Adolescent Substance Abuse

Anthony Dekker, D.O.

SWRSAC 2000

“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 tombcirca 3000 B.C.

• “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 > Hispanic > Black

• Peak drug use late 1970s - 1981

ADOLESCENT SUBSTANCE ABUSE

• 54.7% of seniors had ever used any illicit drug ( 0.6)

• 25.9% used in past month ( 0.3)• 43% believe > 5 drinks 1-2 times a

weekend is risky ()• 25% believe marijuana use once or

twice is risky ()

SUBSTANCE ABUSE TRENDS1999 MONITORING THE FUTURE

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

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

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

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

• 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

ANTICIPATORY GUIDANCEFAMILY CONTEXT

* alcohol, tobacco, and other drugs

• + 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)

POTENTIAL RISK FACTORSGENETIC AND FAMILY 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

POTENTIAL RISK FACTORSPERSONAL 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

POTENTIAL RISK FACTORSENVIRONMENTAL FACTORS

• Substance Abuse• Depression• Other Psychological Issues

DIFFERENTIAL DIAGNOSIS FOR A WIDE RANGE OF PSYCHOSOCIAL PATHOLOGY

& ADOLESCENT DYSFUNCTIONS

• Provider-patient-family trust triangle• Breach

– Presents harm to self or others– Required by law

Maintain privacy and confidentiality

Provider

privacycommunicationconfidentiality

TRUST RELATIONSHIP

parent child/teen

• Interview: – relate and just ask

• Tools: – mnemonics and questionnaires:– HEADSSS

• Refer for specific assessment and testing

SCREENING & ASSESSMENT

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

URINE DRUG SCREEN

• 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

URINE DRUG SCREENINSURING ACCURACY

• Anabolic steroids– p.o. 4 weeks– i.m. 6 weeks

• Amphetamines/ < 48 hours methamphetamines• Barbiturates

– short acting 24 hours– long acting 2-3 weeks

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

URINE DRUG SCREENDURATION OF DETECTION

• PATIENT NOT USING– Affirm decision not to use– Anticipatory guidance

• PATIENT USING/LOWER RISK– State your concern– Elicit patient’s understanding of use. Dispel myths– Assess readiness to change– Negotiate plan and follow up

SYNTHESIS AND PROCESS

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

SYNTHESIS AND PROCESS

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

BRIEF INTERVENTION

Pre-contemplationContemplation

Action PlanImplementationMaintenance

RecoveryRelapse

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

MOTIVATIONAL INTERVIEWING

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

PRINCIPLES OFMOTIVATIONAL INTERVIEWING

• 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

WHEN IS REFERRAL NEEDED?

• 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”

COMMUNITY-BASED INITIATIVES

• 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

SUBSTANCE ABUSEGENERAL ISSUES

• 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

SMOKELESS TOBACCOHEALTH CONSEQUENCES

• Solvents– industrial or household– art or office supply

• Gases– in household or commercial products– household aerosol propellants– medical anesthetic gases

• Nitrites– aliphatic nitrites

CATEGORIES OF INHALANTS

• 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

GENERAL INHALANT EFFECTS

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

GENERAL INHALANT EFFECTS

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

ADVERSE INHALANT EFFECTS

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

ADVERSE INHALANT EFFECTS

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

INHALANT-ASSOCIATED DEATH

• 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

ANDROGENIC ANABOLIC STEROIDS

HISTORY• Athletic appearing person, physical or psychological

complaint• Obsessive interest in health, exercise, weight lifting• School or work difficulties

DIAGNOSING ANABOLICSTEROID USE

HISTORY• Behavior changes: aggressiveness (“roid rage”),

hyperactivity, irritability, cyclic mood swings, anxiety, panic, suicidal ideation, auditory hallucination, paranoid/ grandiose delusions

DIAGNOSING ANABOLICSTEROID USE

HISTORY• Drug history: denies steroid use;

consumes vitamins, nutritional supplements(Creatine); limits other drug use

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

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)

DIAGNOSING ANABOLICSTEROID USE

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

ANABOLIC STEROID USEPOSSIBLE LABORATORY EVIDENCE

• 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

ADVERSE COCAINE EFFECTS