about keeping blood sugars perfect in range. Is this also something you find in your practices as a reason for substance use abuse and how can we help them not feel like they need to escape? And I'm gonna ask this question to Dr. Roberts and Dr. Wasserman, if you'd like to add, you know, Wayne later on, please do so. Yeah, this is great. I do think this definitely is the case. And, you know, I'd have to look, but I don't think there's a lot published out there in terms of like diabetes distress and how that might relate to substance abuse rates. There might be, Dr. Wasserman, feel free to chime in. I haven't looked at that specifically recently, but that, you know, I think that we know like diabetes distress or kind of distress around just having diabetes and the tasks associated with it is high. And it's something that's really associated to a lot of clinical outcomes and other mental health outcomes. Something else I'm really interested in looking at. And, you know, I think it definitely is likely associated with increased rates of substance use and potentially abuse. So yeah, great question. I don't know, Dr. Wasserman, if you wanna chime in on that. Yeah. All right, can you hear me okay? Yes, I'm having internet connection issues, but yes, I would absolutely agree. I think that that's an astute observation and something that I think for sure has happened for others. I also would say that for particularly youth with diabetes, a common thing in adolescence is this idea that they feel different from their peers because they have diabetes. And so sometimes alcohol use or substance use can be a part of a way of feeling more normal or fitting in if their peers are also engaging. And so they're like, okay, well now I'm doing something that is normal for my age. And that being said, I also wanna specify that each person's reasons for using can be very different. So really, I think when you have a family in front of you, when you have a teen in front of you targeting their personal reasons for use, what is it that they're getting out of this personally, that that can be the most powerful thing in changing their behavior rather than kind of coming in with maybe some assumptions of what it might be. Thank you. We're running out of time, but I think we can maybe answer this question very quickly. Any good resources for youth with more of a harm reduction lens? Any comments on that, Dr. Wasserman and Roberts? Yeah, I think in terms of resources, I would say a motivational interviewing definitely is, I think, a good resource and there's lots of resources out there. And in particular, that SBIRT model tries to incorporate motivational interviewing. So a lot of the resources around SBIRT also include some resources about MI skills too. That's my short answer. But Dr. Roberts, did you have anything to add? No, not really. I mean, we use, and I was just trying to, I don't think I have quite enough time to track it down, but we have a handout that we use at Seattle Children's that's available publicly. It's under our toolkit. Do some Googling. That just talks about really focusing on the facts, especially with alcohol in particular. It's talking about the impact and risk for hypoglycemia and just kind of a fact sheet. So I feel like that, I don't know if that's what this, what Jackie, what you're getting at, but that, I mean, I feel like we try to approach it with our written materials and the conversation of like, if you do end up experimenting with alcohol, this is how you do it safely. And so, and I think that most institutions probably have similar handouts available, but Seattle Children's, we definitely do have one on our website that we use. Thank you. So before we end today's session, I wanted to let you know what to expect from this point. Later today, you'll receive a post-test by email. Please complete it soon so you can claim your CE credit and look for today's webinar recording on the ADA's Institute of Learning page in a few weeks. And you can remind any fellow members that they can watch the webinar for one CE credit, eligible until December, 2025. I want to thank our panel again for sharing their expertise today for these excellent presentations. I also want to thank you for joining us. We hope to see you at another ADA webinar in the future. And this concludes our session. Have a great afternoon and see you next month.

substance use

type 1 diabetes

youth

alcohol

cannabis

hypoglycemia

prevention strategies

behavioral aspects

family involvement

educational approach