ADOLESCENT SUBSTANCE ABUSE OBJECTIVES LEADING RISK FACTORS: TEEN OPIATE MISUSE 5/30/2014

Transcription

1 ADOLESCENT SUBSTANCE ABUSE GREGORY X. BOEHM, MD Assistant Professor of Psychiatry Case Medical School Psychiatrist/Addictionologist Recovery Resources and Y-Haven OBJECTIVES 1) Learn easy-to-use, reliable, valid screens which identify LEADING RISK FACTORS for adolescent substance abuse 2) Identify ways to treat leading risk factors, and motivate adolescents and their parents to begin treatment 3) Learn where and how to access 12 step program and OYPAA: Ohio Young People s AA LEADING RISK FACTORS: TEEN OPIATE MISUSE 1) FAMILY history and current disruption 2) PEERS 3) TOBACCO PRODUCTS 4) MARIJUANA 5) UNTREATED ADD 6) ANXIETY/MOOD DISORDRS 1

2 NIDA 2010 HOW IS THIS HAPPENING? THE CULTURE US CONSTITUES: 4.6% of world s population US CONSUMES: over 80% of global opioid supply US CONSUMES: 99% of world s hydrocodone (Vicodin, Lortab) US CONSUMES: 2/3 of world s illegal drugs 2

3 GOOD NEWS SELF-DISCIPLINE: Study/work/ exercise/health habits established in adolescence last a life-time BAD NEWS: Drug/alcohol abuse established in adolescence last a life-time VERY SAME BRAIN PATHWAYS for learning that explode in the adolescent brain 3

4 4

5 SAMHSA 2011 ADOLESCENT HEALTH 75% of teen deaths are due to BEHAVIORAL CAUSES SUICIDE / HOMICIDE: second leading causes of teen death: 25% ACCIDENTS: #1 cause of teen death: 50% NON-BEHAVIORAL: 25% Cancer, Heart Disease, Congenital anomalies 5

6 TEEN-AGE MVA FATALITIES TEENS: 13% of drivers, 35% of MVA 55% of fatalities ARE substance-impaired 19 yo are the HIGHEST RISK AGE of all drivers WHEN TEEN S BAL is.1%: then 51 times more likely to have a fatal accident IN FATAL CRASHES: 2/3 of the time the impaired teenage driver died. MVA and ADD UNTREATED ADD teen drivers: 3-4 times more MVA UNTREATED ADD teens: > 200% alcohol abuse UNTREATED ADD teens: >300% drug abuse OTHER THAN MARIJUANA TEEN DRIVERS in general: less cautious, more impulsive, less experienced, more thrill seeking Total Number of Opioid Prescriptions 6

7 SAMHSA 2011 WHY SO POPULAR? EXCELLENT PAIN RELIEVERS ESPECIALLY FOR: injured student athletes, performance enhancing WELL TOLERATED: less nausea, vomiting, headaches FEEL ENERGIZED No anxiety No pain Feel motivated No depression IN AMERICA MORE PERSONS 12 AND OLDER: use illicit opiates for first time than use THC for the first time INITIATES IN OPIATES: Increase 8% per year INITIATES IN HEROIN: Increase 3% per year 7

8 SAMHSA 2011 SAMHSA 2011 SMHSA

9 COLLEGE STUDENTS SAMHSA SAMHSA 2011 SAMHSA

10 HOW TO INTERPRET: DECREASED HS ALCOHOL CONSPIRACY: nationwide COHORT OF HS SENIORS telling us what we want to hear SUBSTITUTING: increased use of THC/drugs for alcohol CDC 2012 CDC

11 CDC 2012 TEEN BIRTH RATE CDC 2011 CDC

12 USA TODAY USA TODAY 12

13 TOBACCO USE 1/3 smoke first cigarette before age 14 90% of smokers start before age 18 55% of cig smokers, smoke marijuana 90% of marijuana smokers, smoke cigarettes 40% of middle school smokers use flavored cig Tobacco Industry spends $ mil/day advertising IDENTIFY ADD: RELIABLY, EFFICIENTLY, CONSUMER FRIENDLY * Defiant Teens: Clinician s Guide to ADD 2006, Russell Barkley PhD * Driven to Distraction 2011, Ed Hallowell MD 13

14 TREATED ADD IN TEENS AND YOUNG ADULTS 2 TIMES LESS LIKELY TO ABUSE ALCOHOL 3 TIMES LESS AT RISK FOR DRUG ABUSE 4 TIMES FEWER AUTO ACCIDENTS JAMA PSYCHIATRY 3/1/14: Serious Accidents in Untreated ADULT ADD ADD: third most common disorder in PC DIAGNOSING ADD SYMPTOM CHECK LIST: if >50% in last 2 columns, then >90% have ADD BUT FALSE NEGATIVES: 20%, It s just our normal CONNORS TEST: Teaches and Parents ONLY 25% OF ADD IS DIAGNOSED/TREATED NON-CHEMICAL TECHNIQUES FIRST SETTTING MEASURABLE GOALS: q 30 minutes: WRITE IT DOWN Re-assess after 30 minutes: CORE ISSURE: LEARNING time management, pacing, EXECUTIVE functions REQUIRED TO BRING JOURNAL TO NEXT APPT 14

15 DILEMMA: 80% REQUIRE MEDICATION ADOLESCENT ADD with consequences: 1) ACADEMIC: Non-chemical first, then stimulants: Focalin mg bid, or Adderall mg bid, or Vyvanse mg qd 2) SIDE EFFECTS: insomnia, wgt loss, anxiety, TICS: Clonidine.1 mg qd-bid or Tenex 1 mg qd-bid 3) ANXIETY: SSRI paxil, prozac, zoloft; beta blocker propranolol mg bid, prazosin 1 mg bid 4) NON-STIMULANTS: Strattera, Wellbutrin DILEMMA: 80% REQUIRE MEDICATION ADOLESCENT ADD WITH DRUG ABUSE: 1) NON-CHEMICAL and 12 STEP program 2) NON-STIMULANT: Buproprion (Wellbutrin), Atomoxetine (Strattera) Clonidine (Kapvay, Catapres), Guanfacine (Tenex, Intuniv) 3) SYMPTOMATIC AFTER 6 MONTHS SOBRIETY: Then re-assess need for stimulant medication TREATING ADOLESCENT ADD with STIMULANTS SUBJECTIVE FEELING: feeling up, feeling a burst of energy FADES WITH TOLERANCE OBJECTIVE IMPROVEMENT: DOES NOT FADE, improved attention and concentration, as measured in CPT CANNOT use the SUBJECTIVE FEELING as a guide CHASING THE SUBJECTIVE FEELING: leads to abuse 15

16 WHAT IF NOT SURE OF DRUG USE/ABUSE? OPEN ENDED QUESTIONS: What do you do for fun, relaxation, exercise; involved in music, art, sports? THEN: Ask two age specific questions: Ages 9-14 y/o: Do you have any friends who drink beer or smoke? use any pills or drugs? Ages y/o: In past year, on how many days have you had any alcohol? pills or drugs? Martha Wunsch, MD HIGHEST RISK AGES 12-15: 6 DAYS IN PAST YEAR AGES 16-18: 12 DAYS TO WEEKLY How much do you usually have? What is the most you have ever had? Problems: school, fighting, blackouts, property damage, sexual experiences? WHAT ABOUT COLLEGE? GENERAL PRECAUTIONS: 1) NO ONE NEEDS TO KNOW you take medicine Learning how to filter, use judgment, be selective 2) KEEP THE MEDICINE IN A LOCK BOX 3) SHARING SCHEDULE II MEDICINE: Illegal distribution, a felony 16

17 SOCIAL ANXIETY TEEN DILEMMA: Need to fit in, be part of a group, yet FEEL DISTINGUISHED, excel, be recognized at same time NO BENZODIAZEPINES: But can use: Beta-blockers: Propranolol mg bid Clonidine:.1 mg bid, Guanfacine 1 mg qd Buspirone: mg bid NON-CHEMICAL TECHNIQUES RELAXATION EXERCISES: allaboutdepression.com : 5 minicourses MUST BE PRACTICED: Morning, noon, night 17

18 OYPAA: Ohio Young People s AA: WEBSITE WEEKLY MEETINGS: socializing, retreats, conferences MAINTAIN LIST: of active AA teens/young adults, willing to assist AL-ANON FOR PARENTS: Learning how to detach I CAN T GO TO AA BECAUSE RELIGION / GOD ONLY TALK ABOUT ALCOHOL I DON T FEEL COMFORTABLE IN GROUPS I AM NOT A PERSON WHO SHARES PROBLEMS IN PUBLIC YES, YOU CAN, BECAUSE ONLY ALCOHOL: alcohol stands for any unmanageable: drugs, gambling, food, sex, shop-lifting, chronic pain, anxiety, panic disorder, character defect I M (social phobic) : so 110% of all AA s. You are RIGHT where you belong I M NOT RELIGIOUS: Neither is AA. Atheists/Agnostics AA groups 18

19 TROUBLE-SHOOTING: RESISTANCE STAGE I: seemingly does NOT acknowledge any use and/or any problems: ALLOW CONSEQUENCES STAGE II: CONSEQUENCES far out weigh USE, those were the only 2 times : PEER GROUP STAGE III: clean/sober AT TIMES, frequent relapses. WORKING 12 STEPS with SPONSOR? FOR PHYSICIANS IDAA: 6000 physicians worldwide ANNUAL CONVENTION: Palm Springs, CA: 1500 MD s and their families 19

20 20