Substance abuse and chemical dependence

 Every time kids use alcohol or drugs, they put themselves at risk.

• When kids are impaired, they make bad decisions—they drive, do other dangerous activities, get into fights and have unwanted sex.

Advances in neuroscience—at Children’s Hospital Boston and elsewhere—have also shown that the earlier kids start to use drugs and alcohol, the more likely they are to become addicted and have lifelong problems related to alcohol and/or drug use.

Many young people learn about drugs while they’re very young, and they may be tempted to try them.

• As a parent, you are your child’s first and best protection against drug use.
• Tell your children clearly where you stand! 
• Don’t assume that your children know that you don’t want them to drink or use drugs—unless you tell them, they might think alcohol and drug use is OK with you.

Remember that teens usually try to hide, disguise or downplay alcohol or other drug use, so you should learn to recognize the signs of abuse and stay on top of things. For more information on the signs of abuse, see the Symptoms tab.

Trust your instincts! Research has shown us that usually, by the time a parent is suspicious of drug use, their adolescent has a serious substance use disorder. If you suspect a problem, talk with your teen. Tell him about your concerns and explain that you want her to speak with a professional.

Stages of substance use

Substance use can be seen as a spectrum—from experimentation to a full-fledged addiction. Below is a description of each stage of use. Note that experimentation refers to the very first one or two times that an adolescent tries a substance and has nothing to do with age.

Psychoactive substances most often used by teens

Below is a short list of the most commonly used substances, along with a few facts about each one from the National Institute on Drug Abuse. All of the statistics in this section come from the 2008 University of Michigan Monitoring the Future study.

alcohol

• 15.9 percent of 8^th graders, 28.8 percent of 10^th graders, and 43.1 percent of 12^th graders had consumed at least one drink in the 30 days prior to being surveyed, and 5.4 percent of 8^th graders, 14.4 percent of 10^th graders, and 27.6 percent of 12^th graders had been drunk.
• Ethyl alcohol is an intoxicating ingredient found in beer, wine and liquor.
• Alcohol affects every organ in the body. Intoxication can impair brain function and motor skills; heavy use can increase risk of certain cancers, stroke and liver disease.

Research also shows that the early onset of drinking greatly increases the risk of developing alcohol dependence later in life—from less than 10 percent risk among those who begin drinking at age 21, to almost 50 percent risk for those who begin drinking at age 14 or younger.

marijuana

• 10.9 percent of 8^th graders, 23.9 percent of 10^th graders, and 32.4 percent of 12^th graders had abused marijuana at least once in the year prior to being surveyed.
• Marijuana is the most commonly used illegal drug in the United States. It’s made up of dried parts of the Cannabis sativa hemp plant.
• Short-term effects of marijuana use include euphoria, distorted perceptions (which may be pleasurable), memory impairment, and difficulty thinking and solving problems.
• Marijuana is an addictive substance. Like all addictive substances, chronic use of marijuana can cause changes in the brain.
• Adolescents who develop marijuana addiction typically will think they can stop at any time and most often will not associate problems with their use of marijuana. Many will be unwilling to quit or seek treatment.
• Marijuana addiction is associated with serious mental health disorders. Many kids with marijuana addiction will feel they have to continue using marijuana to control their anxiety or depression. While marijuana may help them in the short run, chronic use makes it very difficult to treat these associated conditions.
• Use of marijuana can also precipitate thought disorders, such as schizophrenia, and other serious mental health disorders in susceptible adolescents.

opioids (includes narcotic pain medications, such as morphine, codeine, Vicodin, Percocet, Oxycontin, and illicit drugs, such as heroin and opium

• Heroin: 0.9 percent of 8th graders, 0.8 percent of 10th graders, and 0.7 percent of 12th graders had abused heroin at least once in the year prior to being surveyed.
• Narcotic pain medications: 2.9 percent of 8^th graders, 6.7 percent of 10^th graders, and 9.7 percent of 12^th graders had abused Vicodin and 2.1 percent of 8^th graders, 3.6 percent of 10^th graders, and 4.7 percent of 12^th graders had abused OxyContin for nonmedical purposes at least once in the year prior to being surveyed.
• Misuse of narcotic pain medication by adolescents is on the rise. Many adolescents think that use of pain medications is safe, because they are prescribed by a doctor. Unfortunately, this class of drugs has an extremely high addiction potential, and many kids tell us they became addicted after using just once or a small number of times.
• Kids who become addicted to opioids will use frequently—usually daily or more—and often end up switching to heroin, which has the same physiologic effects but is much cheaper.
• Heroin is an addictive drug that is processed from morphine and usually appears as a white or brown powder or as a black, sticky substance. It can be injected, snorted, or smoked.
• Short-term effects of opioids include a surge of euphoria, clouded thinking and drowsiness, or “nodding off.” Kids who overdose can stop breathing and die.

inhalants

• 8.9 percent of 8^th graders, 5.9 percent of 10^th graders, and 3.8 percent of 12^th graders had abused inhalants at least once in the year prior to being surveyed.
• Inhalants are breathable chemical vapors that adolescents intentionally inhale because of the chemicals' mind-altering effects. The substances inhaled are often common household products (such as lighters, whipped cream cans, keyboard cleaners and body spray).
• Inhalants are often used by younger teens, because these products are easy to get and do not generally arouse suspicion by adults.
• Most inhalants produce a rapid high that resembles alcohol intoxication. If sufficient amounts are inhaled, nearly all solvents and gases produce a loss of sensation, and even unconsciousness.
• A single use of inhalants can be lethal.

amphetamines (this group includes prescription medications such as ADHD medications Adderall and Ritalin)

• Stimulant medications are prescribed to improve the basic symptoms of ADHD, including inattention, impulsivity and hyperactivity.
• These drugs produce a mild euphoria and give the user a higher level of alertness.
• When misused, this class of drugs has effects similar to cocaine.
• These types of drugs were not tested in the 2008 survey. Read a report about the increase in abuse of prescription ADHD medications.

cocaine

• 1.8 percent of 8^th graders, 3.0 percent of 10^th graders, and 4.4 percent of 12^th graders had abused cocaine in any form and 1.1 percent of 8^th graders, 1.3 percent of 10^th graders, and 1.6 percent of 12^th graders had abused crack at least once in the year prior to being surveyed.
• Cocaine is a powerfully addictive central nervous system stimulant that is snorted, injected or smoked. Crack is cocaine hydrochloride powder that’s been processed to form a rock crystal that is then usually smoked.
• Cocaine usually makes the user feel euphoric and energetic, but also increases body temperature, blood pressure and heart rate.

ecstasy

• 1.7 percent of 8^th graders, 2.9 percent of 10^th graders, and 4.3 percent of 12^th graders had abused ecstasy at least once in the year prior to being surveyed.
• Club drugs like ecstasy tend to be used by teenagers and young adults at bars, nightclubs, concerts and parties. Ecstasy is a synthetic drug that has psychoactive properties. It is taken orally as a capsule or tablet.
• Short-term effects include feelings of mental stimulation, emotional warmth, enhanced sensory perception and increased physical energy.

hallucinogens (LSD and others)

• 1.3 percent of 8^th graders, 1.8 percent of 10^th graders, and 2.7 percent of 12^th graders had abused LSD at least once in the year prior to being surveyed.
• LSD can distort perceptions of reality and produce hallucinations; the effects can be frightening and cause panic. It is sold as tablets, capsules, liquid or on absorbent paper.
• LSD produces unpredictable psychological effects lasting as long as 12 hours. With large enough doses, users experience delusions and hallucinations.

methamphetamine

• 1.2 percent of 8^th graders, 1.5 percent of 10^th graders, and 1.2 percent of 12^th graders had abused methamphetamine at least once in the year prior to being surveyed.
• Methamphetamine is a very addictive stimulant that is closely related to amphetamine.
• It is a white, odorless, bitter-tasting powder taken orally or by snorting or injecting, or as a rock “crystal” that is heated and smoked.
• Methamphetamine increases wakefulness and physical activity, produces rapid heart rate, irregular heartbeat, and increased blood pressure and body temperature.

How can I tell if my teen is using drugs? What are the signs?

Certain signs, symptoms and behaviors are red flags for drug use. But keep in mind they may also indicate other problems, such as depression.

Look for:

• alcohol, smoke or other chemical odors on your teen’s breath or clothing
• obvious intoxication, dizziness or bizarre behavior
• changes in dress and grooming
• changes in choice of friends
• frequent arguments, sudden mood changes, unexplained violent actions
• changes in eating and sleeping patterns
• sudden weight gain or loss
• loss of interest in activities
• truancy
• failing grades
• runaway and delinquent behavior
• suicide attempts
• possession of drugs or paraphernalia (be suspicious if you find cough medicine or inhalants in your child’s room)

Remember that your child’s doctor has the knowledge and experience to help you find out if your child has a drug or alcohol problem and how to help your child.

Can substance abuse be associated with other problems?

Some kids use drugs to help them deal with problems or strong emotions, while other kids may develop problems like depression or anxiety because of the effect of drugs on the brain.

• All adolescents with substance use disorders should be evaluated for other mental health disorders.
  • Kids who do have a co-occurring mental health disorder should be treated for both problems simultaneously

Some of these disorders include the following:

• Learning disabilities
• Depression
• Anxiety disorders
• Thought disorders

How can our primary care physicians help?

All adolescents should be screened for substance use as part of their routine health care. If you suspect your teen is using drugs, you should discuss your concerns with your child’s doctor.Be specific about what you’ve noticed so that the doctor can better assess your child.

Primary care physicians can play a critical role in helping adolescents and their parents understand addiction and facilitate appropriate treatment.

• Adolescents with substance-use disorders often hear a multitude of negative messages from parents and other adults, and may benefit simply from hearing an empathetic message from a physician.

Physicians may be in an ideal position to encourage teens and parents to participate in treatment together. Family involvement significantly improves children’s long-term health.

• Adolescents should always be referred to providers and programs designed specifically for this age group.
• Various counseling styles and treatment settings have all been shown to be effective; the key element to successful treatment seems to be engagement and continuation.

What’s the CRAFFT test?

This brief, six-question tool was developed by John Knight, MD, director of Children’s Center for Adolescent Substance Abuse Research (CeASAR), and his colleagues to help pediatricians screen for substance abuse in adolescents.

CRAFFT stands for the key words in the six-questions that make up the questionnaire:

• 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/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 gotten into TROUBLE while you were using alcohol or drugs?

Answering ''yes'' to two or more questions is highly predictive of an alcohol or drug-related disorder.

''The beauty of this questionnaire it can be easily added to any office visit as part of the patient's routine physical,'' says Knight.

Can we use the CRAFFT test at home?

We don't recommend it. Although the questions appear simple, the tool is not designed for use at home.

“It's tempting for parents to think that this is a simple questionnaire that can put the issue to rest in their minds. In reality, many will gain a false sense of security when their teens answer ‘no’ to the questions,” Knight says. “Our research shows that teens are far more likely to tell the truth to their medical providers than their parents.”

What questions should we ask our doctor?

You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider—and that you understand your provider’s recommendations.

If you think your child has a substance-use disorder and you’ve set up an appointment, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling like you have the information you need.

You may want to suggest that your child write down what he wants to ask his health care provider, too.

Some of the questions you may want to ask include:

• Can we—and should we—give our child a drug test?
• What are our treatment options?
• Can a substance abuse disorder be treated with medication?
• What can we do at home/at school to help?
• Where can we go for further information?

Keep in mind that your doctor will want to ask you some questions, too. These can include:

• When did you first suspect that your child was using drugs or alcohol?
• What did you do when you first suspected alcohol or drug use?
• What substances do you think your child is using? What signs and symptoms have you noticed?
• How long has your child had these symptoms?
• Have you tried counseling or any other therapy already?
• Have you tried group therapy or recovery programs?
• Has your child been in rehab before?
• Is there a history of substance abuse in the family?

Should we get a referral to a specialist?

Addiction is a chronic, relapsing neurologic disease.Adolescents who develop an addiction will need specialized treatment for substance-use disorders in order to achieve and maintain abstinence.

• Some adolescents will have recognized their drug problems prior to screening and will be ready to accept a referral to treatment.
  • In these cases, goals for the office-based intervention may include sympathetic listening, identifying an appropriate referral source, facilitating treatment entry, encouraging the adolescent to allow parents or guardians to be involved in treatment, and maintaining a therapeutic relationship with the adolescent during aftercare.
     
• Some adolescents with substance dependence will not see their use of substances as problematic and will not be willing to accept a referral to treatment.
  • In these situations, the physician will encourage the adolescent to consider treatment; parents can help by creating the leverage necessary (taking privileges away, etc.) to convince your child to accept treatment.

For teens

If you think you might have a problem with drugs or alcohol, you might want to talk to your doctor. Here are a few things to keep in mind:

What can I talk with my doctor or nurse about?

You can talk with your doctor or nurse about anything. It’s important for you to share information about your personal life so your doctor can get to know you. Your doctor cares about your feelings and wants to know if everything is OK with friends, family and school.

What if I want to talk with my doctor in private?

Just ask. Time can be set aside by your doctor to talk privately without a parent in the room at almost any visit.

Will my doctor tell my parents what we talked about?

Your doctor will keep the details of what you talk about private, or “confidential.”

• The limit of confidentiality is your safety; if your doctor believes that your life or someone else’s life is in danger, she or he will need to find a way to keep everybody safe.

If that happens, your doctor will share only the information necessary to keep everybody safe. In most cases, your doctor will not share all of the private details that you talked about. Some state laws require doctors to share certain information.

• At your next visit, ask your doctor about what things can be kept confidential in your state.
• Also, be sure to tell your doctor if some of the things you talk about can be shared with your parent or guardian.

Do I have to take a drug test if my school or parent asks me to?

You do have the right to refuse drug testing. However, be sure you understand what might happen if you refuse.

• For example, you might not be allowed to stay in school or play sports.
• Your parents also might take away privileges such as driving and going out at night to ensure your safety.

What if I have a drinking or drug problem? Can I get help without telling my parents?

While it’s best to talk honestly with your parents, you can get help for alcohol or drug problems without their permission.

• Your doctor can help you find a counselor or program that can help.

In many cases parents are disappointed that their child has a drug problem, but happy that their child has asked for help and are supportive. Your doctor may be able to help you “break the news” to your parents.

Where can I get more information?

Children’s has two sites with information specific to teen health—one for guys and one for girls.

• Center for Young Women’s Health
• Center for Young Men’s Health

For parents

“Parents are the best line of defense in protecting their children from the dangers of alcohol and drugs.”
—John Knight, MD, associate in Medicine

Talking to your child about drugs and alcohol: how can I help my child to say “no?”

The use of tobacco, alcohol and other drugs is one of the biggest problems facing young people today.

• As a parent, you are your child’s best protection against drug use.

Here are some tips about how to help your child deal with the issue of drugs and alcohol.

Talk with your child about drugs.

Young people who don’t know the facts about drugs may try them just to see what they’re like. After you become informed, talk with your child about drugs and their harmful effects. Try to get him to share his questions and concerns. Use teachable moments in the media. Set a clear “no drug use” policy, but be sure to really listen; don’t lecture or do all the talking. Ask your child what he thinks about drug use and its consequences.

Help him handle peer pressure.

Peers and friends can strongly influence teens to try drugs. As a parent, your influence can be just as strong to resist peer pressure. Tell your child that it’s okay to say “no” and mean it. Try role-playing: Your child can try saying, “I tried them and didn’t like it,” or “I’d get in a lot of trouble if my parents ever found out.” Practice these and other responses. If a friend is offering drugs, it may be harder to say “no.” Encourage your teen to suggest other things to do with that friend. This shows that he is rejecting the drug, not the friend.

Help your child deal with emotions.

During the teen years, many young people face strong emotions for the first time. These feelings can be hard to cope with, and your child may get depressed or anxious. He may turn to drugs to escape such feelings and forget problems. It’s important to talk with him about concerns and problems he’s facing. Explain that everyone has these feelings. Assure him that everything has an upside, and things don’t stay “bad” for very long. Point out that even after using drugs, the same problems and hassles are still there.

Enhance his self-confidence.

Praise the positive qualities in your child often. Encourage him to set goals and make personal decisions to achieve them. With each success, your child will gain more confidence. Applaud effort as well as success. As your child becomes more responsible, you can still provide guidance, emotional support and security when needed. Becoming responsible also means facing the results of one’s actions—good or bad. Making mistakes is a normal part of growing up; so try not to be too critical when your child makes a mistake.

Instill strong values in your child.

Let your child know that you expect him NOT to use drugs. Teach him the values that are important to your family. Also teach him to think of these values when deciding what’s right and wrong. Explain that these are the standards your family lives by, despite what other people are doing.

Be a good role model.

As a parent, you should use alcohol only in moderation and avoid using drugs. You’re the best role model for your child. Make a stand against drug issues—your child will listen.

Encourage healthy ways to have fun.

Young people are always looking for ways to have fun. They can also get bored easily. Drugs offer what seems to be a carefree “high” with little or no effort. Help your child develop an interest in different hobbies, clubs and activities. Look for healthy ways to reduce boredom and too much free time. Take an active interest in what is important to your child.

Causes

How common is substance abuse in teens?

It varies by substance—see the statistics in our list of commonly abused substances.

• Alcohol is by far the most abused substance, while marijuana is the most common illegal substance abused by teens.

What causes kids to have problems with substance abuse?

Substance-related disorders in adolescence are caused by multiple factors, including the following:

• age: The younger kids start using alcohol and drugs, the more likely they are to develop a substance use disorder. Kids who reach late adolescents/young adulthood without using alcohol or other drugs are unlikely to EVER develop a substance use disorder.
• genetics: Kids with family members who have substance abuse problems have been shown to be a higher risk for developing problems themselves.
• environment: Kids who live in environments when drugs are prevalent may be more likely to try substances and develop substance use disorders.
• abuse: Adolescents who are victims of physical, sexual, or psychological abuse may be more likely to develop a substance-related disorder.
• disabilities: Adolescents with mental or physical health problems may be more likely to develop a substance-related disorder.

Long-term outlook

How will a substance abuse disorder affect my child’s life?

Early detection and intervention are vital in keeping your child safe and preventing a substance abuse disorder from getting worse.

• If untreated, a substance abuse disorder can cause acute and chronic health problems or can be lethal. The most serious problems include overdose, injuries and accidents (especially motor vehicle accidents), failure at school, trouble with the law, difficult relationships with parents and peers and poor self-esteem.

Different kids respond to treatment in different ways. Some adolescents will go through treatment and never have another problem with substance abuse, while others may face a lifelong struggle to stay clean and sober.

FAQ

Q: What kinds of drugs are most commonly used by adolescents?

A: We’ve put together a short list for you in the In-depth section of the most commonly used substances along with a few facts about each one.

Q: How can I tell if my teen is using drugs?

A: Certain symptoms and behaviors are red flags for drug use. But keep in mind they may also indicate other problems, such as depression.

Look for:

• alcohol, smoke or other chemical odors on your teen’s breath or clothing
• obvious intoxication, dizziness or bizarre behavior
• changes in dress and grooming
• changes in choice of friends
• frequent arguments, sudden mood changes, and unexplained violent actions
• changes in eating and sleeping patterns
• sudden weight gain or loss
• loss of interest in activities
• truancy
• failing grades
• runaway and delinquent behavior
• suicide attempts
• possession of drugs or paraphernalia (be suspicious if you find cough medicine or inhalants in your child’s room)

Remember that your child’s doctor has the knowledge and experience to help you find out if your child has a drug or alcohol problem and how to help your child.

Q: I’m worried that my child has a problem; should I confront him?

A: Trust your instincts! Research has shown us that usually, by the time a parent is suspicious of drug use, their adolescent has a serious substance use disorder. If you suspect a problem, talk with your teen. Tell him about your concerns, and explain that you want him to speak with a professional.

Q: How can I help my child say “no” to drugs?

A: One way you can help your child say “no” is to talk to him about drugs. Find out what he knows about drugs, and share your concerns about the harmful effects of drugs. Ask what he thinks are the negatives that come with using drugs. Set a clear “no alcohol or drug use” policy, but be sure to also listen and not do all the talking. For more information, see the Talking to your child about drugs and alcohol discussion in the For parents tab.

Q: Can substance abuse be associated with other problems?

A: Some kids use drugs to help them deal with problems or strong emotions, while others may develop problems like depression or anxiety because of the effect of drugs on the brain.

• All adolescents with substance use disorders should be evaluated for other mental health disorders.
  • Kids who do have a co-occurring mental health disorder should be treated for both problems simultaneously

Some of these disorders include the following:

• Learning disabilities
• Depression
• Anxiety disorders
• Thought disorders

Q: How can our primary care physicians help?

A: Primary care physicians can play a critical role in helping adolescents and their parents understand addiction and facilitate appropriate treatment.

• Adolescents with substance-use disorders often hear a multitude of negative messages from parents and other adults, and may benefit simply from hearing an empathetic message from a physician.

Physicians may be in an ideal position to encourage teens and parents to participate in treatment together. Family involvement significantly improves children’s long-term health.

• Adolescents should always be referred to providers and programs designed specifically for this age group.
• Various counseling styles and treatment settings have all been shown to be effective; the key element to successful treatment seems to be engagement and continuation.

Q: What causes kids to have problems with substance abuse?

A: Substance-related disorders in adolescence can be caused by multiple factors, including the following:

• age: The younger kids start using alcohol and drugs, the more likely they are to develop a substance use disorder. Kids who reach late adolescents/young adulthood without using alcohol or other drugs are unlikely to EVER develop a substance use disorder.
• genetics: Kids with family members who have substance abuse problems have been shown to be a higher risk for developing problems themselves.
• environment: Kids who live in environments when drugs are prevalent may be more likely to try substances and develop substance use disorders.
• abuse: Adolescents who are victims of physical, sexual or psychological abuse may be more likely to develop a substance-related disorder.
• disabilities: Adolescents with mental or physical health problems may be more likely to develop a substance-related disorder.

Q: How will a substance abuse disorder affect my child’s life?

A: Early detection and intervention are vital in keeping your child safe and preventing a substance abuse disorder from getting worse.

• If untreated, a substance abuse disorder can cause acute and chronic health problems or can be lethal. The most serious problems include overdose, injuries and accidents (especially motor vehicle accidents), failure at school, trouble with the law, difficult relationships with parents and peers and poor self-esteem.

Different kids respond to treatment in different ways. Some adolescents will go through treatment and never have another problem with substance abuse, while others may face a lifelong struggle to stay clean and sober.

Q: Should we give our child a drug test?

A: We recommend drug testing be done by a professional because these tests are difficult to administer and evaluate. We don’t recommend home drug testing because the results can often be misinterpreted.

A positive drug test is not in itself evidence of substance abuse. However, drug testing can actually be a very good tool to monitor an adolescent who’s already been diagnosed with a substance abuse disorder.

• We’re exploring drug testing as a therapy for kids with substance abuse disorders. For more information, see the Research & innovation section.

Q: What makes Children’s Hospital Boston different?

Q: Our Adolescent Substance Abuse Program (ASAP) offers individualized diagnosis, consultation and treatment for adolescents with problems with substance abuse and their families.

• This comprehensive diagnostic assessment takes place over the course of three appointments scheduled in a one-to-three week period.

During these visits, the adolescent and her family members meet individually with a pediatric clinician and a mental health provider. Each appointment lasts about an hour. On the first day, the adolescent will meet with a pediatric clinician. On the second day, the adolescent will meet with the mental health clinician and the parents/guardians will meet with the pediatric clinician. And on the third day, the clinicians and the family will meet to discuss treatment recommendations and options.

Q: What kinds of treatments does ASAP offer?

A: You and your child will have access to a team of professionals who are experienced with children and are well trained to accurately diagnose and treat substance abuse.

Some of our treatment options include the following:

• drug testing: 12-week random drug testing program for selected patients  
• individual counseling: using scientifically based therapeutic approaches
• individualized parent and family support: including family meetings for siblings
• group therapy: for adolescents and parents
• psychopharmacology (medication): specialized treatment for adolescents who have been dually diagnosed with psychiatric and substance use disorders
• opioid replacement therapy: for adolescents with opioid dependence (see the Spotlight box for more information)

During your visits, your child and your family meet individually with a pediatric clinician and a mental health provider.