Episode 27
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[00:00:03] Michael Donovan: Welcome to the Evidence to Impact podcast, the podcast that brings together academics and their research partners to talk about insights and real world policy solutions in Pennsylvania and beyond. I'm Michael Donovan, the Associate Director of the Evidence to Impact Collaborative here at Penn State. In this episode, we'll be discussing adolescent substance use. My guests today are Dr. Steve Sandelich, assistant Professor in the Departments of Emergency Medicine and Pediatrics at Penn State Health, and the Associate Director of Outreach at the Penn State Addiction Center for Translation or PSACT. I'm also joined by Sarah Ballard, the Assistant Director of Outreach at PSACT as well. Today we're gonna be discussing a number of topics related to adolescent substance use, in particular the substance use school outreach initiative, but first, I'd love to give my guests the opportunity to introduce themselves a bit, Steve. 

[00:01:02] Stephen Sandelich: Thank you very much for that introduction, Michael. As you said, my name is Steve Sandelich. I am one of the emergency medicine doctors here at Penn State and I work in the pediatric emergency department. My research interests really focus on adolescent substance use. A lot of that stemmed clinically from seeing a lot of teenagers coming in with substance use problems, specifically coming in with withdrawal issues and trying to one, figure out how we can best treat these kids and how we can affect system-based changes to make sure that all of my colleagues across the country are able to treat adolescents with substance use, substance use disorders, and withdrawal. 

[00:01:41] Stephen Sandelich: This is morphed into a lot of outreach out into the community, into schools trying to identify best ways to reach kids as early as we can and try to identify ways to intervene and just sit down and talk to kids about substance use and, it's dangerous. 

[00:02:01] Michael Donovan: Great. Steve, thank you so much. Welcome to the show.

[00:02:03] Michael Donovan: And Sarah. 

[00:02:07] Sarah Ballard: Hi Michael, I'm Sarah Ballard. I'm the coordinator for the Penn State Addiction Center for Translation. And I've been with Penn State for over 16 years, I came out of a basic science lab working with Sue Gregson where we studied addiction and I've transitioned into more work with humans and a lot of outreach.

[00:02:28] Sarah Ballard: And my passion is really harm reduction. 

[00:02:30] Michael Donovan: And when was PS Act founded? 

[00:02:31] Sarah Ballard:, My boss, Sue Gregson created the Penn State Addiction TRA Center for Translation about 10 years ago when she identified a need for researchers and clinicians at Penn State to be talking more with each other and sharing their findings and really using the research that we're finding to drive the work that we're doing with patients. 

[00:02:54] Sarah Ballard: And so the PSACT really has four major arms education research, clinical, practice and outreach. 

[00:03:08] Michael Donovan: Excellent. Thank you so much. Welcome to the show. I'm very excited for the conversation today and I'd love to go building off of Steve's initial kind of framing to particularly around the substance use school outreach initiative and getting a little bit of context about the study and how that is as you mentioned, Steve morphed into, different areas. 

[00:03:28] Michael Donovan: So, what were some of the main goals of this study and how does it really connect to, the broader work that outreach is doing? 

[00:03:39] Stephen Sandelich: Thanks, Michael. So this study initially was something that we had started quite a while ago, and initially it came about for us to try to understand better how to screen adolescents. For substance use, specifically in the emergency department, mostly because that's where I work and that's where I see all of, my clinical patients.

[00:04:00] Stephen Sandelich: So my field in pediatric emergency medicine has been working for a while to determine the best way of screening adolescents for substance use as they're coming into the emergency department.

[00:04:11] Stephen Sandelich: Should we be screening all kids, just those that we think are high risk? What does the high risk group entail? So we're really trying to figure out the best ways to, one, use proven tools that we know work for screening, and find the best ways to implement those tools. Our study specifically was a survey of both adolescents and their parents trying to figure out what they thought as the best way of screening and what they thought would be the best way for us to be doing screening and trying to identify some of those barriers to screening.

[00:04:46] Stephen Sandelich: Often in medicine and in research, we come at things as we, the expert, know best and just try to implement. One of the things we are trying to do with this study is taking a step back and asking kids, asking parents what they think is best, what they think are barriers, what they think are issues related to screening, and just adolescent ideas and perceptions on substance use in general.

[00:05:19] Michael Donovan: And what was the overall size of the study, and how, what was your recruitment like were they folks that you engaged in the emergency department? 

[00:05:28] Stephen Sandelich: So these were not folks that we talked with in the emergency department, it was an online survey through Qualtrics. We had 548 adolescents and 544 caregivers.

[00:05:40] Stephen Sandelich: And it was a online survey that they completed, both asking about their experiences with screening in the emergency department as well as their perceptions and thoughts about should screening be done, how should screening be done, and different barriers or facilitators for screening practices. 

[00:06:01] Michael Donovan: And I'd love to hear a little bit if there's, were there some interesting findings related to misconceptions that made you all and the research team rethink how you were approaching this? You mentioned having that ground truth from the folks that are actually experiencing this can be so valuable and, is so vital to learning more stigma, I think would be a really interesting topical area that we discussed quite a bit on the podcast today. I wonder how that kind of came up in, in the responses. 

[00:06:30] Stephen Sandelich: That actually came up in, in a huge way. We did both qualitative and quantitative analysis. So we looked at numbers as well as people's free text written responses and looking just at the numbers, some of the biggest barriers that we saw were things about privacy, were things about, what are you going to do with my information?

[00:06:48] Stephen Sandelich: Why are you asking me this? And that was really reflected in a lot of those free text answers that people gave us. While the numbers did show that people in general thought screening was a good idea, a lot of what they wrote talked about that privacy aspect that we don't wanna be labeled. We don't wanna have people think of us as druggies as users, and how is that going to impact how my provider then interacts with me. So looking at those responses, there is a huge aspect of stigma and we're also seeing that when we're going out into the community to kind of bounce off the paper a little bit when we're going out and talking in schools in different community venues. I'm hearing that from kids all the time and that they don't often don't want to discuss that because they don't wanna have these labels put upon them.

[00:07:43] Stephen Sandelich: And that's a huge thing we are trying to fight is that idea, of stigma.

[00:07:49] Michael Donovan: So thinking through the responses that you were able to get in the freeform qualitative assessment with the survey, I wonder how that really translates into on the groundwork in schools, for example we're thinking about how do, how are we institutionalizing this? You mentioned this earlier around screening tools, often where we're able to reach kids the best, is in school environments. So I wonder if you could talk a little bit more about how the survey findings have translated into your work in schools. 

[00:08:22] Stephen Sandelich: So I will say that our work in schools is an evolving project. Sarah and I have started this, almost a year ago, and it really stemmed out of us just. Cold calling, emailing schools, asking if they would like us to come in and talk with their kids,And there have been quite a few different programs throughout the years from Nancy Reagan to the DARE program that have been attempting to have outreach into schools.

[00:08:50] Stephen Sandelich: Some have been more successful than others, of course, and there's certainly evidence that different programs have benefit and some have not been shown to have benefit. We are trying to find the best ways to reach each individual school, and one of the things that we have found interestingly is that maybe not surprisingly, every school and every student is a little bit different. What seems to work well with one school may not work well with another school. So one of the things that we have started at is just a baseline going to the schools and asking them what do we feel is going to work best for your students?

[00:09:28] Stephen Sandelich: We've had some schools where we have set up tables in lunchrooms, some where we have gone in health classes and have more of a lecture type of, a format. One of the schools we're looking at now, we're working on an idea of trying to bring in a person with lived experience to talk with students after they come back from disciplinary events and suspension from detention, those type of things.

[00:09:53] Stephen Sandelich: And talk to them about this idea of harm reduction, where, I'm not saying you need to stop using everything completely, but how can we find ways to reduce your use in a more safe manner? We actually are having a meeting with one of our schools soon, and one of the big things we're trying to do is get students involved in these meetings, trying to get the voice of the adolescents of the students and try to figure out, what do you want as the student, as the, as a user of whatever program we're developing.

[00:10:24] Michael Donovan: Yeah, I love that approach. Really trying to understand that you need to meet them where they are that there's adaptation required to your outreach, protocols or efforts. And also ultimately looking at it from approaching this with humility and empathy, understanding that there's gonna be very different approaches.

[00:10:42] Michael Donovan: But the goal is to find how to get through how to reach them, where they are. Are there any key takeaways broadly recognizing that there were a different set of tools for different organizations, but what was your trick to making sure that students felt that they were in a safe and non-stigmatizing environment to share is sharing over Qualtrics online, is one thing, but engaging with folks in person and, folks who, are authority figures is a different one. So I wonder if there's any learnings from there?

[00:11:13] Sarah Ballard: My favorite thing that we did to try to help the students feel comfortable with us being there.

[00:11:19] Sarah Ballard: You know, apart from trying to keep it very casual and, conversational as we gave some basic information, but we kept at least half of the presentation open for answering questions, and we invited those questions through anonymous methods. The teachers would, in the days leading up to the speaking with the students would collect, you know, note cards without names on them, with just any question that the student would have.

[00:11:48] Sarah Ballard: So they didn't feel pressured or stigmatized or anything for just asking questions. And the questions we got were really great. Some of them were, very basic and some of them were very high level and some of them were fun too, right? Folks wanted to know what our experiences with drugs were, they wanted to know just all kinds of things. And I really appreciated that they asked us all those honest questions and that we were able to address them, and really hopefully make a difference and fill in some gaps that they're missing in their education that they're getting from the rest of the world.

[00:12:33] Sarah Ballard: And hopefully, soften some of what they're getting from the rest of the world and alleviate some of their concerns or any, you know, self-stigma that they might have.

[00:12:45] Michael Donovan: Yeah, I was just thinking about that, how stigma can go in different directions here and it's really could be such a topic that is, off limits for students, in certain communities and certain families and certain dynamics are very different. So having a space that is psychologically safe and open to free discussion, I think is, really valuable. And also recognizing, you know, that lived experience component, I think there could be a lot of from our previous guests on this podcast around lived experience and substance use. I think it would be highly valuable to the students that, you work with, was there any approach to or systematic approach to engaging with certain schools or districts? Was there you know, a recognized need? Was it the nearest ones to you geographically? Has there been anything that has kind of structured your approach to different schools, and I wonder if there's been schools, or districts that have been wary.

[00:13:42] Stephen Sandelich: We are open to come and talk to whoever, wherever, anyone at all. Our initial approach came out of the National Save Life Day, which is a initiative to try to get Naloxone into as many hands as possible out into the community. That is something that Sarah pushes hugely and has outreach into many, many different areas. One of the things we are trying to do is trying to get that into schools and while many schools were wary of us bringing in actual Naloxone and handing it out, we were at least trying to open that door of conversation to schools for letting them know that we are here and that we are open to try to meet their needs wherever they are.

[00:14:24] Stephen Sandelich: As to the approach to getting schools, to be totally honest, I pulled up Google Maps and typed in high school and contacted everyone within a driving radius of me. So it was just a very open-ended seeing who's going to talk. I think I sent about 40 or 50 different emails to administrators tapped into all of the kind of professional connections that I knew people with kids in schools that even knew people in schools. So we contacted pretty much as many people as we could think of contacting. The response was unfortunately not huge. I only had a handful of schools reach out to us, and even those ones that did reach out were very it was varied on how much they were willing to let us come and talk, what type of materials we were able to bring in.

[00:15:15] Stephen Sandelich: Almost exclusively known one was willing to let us bring in actual Narcan. Some schools let us have training devices to show kids what Narcan was, but it was very, it's very school by school. And I think that really goes into the stigma that you talked about, Michael, that it's such a huge barrier out there. Many of the schools we, that I talked to came back with that, it's not a problem in our school, it's not a problem in our community. And I would push back a little bit that it is likely a problem, you just don't know about it. And that stigma is so real that people just don't talk about it. One of the other research papers we looked at EMS activations for opiate related activations, and we found that there were actually more of them in more affluent communities.

[00:16:09] Stephen Sandelich: So it is everywhere, it's just, are you asking the right questions? Are you open to talking about it?

[00:16:16] Michael Donovan: Yeah that heterogeneity of response really reflects the diversity of school districts across Pennsylvania as well. I think over 500 different school districts that have very different approaches to addressing challenges that are heavily stigmatized and maybe hidden in their stigmatization. 

[00:16:34] Sarah Ballard: I did just wanna add that in working with these schools my overall impression is that there's a lot of fear. There's fear about substance use and what substance use is, there's fear about acknowledging that it could be in their student population.

[00:16:50] Sarah Ballard: There's fear that they don't, that they feel unable to deal with it once it is, you know, once they're aware of it. and then there's a huge fear about what parents are gonna say and come back on them for the materials, for the whatever education they're giving. And I think we're really trying to balance all of those things and come in as a very neutral, very, just kind of a voice, of reason and presenting facts, and nothing inflammatory. Even though even just by, you know, mentioning the terms harm reduction now, unfortunately seems to be a problem, and I have to say, I'm very thankful for the schools that have partnered with us so far, they've been wonderful.

[00:17:37] Michael Donovan: Great, and we want this podcast to be an opportunity for further engagement. So we'll have opportunities at the conclusion around, Steve, and Sarah's contact information if anyone out there is interested, in hearing from them. And to that point I would love to talk about scaling this. So, the Penn State Addiction Center for Translation is one robust decade old organization, but how do we grow this to really have a bigger reach across Pennsylvania and across various environments, in the US? And I wanna think a little bit, structurally Steve, around how does your field in pediatric emergency department support, such efforts? 

[00:18:21] Stephen Sandelich: So thinking from a more broad standpoint, prevention has always been huge in my field. In pediatric emergency medicine, we push for things like car seats, push for things like gun safety, for things like helmets when riding your bicycle. I see traumas every day. And the idea in the emergency medicine field is, can we prevent those from happening? Prevent you from having your child in my trauma bay, how do we go a couple steps before that and address some of those causes prior to, so pediatric emergency medicine is certainly primed for prevention. Substance use prevention is not as often addressed in the pediatric emergency medicine field, it is something that often is seen as more of an adult problem. In general, the opiate epidemic started in the adult population, but we are seeing it affecting our adolescents more and more. I am seeing adolescents and young adults, even as young as 12 and 13 year olds coming in with both overdose as well as withdrawal symptoms. I'm seeing 13 year olds that need to be started on medications for opiate use disorder. So it is very squarely a problem for our adolescents and young adults and we as a field are moving into more prevention, trying to find ways to scale prevention and to address root causes, of substance use as much as we can identify from a scaling standpoint.

[00:19:55] Stephen Sandelich: You mentioned PSACT and that's certainly one of the programs out there. There are many people at Penn State doing different types of prevention work. We are only a small cognitive, larger machine. And to your point earlier, we welcome any type of outreach if anyone is interested in having us out into the schools, out into the community, and are open to speaking anywhere and anywhere that we can.

[00:20:23] Sarah Ballard: Also if anyone would like to partner with us and not just have us come speak, but help us develop programs we are definitely open to that. 

[00:20:32] Michael Donovan: Excellent. And maybe if you could, describe a little bit of your engagement process with schools and school districts, but what other community partners or organizations what might be a typical kind of engagement that you've done in the past, or you'd hope to do in the future?

[00:20:50] Sarah Ballard: Personally, when I do outreach, I take a very broad approach. I'm happy to talk to anybody about drugs and I try to meet them wherever they are with their knowledge and with their willingness to listen to what I have to share with them. Generally people are very interested and very very kind. You do unfortunately get some folks who have very negative attitudes toward people who use drugs, and. You just have to navigate those situations. Right, but I do outreach to you know, religious groups, I do outreach with community groups, I do a lot of health fairs. I'll go to health fairs. I do Narcan training, substance use education give out lock medication, lock boxes medication disposal pouches. I pretty much do all the harm reduction and education that I can do within the confines of Pennsylvania law. And I also partner with harm reduction projects in our area to help them capacity build and amplify their signal with things that we perhaps aren't able to accomplish on our own. To add on to the end of that, to your point of entry points, there are many different types of ways to get involved, both as if you would like to personally be involved in our outreach, or if you'd like us to come and help provide outreach to your group.

[00:22:21] Stephen Sandelich: If you are, interested in either of those things, feel free to contact us.

[00:22:27] Sarah Ballard: I've been involved in numerous community facing echoes related to substance use and supporting caregivers who are loving and taking care of people who use drugs. As well as echos that are focused on decreasing stigma in the physician and healthcare worker population, which unfortunately, there's considerable stigma against people who use substances in our health systems. And it is so detrimental because the result is that folks who use drugs do not seek care for any medical issue. And, it's really unfortunate to not be able to go to the people that are supposed to be helping you to help you. 

[00:23:10] Michael Donovan: And just for our listeners a little context, the Project Echo, as Sarah noted extends for the extension for community healthcare outcomes, say global health education model often leveraging telehealth and video conferencing. It's a way to extend this work into communities further, and that's actually what I would love to discuss a little bit about this and what are some impediments or barriers to this growth? I'm thinking particularly around rural healthcare deserts the challenge of treatment beds in different communities. I don't know if, there are ways to discuss what's holding this work from really growing.

[00:23:50] Stephen Sandelich: I think we can talk about that deficit, both from a clinical standpoint and from an outreach standpoint. Specifically from a clinical standpoint, there are huge barriers on getting adolescents and young adults treatments, for substance use, specifically for opiate use disorders which is one of our most lethal disorders out there, specifically with the influx and prevalence of fentanyl and other stronger synthetics in the market. As I said before, substance use disorders are not historically something that we as pediatric emergency medicine providers or pediatricians in general, are often trained on in our general training because it wasn't something that we commonly saw. And as a result of that, many of the providers that are out there in our communities, even in our large healthcare systems, are not comfortable treating these type of things. In addition, there is that huge stigma out there on getting treatment, on seeing substance use disorder as a medical problem instead of, a moral shortcoming that these kids have a medical issue the same as my adolescent patients with diabetes. You have a medical issue, you need treatment for your medical issue, you have an opiate use disorder. You need treatment for your opiate use disorder, so trying to get my provider's comfortable seeing it as a medical disorder, seeing it as something that they can treat. At Penn State, we have, an adolescent clinic that specifically treats adolescent substance use and that's wonderful if you can get there. Talking about those rural areas, those healthcare deserts, many of those people out there either don't have access to transportation. They can get them three hours to get to us or many of those people don't have the ability to travel that far to get to our healthcare center or to another large academic center where they have those resources. So one of our pushes in outreach is trying, to reach out to those rural centers and trying to get the providers they're comfortable with treating adolescent opiate use disorder, substance use disorder in a primary care setting, getting those people more comfortable with prescribing buprenorphine, with starting treatment with getting kids onto those medications that we know work and trying to help. Get our adolescent patients with these disorders on a path to treatment and to recovery. 

[00:26:29] Michael Donovan: And Sarah, from an outreach perspective what is the best way to reach these hard to reach communities that are potentially rurally positioned far away from the academic healthcare centers that Steve noted? How do we approach, this bigger structural problem?

[00:26:49] Sarah Ballard: I think the biggest barrier that I see personally is stigma, and that a lot of communities don't believe that substance use is a problem for them, and to combat that one of the approaches that I take is I try to talk to everybody because substance use can touch any sector. So any community-based organization I try to talk to, whether it be housing or domestic violence services or, feeding programs, food pantries, anywhere that we can get in. Anytime I can start that discussion when I'm in a community space I try to do that just to put it on people's radar, and sometimes I'll put it out there and it'll come back a lot later somebody will get in touch with me. But I think trying to have those discussions to broaden people's thinking, that it could be an issue that would be useful to have more information on and to educate their community on other barriers, right? That we face. Like, money, right? There's not money for outreach but we do the best we can, right? And there's also limited person power, right? Right now Steve and I are doing, most of the outreach, and we also have our other full-time jobs and so just very logistical things, traveling along distance to a rural area can sometimes not be possible just because of logistics. I think it's also, it's not just the stigma, but it's also our basis of understanding substance use. When I talk to folks, I say, you know what this field is evolving, every day we're learning new things from the research and from people's experiences.

[00:28:41] Sarah Ballard: And we're, we know so much more than probably what you learned in the DARE program or like I had Nancy Reagan tell me to just say, no, we know so much more now. But unless you're in the field, unless you're paying attention, you don't necessarily know that there have been advancements. And I see it all the time in media portrayals of very old ideas of substance use that we just know are not true anymore. And being able to get folks to listen that there that there have been advancements that maybe there's a different way to think about substance use and open up a dialogue about why do people use drugs? There are very specific reasons why people use drugs and continue to use drugs and don't wanna stop using drugs. And so I think trying to open those dialogues is really important to then moving forward into things like getting more folks into more treatment and looking at local policy changes, looking, in schools, disciplinary changes and stuff like that. 

[00:29:49] Michael Donovan: And there are a number of shifting sands not just in, the scientific and biological kind of study, of substance abuse, but thinking about what substances are prevalent in different communities and how, fentanyl has changed the the story, in many emergency departments. I would imagine so. There's that plus the challenging approach to uptake and reducing, the stigma associated with the human approach to this. It really is, a wealth of challenges, just thinking about going forward what ways could you envision continuing or expanding, extending this outreach program? What are some of the enablers of that kind of extension? You can say money, and that's fine too. We are very much in an unstable funding environment. As of taping, we recently have had the changes around 2 billion from SAMHSA being distributed and then not distributed, and then distributed. There's lots of precocity in this environment. What ways could we look to expanding these efforts and making them even more impactful? Just kind of blue sky thinking here. 

[00:31:03] Stephen Sandelich: Money is always the boogeyman and it's something that is difficult to talk about, but we always have to talk about it. As Sarah mentioned, we both do have full-time jobs, so a lot of the outreach work that we are doing is almost on a volunteer basis. We do it because we think it is important and we love doing it. We love talking with kids. We love getting out there and funding ways to address the problem as early as we can, but it's a lot of what we do is, as I said, volunteer work. So trying to find funding to do it is one of the big barriers. As you said, Michael, we live currently in a very unstable funding environment, so we are trying to find the best funding sources that we can. In the absence of that, it's trying to be as creative as we can with the resources that we have. You mentioned we work at a huge medical center. It's been here for however many years. There are resources out there. We have residents, we have students, we have nurses, we have other staff. We have a huge number of people. And tapping into the power of this huge university system is one of the things that we are trying to leverage it. Currently is Sarah and I as the leaders of the outreach arm of PSACT, but there are many other people that are interested out there, both in the university as well as in the healthcare system at large. So one of the big things we are trying to do is bringing those folks into the fold if people have any interest, getting them in.

[00:32:38] Stephen Sandelich: I know I have some of our residents which are some of our medical trainees, as well as some of our medical students who have had interests. We've taken some of them out to the schools to talk with kids. Some of that has been wonderful. These people have their own life experiences that they bring to their medical training, those life experiences allow them to really talk to kids sometimes where they're at. It also helps that some of them are younger than we are and closer in age to the kids that we're talking to, and sometimes just a little bit better able to connect than the old doctors coming out and talking to you in your classroom. So trying to leverage the people and the power that we have in our healthcare system has been huge and something that we continue to do.

[00:33:24] Sarah Ballard: When we're talking about how we make kids feel safe, to talk to us, we talk with them, but we always give them our contact information, in case they wanna contact us. When we go into schools, we are not allowed to take Naloxone. We do always share how students can get it if they need it. Also with the caveat that hey, you might not need this, but you are equipping yourself to help somebody else who could have a problem, trying to alleviate that stigma a little. And one of the best places to get Naloxone is the group called Next Distro. And they're actually the official state supplier for Pennsylvania, they do free mail order naloxone, it arrives in a unmarked package, right? So your parents aren't gonna know that you got this. You don't have to use your real name, you just need an address that works, and you will get Naloxone and the training that you need to be able to effectively reverse an opioid overdose. And we make sure to tell them what would happen if they went to the emergency department and spoke with Steve about a substance use concern. And, Steve, would they have to tell their parents? Would you have to tell their parents? 

[00:34:44] Stephen Sandelich: So Sarah, that's a great segue and that kind of goes into the making kids feel safe and it's similar to the conversation that I have with kids with pregnancy. If you are pregnant, if you have a serious healthcare condition like this, I don't have to tell your parents, but finding someone who you trust who can support you is huge. With these type of disorders, with substance use disorders, with an opiate use disorder, it's not something that many people, especially adolescents, are able to manage on their own. There's going to be appointments, there's gonna be medications, there's going to be group sessions, there's gonna be all these different avenues of treatment that ideally we're getting our adolescents into. And it's not something that you can do on your own. So does it have to be your parents? No. But trying to find a trusted person who can help, who we can reach out to and talk with is critical. Can that be an uncle? Can that be an older cousin? Can that be anyone? I honestly don't care who we talk to. As long as we have someone who we can identify as a support for you. I would love to have your parents involved in that discussion as much as you feel it is safe to do so as the adolescent.

[00:36:01] Michael Donovan: That's excellent. It really shows the empathic approach, the realizing their structure their challenges, their environment they're in.

[00:36:12] Stephen Sandelich: So one of the big things that we're seeing these days with the substance use, environment and landscape there's two big things that worry me a lot. One, we talked about a little bit is the proliferation of highly potent opiates like fentanyl. We're seeing significant infiltration of fentanyl into the drug supply. And I'm seeing adolescents who have never used before, they tell me they've never used anything before in their life coming in, in respiratory, rest from a single dose, of fentanyl. So with that proliferating in the drug supply, it's making it where a single use can certainly be deadly. Piggybacking on that, one of the things we're seeing a lot nowadays are counterfeit pills. So we're seeing adolescents in college, at home, in high school, wherever, getting pills from a friend that they think are going to help them study better they think are, a pill of Adderall, they think are a benzodiazepine. That's what they're told by their friends and they're actually laced with another substance, sometimes with a illicit opioid like fentanyl. And those are extremely dangerous 'cause as I said, a single use can lead to a respiratory arrest and even death. One of the very scary things is looking at those counterfeit pills. They look exactly like the real thing, side to side pictures, I cannot tell the difference. I've talked to pharmacists, they cannot tell the difference. They look exactly the same. So unless you are getting a medication directly from a pharmacist that is prescribed by a doctor, you don't know that it's the real thing and that it's not intentionally laced with something else. Thinking about the harm reduction strategies that we have talked about already, one of the big ones are fentanyl tests strips. So you can get strips that are distributed out there, you can get them for free, that you can test drugs with, you can test drug paraphernalia with, you can test pills with, and that can help you make sure that the pills that you have are not laced with something like fentanyl.

[00:38:19] Sarah Ballard: And I would also put a plug in for PA groundhogs. They are a drug checking service an anonymous drug checking service that you can mail samples of your drugs away to. And then using an online dashboard you can check later to find out what was really in that drug. They also do a bunch of surveillance for the state and I believe also in New Jersey at this point to help us understand what is in the drug supply right now and what we should be looking out for.

[00:38:50] Sarah Ballard: And they send out periodic alerts when there are mass overdose events and, warnings for folks to watch out with what they're taking. Next Distro is great, they also provide other harm reduction products depending on the state and what is legal, but they provide condoms and HIV test kits and other things that people can use to stay safer, right? As well as a wonderful online library that talks very honestly and openly about substance use and how to, keep yourself safe.

[00:39:27] Michael Donovan: Thank you so much, and we will certainly be including links in our show notes to these resources. And, I may even put a plug in for our past episode with, your colleague Dr. Alice Zhang at Penn State Health around health to go vending machines that have been deployed in various locations in Pennsylvania where, there's also the opportunity to get Naloxone, and other healthcare related items for free, in anonymous ways, so there are resources we wanna point you to as well. This has been a really wonderful discussion, and I'm so grateful for the work that you both do and the efforts and impacts that, you're making in Pennsylvania. And I do wanna give you both the opportunity for any last minute takeaways, or closing thoughts for, our audience.

[00:40:16] Stephen Sandelich: Thank you for a great discussion, Michael. My closing thoughts really take into account my two different hats. One, from a clinical perspective, if there's anyone out there that needs help with a substance use disorder, the emergency department is certainly a place where you can go for help, including any adolescents out there. We are happy to see you, happy to help take care of you, and happy to help you get whatever type of treatment you need. From my other hat on the outreach perspective, anyone with any type of outreach needs, please contact us. We would love to come out to your school, to your community group, to whatever type of venue that you need us to come and talk to and do whatever you need us to do. We are happy to pass out Narcan, happy to talk about it, happy to talk about use prevention. Any topics that you would like us to talk about, we are happy to do and you can certainly reach out to either Sarah and I and if you are a provider or a person with lived experience who would like to join us, you're also welcome to reach out. We are a small but mighty team and open to expansion for whoever wants to help.

[00:41:25] Sarah Ballard: Thanks Steve. That was a great wrap up and please do be in touch with us and even if you don't see a direct line between your work and ours, I would love to get in touch with you and discuss how we might be able to collaborate.

[00:41:40] Michael Donovan: Perfect. Well, thank you both for the opportunity to discuss this important work today. Again my guests were Dr. Steven Sandelich, assistant professor in the Departments of Emergency Medicine and Pediatrics at Penn State Health, and also the Associate Director of Outreach at the Penn State Addiction Center for Translation or PSACT. And Sarah Ballard, the assistant director of Outreach at PSACT as well. Thank you both so much for your time and we really appreciate your work. 

[00:42:09] Stephen Sandelich: Thank you very much. 

[00:42:11] Sarah Ballard: Thank you.