Despite hundreds of millions of dollars poured into prevention and awareness for the opioid epidemic over the past six years, the needle has not moved much. At its peak in 2016, Massachusetts reported 2,110 opioid-related overdose deaths. Four years later, the number of opioid-related deaths is still nearly the same at 2,106, according to the latest state data from 2020.
While numbers might have slowly nudged down a few years ago, the COVID-19 pandemic threw a wrench in any hope for progress on the opioid epidemic, as numbers began to crawl back up again. And although the pandemic forced everyone into isolation, in some capacities, youths and adolescents bore the brunt of these challenges.
"It's been a really isolating couple of years for a lot of people, but I think especially youth as they're going through these development stages, and they've haven't been able to socialize as much, or even just be out in public," said Kate Lena, program manager for Barnstable County Human Services's substance use prevention department. "We're seeing the impact of that now."
While mainstream media coverage might have moved on from this crisis amid the pandemic and political turmoil, the communities most affected by it have not. For year-round residents of Cape Cod, Massachusetts, the opioid epidemic is their reality; there is no escaping it. These individuals work tirelessly to mitigate the effects of this crisis: pushing for safe use sites in the region, providing patients with acute and chronic care, destigmatizing substance use disorder, and offering both intervention and prevention efforts.
Due to the pandemic and in hopes of mitigating the opioid crisis early, some are focusing their attention on the youth demographic, a group that has not received as much attention as adults.
Many believe that youths will inevitably experiment with substances like alcohol, nicotine, and marijuana in their teen and tween years, and there’s nothing adults can do about it. Because of this, substance use has become normalized to the point where some don’t believe adolescents can have a substance use disorder; that it's just an experimental, party phase. In high school especially, there is a pervasive substance culture where adolescents feel they must use substances to be cool or accepted by their peers. An estimated 2.8% of adolescents (ages 12-17) were reported to have alcohol use disorder, according to 2020 data from Substance Abuse and Mental Health Services Administration (SAMHSA). Latest SAMHSA data also reveals that 1.6%, or 396,000, adolescents have misused opioids, and this number increases to 4.1% among young adults ages 18-25.
“We’re really trying to rewrite the narrative or at least bring in a next chapter that says, 'No, you actually can prevent full-blown addiction if you give them the space…to just understand it,'” Stephanie Briody, co-founder of the non-profit Behavioral Health Innovators, said.
Life on the Cape
This substance issue is especially prevalent on the Cape, where addictions and generational use are all too common. There is a tendency for substance use disorders to fall on a familial trend; in fact, the American Psychological Association wrote in 2008 that “at least half of a person's susceptibility to drug addiction can be linked to genetic factors.”
“It's a part of the fabric of the family system to drink casually into not so casually, and it kind of becomes a part of that thread,” Rodrigues said. “So being able to address that early on is, I think, important.”
Having access to these substances at home in medicine cabinets or nightstands, particularly from a young age, can introduce harmful behavior to youths and adolescents that can progress as they grow up.
“People growing up in a household where substances are being used, it can be an entryway to using themselves," Lena said. "When substances are more available like that and there's potentially trauma and a use background, then the likelihood of use can increase.”
Another unique facet to Cape culture is its seasonal nature: while there are over 220,000 year-round residents, the summer months see millions of tourists cross over the Bourne Bridge into the region. The region’s economy relies heavily on these peak months around late spring to early fall, and once the leaves start changing colors, the regional demographic changes significantly. This can be challenging for young children experiencing a more isolated social circle and for young adults who rely on the seasonal industries like lifeguarding or summer camps for work.
“Being a kid on the Cape, it can be really isolative,” Rodrigues, who is from the Cape, said. “It's not like there's a lot to engage kids who are growing up on Cape.”
Youth Programming
Because of these issues, it’s more important than ever to address substance use head-on from both the prevention and intervention side, so local individuals and organizations have banded together to combat youth and adolescent substance use on the Cape.
“I think [youth intervention] is almost the only way to beat the opioid epidemic,” said Erin Ralston, Community Coordinator for the HEALing Communities Study through Community Health Center of Cape Cod. “Prevention is absolutely the way to go because once you start, it's really tough to fight sort of the power of changes in your brain…it changes your brain chemistry.”
It’s particularly important to catch these youths before their substance use progresses because many start drinking alcohol, smoking weed or nicotine, or using illicit drugs from a young age. A 2011 report from SAMHSA found that 74% of individuals aged 18-30 receiving substance abuse treatment started using at age 17 or younger — 10.2% of those being age 11 or younger. Although we'd like to believe that these youngsters aren't engaging in these behaviors, it occurs more often than we may think — and ignoring it won't help.
"Prevention, I think, has to do with talking about it, having opportunities within school systems and in the community to promote wellness, addressing appropriately concerns around substance use, having a better care continuum on Cape Cod," Rodrigues said. "Because we have no treatment programs beyond the [Alternative Peer Group], which again, is a very small speck of sand on the beach of what is needed here for child and adolescent substance use supports."
Duffy Health Center, where Rodrigues works, provides health care to some of the most vulnerable groups on Cape Cod, particularly those at risk of or experiencing homelessness. One program they sponsor is the six-month Alternative Peer Group, or APG, which was created by Briody’s BHI. The group is facilitated by Jeremy Wurzburg, the program supervisor.
Wurzburg, who is in recovery himself, coordinates the different aspects of the program, including the therapist, recovery coach, family therapist, and soon a peer mentor. However, at the heart of the program is a group of teenagers who guide each other through their journey with substance use, whether that be by completely abstaining from substances or rethinking their relationship with substances and how they interact with them through a harm reduction model. Wurzburg wants the team to provide what teens need to get out of the program.
“What we try to do is support the teens in a wraparound care sort of way,” Wurzburg said. “We want to help facilitate the teens making positive connections with each other and help them to achieve the goals that they identify for themselves.”
When Wurzburg was a teenager, he said there "weren't really any supports in place for him" for his substance use. He had a hard time identifying an issue within himself, as did the people in his life. Even the people who could identify an issue did not know where to go.
"I realistically did not know that I had a problem, or that treatment was an option, until I was 18 or 19," he said. "And so to introduce to them that there are other options, that's really important. It's really hard to pull people out once they're really in it."
The group functions on the theory that teenagers may not listen to parents, teachers, or other adults in their life about changing their substance use behaviors — but they will listen to their peers. Briody says that sometimes when a peer shares their experience, the other group members will identify that behavior as harmful, and then recognize that behavior in their own life, which can prompt some personal changes. They feel compelled to talk about their issues in a space where others are experiencing similar situations, and sometimes this is the first or only space they will talk about their substance issues.
“It's a place where they can just be real, totally real — no agendas, no parents,” Briody said.
Even having a place for adolescents to gather after school can be helpful in preventing overdoses or future use. Briody refers to the 5-7 p.m. timeframe as “the witching hour” where, out of boredom, teens will go out and use substances if they don’t have anything else to do — Wurzburg admits to doing the same as a teen.
“Boredom for teens on Cape Cod, I’m sure can get some children that maybe wouldn't have gone down that path into bad habits, bad routines with bad people,” said Danielle Alexandrov, who's executive director of Wellstrong, a substance-free gym community in Falmouth, and in long-term recovery. Anyone is welcome to come, the only requirement being 48 hours of sobriety.
Clockwise from top left: Wellstrong employees and members write motivational messages like "enjoy life" and "free to be me" on the window of the building facing into the parking lot. Gym equipment is pictured in the main workout area of the gym. Wellstrong members can get a drink of coffee, tea, or water, or purchase merchandise at the Falmouth gym. A line of exercise bikes are in the gym. (Photos / Jess Ferguson)
The Role of Schools
Schools are formative spaces for children, so when students are experiencing troubles with substance use, it is their role to step in. But what is the best way to do so? Ordinarily, schools will approach these infractions from a disciplinary, punitive stance. They may be suspended and therefore unable to participate in classes, placing them at a disadvantage educationally. This approach has been met with criticism from specialists within the field because it's not a behavioral issue but rather a health issue.
“Your brain shuts off, and it's almost like you're being shamed, like publicly shamed,” Briody said about the scare tactics used for students with substance use disorders.
Some schools on the Cape have designated counselors from Gosnold, a treatment facility for substance use disorders, who come in as non-school-affiliated resources for students who are struggling with substances in some way. Cara-Leigh Recker, a coordinator for Gosnold’s Structured Outpatient Addiction Program, said one of her clients received services from the program at her middle school. She was addicted to opioids at the time, and her parents didn’t know. Recker recalls the girl saying her experience was “extremely helpful,” and she added it was a “spectacular intervention” since she was so young at the time and they were able to catch her before she fell.
However, not everyone feels comfortable opening up to a stranger about such a deeply personal and stigmatized issue, so even if these services are available, students may not utilize them to their full extent.
Recovery High Schools
Recovery high schools are located throughout Massachusetts in five locations: Boston, Beverly, Brockton, Springfield, and Worcester. They all function slightly differently; however, Brockton's Independence Academy is currently working on a more short-term basis and serves people including students from surrounding towns who may have been suspended or referred by a counselor. Their two main programs now are their 10-day program and their 45-day program, while they followed a more long-term format before.
Another recovery high school, Northshore Recovery High School in Beverly, Massachusetts, created the PASS Program, which offers an alternative to school suspension. The PASS Program is now also affiliated with Briody's Behavioral Health Innovators.
"At the PASS program, kids who are facing suspension get assessed by a licensed counselor for anxiety, depression, substance use disorder, and trauma," Briody said. "It's not punitive; it's psycho-educational groups." She added that nearly 90% of students who go through that program have two or more serious behavioral health conditions like substance use disorders or eating disorders.
In more recent years, Karin Burke-Lewis, the recovery counselor at Independence Academy, says the school does not require students to be completely sober when entering their programming, but they cannot be actively high or drunk when they come in for the day. They have embraced more of a harm-reduction model in recent years, compared to the strict sobriety policy of the past. The school is aimed toward helping teens with their substance use, which can include abstaining from substances altogether, improving their relationship with substances, seeking alternative coping mechanisms, repairing social relationships, and growing as a person.
"Many of them will say, 'This place saved my life,'" Burke-Lewis said. "That doesn't mean they're sober today, but what that means is they know they have a safe place."
Burke-Lewis says that students from the Cape have attended that school, as well as the one in Boston; however, transportation is an issue, as it's a long commute — upwards of an hour each way. Because of this inaccessibility and the vast substance use across the Cape, Danielle Alexandrov from Wellstrong says that she hopes that the Cape opens their own recovery school in the future. Burke-Lewis speculates that stigma plays a big role into why these schools aren't opened up.
"Parents don't want to throw their kids in the recovery school. 'What does that say about us? What does that say about my kid?' So the stigma still that exists around mental health and substance use issues, that's huge," Burke-Lewis said.
Navigating through middle school and high school is difficult enough as is — let alone when you’re struggling with a substance use disorder. It can be embarrassing or confusing to admit as an adolescent that you need help. There’s a fine line when it comes to substances: it’s cool and edgy to experiment and party with them, but the glamor vanishes when casual use shifts to physical addiction. This prevents people of all ages, including adolescents, from seeking out treatment when they need it.
"There's so much shame and secrecy that's involved in addiction, that the amount of information and support that can be given earlier, even before someone even tries a substance, can be life-saving," Recker said.
This stigma often dissipates in places like Independence Academy or the APG, when kids are surrounded by people facing similar issues.
"They have a place where they can meet other kids who struggle with stuff like they do, they have a chance to talk about stuff, they can connect with each other, even if they don't live close by," Burke-Lewis said. "It's an invaluable resource, them having a community."
She added that these students will often create group chats with each other where they can talk about substance-related topics, as well as other typical teen conversations. Even after they leave the program, they will still have this community to reach out to.
Until a recovery school opens up near the Cape, the area has sought out alternative in-school and after-school programs for students affected by substance use. In addition to programs like the APG and Gosnold's school counseling services, some suggest incorporating substance education directly into the curriculum.
"I think we have to do what we did with tobacco," Barnstable County Sheriff Jim Cummings said. "At a very young age, get into the schools and teach young kids how dangerous it is, and what it does to your body and show them some of the graphic photographs, showing somebody withdrawing from opiates."
By incorporating information on substance use and specifically opioids alongside the traditional health curriculum, the hope is that students are aware of the potential issues that substance use can cause, taking off the rose-tinted glasses that may make them view substances in a more romanticized way.
Initiating Substance Use
By now, we’ve probably all heard stories of young people getting substance use disorders after experiencing a sports injury, or doctors overprescribing painkillers. For instance, JR Mell, regional director of Big Brothers Big Sisters of Cape Cod & The Islands, said the Little Brother he was paired with was getting his wisdom teeth removed, and the doctor gave him a 30-day refillable prescription for oxycodone, when other patients are often instructed to just take Advil or Tylenol. Mell recalled saying, “Are you kidding me? He’s 14.”
Again, two years later, the same Little Brother was experiencing extreme stomach pain, and the doctor again offered him opiates; however, Mell suggested giving Tylenol instead. Fortunately, Mell was present in both of these conversations and initiated some conversations with the boy’s mother and confirmed her belief that the prescriptions were unnecessary and could lead down a slippery slope. That is the benefit of organizations like Big Brothers Big Sisters or Boys & Girls Club; having outside resources to guide you through difficult situations.
Big Brothers Big Sisters pairs volunteers with children ages 7-12 who may have under-resourced or difficult home lives, and these Big Siblings can serve as mentors to the children and their families and engage them socially in the community. Programs like these can aid children in a vulnerable stage in their life when they may not have the most resources on their side.
While instances like Mell’s still do happen, experts say that the narrative is shifting. As social media infiltrates every aspect of our lives, it has also been used as a platform for selling substances. Recker from Gosnold says that she's heard from youngsters she's worked with about kids posting private stories on Instagram and Snapchat showing off their pills or other substances and asking if anyone wants them.
Kids may also initiate opioid use inadvertently through laced vapes or marijuana, which may have traces of fentanyl, a strong, highly addictive opioid that users can easily overdose on.
“The ubiquitousness of fentanyl is a big change. And it’s very scary for overdose because it takes such a small amount to overdose and knowing if fentanyl is in your drugs…you don’t know, it’s odorless. You just can’t tell,” Ralston said.
Vaping devices like Juuls or disposable Puff Bars are increasingly popular with young people: 2020 data from SAMHSA finds that 5.1% of adolescents (age 12-17) have used one of these devices. Although the legal age to buy these products in Massachusetts is 21, these devices are believed to be targeted toward a younger audience because of the colors of the devices and the pod flavors offered.
Christina Russell, director of Cape Cod Children's Place's FIRST Steps Together Program, agrees. “This is intentional manufacturing of substances that are highly addictive, and directly marketing it to kids, in terms of like their flavors and all that crazy stuff,” she said. “And then it goes from nicotine to marijuana to all other kinds of stuff.”
And these vape devices too are not safe from fentanyl lacing, according to Recker. Unknowingly smoking marijuana or vaping without realizing there are opioids in it can lead to accidental overdoses or opiate addiction.
Karin Burke-Lewis from Independence Academy said that one student swore he had only smoked weed when entering the school, but because he was acting off, the school did a fentanyl test, and he tested positive. "We are seeing many kids who are inadvertently getting exposed to opiates when that wasn't really their drug of choice," Burke-Lewis said.
There are also some new opioids infiltrating the drug market, Cummings said, including nitazenes, which are 20 times more powerful than fentanyl and 50 times more powerful than heroin, Healthline reported in December 2021. As these opioids trickle into the wider system, there are even more chances for children to get hooked on opioids or other substances because of their immensely addictive nature.
Mental health issues can also be a trigger for substance use, especially when youngsters don't have the proper coping mechanisms or resources to receive the help they may need. Although they are often viewed as two separate entities, substance use and mental health are often closely linked, and one can worsen the other.
"Mental health and substance use tend to be siloed, and the programs don't always overlap, when we really need to be all working together," Kate Lena from Barnstable County Human Services said. "Adequate behavioral health for youth early on before a crisis hits can prevent addiction or substance use later on in life, or even right there in their adolescence."
Burke-Lewis says that most of the students who come through the Independence Academy are experiencing both substance use and mental health disorders, so mental health management is one of the focuses of the school, in addition to self-regulation and substance control. A 2016 study from Journal of the American Academy of Child and Adolescent Psychiatry found that two-thirds of adolescents who developed a substance use disorder also had at least one mental health disorder.
The Future: COVID-19 and Generation Z
The uncertainty of the pandemic, with Omicron variant BA.2 causing more surges, will likely translate into the future of the opioid epidemic, which has not drastically increased but continues to remain a constant for residents of the Cape.
"Because we don't really know where the pandemic is going, we don't really know where the opioid epidemic is going, either. I think they are closely tied," Lena said.
The pandemic has perpetuated some of the existing mental health and substance use issues people of all ages have experienced — only now, treatments are less accessible with skyrocketed demand.
"The waiting list to get counselors or therapists are really, really long, and crisis programs are just overburdened," Lena said.
Because mental health and substance treatment resources are limited, children and adults may turn to self-medication to manage symptoms of depression and anxiety, among other disorders. Or, children and their families have had to rely on alternative 'treatment' models in their community, including the recovery high schools or the Alternative Peer Group. Although these sources can be helpful, they are traditionally recommended to patients in addition to a more clinical approach.
While our lives are still affected by this global health crisis, one thing remains clear: ending the opioid epidemic cannot happen without youth outreach. Briody says that youth programs are intended to get “upstream” on the crisis. If they can intervene or inform kids at a young age, they may be able to prevent future use, addiction, or overdoses.
Ralston doubles down on this idea, and says that despite organizations' best efforts, time will ultimately aid this epidemic.
“This is gonna sound incredibly cynical, but I honestly think that young people in general, not everywhere, of course, but in general, young people are more accepting and have less stigmatizing views,” she said. “So progress happens when generations die off.”
Credits:
Jess Ferguson