PowerPoint Presentation

DRUGS!Adolescent Drug Use and Management:An Update

March 9, 2015

Briefly discuss the prevalence of drug references in popular culture Review pre-teen and adolescent drug use trends from the 2014 Monitoring the Future SurveyBriefly review the main categories of drugs of abuse, their physical manifestations, and other pertinent topics related to each drugDiscuss the overarching theme of resuscitating patients with drug intoxication in the PEDPOP CULTUREDATAMANAGEMENTOBJECTIVESDRUGS OF ABUSE

POP CULTUREI CANT FEEL MY FACE

COCAINE

MARIJUANAALCOHOL

ECSTASY

The brain continues to develop into adulthood and undergoes dramatic changes during adolescence

One of the brain areas still maturing during adolescence is the prefrontal cortex the part of the brain that enables us to assess situations, make sound decisions, and keep our emotions and desires under control. The fact that this critical part of an adolescent's brain is still a work in progress puts them at increased risk for poor decisions (such as trying drugs or continuing abuse). Thus, introducing drugs while the brain is still developing may have profound and long-lasting consequences.

DATAWHAT THE KIDS ARE USING

Monitoring the Future

Annual survey of 8th, 10th, and 12th graders nationwide

Measures drug, alcohol, and cigarette use and attitudes

The findings related to prescription and over-the-counter drug abuse continued downward trends in 2014. Past year use of narcotics other than heroin (which includes all opioid pain relievers) was reported by 6.1% of 12th graders, compared to 7.1% a year ago and markedly lower than the 2004 peak of 9.5 percent. Past year use of the opioid pain reliever Vicodin showed a significant five-year drop, with 4.8% of 12th graders using Vicodin for non-medical reasons, half of what it was just 5 years ago, at 9.7%

6.8%past-year non-medical use of Adderall in 12th graders

Most teens get these medicines from friends or relatives and to a lesser degree from their own prescriptions.

Measured for the firs time in the MTF survey this year, the use of E-cigarettes is high among teens. Past-month use by 8th graders is 8.7%, for 10th graders 16.2%, and 12 graders 17.1%. Daily cigarette smoking has decreased markedly over the past 5 years (almost 50%) across all grades.

However, novel products such as e-cigarettes threaten to undermine these gains and lure kids into an addiction to nicotine. According to the CDC, nicotine use by youths in any form is unsafe and can harm adolescent brain development.This increase in youth e-cigarette use comes as e-cigarette makers have marketed their products with the same tactics long used to market regular cigarettes to kids, including celebrity endorsements, slick TV and magazine ads, and sponsorships of race cars and concerts. In addition, many e-cigarettes come in sweet, colorful flavors such as gummy bear and cotton candy, which helps explain both their appeal to youth and the increase in poisoning incidents.

MOLLY2.3%Past year use of MDMA (10th graders)Down from 3.6% in 2013Peak was 6.2% in 2001

5.8%(down from 7.9% last year and 11.3% in 2012)0.5% (down from 1% last year)

Reasons for Drug-Related Emergency Department (ED) Visits, by Year: 2004 to 2011

adverse reactions to drugs taken as prescribed or directed

Rates of Emergency Department (ED) Visits Involving Illicit Drugs Among Patients Aged 12 to 24 per 100,000 Population, by Age Group: 2011

Rates of Emergency Department (ED) Visits Involving Misuse or Abuse of Pharmaceuticals Among Patients Aged 12 to 24 per 100,000 Population, by Age Group: 2011

In 2009, what percentage of 16 or 17 year olds drove under the influence of drugs or alcohol1.2%3.6%6.3%10.7%

]

This means in a high school with 200 juniors, more than 12 of them dangerously drove while under the influence. According to the CDC, car accidents are the leading cause of death among young people aged 16-19C. 6.3%

3. Drugged Driving 1. Public health threat--puts not only the driver at risk but also passengers and others who share the road 2. Driving under the influence of any drugs or alcohol may impair motor skills, reaction time, and judgment 3. Teens are the least experienced drivers, increasing their risk of being involved in an accident. Combine lack of experience with substances that may impair cognitive and motor skills you increase the chances of tragic results. MVCs are the leading causes of teen deaths (http://www.cdc.gov/nchs/data/databriefs/db37.pdf) 23% of fatally injured drivers who tested positive for drugs were under the age of 25 (ONDCP Press Release, Oct. 2011). Involvement of drugs in fatal crashes has increased by 5% over the past 5 years, even though the overall number of drivers killed by MVC has declined (ONDCP Press Release Nov 2010)

DRUGS OF ABUSEA SURVEY

What is the most common two-drug combination that results in death? Alcohol and cocaine Marijuana and alcohol Prescription painkiller and alcohol Prescription painkillers and LSD

Mixing drugs is always dangerous, and some combinations interact in ways that are particularly deadly. The number of people who died from mixing opioids and alcohol increased more than 300% from 1999 to 2010

NARCOTICS

euphoriadrowsiness shallow-breathingpinpoint pupilsclammy skinconfusioncomadeath

b. death toll from OD of rx painkillers has more than tripled in the past decade. (CDC Vital Sign Press Release Nov 2011). 40 people die daily from OD of narcotic pain relievers

The average cost of asingle dose(100 mg) of heroin purchased on the street has been reported as approximately$15$20in the U.S. state of Ohio.

A single 30-milligram pain pill such as Oxycodone can sell for $1 per milligram on the street, while 10 to 13 bags of powdered heroin can be had for $100. The Charleston area's proximity to Interstate 95, a key drug-smuggling corridor between Florida and New York, generally has translated into an accessible supply of heroin in the area for years, Coatsworth and police said.

A U.S. Government investigation found Purdue encouraged doctors to prescribe OxyContin for numerous conditions not considered severe pain starting in the 1990s. The U.S. Drug Enforcement Administration also reported Purdue promoted the drugs to doctors who werent trained in pain management and delivered coupons and promotional items for patients.

The opioid painkiller is an extended-release version of oxycodone and one of the most widely-used painkillers in the U.S. Its also highly addictive and was easily abused until the U.S. Food and Drug Administration forced Purdue to reformulate it in 2010.

Kentuckys former attorney general Greg Stumbo filed a lawsuit against Purdue Pharma in 2007 for illegally promoting OxyContin after 484 people died from OxyContin overdose in the state the year before, according to USA Today.

At the end of December 2015, Purdue Pharma agreed to pay Kentucky $24 million over the next eight years to settle allegations that it mislead the public about the addictive nature of OxyContin,

Rates of Emergency Department (ED) Visits Involving Misuse or Abuse of Pharmaceuticals Among Patients Aged 12 to 24 per 100,000 Population, by Age Group: 2011

stimulant medications available only with a prescription amphetamines (adderall, dexedrine)--used to treat ADHD; slang names: ice, crank, speed, bennies, uppers, black beauties methylphenidate and dexmethylphenidate (concerta, ritaline, focaline)--used to treat ADHD; slang names: vitamin R

How are stimulants abused: oral, smoked, crushed and snorted, injected

AlertnessEuphoriaHypertensionTachycardiaDilated pupilsAnorexiaAgitationHyperthermiaHallucinationsConvulsionsDeath

COCAINE MECHANISM OF ACTION

Cocaine modifies the action of dopamine in the brain. The dopamine rich areas of the brain are the ventral tegmental area, the nucleus accumbens and the caudate nucleus these areas are collectively known as the brains reward pathway. Cocaine binds to dopamine re-uptake transporters on the pre-synaptic membranes of dopaminergic neurones. This binding inhibits the removal of dopamine from the synaptic cleft and its subsequent degradation by monoamine oxidase in the nerve terminal. Dopamine remains in the synaptic cleft and is free to bind to its receptors on the post synaptic membrane, producing further nerve impulses. This increased activation of the dopaminergic reward pathway leads to the feelings of euphoria and the high associated with cocaine use.

AMPHETAMINE MECHANISM OF ACTION

Amphetamines like Adderall are primarily releasers of dopamine, norepinephrine, and small amounts of serotonin. At higher doses, they have also been seen to inhibit the reuptake of dopamine and norepinephrine, but not to the levels of cocaine.

Amphetamine block the dopamine reuptake pumpCannot be taken in again from synapse, level of dopamine in synapse increases Amphetamine also causes storage vesicles to release dopamine into synapseCausing dopamine level up, increase in heart beat, blood pressure, alertness, focus

Adverse EffectsSlurred speechDisorientationAmnesiaShallow respirationsClammy skinWeak and rapid pulse

HALLUCINOGENS

People who started smoking marijuana regularly as teenagers actually lost IQ points as they got older

Cannabis Dependence: Age at First Diagnosis Affects Impact on IQ The relationship between IQ decline and cannabis dependence was stronger among individuals who were first diagnosed before age 18 than among those who were first diagnosed after age 18.

a. Marijuana/Synthetic marijuana [A study that followed 1,000 people for more than 38 years showed that people who started smoking marijuana regularly as teenagers actually lost IQ points as they got older; and they never got them back, even if they quit as adults. On average, how many points were lost? A. 2, B. 4, C. 8, D. 12; The study showed that people who began smoking marijuana heavily in their teens lost a much as 8 IQ points between the ages of 13 and 38. Fore people starting out with average IQ scores, a loss of 8 IQ points could drop them into the lower third of the intelligence range]:Since bursting on the scene a few years ago, synthetic marijuana (MJ)often called Spice or K2has become the second most popular illegal drug among American teenagers, after MJ. It is especially popular among teenage boys. Sometimes touted as a natural, safe, and (until recently) legal alternative to pot, this veryun-naturalclass of designer chemicals has shown itself to be a dangerous threat. Thousands of teens and young adults, mostly young males, are ending up in emergency rooms with severe symptoms that may include vomiting, racing heartbeat, elevated blood pressure, seizures, or hallucinations. [K2 or spice refers to a variety of herbal mixtures that produce experiences similar to marijuana, but in some cases more powerful and unpredictable. Which fact is NOT true about K2/spice? A. the are more popular among boys than girls, B. The active ingredients come from natural plant material, C. They are abused by 8% of high school seniors, D. Some teens have had heart attacks after smoking then, E. Flavors are sometimes added to encourage you to buy them; Labels on spice products often claim that they contain "natural" psychoactive material taken from a variety of plants. Spice products do contain dried plant material but chemical analysis show that they active ingredients are synthetic cannabinoid compounds.]

K2 and Spice are synthetic marijuana compounds, also known as cannabinoids. But there are more. In fact, there are approximately 90 different synthetic marijuana chemical compounds. Spice has recently made headlines due to hundreds of people having negative reactions to the product across the country.

A combination of cannabis-like synthetic chemicals sprayed on herbs and referred to generically as Spice. Man-made. SPICE/K2

K22nd highest mountain in the world (25,251 ft)

Dr. John Huffman, a Clemson University organic chemistry professor, was researching the effects of cannabinoids on the brain when his work resulted in a 1995 paper that contained the method and ingredients used to make the compound (JWH-018).

That recipe found its way to marijuana users, who replicated Huffmans work and began spraying it onto dried flowers, herbs, and tobacco

Synthetic marijuana attaches to the same cannabinoid receptors as THC but may have a higher affinity (3 to 5 times more potent)

Too Much Rocky Mountain High: Colorado Sees Spike in Pot Tourists Visiting ER

Colorado has seen an influx of out-of-state visitors since marijuana became legal, first for medical use in 2000, and then available for retail sale in 2014. But one worrying side effect has been the uptick in the number of tourists ending up in the hospital, which Dr. Howard Kim first noticed during his medical residency at Denver Health Medical Center.

We noticed that there seemed to be a lot of people coming into our emergency room with marijuana-related symptoms, he said, and the number of out-of-state visitors seemed to be rising quickly. So we wondered if the numbers would bear this out overall.

Read more: Does smoking pot actually make you stupid?

The statewide analysis that Kim and colleagues conducted found that, indeed, the rate of out-of-state emergency room visits for marijuana-related symptoms rose 200 percent from 2012 to 2014. The increase was just 44 percent among Colorado residents over that same period, researchers report in a correspondence to the New England Journal of Medicine.

The reason for that gap, Kim and his colleagues suspect, is that educational media campaigns about safe use of marijuana have been targeted at Colorado residents. They suggest that health messaging at the marijuana dispensaries themselves might be better able to reach marijuana tourists.

Kim said he often saw patients who were in town visiting relatives or on business trips and would decide to try some marijuana.

These patients would then show up at the emergency room with anxiety, agitation, increased blood pressure, and heart rates, along with gastrointestinal distress and vomiting. While some people were admitted to the hospital for observation, most were usually released within a few hours.

ECSTASY MECHANISM OF ACTION

Recently, the media has picked up several stories of Molly-related deaths at electric dance music (EDM) festivals. In 2013, organizers of the popular Electric Zoo festival in New York were forced to cancel the final day of the event after two deaths in the opening days. The victims in these stories are often young and not known as drug users, making the deaths all the more shocking to their parents and friends.In light of these events, it is important that parents understand more about the pervasiveness of club drugs like Molly, a form of MDMA or ecstasy at EDM festivals. Here are some facts to know:

1. MOLLY IS INEXPENSIVE.

Teens can buy it for around $15-20 a pill, making it fairly easy to obtain. There have been reports of several dealers willing to sell to anyone at EDM festivals. This combination of high supply and low cost makes it especially important that parents are active in talking to their kids about the drug and its dangers.

2. MANY TEENS VIEW MOLLY AS A PURE DRUG AND THEREFORE LESS DANGEROUS.

Molly, no matter its chemical purity, is never safe. Molly combines the effects of a stimulant and hallucinogen, both of which can be dangerous. Furthermore, the drug sold under the name Molly is often laced with other substances, including bath salts, cocaine, and methamphetamines, which can make the drug even more dangerous than it already is in its pure form. Based on recent reports, the Molly bought at these festivals is rarely what the dealer claims it is. Teens should be aware of this fact and not have a false sense of security that what they are getting is safe.

3. EDM FESTIVALS CREATE CONDITIONS WHICH CAN INCREASE THE RISK OF SERIOUS MEDICAL CONSEQUENCES.

Our recent blog highlighted the dangers of Molly, including possible death. Molly can also cause nausea, blurred vision and potentially dangerous changes in body temperature and blood pressure. EDM festivals are often crowded, highly stimulating environments, making it difficult to keep track of friends. Attendees can easily get dehydrated; water at these events is often expensive, making it more difficult to stay hydrated and safe. If someone needs help, it can be difficult to find medical personnel.

4. SOME FESTIVALS ARE TAKING ACTION TO CREATE SAFER ENVIRONMENTS FOR ATTENDEES.

In the wake of two deaths, the 2014 Electric Zoo festival implemented several tactics to combat drug use. Attendees were required to watch an anti-drug Public Service Announcement, water was provided for free, and medical personnel monitored the crowd for signs of trouble. There were no drug-related deaths that year. Though these steps may not be adequate to prevent drug use and consequent medical complications, it is important that organizers are trying to create a safer environment.

BATH SALTS

BATH SALTS

MANAGEMENTSELECTED WORK FOR DISPLAYTREAT THE PATIENT NOT THE TOXIN

AIRWAYBREATHINGCIRCULATION

DEXTROSE

Assess vital signs, mental status, and pupil size, skin temperature and moisture, and perform pulse oximetry, continuous cardiac monitoring, and an electrocardiogram. Obtain intravenous access and a finger-stick glucose measurement. In patients with suspected occult trauma, maintain in-line cervical immobilization. Assess the airway and perform endotracheal intubation if there is significant doubt about the patient's ability to protect their airway and avoid aspiration.

UNCONSCIOUSALTERED MENTAL STATUS EMESISSEIZURES HYPOVENTILATIONHYPOXEMIA

HEMODYNAMIC INSTABILITY(TACHYCARDIA, BRADYCARDIA, ARRYTHMIAS HYPERTENSION,HYPOTENSION)

HYPERTHERMIA

DecontaminationAntidotal therapyEnhanced elimination techniquesSupportive careMANAGEMENT

Supportive care Supportive care is the most important aspect of treatment and frequently is sufficient to effect complete patient recovery. Supportive care for the poisoned patient is generally similar to that utilized for other critically ill patients, but certain issues are managed slightly differently:

ANTIDOTES

Antidotes Supportive care is the cornerstone of the treatment of the poisoned patient, and the adage "treat the patient, not the poison" is the guiding principle of medical toxicology. However, there are instances in which prompt administration of a specific antidote is potentially life-saving.

NARCANFirst-line opioid antagonist for respiratory depression or significant sedation resulting from opioids

Strong competitive antagonist at mu receptors and other opiate receptors

(Naloxone)

FLUMAZENILUse is discouraged by many toxicologists

Potential to cause harm in: Patients addicted to dependent on benzos, patients taking bentos to control seizure disorder, benzo OD with another drug that can precipitate seizures

If these patients receive flumazenil then has a seizure, they may be very hard to treat because the first-line anticonvulsanta benzohas been removed

The risk/benefit ratio is more favorable in young kids because they are not addicted to benzos, dont typically present after overdosing on multiple meds, and the history can be supplied by a caretaker

FINAL THOUGHTS

This image study shows brain development, ages 5 through 20 and beyond. It was thought (until these new brain imaging capabilities) that the brain was fully developed by adolescence. We now know its not. There is a great deal of brain development brain changes occurring between ages 12-20, often through age 25. These brain changes are related to:

1) Puberty. Puberty triggers new hormonal and physical changes, as well as new neural networks.

2) Continued development of the cerebral cortex (front area) the thinking part of the brain. This involves neural networks wiring within the Cerebral Cortex the idea of learning calculus vs. memorizing multiplication tables, for example. It also involves neural networks in the Cerebral Cortex writing to those in other areas of the brain the idea of controlling emotions, which originate in the Limbic System, with logical thought, which originates in the Cerebral Cortex, for example.

3) Pruning and strengthening of neural networks. Pruning is when neural connections (explained below) that are not used or are redundant fall away (get pruned), and those that are used get strengthened, which makes the remaining neural connections more efficient (similar to the way an insulted cable wire works more efficiently than a non-insulated one). This concept is explained in more detail at The Partnership at Drug Free.org website, A Parents Guide to the Teen Brain.