Howard King, MD, MPH

	US Surgeon General Vivek H Murthy, MD, recently issued a 

 that reveals that millions of Americans suffer from alcoholism or addiction to legal and illegal drugs-

	The questions are: What power does such a report have to actually change that dismal rate? What else is necessary?

	In 1964, the Surgeon General’s report on smoking and health, issued by one of Murthy’s predecessors, dramatically impacted both policy and public attitudes on smoking-that era’s major national health risk.

	The report’s impact on both citizen perception and behavior was both impressive and measureable. In 1958, only 44% of Americans believed smoking caused cancer according to Gallup. By 1968-a mere 4 years following release of that pivotal report-78% believed it did.

	The 1964 report urgently stated: “Cigarette smoking is a health hazard of sufficient importance to warrant appropriate remedial action”-remedies that were left to politicians to develop and implement.

Related: Can we prediagnose opiate addiction?

	By 1965, Congress had required that cigarette packs carry a health warning by order of the Surgeon General. By 1970, Congress had also banned all cigarette advertising on television and radio. Within a decade, due in large measure to the Surgeon General’s report and the laws it fostered, it had become common knowledge among US citizens that smoking damages health.

	Unlike his predecessor’s report, Murthy’s report on addiction is intended to spur action not just by policy makers, but also by healthcare professionals themselves. [Whereas] many Americans are dying of overdoses of heroin, many others are dying of opioid painkillers legally prescribed by physicians.

	However, even though it is the first Surgeon General report to address the substance abuse crisis, it may not have the same powerful impact on addiction that the 1964 report had on smoking. In fact, in response to its release, Democratic Senator Edward Markey of Massachusetts has already issued a statement calling the report a “missed opportunity,” and calling out his congressional colleagues for their half-hearted response to the addiction crisis that prompted it.

	“Deaths caused by prescription drugs and heroin are growing exponentially every year,” stated Markey. “Yet this report fails to provide a road map [for] how best to curb opioid addiction. Also, the report came at the end of [President] Obama’s tenure [while he was] pleading with Congress for $1 billion to fight the opioid epidemic, but Congress only set aside $181 million.”

	Physicians, Congress, and the pubic alike will be watching for the new administration’s response to the Surgeon General’s call for action on addiction. President Trump has already stated he will “try everything we can” to get Americans “unaddicted.”

	[Although] it remains to be seen how high the addiction crisis ranks on the new administration’s list of priorities, it is worth noting that the new president already learned firsthand the devastating truth of the Surgeon General’s findings. His brother Freddy died of alcoholism at age 43.

	The Surgeon General’s report concludes that speaking openly about addiction is the crucial first step in combatting it. Murthy calls for a cultural change that starts with our perception of addiction itself, “not as a moral failing, but as a chronic illness [that needs] to be treated with skill and compassion.” He has vowed to continue his work to “change how we are talking about addiction and [to] get people to step forward and ask for help.”

Next: The pediatric side of the opioid epidemic

	We pediatricians interact directly with our patients. Politicians don’t. We hold the power to begin conversations about addiction issues with those directly at risk. If we make time to take an adequate history, to probe for generational patterns, to ask parents about their own parents’ experiences with addiction, we may also have the power to intervene in the addiction death spiral itself.

	“The urgency to address addiction is only growing,” Murthy stresses. Today, 1 in 7 US citizens is expected to develop a substance abuse disorder at some point in their lives. Every day, 78 people die from opioid addiction-a number that has quadrupled since 1999. By asking about family addiction patterns right at the point of care, true change may be more likely to start in pediatricians’ offices than in congressional ones.

Read the Surgeon General’s full report 

	Dr King, a board-certified pediatrician, is founder and director of the Children’s Emotional Health Link, and honorary member of the medical staff at Newton-Wellesley Hospital, Newton Lower Falls, Massachusetts.

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	Pediatricians often find themselves sitting across from teenagers trying to counsel them on wise and safe sexual practices. Unsure how much or what kind of information parents provide about sex, these conversations can be as awkward as they are important.  

	However with the ubiquity of social media and children’s exposure to mass media, it is unlikely teenaged or even preteenaged children are unfamiliar with the topic. In fact, they are dying of curiosity about it and beginning to establish their own sexual identities.   

The Internet safety organization, “Enough is Enough,” recently blogged about a 

 magazine tutorial on how to send the “perfect” sext.  They argue that “while 

 continues to push the envelope on soft porn with ‘how to articles’ on having titillating illicit sex, they really crossed the line by promoting and normalizing the dangerous activity sexting.”  To an audience of teenaged and preteenaged girls, 

 is normalizing and glorifying the practice of sexting.  

	• Sexting and self pornification among youth are at crisis levels.

	• Nude and explicit photos of anyone aged under 18 years is considered to be child pornography and can lead to federal prosecution for those who distribute.

	• Many unsuspecting teenagers have found themselves on the sex offenders' registry. There are no “take backs” online and nothing is truly private. Reputations and lives have been ruined when sexting goes bad.

	• Revenge porn, sextortion, and cyberbullying are harmful consequences that can be devastating. 

's articles encourages self pornification and paint a picture in the minds of young men and women that it is exciting and acceptable to degrade themselves, that their worth and value are tied up in their sexuality, and that it  is okay to lower expectations they hold for themselves and each other. That it is okay for them to allow others to strip away their dignity by sending sexts, says Donna Hughes, President and CEO of "Enough is Enough."

, openly displayed at checkout counters, inviting young readers to learn about sexting and child pornography?  One thing is to buy our own copy of 

 and see for ourselves. We also need to talk to kids about sexting, challenging as it might be.

NEXT: Opinion of a social media consultant

	I asked my social media colleague, Martha Golub, for her opinion.  This is what she said.

	"As a parent of preteenaged and teenaged girls, I initiate and encourage casual discussion of online behaviors. I "follow" both of my daughters on their social media accounts as well those of their friends. It gives me some insight beyond their posts into what kind of material they are exposed to. 

	We talk about what is appropriate to post and what’s not, and why. We talk about the concrete dangers and short- and long-term repercussions of online missteps. This provides a safe place for them to ask questions and for me to explore their beliefs about internet safety and sexuality.

	I recently had a conversation about social media with my 15-year-old daughter and her friend.  They said that while sexting was something they would never do, they believed that it was basically safe-that their peers were good people uninterested in harming each other through the distribution of sexual content.

	Teenagers need to be reminded that digital media is not secure and that there are consequences, sometimes criminal, to their actions online.

	The mother of a teenaged daughter recently discovered her daughter was posting inappropriate photos of herself on Instagram. My friend reminded her daughter that she cares about how the world sees her and what might seem harmless and even funny could come back to bite her.

	Beyond potential consequences, the episode was an opportunity to remind her daughter that her self-worth is not tied to her sexuality.

	Children need help guiding them toward appropriate behavior. When my middle schooler got an Instagram account, she posted a selfie lying in bed. She wasn’t trying to be provocative. She was just experimenting with her new app and took a photo of herself where she happened to be. I reminded her that photos of girls in bed have overtones of sexuality and are inappropriate for posting. The photo immediately came down!”

	·      What were we like at our children’s age…and why?

	·      How do we and our spouses deal with our own sexuality?  What messages do we give our own children?

	·      If the child is a grandchild, how comfortable are his or her parents with issues of sexuality?   

	·      How do we as parents or grandparents deal with issues of control?

	A concluding story-who is the child in any of our lives?  Our 9-year-old grandchild came to our house to spend the weekend.  While we finished dinner, she went into another room to dance and sing to music from her iPhone or to act in her own skit. 

	Would we ever for a moment rush her into adolescence, not safely escorting her past stimulating barriers, clarify what kind of risks she maybe confronting?  Is not our task to protect, explain, and make sure she has time to grow?

	What messages might we convey to our teenaged children?

			Help kids take their time/slow down. At 14 or 15 or 16 years of age, kids are likely more digital savvy than their parents, but not ready for the risks (and rewards) of sexuality.

			Nourish their childhood and help them feel that parent/grandparents are giving them a safe place to grow.

Pediatricians often find themselves sitting across from teenagers trying to counsel them on wise and safe sexual practices. Unsure how much or what kind of information parents provide about sex, these conversations can be as awkward as they are important.

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	We have a serious public health problem called “opiate addiction.” It affects all age groups, and in the last 2 decades it has spread across the country. It used to occur only among the poor and minorities. Now it impacts everyone, even family members of those running for presidential office.

More: The reality of oxycontin prescriptions for kids

	The medical community has contributed to the problem by using opiates for treatment of pain. Opiate addictions have a high death rate, particularly among those who use street drugs. Our government tries to manage this by limiting pain prescriptions. Police and firemen do their best by using Narcan or similar drugs as an antidote against overdose.

Those who are severely addicted require expert management, but I believe we may be able to identify those not severely ill by diagnosing those who are predisposed. This essay is about the benefits of and the time needed to take an adequate personal and family history 

	What would it take to discover risk factors that predispose patients to opiate addiction? My premise is the need to spend more time taking comprehensive family histories. Perhaps the “real patient” might be what a few thinkers refer to as “the 3-generation family system.”

	Thomas H. Lee, MD, MSc, of Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, in his 2014 article “

Time after time-health policy implications of a three-generation case study

,” wrote about 3 generations of a single family cared for by the same primary physician. The physician recognized that similar issues kept arising with discouraging predictability.

	According to Lee: “This three-generation case study shows the intertwined effects of poverty, depression, alcoholism, drug addiction, unemployment, domestic violence, and occasionally incarceration on individual family members and the family as a whole. Each family member was born into a chaotic social context, social [and perhaps] genetic factors combined to lead to a downward personal spiral.”

	Unlike the victims with backgrounds cited by Lee, many victims now come from middle- and upper-class families, and have been given legitimate painkiller prescriptions. But even in upscale families, addictions and other dysfunctions often pass from 1 generation to the next. Lee concludes that if pediatricians intervene in the first or second generation, we can favorably affect health, discovering meaningful signs of addiction in earlier generations that might have been overlooked. He felt it’s our best hope for ensuring that 1 or 2 generations from now, the story line of patients’ families might be a different one.

	In short, if you take a multigenerational perspective, you can demonstrate risk factors for family dysfunction. May I suggest that we place ourselves at significant disadvantage if we see our real patient as only the child or the adolescent? I believe it is more useful to consider that the real patient could be the multigenerational family system.

	One of my mentors stressed that obtaining a family history is critical in treating people with addiction. In addition to possible genetic components, trauma is often a huge part of substance use and addiction, and much trauma begins in the family.

	Another mentor, Howard Shaffer, MD, pointed out that there are common causes for seemingly different disorders. He wrote there is a common etiology of behavioral and substance-related addictions. In a 3-generation family, diagnoses such as depression, alcoholism, domestic violence, and abuse are often repeated from 1 generation to the next unless there is appropriate intervention.

	If we want to understand why someone is predisposed to opiate addiction, it is helpful to know whom he or she takes after. We need to be professionally curious in our search for “family secrets,” including family members who struggle with alcoholism. If we discover that an addict had a parent or grandparent who had been abused or was an alcoholic, then it makes sense where the addict came from. Even if young people haven’t demonstrated a tendency toward opiate addiction, we should consider checking for problems of addiction in parents, grandparents, aunts, or uncles. There could be real benefit. It might help diminish the likelihood, one day, of adolescents or adults developing serious opiate addiction.

	What are the implications of this approach for our patients and their families? Hopefully we can discover younger family members who might be predisposed to family addiction and prevent opiate addiction at a later age. Another might be that, if we took time in prenatal visits, we might discover a history of family dysfunction that might impact children in the absence of constructive intervention.

	What would it take to incorporate the 3-generation family system mindset into our pediatric practices? It would require asking ourselves, when meeting with parents to take the time for an adequate history, “Who is the real patient?” It also would require the willingness of parents to trust us.

	Pediatricians have a choice. We can spend 15 minutes in a well-child visit with a patient who 1 day might develop opiate addiction, or we can invite young patients or their parents to return for an hour-long visit to see if we can discover family dysfunction that hadn’t previously been acknowledged. Again, who is the “real patient”? If we invite parents for an hour-long history as needed, we might make available appropriate counseling or alcoholism services. In fact, we have successfully pilot-tested such hour-long visits and their outcomes in my practice and our teaching program.

	Insurers often reimburse pediatricians for providing time for such counseling. Michael Yogman, MD, FAAP, chair, Children’s Mental Health Task Force, Massachusetts Chapter, American Academy of Pediatrics, suggested that the best ICD code is F43.20 or F43.29 for adjustment disorder, or F94.8 for childhood disorders of social functioning. I hope the availability of such codes will encourage pediatricians to conduct the sessions I am proposing.

	Wouldn’t it be something if we could use the scourge of opiate addiction to help us master a new skill if we invest the time? What is the most important idea in this essay focused on diagnosing opiate addiction at the earliest time? It is that there are 2 kinds of pediatricians. The one I identify with asks these questions in the family interview. The second kind is not yet ready to do so.

	Dr King is a board-certified pediatrician, founder and director of the Children’s Emotional Health Link, and honorary member of the medical staff at Newton-Wellesley Hospital, Newton Lower Falls, Massachusetts.

We have a serious public health problem called “opiate addiction.” It affects all age groups, and in the last 2 decides it has spread across the country. It used to occur only among the poor and minorities. Now it impacts everyone, even family members of those running for presidential office.

Author | Howard King, MD, MPH

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Can we prediagnose opiate addiction?