Risk-Taking Behaviors

Qualitative findings support that youth struggle with peer pressure and want to fit in but do not want to disappoint their health care team and caregivers by participating in behaviors that may compromise their health. AYAs are at higher risk for engaging in risk-taking behaviors due to immature executive functioning, and are consequently pre-disposed to an increased risk of compromised graft function, comorbidities, and graft failure. Assessing risk-taking behaviors as part of routine transplant care and educating the AYAs and their parents on the effects of risk-taking behaviors, particularly in regard to their transplant health, is essential. Additionally, referrals for mental health services and opportunities for peer mentoring may help support the AYA during this crucial developmental period and mitigate these behaviors.

Risk-Taking Behaviors: Substance Use

Alcohol

It is important to assess both the frequency and severity of alcohol use (i.e., occasional, regular, or dailyuse, binge drinking) and the associated health risks.
Occassional and regular use may interfere with medication adherence and transient elevations in liver function tests.
Heavy use and binge drinking increases the risk for alcohol-related accidents, liver dysfunction and disease, and adherence.
Alcohol use disorder (AUD; https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder) involves a pattern of alcohol use characterized by an inability to control alcohol use despite adverse consequences. AUD is a serious disorder that requires treatment.

Tobacco and E-cigarettes (Vaping)

Tobacco use is cited as the leading cause of preventable disease, disability, and death in the United States by the US Department of Health and Human Services and warns that any form of tobacco use is unsafe.(National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA. US Centers for Disease Control and Prevention; 2014).
E-cigarettes are the most common form of tobacco use since 2014, with 11.3% of students in grades 6 through 12 confirming they currently use tobacco. (Gentzke AS et al. Tobacco product use and associated factors among middle and high school students—National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ 2022;71(No. SS-5):1–29).
E-cigarette ingredients may include nicotine, ultrafine particles that are inhaled, organic compounds for flavoring that may be harmful, heavy metals, and cancer-causing chemicals.

Cannabis

Although AYAs are overall more likely to use illicit subtances than other age groups, substance use in pediatric and young adult transplant recipients has been reported to be lower than or similar to their healthy peers.
The most common reported illicit substance in the adolescent transplant recipient is cannabis.
- Methods of use include inhalation (joint, bong, pipe, vape pen), edibles (gummies or other food products), or CBD oil.
- Transplant recipients should avoid inhaled cannabis due to the risk of infections from mold and gram negative bacteria.
Determining the effect of cannabis use by the AYA can be challenging due to differences in potency, product quality, frequency, and type of use (inhalation vs edible).
There are known drug-drug interactions with cannabis and it has been shown to impact tacrolimus levels.
This reference may be helpful for providers in counseling AYA’s on cannabis use, particularly with expanding indications for use and legalization:
Melaragno JI, et al. The Clinical Conundrum of Cannabis: Current Practices and Recommendations for Transplant Clinicians: An Opinion of the Immunology/Transplantation PRN of the American College of Clinical Pharmacy. Transplantation. 2021 Feb 1;105(2):291-299. doi: 10.1097/TP.0000000000003309. PMID: 32413017.

Other Concerns

Alternative medicines (herbal supplements, dietary supplements): The use of herbal and dietary supplements, herbal remedies, and probiotics should always be disucssed with the transplant team due to concerns for durg-drug interactions and infection risk.
Pilch NA, et al. Important considerations for drugs, nutritional, and herbal supplements in pediatric solid organ transplant recipients. Pediatr Transplant. 2021 Feb;25(1):e13881. doi: 10.1111/petr.13881. Epub 2020 Nov 3. PMID: 33142023.
ADHD medication abuse
Addiction to pain medications and/or opiates
Illicit drug use (cocaine, ecstasy, LSD, amphetamines)
IV drug abuse (cocaine, methamphetamines, heroin)

Recommendations for the Pediatric and Adult Transition Teams

Providers should interview the AYA independently to insure privacy and confidentiality through open-ended questions that are not threatening to the youth.
The American Academy of Pediatrics (AAP) advises using CRAFFT for substance use disorder. (Shenoi R et al. Predictive Validity of the CRAFFT for Substance Use Disorder. Pediatrics. 2019; 144:2) This is a 6-item screening survey for drug and alcohol abuse in teens is recommended in the AAP’s Guidelines for Adolescent Preventative Services, and can be could be used during routine assessment.

C: Have you ever ridden in a car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R: Do you ever use alcohol or drugs to relax, feel better about yourself or fit in?

A: Do you ever use alcohol or drugs while you are by yourself, alone?

F: Do you ever forget things you did while using alcohol or drugs?

F: Do your family or friends ever tell you that you should cut down on your drinking or drug use?

T: Have you ever gotten into trouble while you were using alcohol or drugs?

Understanding the youth’s rationale for participating in the risky behavior is important. They may feel bullied, pressured to engage, or are seeking acceptance by their peers. If a teen endorses alcohol or tobacco use or other risk-taking behaviors, providers should avoid threats. Transplant Psychology and Social Work assessments will provide resouces and guidance for care.

Resources for teens and parents:

Body Modifcation: Tattoos and body piercings predispose patients to opportunistic infections and other health concerns. Center-specific guidelines should be discussed with the AYA so they are aware of these risks. General guidelines include:

The youth should be advised to use only licensed facilities that adhere to strict safety procedures and sterile practice.
Piercing sites that are safer, have a decreased risk of infection or injury, and that are easier to maintain should be considered to avoid cellulitis, chipped or broken teeth, tongue swelling or airway compromise.
Some transplant centers endorse weekly labs for a few weeks after a tattoo or piercing to monitor for rejection.
Transplant recipients should see their PCP and/or dermatologist for any symptoms of infection, reactions to dye, or keloid formation at the tattoo or piercing sites. They should also update their transplant coordinator with any issue related to body art.
AYAs should understand that tattoos are permanent and complete removal is not possible. Although society is more accepting of body art, their may be some implications for employment or education.

Safer Sex Guidelines:Discussions related to reproductive health, sexuality, safer sex, and sexually-transmitted infections (STIs) should be a part of the AYA transplant recipient’s routine assessment and facilitated by the most appropriate team member. These are sensitive topics that must be discussed with respect for the youth’s need for confidentiality and privacy. The AYA should be be seen independently to ensure privacy and to build a trusting relationship. (Link to Reproductive Health for more information).

Safer Sex Discussion Points for Providers and AYA

The AYA must understand that they carry an increased risk of acquiring an STI due to being immunosuppressed.
AYAs should know the recommended strategies to practice safer sex to avoid STIs and pregnancy based on their level of immunosuppression and other specific risk factors . Discuss options and help them decide what is the best strategy for them.
- Use latex condoms during every sexual contact to reduce exposure to CMV, Hepatitis B and C, HIV, HSV, HPV and other infections.
- Reduce the numbers of sexual partners.
- Avoid fecal exposure during sexual activity.
The Hepatitis B vaccine should be given at the appropriate ages for best efficacy. The Hepatitis A vaccine is also recommended. A 3-dose HPV series is recommended for all immunocompromised individuals who at > 9 years of age after transplant.
Confirm that older adolescents have established care with a PCP, gynecologist, or adolescent medicine provider in their community to ensure that guidance on safer sex and reproductive healthcare is being provided and updated.
Providers are encouraged to review the following guidelines:
- Sexually Transmitted Infections Treatment Guidelines, 2021
- Transplant Infectious Diseases Guidelines: Clinical Transplantation: Vol 33, No 9
The CDC the free STI Treatment Guide Mobile App that provides quick and easy access to STI prevention, diagnostic recommendations, and treatment Provider Resources

References:

Youth Risk Behavior Survey (YRBS): Data Summary and Trends Report. 2021. Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. Division of Adolescent and School Health; www.cdc.gov/healthyyouth Accessed 10/18/2023.
Centers for Disease Control. Sexually Transmitted Infections (STIs). 2022 STI Surveillance Report. https://www.cdc.gov/std/statistics/2022/default.htm
Ardura MI, Coscia LA, Meyers MR. Promoting safe sexual practices and sexual health maintenance in pediatric and young adult solid organ transplant recipients. Pediatr Transplant. 2021; 25:e13949.