Adolescent Substance Abuse

Rachel Gonzales, Ph.D.

What is Prescription and Over the Counter Drug Misuse?

Any Rx and OTC drug can be “misused”

Misuse = “Non-medical use” or any use that is outside of a medically prescribed regimen

Examples can include:Taking for psychoactive “high” effectsTaking in extreme dosesMixing pillsUsing with alcohol or other illicit substancesObtaining from non-medical sources

Adolescents & Young Adults

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10

20

30

'96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06

MTF Study; Past Month Use for 12th Graders

Nationally, there’s Good News…

Illicit Drugs

Cigarettes

Alcohol

-35%

-57%

-47%

Every Generation of Teens Looks for New Ways to Get “High”

Nationally, there’s also Bad News…

Cough medicine

Inhalants

Vicodin

Generation“Pharming Culture”

Epidemiology of Rx and OTC Drug Misuse Among Youth

What do we know about the problem?

NationallyNational Survey on Drug Use and Health (NSDUH)Monitoring the Future Study (MTF)

State/CountyBiannual California Student SurveyPublicly-funded treatment admission data from county data systems

GHBGHB

HeroinHeroin

KetamineKetamine

LSDLSD

MethMeth

EcstasyEcstasy

Cough MedicineCough Medicine

Crack/CocaineCrack/Cocaine

MarijuanaMarijuana 8.6 8.6 millionmillion4.5 million4.5 million

2.4 million2.4 million

2.4 million2.4 million

1.3 million1.3 million1.9 million1.9 million

1.9 million1.9 million

1.1 million1.1 million

1 million1 million

1 million1 million

Prescription MedicinePrescription Medicine

NSDUH, 2006

Landscape of Drug* Abuse among Teens

*Excludes ETOH

“Pharming Culture”

Today's teens are more likely to have abused Rx and OTC drugs than most illicit drugs

Every day 2,500 teens 12-17 try a painkiller for the 1st time

MTF, 2006

Commonly Misused Rx Drugs

Opiates: pain-killersEx) Vicodin, Oxycontin

Sedatives/Tranquilizers (Depressants): treat anxiety and sleep disorders

Ex) Xanax, Valium

Stimulants: treat ADHDEx) Aderall, Ritalin, Concerta

OTC Medicine Misuse•Dextromethorphan DXM (narcotic codeine) the active ingredient in over 100 cold/cough remedies.

•Found in tablets, capsules, gel caps, lozenges & syrups

•Teens discovered using mass quantities of DXM-containing products get them “high”.

Examples of Popular OTC Products

Coricidin HBP Cough & Cold Robitussin Cough products Sudafed Cough medicines Dimetapp DM Tylenol Cold products Vicks NyQuil and Dayquil Alka-Seltzer Plus Cold &

Cough Triaminic Cough syrups

Top 5 Drugs Used by 12th Graders

31.5%

9.7%4.3% 7.5% 6.9% 6.6%

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SOURCE: MTF, 2006

3.8%

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OTC Medications Misused by Teens

38.6%

17.8%18.1%

30.5%

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20%

30%

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SOURCE: MTF, 2006

Concerning Trends

Adolescents 12-13

Teen Females

Young Adults 18-24

Extent of Rx & OTC Drug Misuse among Youth in California

12th Biennial California Student Survey: Drug, Alcohol & Tobacco Use

Secondary students (7th, 9th, 11th graders)

Representative State sample: random schools & classrooms

13,930 students

48 middle and 68 high schools (including 10 continuation)

Misuse of opiate painkillers (no prescription) to get high 2006: 15% of 11th graders 9% of 9th graders 4% of 7th graders

California Student Survey 2006

Changes to Survey

2007: Expanded substances and made separate question on recreational use of pharmaceuticals (high school only)

Added cold/cough medicines, diet pills, and Ritalin/Adderal

Lifetime PrevalenceGrade 9 Grade 11

(%) (%)

Street Drugs Marijuana 25 42 Methamphetamines 5 7 Ecstasy 6 10Prescription/Medicinal Drugs* Painkillers 12 18 Barbiturates 2 3 Sedatives/tranquilizers 4 6 Diet pills 9 8 Ritalin/Adderal 4 6OTC Cold/Cough Medicines 26 25

*to get high – not for medicinal reasons

The Pharming Subculture: Generation Rx

Youth & Young Adult Risk Factors

Top Reasons for Rx & OTC Drug Misuse

Social with friends

Legal - Widely Available

Easily Accessible

Affordable: Low Cost/Free

Safe - Prescribed

Non-addictive: Medicine

Partnership Attitude Tracking Survey (PAT): Released in April 2006 by The Partnership for a Drug-Free America

Recent Research: Why Teens Use?

Teens admit to misusing Rx drugs for reasons other than getting high, including to relieve pain or anxiety, to sleep better, just to experiment, to help with concentration or to increase alertness. (Boyd, McCabe, Cranford & young, 2006).

More than 1/3 of teens say they feel pressure to abuse Rx drugs and say using these drugs is an important part of fitting in with their friends. (Seventeen, 2006).

When teens abuse Rx drugs, they often characterize their use as “responsible” or “controlled” (Friedman, 2006).

Access & Availability

Family & Friends Homes

Retail Pharmacies

Increasing trend to use Psychiatric Drugs to Treat Youth Behavioral Problems…

Problem: Massive Media Marketing from Pharma

Modern Culture

Direct-to-Consumer Advertising of Rx Drugs

“Amazon.com pushing ADHD drugs with front-page, celebrity-endorsed”Free Trials

The RealityBig PharmaEx) Several reports suggest that Purdue Pharma, the maker of OxyContin, helped fuel widespread abuse of the drug by aggressively promoting it to general practitioners not skilled in pain treatment or in recognizing drug abuse…Sales grew from $48 million in 1996 to $1.1 billion in 2000Became leading drug of abuse in 2004…

Oxycontin alone had 21 million prescriptions written for them in 2007 to 3.7 million patients (many of which were minors and young adults)

Van Zee, 2009

# of new non-medical users

Pharm Sales Grew

Oxycontin alone had 21 million prescriptions written for them in 2007 to 3.7 million patients (many of which were minors and young adults)

Development of Medicine Subculture

Endorsements from MDs

The Internet & Technology

Social Networking Web Sites

Venues for penetrating the Medicine Abuse Subculture

YouTubeMySpace

LiveJournal Facebook

Footage of teens “high”User Guides: Rx & OTC abuse instructions (recipes)Blogs & videos of experiences

Social Rx & OTC Slang

Xbrs or xanabars: anti-anxiety Xanax

Vic: Vicodin Skittles, Dex, Robo, Tussin, (any

OTC cold pill containing DXM) Triple Cs or CCC: Coricidin Cough

& Cold med SIZ’zurp: cough syrup & ETOH Trail Mix: Pharm Party

Keeping Parents Clueless

Treatment for Rx Drug Misuse

Abusing Rx drugs before the age of 16 leads to a greater risk of dependence later in life.

The # of teens going into treatment for Rx drug abuse has increased by more than 300% during the last 10 years.

Between 2004-05, the proportion of youth seeking treatment for Rx drugs increased by 9%.

TEDS, 2006

•Little known about specific treatments for addressing Rx drug abuse among youth.

Rx Drug Misuse: Treatment Settings

Youth coming to treatment for “self-medicating” with Rx drugs to treat underlying psychiatric condition.

Rx drug misuse among youth in treatment for co-occurring disorders is problematic:

“Cheeking” or saving unswallowed Rx meds for obtaining a later “high”…

Consequences/Effects

The “High”Slurred speechFlushed skin, sweatingLoss of appetiteMild distortions of color/soundConfusion, forgetfulnessClumsiness/loss of motor controlMood swings, irritabilityExcessive energy or sleepiness

The “Lows”

Delusions Panic attacks Memory problemsBlurred visionStomach pain, nausea, vomiting High blood pressure & Rapid heart beat

Numbness of fingers/toesDrowsiness & Dizziness Fever & headachesRashes/itchy skin Loss of consciousness

Side Effects can be Lethal if…

Combining Rx & OTC medications.Taking Rx and OTC meds with alcohol.Using Rx and OTC with other illicit drugs. Interactions: Rx & OTC meds with other physical medications (i.e., HIV or Hepatitis)

Poison Control System: Prescription Narcotics LA 2005-2008

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2

4

6

8

10

12

14

16

2005 2007 2008

Perc

ent

Hydrocodone Oxycodone Other narc

SOURCE: California Poison Control System

Rx & OTC Drug Over DosesLast 2 months: Rapper Pimp C (Chad Butler): cough syrup & Hennessey– “sizerp”This Year: Heath Ledger: lethal cocktail of Rx drugs - pain, sleeping, anti-anxietyLast Year: Anna Nicole Smith & Son (Daniel) both died due to Rx drugs Last 2 Years: Rapper ODB: fatal mixture of Rx drugs & cocaine

Teens Don’t Understand the Risks & Effects of Abusing Rx and OTC Medicines

Over 50% believe that abusing these medicines to get high is NOT risky…

Join Together, 2006

Unrecognized

Under-screened

Under-treated

Parents Don’t Recognize Problem

Only 8% of parents are aware of Rx & OTC abuse.

75% don’t talk to their kids about the problem.

Unaware that the drug supply can come from their own home.

Under-Screened57.7% of physicians say they don't discuss Rx abuse with their patients because there is a lack of knowledge on what to screen for and how to treatment it...

35.1% of physicians cite time constraints & lack of reimbursements for screening and treating a Rx-abusing patient.

CASA Released Survey of Primary Care Physicians & Patients, 2000

Other Key Stakeholders

Lack of screening and awareness about Rx and OTC problem among:

Substance abuse treatment practitioners

Social workers, juvenile delinquent counselors, probation officers

School teachers, nurses, & counselors

McCabe, S.E., Teter, C.J., & Boyd, C.J. (2004)

Efforts to Address Rx & OTC Misuse

Youth Prevention ActivitiesONDCP

12 week national public awareness campaign Began with 2 Ads aired during Super Bowl1st paid TV advertising targeting parents in 2 years.

DARENew School Curriculum Addresses Rx and OTC Drug Abuse

Five Moms CampaignStopping Cough Medicine Abuse – keeping parents informed and educated of the issue

New Rx Drug Regulations

Action has taken place throughout U.S. federal and state levels.

Federal: address issues with poor Rx practices among MDs:

F.D.A. will be placing new limits on prescriptions of 24 popular narcotics (like OxyContin) for increasing MD responsibility

State: establishing prescription monitoring programs, continuing medical education and practice guidelines

NY Times, 2009; McLellan, 2009

Efforts in CaliforniaEstablishment of Statewide Rx Drug Task force charged with:

Monitoring trends and strategies statewide.

Developing prevention strategies for teens.

Developing intervention strategies for teens entering treatment settings.

Self-Medicated Culture: Be aware of the potential for misuse and abuse

Evidence-based practice…researched-based interventions…science-based services…science-verified practices…empirically-supported practices…essentially mean the same thing.

Programs or practices that are proven to be successful through empirical research study and result in consistently positive results.

Need for Evidenced-Based Practices

SOURCE: NIDA; Institute of Medicine.

9 Key Elements: Effective Adolescent Treatment Program

Assessment and treatment matching: comprehensive assessments that cover psychiatric, psychological, and medical problems, learning disabilities, family functioning, and other aspects of the adolescents life.Comprehensive, integrated treatment approach: Adolescent’s problems should be addressed comprehensively rather than concentrating solely on curtailing substance abuse.Family involvement in treatment: Engaging both adolescent and parents and maintaining close links with the adolescent’s family, home, school. Developmentally appropriate program: Important that programs be specifically designed for adolescents rather than merely modified adult programs. Engage and retain teens in treatment: Programs should build a climate of trust between the adolescent and the therapist.

SOURCE: Brannigan et al., 2004.

Qualified staff: Staff should be trained in adolescent development, co-occurring mental disorders, substance abuse, and addiction. Gender and cultural competence: Programs should address the distinct needs of adolescent boys and girls as well as cultural differences among minorities. Continuing care: Programs should include relapse prevention training, aftercare plans, referrals to community resources, and follow-up. Treatment outcomes: Rigorous evaluation is required to measure success, target resources, and improve treatment services.

SOURCE: Brannigan et al., 2004.

9 Key Elements: Effective Adolescent Treatment Program

What has Traditionally Been Done?

Historically, adolescents were integrated into adult programs, which ignore the unique needs of youths

CSAT now advocates the separation of adolescent and adult services into “Adolescent-only” care that implements unique evidence-based treatment.

Evidence-Based Youth Treatments

Family-Based Therapies Multi-systemic therapy (MST Henggeler, et al., 1996)Multi-dimensional Family TherapyFunctional family therapy (FFT Waldron et al., 2001)Community Reinforcement Approach

Motivational Enhancement Therapy (Wagner et al., 1999)

12-step approach/Minnesota Model (Winters et al., 2000)

***Studies could not clearly identify a superior treatment approach, optimal dosage, and length of required involvement that maximized short-and long-term treatment outcomes***

Evidence-Based Youth Treatments

Cognitive-Behavioral Therapy (Kaminer et al., 1998)

Contingency Management/Reinforcement (Corby et al., 2000)

Integrative treatment models employing CBT combined with MI and/or with a family intervention (Dennis et al., 2000)

***Studies could not clearly identify a superior treatment approach, optimal dosage, and length of required involvement that maximized short-and long-term treatment outcomes***

Effective Strategies During Treatment Engagement

MedicationsMotivational InterviewingVoucher-based TechniquesCounseling to Promote Transfer to Long Term CareNIATx Strategies

Effective Strategies in Rehabilitation Phase

Interventions/ServicesClinical Case Management CRAFT12-Step FacilitationVoucher ReinforcementMatrix Model Treatment

MedicationsAlcohol (Naltrexone, Disulfiram, Citalopram) Opiates (Naltrexone, Methadone, Buprenorphine)

Types of Continuing CareSelf/mutual help programsMedicationsTraditional counseling visitsHome visitsRecovery “check-ups”

Specialty care-basedPrimary care-based

Telephone-based protocolsMonitoring Monitoring and counseling

Other stuff

Evidence-Based Practices for Adolescent Treatment

Resources/Tools

Treatment Protocols for Youth

Community Reinforcement Approach

Motivational Enhancement Therapy

Cognitive Behavioral Therapy

Multi-Dimensional Family Therapy

Family Support Network

Manualized treatment protocols for youth show promising results in clinical trials

NIDA and SAMHSA Resources

“NIDA Red Book”

“NIDA Blue Book”

TIP 31: Screening & Assessing Adolescents for Substance Use DisordersTIP 32: Treatment of Adolescents With Substance Use Disorders

California Treatment Resources

The Need to Invest in Adolescent Treatment: Policy Recommendations for Adolescent Treatment in California (2004).

California Department of Alcohol and Drug Programs (ADP) Youth Treatment Guidelines

Contact Information

Rachel: rachelmg@ucla.edu (310) 267-5316