20: The Nitty-Gritty of Drugs and Alcohol with T1D Kids

Sweet Talk for Parents of Kids with Type One Diabetes

I’m honored to be joined by two guests today. One is a mom who has questions about substance use and her T1D teen. Because I’m not an expert on this topic, I invited Dr. Justin Altschuler to join us. Besides having T1D himself, he has a private practice that specializes in addiction and T1D, and he is the medical director of Diabetes Youth Families (DYF), which is the organization in the Bay Area that hosts the diabetes camps that you hear me mention frequently. Join us for this important conversation!

Show Highlights:

• Guest: Sarah has a 17-year-old son who was diagnosed with T1D at age four.
• After navigating many different T1D issues over the years, the questions now are around alcohol and drug use.
• As he will probably become a social drinker with friends and family, Sarah wants her son to use strategies that will keep him safe.

• Sarah’s First Question: “Is beer better than mixed drinks as far as having well-defined carb counts?"
• Dr. Justin’s Answer: “For teens and young adults, the thing I worry about the most is not high blood sugars and carbs but low blood sugars. When someone drinks alcohol, it goes straight to the liver, which becomes preoccupied with processing the alcohol and stops releasing sugar into the bloodstream for several hours. As regular glycogen isn’t being released when alcohol is present, the implications are that blood sugar lows will happen when someone is drinking, and a sugar release will happen to combat the low. The challenge is that, when someone is drinking, the normal body-rescue mechanism isn’t there. This persists for several hours. The risk with teenage drinking is NOT having them wake up at 300 but their blood sugar going so low that they don’t wake up. The carb counts of beer vs. mixed drinks really don’t matter in this context; the key is to keep them in the safest zone possible with alcohol use. Because you don’t know what’s in a mixed drink, it’s a way of taking in a lot of alcohol very quickly and not recognizing it. From that perspective, I would say beer is preferred.”

• Sarah’s Second Question: “So how do you avoid the lows?”
• Dr. Justin’s Answer: “I tell teens to put their smart pump device in exercise mode and to eat before drinking. Their blood sugar should be around 200-250 before drinking. While they are drinking, I tell them not to bolus, because I’d rather their blood sugar be too high than too low. If they have to bolus, I recommend entering half the amount of carbs that they otherwise would use. It’s a good idea for kids to eat snacks while drinking, and there are good strategies kids can use to fit in socially and not have to drink excessively. They can open a beer, pour half of it out, and walk around with the rest of it throughout the night. They can still fit in without putting a bunch of alcohol into their bodies.

• JoAnne’s Question: “What about those kids who want to get drunk? What do you recommend for them in staying as safe as possible?”
• Dr. Justin’s Answer: “Recognizing that spectrum and knowing what your kid wants in their relationship with alcohol is important. If they want to get drunk, the important safety issues are not to disconnect their pump. I’ve seen kids do that in order to avoid the low readings, but they can wake up eight hours later in DKA. Another thing is that they need a buddy who knows them and their T1D and how to interpret the Dexcom numbers. At a party, if someone is passed out in a corner, everyone assumes they are drunk and won’t think about their blood sugar being low; that’s where a buddy comes in who knows what’s going on. The issue can become that a T1D kid needs IV glucose, but no one wants to call EMS for that and get in trouble. To keep your T1D kid safe while drinking, there is a lot of prep work that needs to happen before the drinking starts. I encourage parents when talking to their kids, to make their intention clear about keeping them safe above all else.”

• Sarah’s Third Question: “How do we coach our son regarding practical advice on buddy training?”
• Dr. Justin’s Answer: “Even outside the T1D realm, parents need to have conversations with their kids about drinking and driving. I think of this conversation in a similar way to parents wanting to give their kids the freedom to go out and do things with the confidence that they are safe. Part of their safety plan should be to be with someone who can look at their dexcom, check their numbers, and know what to do. It’s as simple as the buddy knowing that if the number drops below 100-150 that they need to make the T1D person eat something. They should know not to assume that any strange behavior means that they are drunk, but that low blood sugar means they need to eat something right away. These conversations aren’t a one-time thing, but should start with young teens and be part of what they learn and discuss within their families.”

• Sarah’s Fourth Question: “Is there much known about T1D and marijuana use? Are there things we should advise T1D kids to do differently around smoking weed or taking gummies?”
• Dr. Justin’s Answer: “The physiology around marijuana use is different from alcohol and glucose metabolism. The concerns around alcohol use with kids not being able to accurately count carbs and read their numbers are still true with marijuana use. I tend to err on the conservative side of wanting them to be on the hyperglycemic side rather than the hypoglycemic side, but it’s not quite as scary in terms of glucose metabolism. The perception that ‘if it’s legal, it must be OK’ is dangerous; we know that early exposure to marijuana is not good for developing brains. The concern is that doing this at age 16 is different than doing it later in your 20s. The marijuana products on the market today are much more potent than over the last few years, and that difference is tremendous in the effect on young, developing brains. In talking to kids about substance use, it’s important to think about the underlying context in why kids are drawn to it. I think of it as a ‘push and pull’ of why they don’t like being sober and how the chemical makes them feel. T1D kids using these substances as an escape valve is something I worry about in the long term.”

• Dr. Justin’s General Takeaways: “These conversations around substances don’t take place one time but should be occurring over and over with your kids. It’s important to acknowledge that parents can’t control this with their kids, and the locus of control lies within the child’s decision-making. Adolescents and young adults have to take ownership of these decisions, and that requires that they have all the information to make informed decisions. As a parent, surrendering control and actually trusting your kid helps paradoxically and lays the groundwork for their own choices. That attitude takes substance use out of the realm of ‘rebelling against mom and dad’ and gives them the chance to make good choices in a much more helpful framework. Adolescents view risk-taking and novelty-seeking behaviors differently because their brains are different; we have to help them walk through concrete steps to take so they can make good decisions when those times come.”

Resources:

Connect with Dr. Justin: Website and Newsletter

Visit my website for available resources and upcoming courses/webinars: www.diabetessweettalk.com

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