Nurses and Pediatricians:

Powerful Partners in Challenging TimesJuly Webinar Series

Continuing Medical Education Disclosure

CME Accreditation Statement:This activity has been planned and implemented in accordance with the accreditation

requirements and policies of the Medical Society of New Jersey through the jointprovidership of Atlantic Health System and the American Academy of Pediatrics,

New Jersey Chapter. Atlantic Health System is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.

AMA Credit Designation Statement:Atlantic Health System designates this live activity for a maximum of 8.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with

the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the activity, with individual assessments of the participant and feedback to the participant, enables the

participant to earn 8.0 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant

completion information to ACCME for the purpose of granting ABP MOC credit.

It is the policy of the HRET to ensure balance, independence, objectivity, and scientific rigor in all directly or jointly provided educational activities.All individuals who are in a position to control the content of the educational activity (course/activity directors, planning committee members, staff, teachers, or authors of CE) must disclose all relevant financial relationships they have with any commercial interest(s) as well as the nature of the relationship. Financial relationships of the individual’s spouse or partner must also be disclosed, if the nature of the relationship could influence the objectivity of the individual in a position to control the content of the CE. The ACCME and ACPE describe relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose will be disqualified from participation in the development, management, presentation, or evaluation of the CE activity.

The Health Research and Education Trust of New Jersey (HRET)

Disclosure Policy

CONTINUING EDUCATION CREDITSPediatricians and Nurses: Powerful Partners in

Challenging TimesEDU 2052-2: July 15, 16, 22, 23, 2020

(All four sessions required)

New Jersey State Nurse Association Accreditation StatementThis activity has been planned and implemented in accordance with the Essential Areas and policies of the American Nurses Credentialing Center’s Commission on Accreditation and New Jersey State Nurses Association through joint providership of Health Research and Educational Trust of New Jersey (HRET) and New Jersey American Academy of Pediatrics (NJAAP).

HRET is an approved provider of nursing professional development by the New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Provider Number P131-2/18-21.

This activity provides 8.0 nursing contact hours.

There are no conflicts of interest, sponsorship or financial/commercial support being supplied for this activity. Accredited status does not imply endorsement by the provider or American Nurse Credentialing Center’s Commission on Accreditation of any commercial products displayed in conjunction with an activity.

Attention – CEU Certificate Criteria

The validation of participant attendance for this webinar series is confirmed through the webinar

software.Attendees must be logged on for at least 85% of the duration of each of the four webinars AND are also

required to complete an evaluation at the conclusion of the program. Certificates will be

provided only to those who meet this criteria. No exceptions will be considered.

To Obtain Your Certificate

A SurveyMonkey hyperlink will pop-up at the conclusion of the webinar. Click on the link to access the program evaluation.

Attendees are required to complete the evaluation AND participate in at least 85% of each of the live webinars in order to receive a certificate.

Certificates will be emailed on or about July 31, 2020.

Thank youNancy E. Winter, MSN, RN, NE-BCDirector of Clinical Quality and Program DevelopmentPrimary Nurse Planner

(EDU 1905)

Opioid Use &Vaping Updates

during a Pandemic

Eileen Gavin, MSN, FNP-BC, NCSNCathy Grano, RN, MSN, CSN-NJPresented July 23, 2020

Participants will be able to:

❖ Share concerning health risks surrounding opioid use and e-cigarette

related to adolescent use.

❖ Gain an understanding of pandemic effects on SUD including opioid,

tobacco and other substances.

❖ Identify an evidence-based resource that has been an effective tool to

address SUD/vaping in schools.

The Working of the Adolescent Brain

“The adolescent brain is often likened to a car with a fully functioning gas pedal (the rew ard sy stem ) but w eak brak es (the prefrontal cortex )”.

N IDA , 2020

Adolescent Brain

● 2 of 3 adults treated for opioid use disorder (OUD) 1st used opioids when they were younger than age 25.

● In the past 15 years, the use of RX opioids, heroin, and fentanyl has skyrocketed.

● Adolescent and young adult OD-related deaths were almost 5,000 in 2017 (CDC, 2019).

● Between 1999-2016 there were 8986 children & adolescents that died from RX & illicit opioid poisonings. ○ The mortality rate increased 268.2%

(Gaither JR, Shabanova V, Leventhal JM, 2018).

Trending in Adolescent/Young Adult Opioid Use Disorders (OUDs) related OD & death

● Challenges of COVID-19 for people having an addiction:○ The healthcare system is not prepared to take care of them. ○ Stigma and social issues. ○ Social distancing increases vulnerability by limiting support

systems.○ Using the drugs themselves negatively influence human

physiology, making one more vulnerable to getting infected & more vulnerable to adverse outcomes. (Dr. Nora Volkow, Director of NIH’s National Institute on Drug Abuse, 2020)

Coping with the Collision of Public Health Crises: COVID-19 & Substance Use Disorders

● Need flexibility in evaluating & prescribing requirements using telemedicine.

● Designate medications to treat addiction (buprenorphine, methadone, naltrexone) and medications to reverse opioid-related overdose (naloxone) as “essential services” to reduce barriers to access during “shelter-in-place” orders. ○ Medical Assisted Treatment (MAT)

● Increase screening for SUD in primary care

Challenges faced during COVID Pandemic

● MAT at least doubles rates of opioid-abstinence outcomes (Connery, 2015)

● The AAP recommends both increasing resources for MAT within primary care & access to developmentally appropriate SUD counseling in community settings.

● Pediatricians have access to an AAP-endorsed buprenorphine waiver course at www.aap.org/mat.

● The AAP recommends that pediatricians consider offering MAT to their adolescent & young adult patients with severe OUD or discuss referrals to other providers for this service.

MAT for Adolescents and Young Adults

Public Health Benefits of MAT (NIDA, 2016)Decreases:

• opioid use• opioid-related overdose deaths• criminal activity• infectious disease

Increases:• social functioning• retention in treatment

*FDA approved for 16 years and older in combination with counseling and behavioral therapies, provide a whole-patient approach to the treatment of opioid dependency.

● Schedule III so can be office-based practice

● Partial agonist=less sedative effects

● Less potential for diverted combo BUP/NLX-Lower the potential

for misuse

● Fewer side effects

● Diminish the effects of physical dependency to opioids, such as

withdrawal symptoms and cravings

● Increase safety in cases of overdose

Buprenorphine

Currently, <25% of adolescents and young adults (herein, “youth”) identified as having OUD are prescribed medications; for those younger than 18, <2%receive MAT.

These low rates of MAT for youth are driven in part by:● A scarcity of providers who are trained/waivered to manage OUD among

youth ● By an underdeveloped infrastructure for case identification and referral.

(Levy, 2019)

Youth and the Opioid Epidemic

NIDA Screening Tools SUD

National Association of School Nurses (NASN) state that the safe and effective management of opioid-related overdoses in schools must be incorporated into the school emergency preparedness and response plans. (NASN position statement)

● School nurses in this role should facilitate access to naloxone for quick response in the management of opioid-related overdoses in the school setting.

Be Opioid Overdose Emergency Prepared

SAMHSA recognizes the concerns about COVID-19 exposure & recommends the following to promote first responder safety:

● Intranasal Naloxone: Personal Protective Equipment (PPE) should be used by first responders:○ Gloves and facial protection, intranasal naloxone should still be

considered. ● Intramuscular Naloxone: If first responders feel the use of intranasal

naloxone poses too great a risk, there is another lower risk option. ○ IM naloxone can be injected into the thigh muscle - far away from

the nose and mouth - thereby reducing the risk to the rescuer.

Administering Naloxone and COVID-19 Exposure Risk (SAMHSA, 2020)

School Nurses Reentry Concerns

Conditions for LearningHealth and Safety

Flow, Entry, Exit, and Common Areas during time of Pandemic

Reduce congestion in the health office for Contagion Preventions

Policy Revision for in School Urine or Saliva Drug Screening

What are E-Cigs, Vapes, Electronic Nicotine Delivery Systems (ENDS)?

Why is E-Cig or Vaping Concerning?

Vaping is not harmless!!!

● Nicotine● Ultrafine particles● Flavorings-Diacetyl● Volatile organic

compounds-benzene● Heavy metals, nickel,

tin and lead

Vaping is not harmless!!!

Defective e-cig batteries have caused fires, explosions, and

life threatening injuries

https://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-research-based-guide/introduction

Nicotine drawn into the lungs

Rapid delivery of nicotine to the brain

NicotineBuzz

Nicotine levels drops,

causing cravings

CYCLE OF NICOTINE ADDICTION

Dual Use

❖ The vast majority of current e-cigarette users are also current smokers.

❖ 65% of youth who had used an e-cig in the last 30 days also reported using another tobacco product in the same time frame.

❖ Young adults who use e-cigs are more than 4X as likely to begin smoking traditional cigarettes within 18 months as their peers who do not vape.

❖ Of youth who have ever used JUUL, 1 in 3 used marijuana with the device.

National Academies of Sciences, Engineering, and Medicine. 2018; Primack, B. A. et al. (2018)

Don’t Get Vaped In, 2020)

Anatomy of an e-cigarette and classifying products

Don’t Get Vaped In, (2020)

First Generation Second Generation

(Don’t Get Vaped In, 2020)

Third Generation Third Generation

(Don’t Get Vaped In, 2020)

Fourth Generation Vaporizers

BE CUUL…JUUL!

● E-cig that look like a USB device, about 3” in height

● Pods = colorful rectangles that contain nicotine in a variety of flavors

● One pod = 20 cigarettes

● Patented nicotine salt formula (2015)

○ Free base nicotine + acid to lower the pH = higher concentration of nicotine in smaller doses (2.7x faster)

● Does not give off the large cloud of smoke

(Don’t Get Vaped In, 2020)

Hacking Pods/CartridgesHacking a Mod System

Vape Tricks(Banned in

NJ)

Don’t Get Vaped In, 2020)

SUBSTANCES

Images from the classroom

Hiding in plain sight

Oct, 2019

● Leaving class to use the bathroom at the same time everyday○ Mood changes before and after leaving the room

● Hanging out the in the bathroom stalls together● Returning to a room with the smell of fruity sweet scents● Putting thick markers or pens in their mouth● Look for lanyards or hoodies that my hide vaping devices● Carrying devices can be concealed and may look like colorful USBs

Signs that a student/child may be using:

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm; Don’t Get Vaped IN, 2019

Other signs: ➢ Increase Thirst➢ Nosebleeds➢ Passing on Caffeine

Vaping LingoWould you be able to spot

the terms?

Zero- Keeping the puff in to hide use

Rip It - Vaping as much as you can toleratePuff bars - disposable vaping products that come in a variety of flavors marketed to youth

Kit Kat - type of vape juice

VAPING IN A

COVID-19WORLD

Irritating substance in smoking & vaping products disrupt the airway immune and defense systems, inflame lung tissue, and impact the mucociliary system which may increase the lungs susceptibility to infection.

COVID-19 attacks the lungs, which may cause cell injury and death. Inflammation within the lungs may make it harder for an individual to fight SARS-CoV2 and more susceptible to complications from the illness. (Volkow, 2020; Rizzo, 2020)

Considerations: Do vaping associated behaviors increase risk of spread: Sharing of e-cigs, frequent touching of and contact with the face, coughing/spitting removal of face coverings, drifting vapor and smoke.

Vaping companies marketing during pandemic with giveaways such as free masks, hand sanitizer with purchases

Is social distancing during the pandemic decreasing use of e-cig products or is there an increase in use due to stress and anxiety?

Mass General Hospital for Children and Office

of the Attorney General Maura Healy released April 2020

“My message today is that it’s so important you do everything you can to keep yourself healthy. I f you are smoking or vaping, I urge you to quit. Quitting during this pandemic could not only save your life, but by preventing the need for treatment in a hospital, you might also save someone else’s life.”

Dr. Jonathan Winickoff

“The threat of COVI D-19 further highlights

the dangers that e-cigarettes pose,

especially to our young people,” AG Healey.

“NYSAFP calls for an immediate ban on the sale of all tobacco and

vaping/e-cigarette products…...to protect

New Yorkers and lessen the impact and

progression of this serious virus on those who contract it.” April

2002

Parents who "vape" should be aware that a very small amount of the liquid nicotine used to refill e-cigarettes can kill a child.

3 toxic routes of exposure for children:● Their mouth even without swallowing it will be absorbed into the

mucous membranes, just like nicotine gum. ● If they swallow, it will be absorbed in the intestinal tract. ● If they spill it on their skin, it's absorbed through the skin

Children ages 1-2 years are ^ risk of getting into the product.

E-cigarette, or vaping, product use-associated lung injury

(EVALI)

● Linked to THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers

● Vitamin E acetate is strongly linked to the EVALI outbreak. ○ Vitamin E acetate in patient lung fluid samples tested by CDC . ○ Vitamin E acetate has not been found in the lung fluid of people

that do not have EVALI.● Evidence is not sufficient to R/O the contribution of other chemicals of

concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

Vaping Illness Updates & Recommendations for

the Public (2019)● Do not use vaping products that contain THC:

○ obtained off the street or from other illicit or social sources.○ modify or add any substances, adding THC or other oils, to vaping

products.● No vaping product has been approved by the FDA for therapeutic uses or

authorized for marketing by the FDA. ● No youth or pregnant women should be using any vaping product.● Adults who do not currently use tobacco products should not start using these

products. If you are an adult who uses e-cigarettes instead of cigarette smoking, do not return to smoking cigarettes.

● If you choose to use these products, monitor yourself for symptoms (e.g., cough SOB chest pain) and promptly seek medical attention

● Marijuana’s negative effects on attention, memory, and learning can last for days or weeks after the acute effects of the drug wear off, depending on the person’s history with the drug.

● Someone who smokes marijuana daily may be functioning at a reduced intellectual level most or all of the time.

● Considerable evidence suggests that students who smoke marijuana have poorer educational outcomes than their nonsmoking peers.

Volkow, (July 2020)

What are school districts doing to address Vaping and E-cig use?

● Educating staff, families and students on e-cig use, devices and associated risks

● Offering tobacco/vaping/SU prevention programs

● Advocating for policy changes for:○ Non-punitive regulations for students who violate tobacco codes

■ “ASPIRE” (TFHNJ) focuses on education to prevent and correct behaviors; in school suspension in place of out of school suspension

○ No tobacco-e-cig sponsors for staff, students and visitors on campus.○ Positive Behavioral Interventions & Supports (PBIS) Returning to School

After Crisis○ National Center on Safe Supportive Learning Environments

Age appropriate, cross-curricular, school-based tobacco & drug prevention education included in the education provided for all students in K-12

Smart Moves, Smart Choices Stanford Toolkit Don’t Get Vaped In

Final thought, when dealing with adolescents and SUD think about

unmasking the ACEs!

http://www.youtube.com/watch?v=uXXTLf7oouU

ReferencesAAP (2020) Liquid Nicotine Used in E-Cigarettes Can Kill Children

Baumgaertner, E. (2019).Juul wanted to revolutionize vaping. It took a page from Big Tobacco’s chemical formulas. Los Angeles Times. https://www.latimes.com/politics/story/2019-11-19/juul-vaping-chemical-formulas-based-in-big-tobacco

Boston Children’s Hospital. (n.d). Adolescent Substance Use & Addiction Program | Parent Resources. http://www.childrenshospital.org/centers-and-services/programs/a-_-e/adolescent-substance-use-and-addiction-program/parent-resources#

CDC. (2019). Annual Surveillance Report of Drug-Related Risks and Outcomes. Retrieved from https://www.cdc.gov/drugoverdose/data/analysis.html

Connery, H.S. (2015). Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard Review of Psychiatry. 2015 Mar-Apr;23(2):63-75. doi: 10.1097/HRP.0000000000000075.

Gaither, J. R., Shabanova, V., & Leventhal, J. M. (2018). US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA Network Open, 1(8):e186558. doi:10.1001/jamanetworkopen.2018.6558

Kelly, S. M., Gryczynski, J., Mitchell, S. G., Kirk, A., O'Grady, K. E., & Schwartz, R. P. (2014). Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use. Pediatrics, 133(5), 819–826. https://doi.org/10.1542/peds.2013-2346

ReferencesMass General Hospital for Children and Office of the Attorney General. (2020). Smoking, vaping, & COVID-19. https://www.mass.gov/doc/covid-vaping-advisory-english-and-spanish/download

Mass.gov. (2020). AG Healey Warns Public About Increased Risks Associated with Smoking and Vaping During COVID-19 Crisis. https://www.mass.gov/news/ag-healey-warns-public-about-increased-risks-associated-with-smoking-and-vaping-during-covid

National Academies of Sciences, Engineering, and Medicine. 2018. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. doi:https://doi.org/10.17226/24952.

National Association of School Nurses [NASN]. (2020). Naloxone in the School Setting. Retrieved from https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-naloxone

Primack, B. A. et al. (2018). Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use Among Tobacco-Naïve US Young Adults. The American Journal of Medicine, 131(4), P443.E1-443.E9.

National Institute of Drug Abuse [NIDA].. 2020, April

National Institute of Drug Abuse [NIDA].. 2020, June 11. How does marijuana use affect school, work, and social life?. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/how-does-marijuana-use-affect-school-work-social-life on 2020, July 16

National Institute of Drug Abuse [NIDA] (2020) Introduction Retrieved from

ReferencesNew York State Academy of Family Physicians. (2020).Statement by NYSAFP on Link Between Tobacco Use and COVID-19 Call for a Ban on the Sale of All Tobacco/Vaping Products During Pandemic Period.

Rizzo, A. (2020). What you need to know about smoking, vaping and COVID-19. https://www.lung.org/blog/smoking-and-covid19

SAMSHA. (2020). Guidance for Law Enforcement and First Responders Administering Naloxone. Retrieved from https://www.samhsa.gov/sites/default/files/guidance-law-enforcement-first-responders-administering-naloxone.pdf

Stanford Medicine. (2019). E-Cigarettes and Vape Pens. https://med.stanford.edu/tobaccopreventiontoolkit/E-Cigs.html

Volkow, N. (2020). COVID-19: Potential Implications for Individuals with Substance Use Disorders. https://www.drugabuse.gov/about-nida/noras-blog/2020/04/covid-19-potential-implications-individuals-substance-use-disorders

Tobacco Free for a Healthy NJ. (2020). Don’t get vaped in. https://www.tobaccofreenj.com/don-t-get-vaped-in-1