Adolescent Substance Abuse

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Adolescent Substance Abuse

• Anthony Dekker, D.O.
• SWRSAC 2000

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• We live in a decadent age. Young people no
  longer respect their parents. They are rude and
  impatient. They frequent taverns and have no
  self-respect.
• Inscription on Egyptian tomb
• circa 3000 B.C.

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ADOLESCENT SUBSTANCE ABUSE

• Monitoring the Future Study
• NIDA, University of MichiganSince 1975, high
  school seniorsSince 1991, also 8th 10th
  graders
• Those in school use less
• White seniors use gt Hispanic gt Black
• Peak drug use late 1970s - 1981

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SUBSTANCE ABUSE TRENDS1999 MONITORING THE FUTURE

• 54.7 of seniors had ever used any illicit drug (
  ? 0.6)
• 25.9 used in past month ( ? 0.3)
• 43 believe gt 5 drinks 1-2 times a weekend is
  risky (?)
• 25 believe marijuana use once or twice is risky
  (?)

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MONITORING THE FUTURE1999 PREVALENCE OF USE
()U.S. HIGH SCHOOL SENIORS

• Lifetime 30 days Daily
• Alcohol 80.0 51.0 3.4
• Cigarettes 64.6 34.6 23.1
• Smokeless 23.4 8.4 2.9
• tobacco
• Marijuana 49.7 23.1 6.0

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MONITORING THE FUTURE1999 PREVALENCE OF USE
()U.S. HIGH SCHOOL SENIORS

• Lifetime 30 days Daily
• Stimulants 16.3 4.5 0.3
• Inhalants 15.4 2.0 0.2
• Hallucinogens 13.7 3.5 0.1

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MONITORING THE FUTURE1999 PREVALENCE OF USE
()U.S. HIGH SCHOOL SENIORS

• Lifetime 30 days Daily
• Cocaine 9.8 2.6 0.2
• Crack 4.6 1.1 0.2
• Heroin 2.0 0.5 0.1
• Steroids 2.9 0.9 0.2
• Barbiturates 8.9 2.6 0.2

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ANTICIPATORY GUIDANCEFAMILY CONTEXT

• Childhood parent use and behaviors, attitude,
  parenting, coping styles, family dysfunction,
  prevention efforts
• Adolescence parent use role-modeling, family
  expectations, permissiveness, tolerance of teen
  use peer group, teen/peer ATOD use
  behaviors HEADSSS

alcohol, tobacco, and other drugs
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POTENTIAL RISK FACTORSGENETIC AND FAMILY FACTORS

• Family history of alcoholism, addiction or
  antisocial behavior
• Family modeling of substance use behaviors
• Poor parenting skills, family dysfunction
• Permissive attitude toward teen use
• ? household conflict, family chaos
• Child abuse or neglect (physical, sexual)

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POTENTIAL RISK FACTORSPERSONAL FACTORS

• ? interest in school and achievement, early
  academic failure
• ? self-esteem
• ? religious activity
• Rebelliousness and social alienation
• Early antisocial behavior, delinquency
• Psychopathology, esp. depression
• Early ? risk behaviors ATOD, sex

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POTENTIAL RISK FACTORSENVIRONMENTAL FACTORS

• Perceived peer ATOD use, best friend ATOD use
• Ethnic or cultural influences
• Community/neighborhood deterioration/
  disorganization
• Easy access, early access
• Advertising and media portrayal

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DIFFERENTIAL DIAGNOSIS FOR A WIDE RANGE OF
PSYCHOSOCIAL PATHOLOGY ADOLESCENT DYSFUNCTIONS

• Substance Abuse
• Depression
• Other Psychological Issues

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Maintain privacy and confidentiality

• Provider-patient-family trust triangle
• Breach
• Presents harm to self or others
• Required by law

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TRUST RELATIONSHIP

• Provider
• privacy
• communication
• confidentiality

parent
child/teen
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SCREENING ASSESSMENT

• Interview
• relate and just ask
• Tools
• mnemonics and questionnaires
• HEADSSS
• Refer for specific assessment and testing

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URINE DRUG SCREEN

• Thorough psychosocial history is vital
• Confidentiality and informed consent
• Indications
• identify user for treatment referral
• monitor drug use while under treatment
• emergency diagnosis for altered states
• Random, covert or parent requested testing
• AAP opposes
• adversarial, breaches trust and alliance
• does not identify pattern or dependency

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URINE DRUG SCREENINSURING ACCURACY

• Knowledge of techniques, limitations
• Urine collection under observation
• Urine temp, pH, specific gravity
• Legal or forensic
• confidentiality, chain of command
• careful labeling, storage
• confirmatory testing - GC/MS

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URINE DRUG SCREENDURATION OF DETECTION

• Anabolic steroids
• p.o. 4 weeks
• i.m. 6 weeks
• Amphetamines/ lt 48 hours
• methamphetamines
• Barbiturates
• short acting 24 hours
• long acting 2-3 weeks

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URINE DRUG SCREENDURATION OF DETECTION

• Cocaine metabolites 2-4 days
• Inhalants or LSD undetectable
• Marijuana 3-30 days
• Methadone 3 days
• Opiates 2 days
• Phencyclidine 1 week

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SYNTHESIS AND PROCESS

• PATIENT NOT USING
• Affirm decision not to use
• Anticipatory guidance
• PATIENT USING/LOWER RISK
• State your concern
• Elicit patients understanding of use. Dispel
  myths
• Assess readiness to change
• Negotiate plan and follow up

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SYNTHESIS AND PROCESS

• PATIENT USING/HIGHER RISK
• State your concern
• Elicit patients understanding of use. Dispel
  myths
• Assess readiness to change
• Prepare patient/family for referral
• Negotiate plan and follow up

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BRIEF INTERVENTION

• is an interpersonal interaction whose primary
  impact is motivational, working to trigger a
  decision and commitment to change

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MOTIVATIONAL INTERVIEWING

• Pre-contemplation
• Contemplation
• Action Plan
• Implementation
• Maintenance
• Recovery
• Relapse

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MOTIVATIONAL INTERVIEWING

• is a particular way to help people recognize and
  do something about their present or potential
  behavioral problems, including AODA use
• motivates a person to resolve ambivalence and to
  get moving along the path of change

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PRINCIPLES OFMOTIVATIONAL INTERVIEWING

• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy

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WHEN IS REFERRAL NEEDED?

• Practitioner uncertain or inexperienced
• Frequent, regular or compulsive use
• Concurrent psychopathology
• Impaired function school, legal, work or social
  (family, peers, etc.)
• Certain circumstances imminent health risk,
  behavior presents danger to self or others
• Inability to ? use or maintain abstinence

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COMMUNITY-BASED INITIATIVES

• Local chapter of national groups
• SADD, MADD, NFP, Safe Rides, DARE
• Focus awareness, education, action
• positive peer role-modeling
• promote parent involvement
• various projects
• hotlines, safe rides, lobby, media
• i.e., SADD Contract for Life

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SUBSTANCE ABUSEGENERAL ISSUES

• Teens more often abuse multiple drugs
• smorgasbord vs. drug of choice
• Multiple drug use/overdose effects are more
  difficult to interpret and treat
• Street drugs often misrepresented
• toxic on other than alleged drug
• overdose represents drug combination

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SMOKELESS TOBACCOHEALTH CONSEQUENCES

• Nicotine effects and addiction, gateway drug
• Teen users more likely to become smokers
• Leukoplakia various oral cancers gum, mouth,
  pharynx, larynx, esophagus
• Periodontal disease gingivitis, recession
• Tooth and filling staining, abrasion of teeth,
  caries, halitosis
• Hypertension, vasoconstriction

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CATEGORIES OF INHALANTS

• Solvents
• industrial or household
• art or office supply
• Gases
• in household or commercial products
• household aerosol propellants
• medical anesthetic gases
• Nitrites
• aliphatic nitrites

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GENERAL INHALANT EFFECTS

• ACUTE
• anesthesia, intoxication, quick drunk
• initial excitement turns to drowsiness
• disinhibition, lightheaded, agitation, HA
• ataxia, dizzy, disoriented, dysarthria, weakness,
  nystagmus, loss of consciousness
• sensitization to endogenous catecholamines

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GENERAL INHALANT EFFECTS

• CHRONIC
• weight loss
• muscle weakness
• general disorientation
• inattentiveness
• lack of coordination

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ADVERSE INHALANT EFFECTS

• IRREVERSIBLE
• Hearing loss
• Peripheral neuropathies or limb spasms
• CNS or brain damage
• Hematologic dyscrasias

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ADVERSE INHALANT EFFECTS

• POTENTIALLY REVERSIBLE
• Renal toxicity
• Hepatotoxicity
• Respiratory distress
• Hematologic methemoglobenemia

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INHALANT-ASSOCIATED DEATH

• Blood oxygen depletion/suffocation
• Cardiac toxicity ventricular fibrillation,
  arrhythmia, arrest
• Gastric content aspiration
• Trauma
• Nitrite use in HIV may ? risk of Kaposi sarcoma

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ANDROGENIC ANABOLIC STEROIDS

• Synthetic derivatives of testosterone po, IM
• Lay beliefs ? muscular capacity, ? LBM,
• ? body fat, ? strength/endurance, hastens
  recovery from exercise, allows more frequent and
  higher-intensity workouts
• Research limited, generally inconclusive
• Injection adds risks of hepatitis, HIV

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DIAGNOSING ANABOLICSTEROID USE

• HISTORY
• Athletic appearing person, physical or
  psychological complaint
• Obsessive interest in health, exercise, weight
  lifting
• School or work difficulties

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DIAGNOSING ANABOLICSTEROID USE

• HISTORY
• Behavior changes aggressiveness (roid rage),
  hyperactivity, irritability, cyclic mood swings,
  anxiety, panic, suicidal ideation, auditory
  hallucination, paranoid/ grandiose delusions

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DIAGNOSING ANABOLICSTEROID USE

• HISTORY
• Drug history denies steroid use consumes
  vitamins, nutritional supplements(Creatine)
  limits other drug use

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DIAGNOSING ANABOLICSTEROID USE

• PHYSICAL EXAM
• Generally muscular
• Paradoxical lack 2o sex characteristics
• Female hirsutism, deep and coarse voice, breast
  atrophy, clitoral hypertrophy, acne, male-pattern
  baldness

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DIAGNOSING ANABOLICSTEROID USE

• PHYSICAL EXAM
• Male gynecomastia, testicular atrophy, acne,
  increased male-pattern baldness
• May complain sore tendons, difficult voiding
• May find edema, jaundice
• Adolescents premature virilization with stunted
  growth (epiphyseal closure)

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ANABOLIC STEROID USEPOSSIBLE LABORATORY EVIDENCE

• ?HDL, ? LDL and triglycerides
• ? LH, FSH
• ? TSH, thyroxin, TBG
• ? liver enzymes alk phos, LDH, SGOT, SGPT
• ? glucose
• ? hematocrit

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ADVERSE COCAINE EFFECTS

• Any psychiatric symptoms/disorders anxiety,
  depression, suicidal, paranoid, hallucinations
• Tremors, muscle twitches, seizures
• Arrhythmia, MI, CVA, sudden death
• Nasal congestion, perforated nasal septum
• Nausea, vomiting, abdominal pain
• Physical and mental exhaustion