Even before she went to medical school, Pamela Gonzalez’s experiences as an undergraduate were already laying the groundwork for her work as a pediatrician. As a volunteer at an emergency shelter for teens, she saw firsthand the destruction that addiction wreaked on families and individual lives.

She met a 17-year-old boy who likely had mania, as his dad did, and who struggled with addiction—as his dad did. When he died by self-inflicted hanging, she was haunted by how society had failed him.

“I think of how many ways we fell short systematically in taking care of that kid and that dad and taking care of people as families,” says Gonzalez, an assistant professor in the University of Minnesota Medical School’s Department of Psychiatry. “And to see it that young really reinforced early on that it’s a life cycle issue.” 

Today, in the midst of an opioid epidemic that the nation is only starting to grasp, Gonzalez is on a mission to stem it at its source. Pediatricians, she believes, need to understand that they have a key role to play in interrupting that cycle. And society needs to understand it has a role in addressing the social conditions that increase the risk of addiction. 

Five adolescents and young adults ages 15 to 24 die every single day in the United States from a heroin overdose, according to the federal Centers for Disease Control. Their drug habits start when they’re even younger, often from prescription opioids. A recent study in JAMA Pediatrics found that from 1997 to 2012, hospitalization rates from opioid poisonings among youth ages 1 to 19 jumped from 1.4 to 3.71 per 100,000. As Gonzalez pointed out in a talk about opioid misuse as the “highway to heroin” at the American Academy of Pediatrics conference last October, heroin poisonings increased from 1 to 2.5 per 100,000 children over those 15 years. Any use of opioids to treat pain before 12th grade triples the risk of nonmedical opioid use in early adulthood. The risk is even greater for youth with mental health conditions.

Part of the problem, Gonzalez says, is that people have become inured to the toll opioids are taking, due in no small measure to the stigma of addiction and misunderstanding when and how it starts. It’s not the patient’s fault, she says. Even the term “substance abuse”—properly called substance use disorder—increases stigma. “When people start assigning responsibility or blame for an illness, it can color how we interpret the available data and make treatment decisions.”

The view that substance use disorder is an adult problem is myopic, Gonzalez says. In fact, it’s an illness that pediatricians are uniquely situated to help prevent. That’s especially true now that the pathway to addiction has changed so dramatically from what it was in heroin’s first heyday a half century ago.

“Looking back at the 1960s and 1970s during the first big wave of heroin use, most people who used heroin started with heroin,” Gonzalez explains. But today, approximately 75 percent to 80 percent of people who start using heroin receive their introduction to opioids through prescription drugs. The distinction is particularly important when it comes to understanding why addiction is not a failure of willpower or moral character.

One of the biggest fallacies about addiction is the misconception that people make a choice to start to use in the first place. “The problem with that is the people with the most severe disorders started the youngest,” Gonzalez says. “Let’s say we have a 13-year-old: What does it mean that they had ‘choice’? What put them at risk in the first place? What’s going on at home? Do their parents need help? Does the kid have other problems in terms of depression, chronic illness, or ADHD?” 

Living in poverty, for example, changes the brain, she notes. 

“They’re at risk for being young, and they’re at risk for being underprivileged and underserved,” she says. “And then they get older and we blame them for things that are social determinants of health. There are environmental and social justice factors that really play a part in who goes on to develop the severest problems. It really is misleading to say this is something that somebody did to themselves.”

Gonzalez says the key is to start routinely screening all youth for substance use disorders just as they already get screened for lead poisoning, developmental milestones, and depression. Health care practice in the United States has long revolved around a crisis and disease model rather than prevention and health, she says, but health and prevention comprises the bulk of pediatricians’ job. That is why she believes they are so well poised to be on the forefront of addressing the nation’s epidemic of opioid addiction. 

“We’re the voice that says, ‘We need to start looking at this differently because it’s negatively impacting future adults by us not recognizing its roots, and understanding its origins is involved in prevention,’” Gonzalez says. 

That prevention includes looking at risk factors, especially social determinants of health such as poverty, untreated parental illness, neighborhood violence, food insecurity, and other adverse childhood experiences. But parents also play an important role. “Kids’ greatest role model is us, as parents,” Gonzalez says. “They might cross their arms and slam the door, but they remember what we said, and when we give messages consistently, it does influence the choices that they make.” 

Pediatricians’ roles include empowering parents at the clinical level and advocating at higher levels for policies that support kids, parents, and families. Others are starting to realize the importance of this conversation as well: The questions and comments Gonzalez received at October’s conference showed her that pediatricians are starting to explore what they can do to make a difference.

“Every pediatrician has a role,” she says, “and it’s our job to figure out what little piece of it is mine and to do something about it.”