Adolescent Substance Abuse

Mike Guyton, MD

Assistant Clinical Professor/Academic Faculty in General Pediatrics

Overview

• Myths, Misconceptions, and the Adolescent Brain• Common Drugs of Abuse

– Alcohol– Marijuana– Tobacco

• Emerging Trends in Substance Abuse• Co-morbid conditions with Substance Abuse

– Depression and Anxiety– Bullying– High Risk Sexual Behavior

• Prevention Strategies/Resources

Drug Myths and Misconceptions

• Drug addiction is a choice

• Substance use is just a phase during adolescence

• Marijuana is safer than traditional tobacco products

• Teenagers are drinking alcohol and doing drugs now more than ever

Drug Facts

• Illicit drug use among teenagers remains high, largely due to increasing popularity of marijuana.– Rising marijuana use reflects changing perceptions and attitudes.

• Nonmedical use of prescription and over-the-counter medicines remains a significant part of the teen drug problem.– Purple Drank/Sizzurp/Lean

• Alcohol use among teens remains at historically low levels.• Fewer teens smoke cigarettes than smoke marijuana.• Other forms of smoked tobacco are becoming popular, however.

– Hookah Water Pipes, Small Cigars

The Biology of Adolescence

• In general, adolescence includes ages 10-25

• Lack of frontal lobe lack of judgment

• Behavior controlled by response to impulses

– Amygdala/Limbic System

Alcohol

• The most widely used/abused drug among US adolescents– In US, children and adolescents account for 11% of total alcohol

consumed– Almost 40% of HS students report current use; ¼ binge drink

• Multitude of negative health effects associated with abuse– Acute Effects

• Nervous System Depression, Hypoglycemia, Dehydration, GI

– Chronic Effects• Chronic Liver disease, Nutritional deficiencies, Impairment in

Cognition

• Many negative societal outcomes as well– Fatal MVA’s, aggression, suicidal behavior, unplanned

pregnancies, sexual assault

How much is too much?

• Legal limit in SC is 0.08

• Reaching limit depends on many factors

– Age and Gender

– Weight

– Rate of consumption

– Metabolism

– Hydration

Standard Drinks

Binge Drinking Facts

• In general, risk of experiencing problems is greater for binge drinkers– School, social, legal, etc.

• Youth who start drinking <15yo are 5X more like to develop alcohol dependence or abuse– Vs those after 21yo

• Data from 2011 Youth Risk Behavior Survey– 16% of youth 12-20 report

binge drinking– In high school students, 22%

reported binge drinking in the last 30 days

Standard Drink Measurements (0.6-oz of pure alcohol):

• 12-oz of beer (5% a.c)• 8-oz of malt liquor• 5-oz of wine (12% a.c.)• 1.5-oz of 80 proof liquor

Binge Drinking = 4+(women) or 5+(men) drinks on one occasion

Binge Drinking

• Neknominate

– Most popular in the UK/Ireland, trend spreading over 2014

– Believed to be directly responsible for 5 deaths in the UK

– Each nomination more intense, daring, or humiliating than the last

Tobacco

• Leading preventable cause of disease, disability, and death in US– Causing/related to 1 in 5 deaths in the US– 41,000 non-smokers die annually due to passive smoke exposure

• Active ingredient is Nicotine– The most addictive substance in existence; withdrawal– Toxic/Fatal in certain quantities– Stimulates adrenal glands/nervous system

• blood pressure, heart rate, respiration

• Cigarette smoking alone accounts for 1/3 of all cancers, in addition to those caused by smokeless tobacco

• Passive smoke exposure also linked with health compromise– Heart disease risk (25-30%) and Lung cancer risk (20-30%)

Tobacco Carcinogens

Marijuana

• Most common illicit drug used in the US– Increasingly popular among teenagers

• Use is extremely controversial– Schedule 1 per Federal Government– Approved for medicinal use in 21 states– Approved for recreational use in 2 states

• Nervous System effects are the most well known– THC attacks the cannabinoid receptors in the brain affect

pleasure, memory, thinking, concentration, and coordination– Overstimulation altered perceptions, “high”– Affects brain development in heavy/chronic users

• Loss of, on average, 8 IQ points between age 13-38 when started in teenage years

Lesser Known Facts

Recognized Medicinal Uses

• Chemotherapy related Nausea and vomiting

• Appetite Stimulation

• Cancer Pain Relief

• Anxiety and Sleep

Long Term Health Effects

• Substance Addiction

• Carcinogen Exposure– Benzopyrene

– Benzanthracene

• Increased respiratory infections

• Increase risk of CVD

• Mental Illness

• Infertility/Pregnancy Related concerns

Emerging Trends in Substance Abuse

http://www.drugabuse.gov/

Emerging Trends

Days of Yore

• Cigarettes

• Alcohol

• Cocaine

• Heroin

• Marijuana

New Kids on the Block

• Bath Salts

• Inhalants

• K2/Spice

• MDMA

• Steroids

• Krokodil

• Natural Substances– Caffeine

– Spices

Bath Salts

• Drugs containing 1+ synthetic cathinones– Amphetamine-like stimulant

• Marketed under many names; used in several ways– Ivory Wave, Vanilla Sky, White

Lightning

– Orally, Inhaled, Injected

• Symptoms of “excited delirium”– Elevated HR/BP, Euphoria,

Paranoia, hallucinations, panic attacks

Traditional Caffeine Use

• Traditionally, soda and tea have been the main sources of caffeine for kids and adolescents– ~73% consume caffeine on a given day

• Mean caffeine intake among adolescents and young adults in the US has remained stable over the years– Actually decreased among young kids over the last 10 years

• Proportion of intake from soda has decreased, but intake from coffee and energy drinks has markedly increased– Coffee: 10% 24% (2009-2010); Energy Drinks: 0% 6%

(2009-2010)

• AAP has a very clear statement – “Stimulant-containing energy drinks have no place in the diets

of children and adolescents”

Caffeine of 2014: Caffeine Powder

• Hit the headlines in March 2014– Fatal overdose by a senior high school student

• Caffeine powder is pharmaceutical grade– Basically 100% pure; safe amounts can not be measured with

traditional household/kitchen measuring tools

• Some potential uses have been discussed– Added stimulatory/concentration effects– Help in losing weight

• Side effects are varied– Arrhythmia– Seizures– AMS– GI Symptoms: Nausea, Vomiting, Diarrhea

How does caffeine powder measure up?

Caffeine Powder

• 1/16 tsp = 190mg

• 1/8 tsp = 380mg

• ¼ tsp = 760mg

• 1tsp = ~3,000mg

Traditional sources of Caffeine

• Coffee = 80-175mg

• Tea = 15-60mg

• Red Bull = 80mg

• Mountain Dew = 55mg

• Diet Coke = 45mg

• 5-hour energy = ~210mg

1tsp of Caffeine Powder = ~25-30 cups of Coffee

The E-Cig Craze

• First nicotine based E-cigarette was created in 2003

• Cost ranges from $10 to hundreds of dollars

• The trend, known as “vaping,” is set to surpass the sales of regular cigarettes in the next 10 years

• Doctor Plug• Office Plug

E-cig? Never heard of them!

What's the Difference

• Vapor vs Smoke– No burning means no CO

• Nicotine Levels– Not as predictable

• Lack of Carcinogens

• Reusable– Charging stations, cartridges

• Cheaper– $600/year vs $1,000/year

What's the Problem• Not FDA regulated….yet

– Family Smoking Prevention and Tobacco Control Act

• Health Risks of Nicotine Alone– Lethal at certain doses– Multiple forms of exposure

• Impact on Lungs– Decreased lung function,

increased airway resistance, cellular changes

• Risks not related to Vaping– Accidental poisoning of

children

How does this affect our Adolescents

• Between 2010-2012, ever use of e-cigarettes among U.S. youth doubled 3.3% 6.8%; current use doubled 1.1% 2.1%

• Well known that adolescents are impressionable, stubborn and for the most part invincible– Majority of adolescents (64%) see the harmfulness of cigarettes as

dose-dependent and on a continuity

• Curiosity is a hallmark of this period of development– Estimated 30% of youth are curious about cigarette smoking

• Brain is still making pathways that can be interrupted– In animal studies, deficits in serial pattern learning, attention and

impulsivity, and memory were seen after exposure to nicotine– Also, increased anxiety and depression

Combining Curiosity and Exposure

• Youth exposure to TV E-cig ads increased 256% from 2011 2013– Reaches 24 million youth

• Cable television accounts for the largest source of exposure

• Depicts e-cigs with vapor that looks similar to smoke– Visual Cue urge to smoke

• Ads harp on smoking being an adult behavior

• All this combined can alter and create new social norms about tobacco, thus influencing smoking behaviors

Current Burden of Mental Illness

Among Youth• Depression

– Point prevalence in those 4-17yo estimated to be 3-3.5%

– Lifetime prevalence as high as 7-8%• Relapse as high as 40% in 2 years

– F:M 2:1; increased risk to those born in latter half of 20th century

• Anxiety– Usually co-morbid with depression

• Estimated to be current in ~3% of those 3-17yo

• Suicide– 3rd leading cause of death among all children and adolescents in

the US

– In 2010, rates estimated to be 4.5/100,000 youth 10-19yo

– Overall, rates of pediatric suicide are increasing

Depression, Anxiety, and Substance Abuse

• Association is multifaceted– Anxiety/Depression may increase substance use;

substance use may affect course and severity of anxiety/depression

• Stress highly linked with relapse– HPA axis shows responses that can promote relapse

• Many neurochemical components shared between depression/anxiety and substance use disorders– Dopamine

– Catecholamines

– GABA receptors

What Makes Identification Tough

• Kids/Adolescents have many reasons to hide their feelings of depression/anxiety– Fear of Stigma

– Belief that depression is not treatable by primary care docs

– Depression is not a “real” illness, but instead a personal flaw

– Concerns about confidentiality

– Do not want medication or involvement of a psychiatrist

Teen suicide tries increased after FDA toughened antidepressant warning

The Study

• Harvard Medical School followed 2.5 million teens/young adults between 2000-2010– Published in The BMJ June 18, 2014

• Use of SSRI’s fell by 25%-30% – Young adults and teens respectively

• Suicide attempts rose 22% in teens and 34% in young adults• At the heart, its all about communication

– Treating depression in teens with SSRI’s has been proven safe and effective time and time again

– Appropriate follow-up must be an integral part of the management plan

– View SSRI treatment as a temporary measure, and communicate that to the patient

– Don’t neglect to role of psychotherapy as well

Bullying

• “Repeated infliction of harm on younger, smaller, or less powerful peers”

• 10% of students grade 6-12 have reported bullying in varying environments– School, on the way to school, online, extracurricular

activities/sports

• Both the bully and victim are affected– Victim: Physical injury/symptoms, lapse in concentration,

anxiety depression, poor self esteem, high school absence– Bullies (long term): incarceration, social/financial/personal strife

• Bullying Vulnerability Impulsivity substance abuse

Anabolic Steroids

• Official name is Anabolic-Androgenic Steroids (AAS)– Synthetic variants of testosterone

• Prevalence trend has been overall stable from 2010-2013– Ranging 1.1%-2.1% for 8th-12th grade adolescents; as high as 5.4%– Sexual Minority Boys have a prevalence of 21%

• Abusers usually “cycle” use but use higher dosages than those medically prescribed

• Many long term side effects– Stunted growth– Gynecomastia– Testicular atrophy– Androgenic effects– Infertility– Increased risk of prostate cancer

High Risk Sexual Behavior

• Link between substance use and high risk sexual behavior– Decreased inhibitions poor decision making

• Compounded by natural curiosity about sex and biological impulsivity– Lack of prefrontal cortex control

• Interventions should be multifaceted– Education on safe/responsible sexual practices– Assessment of degree of substance use– Screening for episodes of domestic violence

• Sexual minorities particularly at risk

Prevention Strategies

• Routine medical care

• Don’t be afraid to ask questions

• Educate yourself on the common signs of substance abuse

• Focus on reduction of risk factors– Teaching life skills at school

– Education/discussion on co-morbid conditions

Common Signs of Substance Abuse

• Physical Signs– Bloodshot eyes– Weight loss– Deterioration in personal hygiene– Tremors, slurred speech

• Behavioral Signs– Increased withdrawal from others– Loss of enjoyment in activities previously liked– Sudden changes in friends– Change in school/work performance– Unexplained need for money

• Psychological Signs– Anxiety/Fear/Paranoia for no reason– Sudden mood swings– Lack of motivation

Resources

• Greenville Family Partnership

• Local Law Enforcement: Greenville County Police Department/Greenville City Police Department

• CDC: www.cdc.gov

• National Institute on Drug Abuse: www.nida.nih.gov ; www.nida.nih.gov/students.html

• Partnership for a Drug Free America: www.drugfree.org