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Substance Use and Adolescence

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  1. Substance Use and Adolescence Edward S. Yuzda, MD, MSc, FRCPC (Psychiatry) Claude Ranger Mental Health Clinic Dec. 9th/04

  2. Outline • Historical Perspectives • Terminology • Types of Substances • Diagnoses (DSM-IV) • Epidemiology • Etiology • Risk Factors • Course and Prognosis • Treatment

  3. Historical Perspective • Since the first accidental discovery of beer and wine millennia ago, humankind has utilized substances for their psychoactive properties • The personality of the culture intertwined with and was influenced by the drug of choice for that era

  4. Terminology • Drug vs.Substance • Legal vs. illegal • Addiction • Substance Dependence • Biological vs. Psychological Dependence

  5. Types of Substances • Central Nervous Depressants • Alcohol • Cannabis • Sedative/hypnotics/anxiolytics • Opioid analgesics • Inhalants (ie. Glue/gasoline)

  6. Types of Substances • Central Nervous Stimulants • Amphetamines • Caffeine • Cocaine • Nicotine • Ecstasy (mixed stimulant/hallucinogen)

  7. Types of Substances • Hallucinogens • LSD • Mescaline • PCP

  8. Types of Substances • Other • Gamma hydoxy butyrate (date rape drug) • Nitrite inhalants • Nitrous oxide • Kava • Betel nut • Nutmeg • Antihistamines • Antiparkinsonian drugs

  9. Alcohol • By far the most common cause of substance related disorders in Canada • 50% of all fatal MVAs involve alcohol • 25% of all suicides involve alcohol • 1.5 oz. Spirits = 5 oz. Table wine = 12 oz. Beer = 3 oz. Fortified wine (13.6 grams of alcohol) • Intoxication can lead to blackouts/trauma/tolerance/ psychiatric symptoms

  10. Amphetamine and Amphetamine-Like Drugs • Drastic increase in its use in 12-17 year olds over the past decade • Largely due to the popularity of the rave culture and designer rave drugs • Amphetamine related deaths have tripled in the 90’s • Serious psychiatric effects include psychotic symptoms

  11. Caffeine • Most widely used psychoactive substance in the world • Present in pop/OTC medications/ chocolate/’pep’ pills • Meets criteria for abuse potential: • Positive reinforcer • Discriminated from placebo • Tolerance/withdrawal (yet not recognized by DSM-IV) • Largely associated with anxiety disorders

  12. Cannabis • Most common illicit substance • Earliest recorded use (500BC) • Analgesic/anticonvulsant/hypnotic/anti-glaucoma/ appetite stimulant • 5% of people over age 12 have used cannabis within the past month • Use is on the rise after two decades of decrease • Good social drug • Controversy exists with regards to its psychiatric adverse effects (psychosis?/amotivation syndrome?)

  13. Nicotine • An overlooked addiction • 1 billion users worldwide • Second to no other drug in its addictive potential • Use has steadily declined in the Western world secondary to extensive public education campaigns • Its use is a risk factor for use of other drugs

  14. Diagnoses (DSM-IV) • Substance Use Disorders • Substance-Induced Disorders

  15. Substance Use Disorders Substance Abuse Criteria A) A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by any of the following criteria within a 12 month period: 1) symptoms lead to a failure to fulfill a major life role or obligation at work, home school 2) Repeatedly demonstrates intoxication when engaged in hazardous activities 3) Legal problems 4) cont’d use despite recurrent interpersonal/social consequence B) Never met criteria for substance dependence

  16. Substance Use Disorders Substance Dependence Criteria A) Three or more of the following occurring at any time during a within a 12 month period: • Tolerance • Dependence • Takes larger quantities for longer times • Persistent unsuccessful efforts to cut down • Great deal of time spent trying to acquire the substance • All of daily activities are spent trying to obtain, use or recover from the effects of the substance • Cont’d use despite recurrent interpersonal/social problems Specify with/without physiological dependence

  17. Epidemiology • 37% of people report to having used an illicit substance • 66% for people aged 16-25 • 15% of people over 28 have a serious substance use problem • 2/3 alcohol • 1/3 other drugs • 3.3% of 15 year olds meet criteria for substance abuse or dependence • The total cost of substance use problems is estimated at $200 billion/year

  18. Epidemiology (cont’d) Male>Female Alcohol use : White=Hispanic>Black Marijuana use: Black>White

  19. Epidemiology (cont’d) Use in past 12 months: Alcohol – 59.6% Nicotine – 27.6% Cannabis– 24.9% LSD – 7.6% Hallucinogens - 10.1% Stimulants – 6.6% Methamphetamine – 3.6% Ecstasy – 3.1% Cocaine – 2.7% Crack – 2.2% PCP – 2.0% Heroin – 1.8% Glue – 1.5%

  20. Epidemiology (cont’d) Alcohol use (in past 12 months) 12th grade – 79.2% 10th grade – 71.8% 8th grade – 55.3% Alcohol ‘Drunk’ (in past 12 months) 12th grade – 61.8% 10th grade – 48.5% 8th grade – 26.8% Alcohol ‘regular use’ 12th grade – 30.2% 10th grade – 24.0% 8th grade – 15.6%

  21. Epidemiology (cont’d) Cigarette use (in past 30 days) 12th grade – 34% 10th grade – 30% 8th grade – 21% Daily use 12th grade – 22.2%

  22. Epidemiology (cont’d) Illicit drug use (in past 12 months) 12th grade – 40% 10th grade – 38% 8th grade – 24%

  23. Epidemiology (cont’d) Marijuana use (in past 12 months) 12th grade – 36% 8th grade – 18% Daily Marijuana use 12th grade – 5%

  24. Epidemiology (cont’d) LSD use (in past 12 months) 12th grade – 9% 8th grade – 4%

  25. Epidemiology (cont’d) Amphetamine use (in past 12 months) 12th grade – 10% 8th grade – 9% Methamphetamine use (in past 12 months) 12th grade – 2.8% Ecstasy use (in past 12 months) 12th grade – 5%

  26. Epidemiology (cont’d) Heroine use (in past 12 months) 12th grade – 1% 8th grade – 1.6%

  27. Epidemiology (cont’d) Cocaine use (in past 12 months) 12th grade – 4.9% 8th grade – 3% Crack use (in past 12 months) 12th grade – 2.1% 8th grade – 1.8%

  28. Number of people age 12 or older that have used illicit drugs in the past month (U.S.) Number of millions Year

  29. Etiology • Psychological • Cultural • Genetic • Neurochemical

  30. Individual-related Risk Factors • Early age of onset • Presence of early childhood behavioral problems • Poor academic performance • Risk-taking behaviors • Favorable beliefs about substance use • Shorter attention spans • Increased impulsivity • Increased irritability/emotionality

  31. Family-related Risk Factors • Favorable beliefs about substance use in parents • Parental tolerance of substance use • Lack of closeness and attachment between adolescent and parent • Lack of discipline/supervision by parent • Parental substance use

  32. Peer-related Risk Factors • Peer substance use • Favorable peer attitudes to use • Greater orientation of adolescents to peers as opposed to parents

  33. Community-related Risk Factors • Low SE status • High population density • High crime rate

  34. Natural History • Most adolescents try ‘gateway’ drugs (such as cigarettes or alcohol) which are legal and more accessible • such ‘gateway’ drugs then can lead to illicit drug use

  35. Evaluation of a substance use problem • Evaluation includes: • Substance-use related behaviors • Observation of other psychiatric problems • School/vocational functioning • Family functioning • Social competency • Leisure activities • Medical status

  36. Clinical indicators of a substance use problem • Psychosocial/behavioral • Change in school performance • Involvement in illegal activities • Sexual acting out (ie. Prostitution) • Increased demands for money • Change in peer group/involvement • Driving under the influence

  37. Clinical indicators of a substance use problem (cont’d) • Medical • Frequent injuries • Suicide attempts • Sudden weight changes • Chronic respiratory symptoms • Gastrointestinal complaints • Insomnia • Infections • Anxiety • Depression • Sexually transmitted diseases

  38. Clinical indicators of a substance use problem (cont’d) • Historical • Parental use • Estrangement from family • Poor quality relations in the family • Abuse/neglect • Psychiatric disorders • Early age of first use of substances

  39. Clinical indicators of a substance use problem (cont’d) • Psychosocial behavioral • Change in school performance • Involvement in illegal activies • Sexual acting out (ie. Prostitution) • Increased demands for money • Change in peer group/involvement • Driving under the influence

  40. Psychiatric Disorders Commonly Associated with Substance use disorders • Oppositional defiant disorder • Conduct disorder • ADHD • Mood disorders • Anxiety disorders • Bulimia nervosa • Schizophrenia • Personality disorders

  41. Course and Prognosis • Most adolescents who use substances do not go on to develop problems • Levels of use often peak in late adolescence • Life events such as career attainment, education, marriage, parenthood tend to decrease substance use • Despite such maturational processes, substance use can disrupt the ability of adolescents to negotiate these tasks

  42. Treatment • Young and socially stable patients have a better prognosis • Treatment can be divided into four phases: • Assessment and referral • Detoxification and withdrawal management • Active treatment • Continuing care

  43. Treatment (cont’d) • Biological • Supportive medical measures • Treatment of withdrawal symptoms • Replacement pharmacological therapies (ie. Methadone) • Treat psychiatric co morbidities (ie. depression/ADHD/ etc.)

  44. Treatment (cont’d) • Psychological • Twelve step programs (AA/NA) • Motivational interviewing • Cognitive behavioral therapy

  45. Treatment (cont’d) • Social • Residential Programs : total control of adolescents environment • Intensive outpatient programs • Program characteristics associated with better outcomes include: • longer duration of Tx • available follow-up care • family involvement • social services

  46. Treatment (cont’d) Prevention Direct vs. General (ie. Public health education campaigns) Successful prevention programs: target salient risk factors skills-oriented follow-up available culturally-oriented towards the targeted community

  47. Q + A