Substance UseSubstance Use

Why do adolescents use Why do adolescents use substances?substances?

CuriosityCuriosity

Boredom Boredom

Fit in with peers/peer pressureFit in with peers/peer pressure

Normal adolescent explorationNormal adolescent exploration

2004 National Survey on Drug Use and 2004 National Survey on Drug Use and HealthHealth (SAMHSA, 2005)(SAMHSA, 2005)

Alcohol – Prevalence increases with ageAlcohol – Prevalence increases with age– 2% of 12 year olds use alcohol2% of 12 year olds use alcohol– 36% of 17 year olds36% of 17 year olds– Peaks at 71% at age 21 Peaks at 71% at age 21

Tobacco Tobacco – 15.2% of adolescents between ages 12 & 17 15.2% of adolescents between ages 12 & 17

report using tobaccoreport using tobacco– Males are more likely to use tobacco than Males are more likely to use tobacco than

females, but females are more likely to smoke females, but females are more likely to smoke than malesthan males

2004 National Survey on Drug Use and 2004 National Survey on Drug Use and HealthHealth (SAMHSA, 2005)(SAMHSA, 2005)

Illegal Drugs – 11.6% of adolescents between Illegal Drugs – 11.6% of adolescents between 12 & 17 (4.2% between ages 12 & 13) use illegal 12 & 17 (4.2% between ages 12 & 13) use illegal drugs (other than alcohol and tobacco)drugs (other than alcohol and tobacco)– Use is high among boys than girls Use is high among boys than girls – Boys are more likely to use marijuana than girlsBoys are more likely to use marijuana than girls– Girls are more likely to use prescription drugsGirls are more likely to use prescription drugs

Inhalants – the only drug whose use decreases Inhalants – the only drug whose use decreases during adolescence during adolescence – 4.1% at age 134.1% at age 13– 2.2% at age 152.2% at age 15– 1.5% at age 171.5% at age 17

Annual Numbers of New Users of Annual Numbers of New Users of Marijuana: 1965–2002 Marijuana: 1965–2002

Source: SAMHSA

Annual Numbers of New Nonmedical Annual Numbers of New Nonmedical Users of Pain Relievers: 1965–2002Users of Pain Relievers: 1965–2002

Source: SAMHSA

Annual Numbers of New Users of Annual Numbers of New Users of Ecstasy, LSD, and PCP: 1965–2002Ecstasy, LSD, and PCP: 1965–2002

Source: SAMHSA

Associated ConcernsAssociated Concerns

Physical problemsPhysical problems– Heart problemsHeart problems

– Liver functioning/Hepatitis CLiver functioning/Hepatitis C

– Neuronal/brain damageNeuronal/brain damage

– Overdose/deathOverdose/death

Associated ConcernsAssociated Concerns

Social/BehavioralSocial/Behavioral– Impact on educationImpact on education

Increased likelihood of being diagnosed with a learning Increased likelihood of being diagnosed with a learning disabilitydisability

Impaired concentrationImpaired concentration

Behavioral disruptionsBehavioral disruptions

TruancyTruancy

School Drop outSchool Drop out

– Correlated with Correlated with Increased AggressivenessIncreased Aggressiveness

Limited frustration toleranceLimited frustration tolerance

DelinquencyDelinquency

Past Month Illicit Drug Use among Youths Aged Past Month Illicit Drug Use among Youths Aged 12 to 17, by Participation in Delinquent 12 to 17, by Participation in Delinquent

BehaviorsBehaviors

Associated ConcernsAssociated Concerns

Most common co-morbid disordersMost common co-morbid disorders– Conduct disorderConduct disorder

– ADHDADHD

– Depression/Bi-polar DisorderDepression/Bi-polar Disorder

– Learning DisordersLearning Disorders

Substance Abuse History - DSMSubstance Abuse History - DSM

DSM-III (1980) DSM-III (1980) – Prior to DSM-III diagnosis consisted of “addiction”Prior to DSM-III diagnosis consisted of “addiction”– ““Abuse” and “Dependence” replaced “addiction” in Abuse” and “Dependence” replaced “addiction” in

DSM-IIIDSM-III

DSM-III-R (1987)DSM-III-R (1987)– Dependence criteria reorganized to fit Edwards & Dependence criteria reorganized to fit Edwards &

Gross “Alcohol Dependence Syndrome”, from their Gross “Alcohol Dependence Syndrome”, from their observations of patientsobservations of patients

– Abuse was a residual category for people who had a Abuse was a residual category for people who had a problem but did not meet the criteria for dependenceproblem but did not meet the criteria for dependence

Substance Abuse History - DSMSubstance Abuse History - DSM

DSM-IV (1994)DSM-IV (1994)

– Criteria were again reorganizedCriteria were again reorganized

– Abuse designed to serve as its own Abuse designed to serve as its own independent diagnosisindependent diagnosis

– Physiological vs. psychological dependencePhysiological vs. psychological dependence

DSM-IV Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(2) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the

substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work

performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

B. The individual has never met criteria for Substance Dependence for the same class of substance.

DSM-IV Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring during a 12-month period:

1. Tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve

intoxication b. markedly diminished effect with continued use of the same amount of the

substance 2. Withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance b. the same (or related) substance is taken to relieve or avoid withdrawal

symptoms 3. The substance is often taken in larger Amounts or over a longer period than was

intended 4. There is a persistent desire or unsuccessful efforts to cut down or Control substance

use 5. A great deal of Time is spent in activities necessary to obtain the substance (e.g.,

visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

6. Important social, occupational, or recreational activities are given up or reduced because of substance use

7. The substance use is continued despite Knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or

exacerbated by the substance (e.g., cocaine-induced depression, or ulcer from drinking)

DSM-IV Drug Categories DSM-IV Drug Categories

AlcoholAlcohol

Amphetamine & Amphetamine &

Amphetamine-likeAmphetamine-like

CaffeineCaffeine

Cannabis Cannabis

CocaineCocaine

HallucinogenHallucinogen

InhalantInhalant

NicotineNicotine

OpioidOpioid

Phencyclidine & Phencyclidine &

phencyclidine-likephencyclidine-like

Sedative, hypnotic, Sedative, hypnotic,

anxiolyticanxiolytic

PolysubstancePolysubstance

Other Other

Problems with the DSM-IV Substance Use Problems with the DSM-IV Substance Use Criteria when used with Children and Criteria when used with Children and

AdolescentsAdolescentsAbuse criteria are composed of how an individual interacts with his or her environment.

Requiring three or more dependence criteria for the dependence diagnosis – about 1/3 of adolescent “regular” alcohol users “fall through the

cracks” because they meet only one or two criteria (called diagnostic orphans)

– about 1/5 of adult regular drinkers are diagnostic orphans.

Should substance use during adolescence even be categorized as a disorder because of how common it is for adolescents to use alcohol and other substances

Should substance use during adolescence even be categorized as a disorder because of how common it is

for adolescents to use alcohol and other substances?

Regardless of how common substance use is, adolescents who meet the criteria of abuse: continued use in spite of the problems that use causes, are still using in a pathological manner.

Assessing Substance UseAssessing Substance Use

Clinical interviews (child/parent/others)Clinical interviews (child/parent/others)

Self-Report InventoriesSelf-Report Inventories– Substance Abuse Subtle Screening Inventory Substance Abuse Subtle Screening Inventory

(SASSI)(SASSI)– MMPI-A McCarthy ScaleMMPI-A McCarthy Scale

Drug TestsDrug Tests– UrineUrine– Blood/Cerebrospinal fluidBlood/Cerebrospinal fluid– HairHair

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

MedicationsMedications– AlcoholAlcohol

LibriumLibrium

Antabuse Antabuse

NaltrexoneNaltrexone

– Heroine/opioidsHeroine/opioids Methadone Methadone

Buprenorphine Buprenorphine

– CocaineCocaine Ibogaine Ibogaine

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

MedicationsMedications– Anti-depressantsAnti-depressants

– Mood stabilizersMood stabilizers

– Anti-anxiety medicationsAnti-anxiety medications

– Anti-psychoticsAnti-psychotics

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

Behavioral and Cognitive-Behavioral Behavioral and Cognitive-Behavioral TreatmentsTreatments– Behavioral TherapyBehavioral Therapy

Create new associationsCreate new associations

Change behaviorsChange behaviors

Antabuse Antabuse

– Rational Emotive TherapyRational Emotive TherapyDevelop an internal locus of controlDevelop an internal locus of control

Dispute irrational beliefsDispute irrational beliefs

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

Group TherapyGroup Therapy– The most effective form of therapy for The most effective form of therapy for

adolescent substance abuseadolescent substance abuse– May be mixed gender or single genderMay be mixed gender or single gender– Groups are for both support and for treatmentGroups are for both support and for treatment– Should focus on social skills training, coping Should focus on social skills training, coping

skills, refusal skills, and self-awareness as skills, refusal skills, and self-awareness as well as addiction treatment and educationwell as addiction treatment and education

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

Support groupsSupport groups– Alcoholics Anonymous (AA) and Narcotics Alcoholics Anonymous (AA) and Narcotics

Anonymous (NA) Anonymous (NA) No facilitatorNo facilitator

Adolescents should attend adolescent groups, not Adolescents should attend adolescent groups, not adult groups!adult groups!

– SMART Recovery (Self-Management and SMART Recovery (Self-Management and Recovery Training)Recovery Training)

Uses an adult facilitatorUses an adult facilitator

Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders

Residential TreatmentResidential Treatment– Generally 30 to 90 days for adolescentsGenerally 30 to 90 days for adolescents– Usually rely on AA/NA as well as traditional Usually rely on AA/NA as well as traditional

group therapiesgroup therapies– Therapeutic Community Therapeutic Community

Levels of TreatmentLevels of Treatment

Outpatient TreatmentOutpatient Treatment1.1. Traditional OutpatientTraditional Outpatient

– Individual therapyIndividual therapy– Group TherapyGroup Therapy– Family TherapyFamily Therapy

2.2. Intensive Outpatient ProgramsIntensive Outpatient Programs– Individual and group therapyIndividual and group therapy– Family and family groupsFamily and family groups

3.3. Partial HospitalizationPartial Hospitalization

Levels of TreatmentLevels of Treatment

Medically Monitored Medically Monitored 4.4. DetoxificationDetoxification

– Staffed by counselors, sometimes nursesStaffed by counselors, sometimes nurses– Not really “treatment”, but “drying out”Not really “treatment”, but “drying out”– Not meant to be the last stop of treatmentNot meant to be the last stop of treatment

5.5. RehabilitationRehabilitation– Staffed by counselors, therapists, nurseStaffed by counselors, therapists, nurse– Doctor is “on-call” and consults with staffDoctor is “on-call” and consults with staff

Levels of TreatmentLevels of Treatment

Medically ManagedMedically Managed6.6. DetoxificationDetoxification

– Usually a hospital settingUsually a hospital setting– Staffed by nurses and doctorsStaffed by nurses and doctors

7.7. RehabilitationRehabilitation– Usually in hospital settingUsually in hospital setting– Staffed by nurses and doctorsStaffed by nurses and doctors– Usually shorter-term than medically monitored Usually shorter-term than medically monitored

rehab, but can also be long-termrehab, but can also be long-term

PreventionPrevention rather than rather than TreatmentTreatment

Treatment has limited success; prevention Treatment has limited success; prevention is cheaper and more effectiveis cheaper and more effectiveD.A.R.E.D.A.R.E.– Not found to be effectiveNot found to be effective– Actually found to positively correlate with Actually found to positively correlate with

substance use substance use

Life Skills TrainingLife Skills Training– Evidence-based prevention programEvidence-based prevention program– School-based/community-based groupsSchool-based/community-based groups– Cognitive-behavioral based treatmentCognitive-behavioral based treatment