iiinova — where your digital self keeps evolving

Stephen Sandelich @sandelichmd.bsky.social · 4h

Most teens who survive a fentanyl overdose didn't know they took fentanyl. They thought it was a Xanax. A perc. Something familiar. The ED is where that misunderstanding lands. What we see after the naloxone works:

111

Stephen Sandelich @sandelichmd.bsky.social · 9h

She was 14. Came in for "anxiety." It took three visits before anyone asked about the pills she was taking to manage it. The substance use was the story. The anxiety was the entry point. The ED keeps seeing the symptom. The system keeps missing the cause.

000

Stephen Sandelich @sandelichmd.bsky.social · 23h

Parental recovery changes pediatric outcomes. Per NIDA, family-based treatment that includes a parent's own SUD care cuts adolescent relapse rates significantly. We keep treating the teen in isolation. The household is the intervention we keep skipping.

000

Stephen Sandelich @sandelichmd.bsky.social · 29/09/2026

The toddler with lead poisoning didn't have a pediatrician. The family hadn't seen one in two years. The ED was their primary care. PEM training prepares you for that reality in ways general EM never does. Acute medicine is often the last net, not the first door.

000

Stephen Sandelich @sandelichmd.bsky.social · 29/09/2026

Buprenorphine works in teens. Same mechanism. Same evidence. Adolescents with OUD who receive MOUD are significantly less likely to die. The hesitation to prescribe isn't pharmacology. It isn't age. What's actually driving the gap:

100

Stephen Sandelich @sandelichmd.bsky.social · 28/09/2026

Harm reduction saved her life. Not abstinence. Not a lecture. She used with a friend who had naloxone and knew to stay. Most families have never heard the word naloxone. That gap is costing lives. What the ED keeps seeing:

120

Stephen Sandelich @sandelichmd.bsky.social · 28/09/2026

I didn't choose this field. It chose me the first time I watched a system work perfectly and still fail a kid completely. The science keeps me honest. The patients keep me from hiding behind the science. That tension is the job.

000

Stephen Sandelich @sandelichmd.bsky.social · 28/09/2026

Adolescent overdose ED visits cluster in high-poverty zip codes. Not evenly. Not randomly. And the kids who make it to us are already the lucky ones. The ones with the least support are least likely to arrive. What that looks like from the inside:

110

Stephen Sandelich @sandelichmd.bsky.social · 27/09/2026

Teens don't distinguish between "legal" and "low risk." But neither do most clinicians counseling them. The evidence on adolescent cannabis and psychosis risk, IQ, and dependency is real but incomplete. Policy moved. Training didn't. That gap lands in the ED.

100

Stephen Sandelich @sandelichmd.bsky.social · 27/09/2026

Most teens who try a pill at a party don't know what's in it. They think they're taking a Xanax or a Percocet. Per CDC, 6 in 10 counterfeit pills now contain a lethal dose of fentanyl. One pill. What the ED sees:

100

Stephen Sandelich @sandelichmd.bsky.social · 26/09/2026

She came in unconscious. Her friends waited outside because they were scared to call 911. By the time EMS arrived, six minutes had passed. She survived. But that fear of calling for help is its own public health emergency.

100

Stephen Sandelich @sandelichmd.bsky.social · 26/09/2026

Family structure is a clinical variable. Per NIDA, a parent's untreated SUD is one of the strongest predictors of adolescent addiction. Family-based interventions reduce teen relapse rates. We rarely treat the household. We treat the patient and send them back into the same system that shaped …

000

Stephen Sandelich @sandelichmd.bsky.social · 26/09/2026

The teenager in mental health crisis waited 11 hours because there were no inpatient beds. Not in our city. Not in the state. The ED became a holding unit. That's not a care failure. That's a system failure wearing a clinical disguise.

000

Stephen Sandelich @sandelichmd.bsky.social · 25/09/2026

Teens with OUD are half as likely to receive buprenorphine as adults presenting the same way. Same drug. Same disorder. Wildly different prescribing rates. The hesitation isn't evidence. It's age. What that costs:

100

Stephen Sandelich @sandelichmd.bsky.social · 25/09/2026

Most teens who died of opioid overdose in 2023 had no prior OUD diagnosis. Per CDC, over 75% of adolescent overdose deaths now involve fentanyl. They weren't known to us. They never made it to the door. What the ED sees last:

110

Stephen Sandelich @sandelichmd.bsky.social · 25/09/2026

The kid who keeps me up isn't the one I couldn't treat. It's the one I treated perfectly and sent home to the same circumstances that brought them in. Medicine handled. Everything else untouched. That's the loop I can't stop thinking about.

000

Stephen Sandelich @sandelichmd.bsky.social · 24/09/2026

Your zip code predicts your kid's overdose ED visit better than most clinical risk scores. Not metaphorically. Structurally. Social vulnerability index data back this up. What that looks like from inside a pediatric ED:

100

Stephen Sandelich @sandelichmd.bsky.social · 24/09/2026

Cannabis policy is lapping the clinical evidence. Legalization expanded access faster than we built counseling frameworks, provider training, or dosing data for adolescents. Teens see "legal" and read "safe." Those are not the same word. Clinicians often don't know what to say either.

000

Stephen Sandelich @sandelichmd.bsky.social · 24/09/2026

Good evidence takes 17 years on average to reach clinical practice, per NEJM data. Most interventions never make it. Not because the science failed. Because dissemination was never funded. What most people miss:

100

Stephen Sandelich @sandelichmd.bsky.social · 24/09/2026

Seven years is too long when the science could be preventing overdose deaths today.

000

Stephen Sandelich @sandelichmd.bsky.social · 24/09/2026

Sports gambling and opioids share a neurobiology. Both hijack dopamine reward circuits. Per 2023 data, problem gambling rates are rising fastest in 18-24 year olds, the same cohort we lost to fentanyl. We built this infrastructure without treatment systems ready. We are doing it again.

000

Stephen Sandelich @sandelichmd.bsky.social · 23/09/2026

Parental SUD treatment isn't just adult care. Per NIDA, kids whose parents engage in recovery show measurable reductions in their own risk trajectories. We treat the parent in one building and the teen in another. That separation has consequences.

000

Stephen Sandelich @sandelichmd.bsky.social · 22/09/2026

The toddler with lead poisoning hadn't seen a doctor in two years. No PCP. No insurance. The ED was their entire medical system. PEM training teaches you to treat the acute presentation and see the structural failure behind it. Both are the diagnosis.

000

Stephen Sandelich @sandelichmd.bsky.social · 22/09/2026

Buprenorphine is FDA-approved for adolescents 16 and up. Effective. Evidence-backed. Mortality-reducing. And most EDs still don't offer it to teenagers. The hesitation isn't pharmacology. It's discomfort. What that costs patients:

100

Stephen Sandelich @sandelichmd.bsky.social · 22/09/2026

Naloxone access saves lives. That part is settled. But most families still don't have it, and the gap isn't knowledge. It's friction. Here's what that looks like:

100

Stephen Sandelich @sandelichmd.bsky.social · 21/09/2026

The hardest part isn't the uncertainty. It's knowing the evidence exists and watching it sit unused while kids keep coming through the door. That gap between what we know and what we do is where I live. It's frustrating. It's also the only place worth working.

000

Reposted by Stephen Sandelich

JACEP Open @jacepopen.bsky.social · 21/09/2026

New in JACEP Open: An Implementation Science Approach to Introducing the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist: Understanding Facilitators and Barriers Article link: buff.ly/mvbGXin

001

Stephen Sandelich @sandelichmd.bsky.social · 21/09/2026

Gambling disorder and opioid use disorder share overlapping neurobiology. Same dopamine dysregulation. Same compulsion loops. Per NIDA data, co-occurrence rates are striking. We learned too late with opioids that industry self-regulation fails. We are watching it happen again in real time.

010

Stephen Sandelich @sandelichmd.bsky.social · 20/09/2026

Fourteen years old. Brought in by police, not parents. No one knew where his parents were. Tox screen positive for fentanyl. He told me he thought it was a Perc. He said it like it was nothing. That calm is what stays with me. Kids aren't scared of what they can't see.

101

Stephen Sandelich @sandelichmd.bsky.social · 19/09/2026

Family structure predicts adolescent SUD outcomes as strongly as peer exposure, per NIDA data. Not as background context. As a direct clinical variable. We screen teens for substances. We rarely screen for what's happening to the adults raising them. That gap has a body count.

000

Stephen Sandelich @sandelichmd.bsky.social · 19/09/2026

The teenager came in for a sprained ankle. Routine. Except she'd lost 12 pounds since her last visit two years ago and nobody had flagged it. No PCP. No follow-up. The ED is often the only place the whole picture surfaces. That's not a feature. That's a failure we've normalized.

020

Stephen Sandelich @sandelichmd.bsky.social · 19/09/2026

Teens with OUD have the same neurobiological response to buprenorphine as adults. Same receptor binding. Same craving reduction. Same mortality benefit. The hesitation to prescribe isn't pharmacology. It's bias. What that costs:

100

Stephen Sandelich @sandelichmd.bsky.social · 18/09/2026

Most teen overdose deaths now happen the first time they use. Not after months of use. Not after signs families missed. The first time. That single exposure window changes everything about how we think about prevention.

100

Stephen Sandelich @sandelichmd.bsky.social · 18/09/2026

I didn't choose this work because it was solvable. I chose it because it wasn't. The ED keeps showing you what the system refuses to see. That tension is uncomfortable. It's also the most honest place I know to work from.

000

Stephen Sandelich @sandelichmd.bsky.social · 18/09/2026

Most people misread health stats. They see a number and take it at face value. I wrote about a quick mental check that helps cut through the noise. Takes about 10 seconds. Useful whether you're a clinician, a parent, or just reading the news. Read the full piece

000

Stephen Sandelich @sandelichmd.bsky.social · 17/09/2026

Teens using cannabis daily now are often using products with THC concentrations 3 to 5 times higher than what most clinical studies were built on. The evidence base is behind the product market. Clinicians counseling on "cannabis risk" may be quoting data that no longer reflects what's actuall…

000

Stephen Sandelich @sandelichmd.bsky.social · 17/09/2026

Fentanyl doesn't look like heroin. It looks like a blue pill with an M on it. Teens aren't seeking opioids. They're seeking something familiar, something their friend had. What the ED sees that families don't:

100

Stephen Sandelich @sandelichmd.bsky.social · 16/09/2026

She came in for the third time in four months. Different story each time. Same hollow look. Nobody had ever asked her directly about home. I did. Thirty seconds. That's all it took for her to tell me everything. The ED keeps catching what everyone else missed.

000

Stephen Sandelich @sandelichmd.bsky.social · 08/09/2026

Parental SUD is a pediatric diagnosis. Per NIDA, a child's lifetime addiction risk roughly doubles when a parent has untreated SUD. Family-based interventions change that trajectory. We have the evidence. We just keep treating the parent and the kid in separate rooms.

000

Stephen Sandelich @sandelichmd.bsky.social · 08/09/2026

The teen in mental health crisis waited 11 hours in my ED because there were no inpatient beds. Not regionally. Anywhere. That's not a boarding problem. That's a collapsed system using the pediatric ED as its last wall.

000

Stephen Sandelich @sandelichmd.bsky.social · 08/09/2026

Buprenorphine works in adolescents with OUD. The data are solid. Yet most teen patients leave the ED without it, not because it's contraindicated, but because providers hesitate to prescribe it. That hesitation has a body count. Here's what the evidence actually shows:

100

Stephen Sandelich @sandelichmd.bsky.social · 07/09/2026

Counterfeit pills now account for the majority of adolescent overdose deaths, per CDC. Most teens buying what they think is Adderall or Xanax are buying fentanyl. They don't know. Their parents don't know. The ED knows. What that gap actually costs:

121

Stephen Sandelich @sandelichmd.bsky.social · 07/09/2026

The work isn't abstract to me. It's the kid who waited six hours and then left. It's the note I wrote that nobody read. Staying in this space means accepting that the distance between evidence and a real person's life is where most of the actual work happens.

010

Stephen Sandelich @sandelichmd.bsky.social · 06/09/2026

Cannabis legalization is moving faster than the clinical evidence. We don't have strong adolescent-specific data on dose, frequency, or product type and harm. Providers are counseling families with gaps we haven't filled yet. That's not opinion. That's where the literature actually stands.

000

Stephen Sandelich @sandelichmd.bsky.social · 06/09/2026

Funders want scalability. Policymakers want cost data. Clinicians want workflow fit. Researchers write for journals. None of those audiences speak the same language. That's not a communication problem. That's a structural one. What gets lost in the gap:

111

Stephen Sandelich @sandelichmd.bsky.social · 06/09/2026

Overdose survivors who leave the ED without a follow-up plan are significantly more likely to return within 90 days, per CDC data. Most leave with nothing. Not a referral. Not a prescription. Not a phone number. What changes that outcome:

100

Stephen Sandelich @sandelichmd.bsky.social · 05/09/2026

Ran a tox screen last night on a 15-year-old who swore he'd only had a beer. It came back positive for benzodiazepines he'd never been prescribed. He had no idea. That's the part the clinical literature doesn't fully capture. The exposure is happening without consent.

000

Stephen Sandelich @sandelichmd.bsky.social · 05/09/2026

Parental recovery changes pediatric outcomes. Per NIDA, when a parent enters SUD treatment, their child's own risk trajectory shifts measurably. The family is a clinical unit. We keep treating them like separate patients.

000

Stephen Sandelich @sandelichmd.bsky.social · 05/09/2026

The toddler with lead poisoning has a PCP. The PCP didn't know the family lived above a remediated building that wasn't. The ED finds this at 11pm. That gap isn't clinical. It's structural. PEM trains you to see both at once.

000

Stephen Sandelich @sandelichmd.bsky.social · 04/09/2026

Teens with OUD can be started on buprenorphine in the ED. Today. Without a specialist. The evidence supports it. The FDA allows it. Most EDs still don't do it. That gap is costing lives. What low-barrier initiation actually looks like:

100