Understanding Substance Abuse in Adolescents: A Primer for Mental Health Professionals

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1 Uderstadig Substace Abuse i Adolescets: A Primer for Metal Health Professioals Metal health programs desiged to reduce commo psychological problems associated with child ad adolescet victimizatio are commo, but few iclude specific itervetios delayig the oset of substace use ad reducig substace abuse... 1 Dea Kilpatrick, Bejami Sauders & Daiel Smith Youth Victimizatio: Prevalece ad Implicatios O ay give day, approximately 8% of America adolescets betwee the ages of 12 ad 17 meet the America Psychiatric Associatio s diagostic criteria for substace abuse or depedece 2, more tha 5% meet the criteria for alcohol abuse or depedece 2, ad more tha 11% show sigs of problematic use of alcohol or drugs, defied as more tha oe substace-related problem durig the past year. 3 Take together, these data idicate that oe i five America adolescets is egaged i maladaptive or dagerous use of alcohol or drugs. 2,3 Numerous studies have documeted a strog correlatio betwee trauma exposure ad substace abuse i youg people. The most recet Natioal Survey of Adolescets revealed that tees who had experieced physical or sexual abuse/assault were three times more likely to report past or curret substace abuse tha those without a history of trauma 1, ad surveys of adolescets receivig treatmet for substace abuse have show that more tha 70% had a history of trauma exposure. 4,5 The lik betwee trauma ad substace abuse is eve more strikig amog adolescets with PTSD: studies idicate that up to 59% of youg people with PTSD subsequetly develop substace abuse problems. 5 8 Although recreatioal alcohol ad drug use are more commo i adults, studies have show that youth who egage i drug ad alcohol use are at greater risk for lifelog egative cosequeces, especially whe they start usig at a youg age. Because the teeage brai is still growig ad chagig, alcohol ad drug use at a early age have a greater potetial to disrupt ormal brai developmet. The most affected brai regios iclude the hippocampus which is related to learig ad memory ad the prefrotal cortex, which is resposible for critical thikig, plaig, impulse cotrol, ad emotioal regulatio. 9,10 Drug ad alcohol use also iterfere with may other physiological processes ad have bee show to destabilize mood. Thus, adolescet substace use is associated with higher rates of depressio, aggressio, violece ad suicide. 11 These fidigs are particularly disturbig give that, for most tees, iitiatio of substace use teds to be at a early age. Oe The Natioal Child Traumatic Stress Network

2 atioal survey foud that by the time they fiish 8th grade, early oe i three (29%) adolescets has experimeted with illegal drugs, ad 41% have cosumed alcohol. 12 The earlier oset the age of first drikig, the greater the risk for lifetime alcohol abuse or depedece. 13 Give these fidigs, it is clear that substace abuse screeig should be a itegral part of the services provided by agecies ad idividuals workig with adolescets. This is particularly importat i metal health service systems, where adolescets i treatmet for traumatic stress ad other emotioal problems could beefit greatly from receivig care from cliical staff that uderstads the strog fuctioal relatioship betwee substace abuse ad traumatic stress. Substace Abuse ad Trauma: Makig the Coectio May researchers ad providers poit to the self-medicatio hypothesis to explai the coectio betwee trauma exposure ad substace abuse, suggestig that youth tur to psychoactive drugs ad alcohol i a attempt to cope with traumatic stress or remiders of loss. Although there is much evidece to support this pathway studies evaluatig the frequecy of substace abuse followig trauma exposure have reported rates as high as 76% 8 11 it is also true that substace abuse ca icrease a adolescet s risk of trauma exposure ad of experiecig traumatic stress symptoms. Epidemiological studies have foud that for may adolescets (up to 66% i some studies) substace use disorders precede the oset of trauma exposure. 6,7 This may be due to the fact that substace abusig adolescets are more likely to egage i risky activities that could lead to harm to themselves or others. 6 8 For example, tees with substace abuse disorders are more likely to drive while uder the ifluece, hitchhike, or walk i usafe eighborhoods. 2,14 There is also evidece that substace use disorders decrease youths ability to appropriately cope with ew distressig ad traumatic evets, thus leadig to the icreased likelihood of developig PTSD. I oe study, adolescets with substace abuse disorders were two times more likely to develop PTSD followig trauma tha were their osubstace abusig peers. 7 Whatever the temporal relatioship betwee trauma ad the developmet of substace abuse, it is clear that the egative effects ad cosequeces of oe disorder compoud the problems of the other. All idividuals with substace abuse disorders are at risk of experiecig itese cravigs for their substace(s) of abuse whe exposed to stimuli associated with use (e.g., substace-usig peers, places where they obtai drugs, time of day). I substace abusig tees with a history of trauma, such cravigs ca also be triggered by people, situatios, places, or thigs that evoke past traumatic evets. Research 2 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

3 with substace abusig adults has show that cravig icreases whe idividuals with co-occurrig trauma ad substace abuse are exposed to cues of the traumatic evet. 15,16 Amog adults with cocaie depedece, for example, idividuals with PTSD are more likely to use followig egative experieces (such as upleasat emotios ad physical discomfort) whe compared with those without PTSD. 17 Successful treatmet of adolescets with co-occurrig traumatic stress ad substace abuse therefore requires itervetios that address the challeges of both disorders. Failure to provide such comprehesive treatmet may sigificatly impair these tees likelihood of log-term recovery. I the absece of copig strategies to maage distress associated with trauma, adolescets with co-occurrig disorders are more likely to relapse ad revert to maladaptive copig strategies tha tees with substace abuse aloe: I surveys of adolescets receivig substace abuse treatmet, a history of victimizatio has cosistetly bee associated with egative treatmet outcomes 4,18 Tees with a history of physical abuse are less likely to achieve posttreatmet abstiece tha tees without a trauma history 19 Higher iitial symptom severity amog youth with co-occurrig traumatic stress ad substace abuse problems has bee associated with more iteral distress ad violet behavior posttreatmet 18 Research i adults with co-occurrig trauma ad substace abuse supports the same coclusio. I studies of adults receivig substace abuse treatmet, idividuals with cooccurrig PTSD ad substace abuse had higher relapse rates tha those with substace abuse problems aloe 20, ad iitial PTSD severity was a sigificat predictor of relapse. 21,22 These fidigs illustrate the eed for icreased awareess amog metal health professioals of the strog ad complex relatioship betwee substace abuse ad traumatic stress. Tees battlig the effects of traumatic stress ad substace abuse eed to acquire copig skills to maage the distress associated with either type of problem. Improvemets i the ability to maage substace abuse cravigs, for example, may ehace the youth s readiess to lear how to maage trauma ad loss remiders. Why Do Adolescets Use? Uderstadig the reasos youth start usig drugs or alcohol as well as their reasos for cotiuig or discotiuig use is crucial to developig effective substace abuse itervetios. A recet 30-moth study of 923 teeagers receivig outpatiet ad residetial substace abuse treatmet has provided some isight ito the motivatios behid adolescets substace abuse ad evetual recovery. 23 The Natioal Child Traumatic Stress Network

4 I this study, three quarters of the tees cited social pressures ad experimetatio as their reasos for iitiatig drug or alcohol use. Tees may use because they see everyoe else doig it ad wat to bled i, because it s a way of spedig time with frieds, of beig accepted, of becomig popular, of ehacig social ad other activities, or because they fear that if they refuse, they might alieate potetial frieds. May If I do t do drugs, I feel like I m goig to go isae. Because I have all these thoughts ad all this pai i my heart ad I ca t get rid of it, you kow? Drugs is the oly thig that takes that away. That s why I do drugs. Because it keeps me, ot happy, but it keeps me from beig so sad that I wat to die. 24 adolescets reported that curiosity led to first use, while others reported that they decided to start after witessig use by a paret or relative. Of ote, oly 7% reported iitiatig use to cope with difficulties. 23 This situatio chages whe it comes to tees reasos for cotiuig use. Whe asked why they cotiue to use, more tha half reported usig drugs because it feels good (29%) or because it helps them cope with difficulties (23%). Aother 7% reported that it was a addictio or habit, ad 4% felt that drug or alcohol use ehaced their sese of self i some way (greater cofidece, self esteem, etc.). 23 I light of these fidigs, it is likely that, for tees experiecig traumatic stress, cotiued substace use may serve as a copig strategy to deal with stress, forget upleasat experieces, avoid egative emotios, do away with worries, or feel umb or idifferet to the challeges of daily life or the remiders of past trauma. Amog tees who quit usig drugs or alcohol, the most frequetly reported reasos accoutig for 57% of resposes had to do with the egative effect that usig had or could have o the adolescets lives. Some respodets said they had tired of usig (22%), others were cocered about the effect drug use could have o their overall life path (21%), ad others were worried about the egative physical ad psychological effects of their drug or alcohol use (14%). By compariso, exteral pressures accouted for less tha oe quarter of tees reasos for quittig: 14% of respodets idicated they had quit i respose to exteral factors such as jail or madated treatmet, 4% reported quittig for family ad frieds, ad 3% reported quittig to avoid trouble. 23 Recogizig Substace Abuse ad Depedece i Adolescets Although the reasos for iitiatig ad cotiuig drug ad alcohol use are varied, the sigs of abuse ad depedece are remarkably cosistet. Accordig to the America Psychiatric Associatio 25, substace abuse is a patter of use that leads to sigificat impairmet or distress, maifested as oe or more of the followig occurrig durig a 12-moth period: 4 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

5 Recurret use resultig i a failure to fulfill major obligatios at work, school, or home Recurret use i situatios i which it is physically hazardous (e.g., drivig while high or druk) Recurret substace-related legal problems Cotiued use despite persistet or recurret social or iterpersoal problems caused or exacerbated by the effects of the substace (e.g., argumets with parets, fights) Substace depedece (more commoly referred to as addictio) ivolves the same problems, with the additio of clear sigs of physical ad psychological depedece, as maifested by three or more of the followig occurrig at ay time over a 12-moth period: 25 Tolerace, defied as the eed for icreased amouts of the substace to achieve the desired effect, or markedly dimiished effects with cotiued use of the same amout of the substace Withdrawal, maifested as either the characteristic withdrawal sydrome for the substace or cotiued use of the substace (or a closely related drug) to relieve or prevet withdrawal symptoms Takig the substace ofte i larger amouts or over a loger period tha iteded A persistet desire or usuccessful efforts to cut dow or cotrol substace use Spedig a great deal of time i activities ecessary to obtai or use the substace or to recover from its effects Givig up social, occupatioal, or recreatioal activities because of substace use Cotiued use with the kowledge that it is causig or exacerbatig a persistet or recurret physical or psychological problem Some researchers have added aother category problematic use to describe adolescets who do t meet the strict diagostic criteria for alcohol abuse or depedece, but who show two or more symptoms of alcohol depedece. The most commo symptoms see i these diagostic orphas are: 26 Tolerace Usig more or loger tha iteded Usuccessful attempts to quit or cut dow A cosiderable amout of time spet usig The Natioal Child Traumatic Stress Network 5

6 The specific sigs ad symptoms of itoxicatio, depedece ad abuse may vary depedig o the substace used (See Table 1 ad Table 2); however, major idicators that a adolescet may be egaged i problematic use or depedece iclude: 25,27,28 Difficulty sleepig Disruptive behavior Depressio Maria s Story* Maria is a 14-year-old girl who has bee physically ad sexually abused by her 22-year-old stepbrother for five years. The first icidet of abuse happeed whe she ad her mother moved i with the ew stepfamily, after havig bee evicted from their old apartmet. I additio, Maria has see her stepfather severely beat her mother several times, ad is ow costatly worried about her mother s safety. She also fears that someoe will fid out about the abuse ad that she will be take away from her mother. School avoidace Declie i academic performace Axiety Rapid chages i mood or hostile outbursts Chages i peer group or failig to itroduce peers to parets Chages i physical appearace or poor hygiee Secretive behaviors such as seakig out, lyig, ad lockig doors Maria has become withdraw at school ad o loger participates i activities she oce ejoyed. Oce very popular with her peers, she has isolated herself from may of her frieds ad speds most of her time aloe. The oly perso Maria speds time with is a older cousi who lives i the eighborhood. Lately, they have bee skippig school to smoke marijuaa ad drik alcohol. Maria used to be a hoor-roll studet, but her grades have bee spiralig dowward. Her favorite teacher is extremely cocered ad has bee tryig to get Maria to talk to her about what is causig such a chage. * Maria is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. Alcohol ad Illicit Drugs: Prevalece Rates ad Geeral Iformatio Alcohol Adolescets use alcohol more frequetly tha they do all other drugs combied. The Natioal Logitudial Study of Adolescet Health foud that more tha 30% of surveyed adolescets had druk more tha five driks i a row i the past 12 moths ad more tha 30% reported gettig druk durig that same period. 31,32 Similarly, the most recet Natioal Survey o Drug Use ad Health foud that more tha 25% of uderage drikers are bige or heavy drikers, ad approximately 20% oe i five report drivig while uder the ifluece durig 6 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

7 the past year. 2 I 2006, 63% of 8th graders ad more tha 80% of high-school age tees reported that alcohol was easy or very easy to obtai. 12 Caabioids The caabioids are the most commoly used illegal drugs i the Uited States. Accordig to the 2006 Natioal Survey o Drug Abuse, every day 6,000 people try marijuaa for the first time ad more tha 63% of them some 3,800 people are uder the age of 18. Overall, 6.7% of adolescets betwee the ages of 12 ad 17 are curret marijuaa users. 2 I 2006, approximately 40% of 8th graders ad three quarters of high school studets reported that marijuaa was easy or very easy to obtai. 12 Cocaie Cocaie is a powerfully addictive cetral ervous system stimulat. Oce the secodmost commoly used illicit drug i the Uited States, it has recetly bee overtake by prescriptio paikillers (see Opioids, below). Accordig to the 2005 Youth Risk Behavior Surveillace Survey 33, 7.6% of high school studets surveyed had used cocaie at least oce, ad 3.4% had used withi the last 30 days. Of ote, the percetage of tees who report that cocaie (i ay form) is easy or very easy to obtai rises with age: from approximately 20% i 8th grade to more tha 50% i seior year of high school. Cocaie use i combiatio with alcohol is especially dagerous because it facilitates the productio of cocaethylee, a cocaie metabolite that is more toxic tha cocaie aloe. Gamma hydroxybutyrate (GHB) GHB was sythesized i 1960 for use as a aesthetic. I the Uited States, GHB has bee widely abused sice the early 1990s. It is ofte used by youg ad predomiatly white partygoers i combiatio with various other drugs or alcohol at raves ad other gatherigs. It has bee used i a umber of sexual assaults ad, like the drug Rohypol (fluitrazepam), is kow as a date-rape drug because of its ability to sedate ad impair the memory of potetial victims. Because it metabolizes quickly, there are ofte o traces of it i a victim s bloodstream by the time the assault is remembered. GHB geerally comes mixed with water or i powder form. It is commoly sold i small bottles (the size of complimetary shampoo cotaiers supplied by hotels), which are geerally iexpesive ad cotai about 10 hits. GHB use has greatly icreased i recet years, with the most prevalet use observed i the southeaster ad wester Uited States. I 2006, 0.8% of 8th graders, 0.7% of 10th graders, ad 1.1% of 12th graders reported usig GHB at least oce i the prior year. 12 Accordig to data gathered by the Drug Abuse Warig Network (DAWN), i 2002 early 5,000 emergecy room visits were related to use of GHB. 37 The Natioal Child Traumatic Stress Network 7

8 Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 Category ad Name Examples of Commercial ad Street Names Alcohol Booze, brew, hooch, sauce, forty, brewsky, hard stuff, hard A, liquor, spirits, various brad ames DEA Schedule* How Admiistered** Not scheduled Swallowed Relaxatio, decreased cocetratio, impaired judgmet, coordiatio, ad reactio time, loss of cosciousess, blackouts, ad memory lapses Itoxicatio Effects Potetial Health Cosequeces Caabioids Class effects Hashish Boom, chroic, gagster, hash, hash oil, hemp Marijuaa Blut, dope, gaja, grass, herb, joits, Mary Jae, pot, reefer, sisemilla, skuk, weed I Swallowed, smoked Euphoria, slowed thikig ad reactio time, cofusio, impaired I Swallowed, smoked balace ad coordiatio Depressats Class Effects Liver disease, ulcers, cacer (esophageal, oral, hepatic), hypertesio, hypoglycemia, depedece, addictio Cough, frequet respiratory ifectios, impaired memory ad learig, icreased heart rate, axiety, paic attacks, tolerace, addictio Barbiturates Amytal, Nembutal, Secoal, Pheobarbital: barbs, reds, red birds, pheies, tooies, yellows, yellow jackets Bezodiazepies (other tha fluitrazepam) Ativa, Halcio, Librium, Valium, Xaax: cady, dowers, sleepig pills, traks Fluitrazepam*** Rohypol: forget-me pill, Mexica Valium, R2, Roche, roofies, roofiol, rope, rophies Reduced axiety, feelig of wellbeig, lowered ihibitios, slowed pulse ad breathig, lowered blood pressure, poor cocetratio Fatigue, cofusio, impaired coordiatio, memory, judgmet, addictio, respiratory depressio ad arrest, depedece, addictio, death II, III, V Ijected, swallowed Sedatio, drowsiess Depressio, uusual excitemet, fever, irritability, poor judgmet, slurred speech, dizziess, lifethreateig withdrawal IV Swallowed, ijected Sedatio, drowsiess Dizziess IV Swallowed, sorted Visual ad gastroitestial disturbaces, uriary retetio, memory loss for the time uder the drug s effects Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue

9 Category ad Name Examples of Commercial ad Street Names GHB*** gamma-hydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy Methaqualoe Quaalude, Sopor, Parest: ludes, madrex, quad, quay DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces I Swallowed Drowsiess, ausea Vomitig, headache, loss of cosciousess, loss of reflexes, seizures, coma, death I Ijected, swallowed Euphoria Depressio, poor reflexes, slurred speech, coma Dissociative Aesthetics Class Effects Ketamie Ketalar SV: cat Valiums, K, Special K, vitami K PCP ad aalogs Phecyclidie: agel dust, boat, hog, love boat, peace pill III Ijected, sorted, smoked I, II Ijected, swallowed, smoked Icreased heart rate ad blood pressure, impaired motor fuctio At high doses, delirium, depressio, respiratory depressio ad arrest Possible decrease i blood pressure ad heart rate, paic, aggressio, violece Hallucioges Class Effects LSD Lysergic acid diethylamide: acid, blotter, boomers, cubes, microdot, yellow sushies I Swallowed, absorbed through mouth tissues Altered states of perceptio ad feelig, ausea Icreased body temperature, heart rate, ad blood pressure, loss of appetite, sleeplessess, umbess, weakess, tremors, persistet metal disorders Mescalie Buttos, cactus, mesc, peyote I Swallowed, smoked Icreased body temperature, heart rate, ad blood pressure, loss of appetite, sleeplessess, umbess, weakess, tremors Psilocybi Magic mushroom, purple passio, shrooms I Swallowed Nervousess, paraoia Memory loss, umbess, ausea. vomitig Loss of appetite, depressio Persistig perceptio disorder (flashbacks) The Natioal Child Traumatic Stress Network 9

10 Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 (cotiued) Category ad Name Examples of Commercial ad Street Names DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces Opioids ad Morphie Derivatives Class Effects Codeie Empiri with Codeie, Fiorial with Codeie, Robitussi A-C, Tyleol with Codeie: Captai Cody, Cody, schoolboy (with glutethimide), doors & fours, loads, pacakes ad syrup Fetayl ad fetayl aalogs Actiq, Duragesic, Sublimaze: Apache, Chia girl, Chia white, dace fever, fried, goodfella, jackpot, murder 8, TNT, Tago ad Cash Heroi diacetylmorphie: brow sugar, dope, H, horse, juk, skag, skuk, smack, white horse Morphie Roxaol, Duramorph: M, Miss Emma, mokey, white stuff Opium laudaum, paregoric: big O, black stuff, block, gum, hop II, III, IV, V Ijected, swallowed Less aalgesia, sedatio, ad respiratory depressio tha morphie I, II Ijected, smoked, sorted I Ijected, smoked, sorted II, III Ijected, swallowed, smoked II, III, V Swallowed, smoked Oxycodoe HCL OxyCoti: Oxy, O.C., killer II Swallowed, sorted, ijected Hydrocodoe bitartrate, acetamiophe Vicodi: vike, Watso-387 II Swallowed Pai relief, euphoria, drowsiess Nausea, costipatio, cofusio, sedatio, respiratory depressio ad arrest, tolerace, addictio, ucosciousess, coma, death Staggerig gate Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue

11 Category ad Name Examples of Commercial ad Street Names DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces Stimulats Class Effects Amphetamie Biphetamie, Dexedrie: beies, black beauties, crosses, hearts, LA turaroud, speed, truck drivers, uppers Cocaie Cocaie hydrochloride: blow, bump, C, cady, Charlie, coke, crack, flake, rock, sow, toot MDMA (methyleedioxymethamphetamie) Adam, clarity, ecstasy, Eve, lover s speed, peace, STP, X, XTC Methamphetamie Desoxy: chalk, crak, crystal, fire, glass, go fast, ice, meth, speed Methylpheidate (safe ad effective for treatmet of ADHD) Ritali: JIF, MPH, R-ball, Skippy, the smart drug, vitami R Nicotie Cigarettes, cigars, smokeless tobacco, suff, spit tobacco, bidis, chew II Ijected, swallowed, smoked, sorted II Ijected, smoked, sorted Icreased heart rate, blood pressure, metabolism; feeligs of exhilaratio, eergy, icreased metal alertess I Swallowed Mild halluciogeic effects, icreased tactile sesitivity, empathetic feeligs II Ijected, swallowed, smoked, sorted II Ijected, swallowed, sorted Not scheduled Smoked, sorted, take i suff ad spit tobacco Rapid or irregular heart beat, reduced appetite, weight loss, ervousess, isomia, heart failure Rapid breathig Tremor, loss of coordiatio, irritability, axiousess, restlessess, delirium, paic, paraoia, impulsive behavior, aggressiveess, tolerace, addictio, psychosis Icreased temperature Chest pai, respiratory failure, ausea, abdomial pai, strokes, seizures, headaches, malutritio, paic attacks Aggressio, violece, psychotic behavior Impaired memory ad learig, hyperthermia, cardiac toxicity, real failure, liver toxicity Memory loss, cardiac ad eurological damage, detal decay ad damage, impaired memory ad learig, tolerace, addictio Additioal effects attributable to tobacco exposure: adverse pregacy outcomes, chroic lug disease, cardiovascular disease, stroke, cacer, tolerace, addictio The Natioal Child Traumatic Stress Network 11

12 Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 (cotiued) Category ad Name Other Compouds Examples of Commercial ad Street Names Aabolic steroids Aadrol, Oxadri, Duraboli, Depo-Testosteroe, Equipoise: roids, juice Dextromethorpha (DXM) Foud i some cough ad cold medicatios, Robotrippig, Robo, Triple C Ihalats Solvets (pait thiers, gasolie, glues), gases (butae, propae, aerosol propellats, itrous oxide), itrites (isoamyl, isobutyl, cyclohexyl), laughig gas, poppers, sappers, whippets DEA Schedule* How Admiistered** III Ijected, swallowed, applied to ski Not scheduled Swallowed Dissociative effects, distorted visual perceptios to complete dissociative effects Not scheduled Ihaled through ose or mouth Itoxicatio Effects Potetial Health Cosequeces Noe Hypertesio, blood clottig ad cholesterol chages, liver cysts ad cacer, kidey cacer, hostility ad aggressio, ace. I adolescets, premature stoppage of growth. I males, prostate cacer, reduced sperm productio, shruke testicles, breast elargemet. I females, mestrual irregularities, developmet of beard ad other masculie characteristics Stimulatio, loss of ihibitio, headache, ausea or vomitig, slurred speech, loss of motor coordiatio, wheezig For effects at higher doses see dissociative aesthetics Ucosciousess, cramps, weight loss, muscle weakess, depressio, memory impairmet, damage to cardiovascular ad ervous systems, sudde death * Schedule I ad II drugs have a high potetial for abuse. They require greater storage security ad have a quota o maufacturig, amog other restrictios. Schedule I drugs are available for research oly ad have o approved medical use; Schedule II drugs are available oly by prescriptio (urefillable) ad require a form for orderig. Schedule III ad IV drugs are available by prescriptio, may have five refills i six moths, ad may be ordered orally. Some Schedule V drugs are available over the couter. **Takig drugs by ijectio ca icrease the risk of ifectio through eedle cotamiatio with staphylococci, HIV, hepatitis, ad other orgaisms. ***Associated with sexual assaults Sources: Natioal Istitute o Drug Abuse. (2007). Commoly Abused Drugs. Bethesda, MD: Natioal Istitute o Drug Abuse, Natioal Istitutes of Health. Retrieved April 28, 2008 from Saitz, R. (2007). Treatmet of alcohol ad other drug depedece. Liver Traspl, 13(11 Suppl 2), S59-64; Saitz, R. (2005). Cliical practice. Uhealthy alcohol use. N Egl J Med, 352(6), Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue

13 Hallucioges Hallucioges are a class of illicit drugs that alter perceptio ad, i some cases, produce euphoria. Hallucioge use is geerally rare i the overall populatio, although higher amog tees ad youg adults. I 2006, reported lifetime use of ay hallucioge was less tha 4% amog 8th graders, approximately 6% amog 10th graders, ad slightly more tha 8% amog 12th graders. Reported lifetime use was eve lower for LSD: 1.6%, 2.7%. ad 3.3% amog 8th, 10th, ad 12th graders, respectively. Ihalats Ihalats are breathable chemical vapors that produce psychoactive effects. Siffig ihalats is ofte referred to as huffig. Ihalats ca also be used by placig the ihalat i a bag ad the siffig ito the bag or puttig the bag over the head ( baggig ). Ihalats are very easy to fid, are ot illegal, ad are less expesive tha most drugs. Accordig to the most recet Natioal Survey o Drug Use ad Health, ihalats are the secod most frequetly used illicit drug amog 12- to 13-year-olds, third amog 14- ad 15- year-olds, ad fourth amog 16- ad 17-year-olds. 2 Most ihalat users start usig before their 16th birthday. 2 MDMA (Ecstasy) MDMA acts as both a stimulat ad a hallucioge. It is amog the most frequetly reported club drugs. I the 2006 Natioal Survey o Drug Use ad Health, approximately 500,000 tees betwee the ages of 12 ad 17 reported usig MDMA withi the last 30 days. 2 Overall use rates icrease with age, from less tha 2% amog 8th graders to more tha 4% i 12th graders. 12 Perceived availability of MDMA also icreases with age: less tha 15% of 8th graders report that it is easy or very easy to obtai, versus approximately 25% of 10th to 12th graders. 12 Methamphetamie Methamphetamie is a addictive stimulat closely related to amphetamie. It has loger lastig ad more toxic effects o the cetral ervous system tha amphetamie, ad is ofte made i small, illegal laboratories called meth labs, usig relatively iexpesive overthe-couter igrediets. Methamphetamie has a high potetial for abuse ad addictio. Methamphetamie users may experiece upredictable mood swigs, as well as tooth decay caused by dry mouth ad excessive tooth gridig. Users commoly have the sesatio that isects are crawlig o their ski, ad may users will scratch themselves raw, causig laceratios o their face ad arms. Durig 2006, 731,000 people age 12 or older i the Uited States reported curret use of methamphetamie, with highest rates of use amog older adolescets ad youg adults. 2 Less tha 2% of 8th ad 10th graders reported usig durig the past year, versus 2.5% of 12th graders. 12 The Natioal Child Traumatic Stress Network 13

14 Nicotie Nicotie is oe of the most frequetly used addictive drugs. I the 2006 Natioal Survey o Drug Use ad Health, 12.9% of 12- to 17-year-olds 3.3 millio tees reported usig some form of tobacco durig the past moth. The umber of curret cigarette smokers icreases with age, from a low of 2% amog 12- to 13-year-olds to a high of 20% amog 16- ad 17-year-olds. 2 Such high prevalece rates may be accouted for by research that suggests adolescets are more susceptible to rapid developmet of icotie addictio, with measurable symptoms of depedece observable after oly a few weeks of casual use. 38 Opioids Opioids are the most powerful kow pai relievers, ad their aalgesic ad euphoric effects have bee kow sice 4000 BC. I the Uited States, heroi use has icreased over the last decade, particularly amog adolescets, although overall heroi use remais low. I 2006, 1.4% of 8th graders, 10th graders, ad 12th graders reported usig heroi at least oce i their lifetime. The same survey foud that less tha 1% of youth i each of these grades reported usig heroi i the year prior to the survey. 12 By cotrast, the abuse of prescriptio paikillers particularly arcotics such as Vicodi, OxyCoti, Percocet, Demerol, ad Darvo has rise dramatically. The overall icidece of emergecy departmet visits related to arcotic abuse has bee icreasig i the U.S. sice the mid-1990s ad has more tha doubled betwee 1994 ad Accordig to emergecy departmet data, i 2005 early 50,000 youth betwee the ages of 12 ad 17 preseted to the emergecy departmet because of o-medical uses of prescriptio paikillers. Natioally, a estimated 14% of high school seiors have used prescriptio drugs for omedical reasos at least oce i their lifetime, makig prescriptio drugs the secodmost commoly abused illegal substace by teeagers, after marijuaa. 2 Steroids Aabolic steroids were origially developed i the late 1930s to treat hypogoadism (a coditio i which the testes do ot produce sufficiet testosteroe for ormal growth, developmet, ad sexual fuctioig); steroids are legal by prescriptio but are ofte abused. Accordig to the 2006 Moitorig the Future survey, most tee aabolic steroids users are male. 12 Amog male studets, use of steroids durig the past year was reported by approximately 1% of 8th graders ad 10th graders, ad early 2% of 12th graders. Adolescets may be more likely to abuse aabolic steroids if they have experieced muscle dysmorphia, a history of physical or sexual abuse, or a history of egagig i high-risk behaviors Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

15 Table 2: Sources of Additioal Iformatio o Specific Drugs of Abuse Drug Class/Drug Source URL Alcohol Caabioids Depressats NIAAA Leadership to Keep Childre Alcohol Free DEA NIDA Rohypol/GHB DEA Hallucioges NIDA Geeral DEA NIDA LSD DEA Ihalats Opioids DEA NIDA Heroi DEA NIDA OxyCoti DEA Prescriptio Pai Medicatios Stimulats NIDA Cocaie/crack DEA NIDA MDMA (Ecstasy) DEA NIDA Methamphetamie DEA NIDA Nicotie NIDA Steroids DEA NIDA DEA=Drug Eforcemet Agecy, NIAAA=Natioal Istitute o Alcohol Abuse ad Alcoholism, NIDA=Natioal Istitute o Drug Abuse The Natioal Child Traumatic Stress Network 15

16 Recogizig Withdrawal Regular users of alcohol ad drugs may evetually develop tolerace ad eed larger amouts of the substace to achieve the same effect. Whe the body adjusts to havig the substace preset, users may feel emotioally ad physically ill whe they discotiue use (withdrawal). Substace use iitially may serve as a meas to fid pleasure or relief from emotioal distress, but oce physiological depedece develops, substace use becomes a way to maage cravigs ad withdrawal symptoms (see Table 3 below). Adolescets exhibitig sigs of withdrawal require medical as well as metal health itervetio to prevet severe (or, i the case of alcohol, potetially fatal) physiological reactios. Table 3. Sigs ad Symptoms of Withdrawal Alcohol Substace Caabioids (marijuaa, hashish) Cocaie (crack) GHB (date rape drug) Ihalats (pait thier, gasolie, glues, laughig gas, poppers, sappers, whippets) Methyleedioxymethamphetamie (MDMA, Ecstasy, X, XTC, etc.) Methamphetamie Nicotie Opioids ad Morphie Derivatives (codeie, fetayl, heroi, morphie, opium, oxycodoe, hydrocodoe) Steroids Withdrawal Symptoms Cravig for alcohol, isomia, vivid dreams, axiety, hypervigilace, agitatio, irritability, loss of appetite (i.e., aorexia), ausea, vomitig, headache, sweatig, tremors, tactile ad auditory halluciatios, seizures, delirium tremes Irritability, axiety ad physical tesio, decreases i appetite ad mood Agitatio/irritability, depressio ad/or axiety, itese cravigs, agry outbursts, lack of motivatio, fatigue, ausea/vomitig, shakig Profuse sweatig, axiety attacks, high blood pressure ad pulse, halluciatio, rapid pulse Had tremors, excess sweatig, costat headaches, ervousess Depressio, axiety, icludig paic attacks, depersoalizatio/ derealizatio, paraoid delusios, sleeplessess Irritability, moderate-to-severe depressio, psychotic reactios, axiety Irritability/aggressio, depressio, poor cocetratio, icreased appetite, light-headedess, restlessess, ight-time awakeigs, cravig Nausea/vomitig, isomia, diarrhea, irritability, loss of appetite, shakig, tremors, paic, chills or profuse sweatig Nausea/vomitig/diarrhea, joit/muscle pai or weakess, weight loss, fever, headache ad fatigue, low blood pressure 16 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

17 Substace Use Problems: Risks ad Protective Factors I order to provide appropriate, effective care to tees with or at risk for substace abuse disorders, it is importat to recogize ad evaluate the various factors that ca ehace or mitigate risk. These factors ca have a profoud impact o how teeagers cope with difficulties, ad o log-term treatmet outcomes. For example, studies have show that adolescets who use positive copig strategies such as good decisio-makig skills, assertiveess, ad cogitive mastery, are less likely to use substaces or egage i deliquet behavior. 41 Coversely, adolescets who egage i avoidat stress copig ad have difficulty i maagig temptatios are more likely to use drugs ad alcohol. 42 Geder is a importat factor i the use ad effects of alcohol ad other drugs of abuse. Boys ted to have opportuities for use earlier i life ad thus ted to iitiate at youger ages. 43 However, oce girls have the opportuity to experimet, they are just as likely as boys are to use. 44 Data from the 2006 Moitorig the Future survey suggest that there are similar treds for substace use amog boys ad girls, but that boys are more likely to cosume marijuaa, steroids, ad smokeless tobacco, whereas girls are more likely to abuse amphetamies ad methamphetamie. 12 Rates of drug use for both geders have bee covergig over the past decade. 45 Research idicates that there are few differeces i the type or amout of substaces that male ad female adolescets use; however, the effects of substaces o their emotioal ad physiological health ca vary. Substace abuse stemmig from traumatic evets ad/ or psychological problems is more commo i females tha i males. Additioally, female substace abusers are more vulerable to some of the physiological effects ad psychological difficulties that ca result from substace use. Research has also show that females have a greater chace of developig eurological problems associated with alcohol abuse. 46 I additio to varyig by geder, adolescet drug ad alcohol use also teds to vary by populatio. For example, rates of curret drug use amog America Idia/Alaska Native Youth are approximately twice the rate amog tees overall. 2 Much research has bee devoted to idetifyig commo risks ad protective factors associated with adolescet substace use. Table 4 outlies some of the factors that are associated with the idividual, family, peer, school, ad commuity domais of a adolescet s life. I geeral, tees are less likely to succumb to exteral pressures toward drug use if they have a strog sese of attachmet to parets who clearly commuicate their disapproval of substace use ad atisocial behaviors ad a strog commitmet to doig well i school. 50,51 Coversely, associatig with substace abusig peers 41,48,52 55, ad limited availability of educatioal ad recreatioal opportuities 56 are associated with icreased risk of substace abuse. The Natioal Child Traumatic Stress Network 17

18 Table 4: Risks ad Protective Factors Associated with Adolescet Substace Use Domai Risk Factors Protective Factors Idividual Family Peer School Commuity Aggressive behavior Geetic vulerability Low self-esteem Academic failure Risk-takig propesity Impulsivity Lack of paretal supervisio Family member with a history of alcohol or other drug abuse Lack of clear rules ad cosequeces regardig alcohol ad other drug use Family coflict/abuse Loss of employmet Substace abuse Ties to deviat peers/gag ivolvemet Iappropriate sexual activity amog peers Drug availability Studets lack commitmet or sese of belogig at school High umbers of studets who fail academically at school Parets ad commuity members ot actively ivolved Poverty Alcohol ad other drugs readily available Laws ad ordiaces uclear or icosistetly eforced Norms uclear or ecourage use of drugs Lack of sese of coectio to commuity High uemploymet Youths activities ot moitored Self-cotrol Positive relatioships with adults (e.g., parets, teachers, doctors, law eforcemet officers, etc.) Ivolvemet i extracurricular activities Positive future plas Paretal moitorig Close family relatioships Educatio valued ad ecouraged; parets actively ivolved Clear expectatios ad limits regardig alcohol ad other drug use Shared family resposibilities icludig chores ad decisio makig Nurturig family members who support each other Academic competece Ivolvemet i substace-free activities Negative view of alcohol ad other drug use amog peers Atidrug use policies Positive attitudes toward school ad regular school attedace promoted Goal-settig, academic achievemet, ad positive social developmet ecouraged Tutorig made available Leadership ad decisio-makig opportuities for studets provided Substace-free evets sposored Laws ad ordiaces cosistetly eforced Norms ad policies ecourage ouse of drugs Strog sese of coectio to eighborhood Jobs ad other resources (e.g., housig, healthcare, childcare, commuity service opportuities, recreatio; religious orgaizatios) available 18 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

19 Coclusio Youth services providers should always be aware of the liks betwee adolescet traumatic stress ad substace abuse problems. The traditioal divisio betwee metal health ad substace abuse service systems, the limited availability of evidece-based itegrated approaches, ad the difficulties associated with havig separate sources of fudig available for these types of problems all ca pose may challeges to providig itegrated ad coordiated care. However, a coordiated approach offers the best hope of lastig recovery i tees strugglig with the effects of traumatic stress ad substace abuse. The Natioal Child Traumatic Stress Network 19

20 Refereces 1. Kilpatrick, D. G., Sauders, B. E., ad Smith, D. W. (2003). Youth victimizatio: Prevalece ad implicatios. NIJ research i brief. Washigto, DC: U.S. Departmet of Justice, Office of Justice Programs, Natioal Istitute of Justice. Retrieved April 16, 2008 from pdffiles1/ij/ pdf. 2. Substace Abuse ad Metal Health Services Admiistratio. (2007). Results from the 2006 Natioal Survey o Drug Use ad Health: Natioal fidigs. Rockville, MD: Departmet of Health ad Huma Services. Retrieved April 7, 2008 from 2k6sduh/2k6Results.pdf. 3. Kight, J. R., Harris, S. K., Sherritt, L., Va Hook, S., Lawrece, N., Brooks, T., et al. (2007). Prevalece of positive substace abuse scree results amog adolescet primary care patiets. Arch Pediatr Adolesc Med, 161(11), Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), Deyki, E. Y., ad Buka, S. L. (1997). Prevalece ad risk factors for posttraumatic stress disorder amog chemically depedet adolescets. Am J Psychiatry, 154(6), Clark, D. B., Lesick, L., ad Hegedus, A. M. (1997). Traumas ad other adverse life evets i adolescets with alcohol abuse ad depedece. J Am Acad Child Adolesc Psychiatry, 36(12), Giacoia, R. M., Reiherz, H. Z., Hauf, A. C., Paradis, A. D., Wasserma, M. S., ad Laghammer, D. M. (2000). Comorbidity of substace use ad post-traumatic stress disorders i a commuity sample of adolescets. Am J Orthopsychiatry, 70(2), Perkoigg, A., Kessler, R. C., Storz, S., ad Wittche, H. U. (2000). Traumatic evets ad posttraumatic stress disorder i the commuity: Prevalece, risk factors ad comorbidity. Acta Psychiatr Scad, 101(1), De Bellis, M. D., Narasimha, A., Thatcher, D. L., Keshava, M. S., Soloff, P., ad Clark, D. B. (2005). Prefrotal cortex, thalamus, ad cerebellar volumes i adolescets ad youg adults with adolescet-oset alcohol use disorders ad comorbid metal disorders. Alcohol Cli Exp Res, 29(9), Zeigler, D. W., Wag, C. C., Yoast, R. A., Dickiso, B. D., McCaffree, M. A., Robiowitz, C. B., et al. (2005). The eurocogitive effects of alcohol o adolescets ad college studets. Prev Med, 40(1), Diamod, G., Paichelli-Midel, S. M., Shera, D., Deis, M., Tims, F., ad Ugemack, J. (2006). Psychiatric sydromes i adolescets with marijuaa abuse ad depedecy i outpatiet treatmet. Joural of Child & Adolescet Substace Abuse, 15(4), Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008

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