Approaching Substance Abuse in Adolescents - PowerPoint Presentation

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Approaching Substance Abuse in Adolescents

Celia Neavel, MD FSAHMDirector, Center for Adolescent HealthPeople’s Community Clinic

Kirsten Gibbs Nieto, MD

Internal Medicine & Pediatric Hospitalist

Dell

Children’s & University Medical Center Brackenridge

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Case Presentation

National & Local StatisticsScreening (Procedure applied to populations & intended to identify those w/ disease, condition, or symptom. D

oes

not yield diagnosis, but guides further decision-making)Intervening (Screening outcome-responsive conversation that focuses on encouraging making healthy choices & personal behavior changes regarding risky activity) Resources

OUTLINE

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17 year old male in your office for WCC

Sister is seeing your partner and in therapyMother is upset and wants to speak with you aloneJULIO

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Smoking marijuana daily

Does not think this is a problemAttending school, has a counselor he likes, wants to be a chefHas a girlfriend who stays soberFamily chaosJULIO

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Monitoring the Future (MTF) Survey 2013

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Bath Salts 0.9%

 10.5% in 2005

 6.9% in 2006

 11.4% in 2011

15%

(K2/Spice)

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NIDA Monitoring the Future Survey 2013

Alcohol use among teens remains at historically low levels

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Now Fewer Teens Smoke Cigarettes than Marijuana

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2008

2013

8

th5.8%

7%

10

th

13.8%

18%

12

th

19.4%

22.7%

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AISD Student Substance Abuse & Safety Survey 2013

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You can find data on the specific schools in your area…

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AISD Survey 2013

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AISD High School Students

Self Reporting Marijuana Use

2012-13

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AISD Middle School Students

Self Reporting Marijuana Use

2012-13

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“I’ve Never Heard of that Drug!”

NIDA  EMERGING TRENDS

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Update Local Drugs of Abuse

Contributed by John Abraham DO, Child and Adolescent PsychiatristCollaboracare and Phoenix Academy

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New Synthetics “K2” “spice”

Packaged under a variety of namesNot easily detected under basic drug screensNot one single compound but an ever changing array of synthetic cannabisIntoxication is similar to cannabis However, more profound effects are seen

Paranoia

Alterations in sense of timeMigrainesIn one instance, I had a patient develop “Alice in Wonderland Syndrome” extending weeks after last use

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A cheap, easy way to get highAt high levels can cause hallucination, dissociation, rapid heart rate

If used in a form with acetomeniphen can cause liver damageOften used in combination with other drugsDXM can increase the effective concentration of other serotoninergic drugs (fluoxetine and others) and increase the risk of serotonin syndrome

Dextromethorphan “DXM”

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Stimulants

Effects are increase alertness, irritability, or euphoriaADHD medsDextroamphetamine and more short acting formulations seem to be more easily abused (but all of them can be!)Keep in mind that both clonidine and guanfacine are also used in ADHD treatment. A patient abusing a peers “ADHD meds” may not know the difference

Usually taken orally when abused

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Bath Salts

Does not appear to be a major local contributor However, they are packaged and distributed in the same way that K2/spice is so a person may not know what they haveJust like synthetics the compound is ever changingSeems to be most closely associated with Mephadrone which is similar to effects of MDMA, cocaine, amphetamines

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Heroin

Starting to make a comebackOften starts with Rx opiate abuse that becomes too expensiveHydrocodone pills cost $5 to $15 on the street

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Prescription Abuse

Hydrocodone/opiate derivativesOften in forms with Acetaminophen (liver damage)Can be a number of different drugs from tramadol to antihypertensive medsInquire about a child or teenagers access to drugs at relatives and friends homes

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Inhalants

“Duster” air can computer duster = easy and cheap way to get high

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Others “The standard three”

Alcohol CannabisBenzo’s/ “bars” These are the most commonly abused that I generally see and often go together. Likely, because they are all readily available and generally inexpensive.

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Prescription Abuse

Hydrocodone/opiate derivativesOften in forms with Acetaminophen (liver damage)Can be a number of different drugs from tramadol to antihypertensive medsInquire about a child or teenagers access to drugs at relatives and friends homes

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Assess What

Substance Abuse Severity + Home Life Psychiatric Status School StatusHowShort QuestionnaireBrief InterviewWhom

Youth

Accompanying Adulthttp://store.samhsa.gov/shin/content//SMA12-3597/SMA12-3597.pdfSCREENING

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“

I’m going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential.” Part A: During the PAST 12 MONTHS, did you:

1

. Drink any alcohol (more than a few sips)? (Do not count sips of alcohol taken during family or religious events. 2. Smoke any marijuana or hashish? 3. Use anything

else*

to

get high

?

*includes

illegal drugs,

over-the-counter, prescription

drugs, and things that you sniff

CRAFFT

http://www.ceasar-boston.org/clinicians/crafft.php

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1

. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to

RELAX

, feel better about yourself, or fit in? 3. Do you ever use alcohol or drugs while you are by yourself, or ALONE? 4. Do you ever FORGET things you did while using alcohol or drugs? 5. Do your FAMILY

or

FRIENDS

ever tell you that you should cut down on your drinking or drug use?

6.

Have you ever gotten into

TROUBLE

while you were using alcohol or drugs?

CRAFFT-Part B

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Each “yes” response in

Part B scores 1 point. ≥2 is (+), need for additional assessment Probability of substance abuse/dependence diagnosis correlates with # of (+) answers

CRAFFT Scoring

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Abuse = 1 or more:

Use causes failure to fulfill obligations work, home, schoolRecurrent Use in Hazardous SettingsRecurrent Legal ProblemsContinued Use Despite Recurrent ProblemsABUSE vs DEPENDENCE

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Dependence = 3 or more:

ToleranceWithdrawalUse larger amounts or over longer time than plannedUnsuccessful efforts to cut down or quitGreat deal of time spent obtaining or recovering fromImportant activities given up because ofContinued use despite harmful consequences

ABUSE vs DEPENDENCE

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DRUG

DURATION OF DETECTABILITYAlcohol

Very Short

Amphetamine2-4 DaysMethamphetamine2-4 DaysBarbiturates (most types)2-4 Days

Phenobarbital

Up to 30 Days

Benzodiazepines

Up to 30 Days

Cocaine

12-72 Hours

Methadone

2-4 Days

Opioids

(heroin, codeine)

2-4 Days

Marijuana

casual

2-7 Days

Marijuana

chronic

Up to 30 Days

Phencylidene

casual

2-7 Days

PCP chronic

Up to 30 Days

DRUG SCREENING?

http://store.samhsa.gov/shin/content//SMA12-3597/SMA12-3597.pdf

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Drug Metabolism and ½ Life

ETOH 1 oz excreted per hourYouth’s Physical ConditionFluid Balance and Hydration StatusRoute and Frequency of Ingestion

VARIABILITIES DRUG SCREENING

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COMPREHENSIVE ASSESSMENT

Home LifeDelinquency HistoryPhysical/Sexual Abuse HistoryMedical StatusLearning Status

In-Depth Psychiatric Status

Environmental RisksEnvironmental Assets/StrengthsSexual BehaviorDevelopmental StatusLeisure & Recreational PreferencesFamily Dynamics

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Screening, Brief Intervention, and Referral to Treatment

Endorsed by SAHMSA and AAPUse Motivational Interviewing Skillshttp://pediatrics.aappublications.org/content/early/2011/10/26/peds.2011-1754.full.pdf+html

SBIRT

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Stage

Description

Office Intervention Goals

Abstinence (CRAFFT -, Low Risk)Time before ever used drugs or alcohol(more than a few sips)Prevent/delay initiation through positive reinforcement &

patient/parent education

Experimentation (CRAFFT

0-1,

Mod Risk)

The first 1–2 x use &

wants to know how using

feels

Promote

strengths; encourage abstinence

&

cessation through brief,

clear medical advice &

educational counseling

Limited Use (CRAFFT 0-1, Mod Risk)

W/friends in relatively low-risk situations

&

without problems; typically occurs

predictable times, weekends

Promote strengths; encourage cessation through brief, clear

medical advice & educational counseling

Substance Use Spectrum and Goa

l

s for Office Intervention

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Stage

Description

Office Intervention Goals

Problematic Use (CRAFFT 2+, High Risk)Use in high-risk situation, i.e. driving/babysitting; use associated w/problem like fight, arrest, school suspension; use for emotional regulation to relieve stress or depressionAbove + initiate office visits or referral for brief intervention to enhance motivation to make behavioral changes; provide close follow-up; consider breaking confidentiality

Abuse (CRAFFT +, High Risk)

Associated w/ recurrent problems or interferes w/ functioning as defined in the DSM-IV

Above

+

enhance motivation to make behavioral changes,

explore ambivalence & triggering preparation for action; monitor closely for progression to addiction; refer for comprehensive assessment & treatment; consider breaking confidentiality

Addiction/Dependence

(

CRAFFT +, High Risk)

Loss of control or compulsive drug use, as defined in the DSM-IV-TR as “dependence”

Above,

+

enhance motivation to accept referral to subspecialty

treatment if necessary; consider breaking confidentiality; encourage

parental involvement whenever possible

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Summarize Assessment

Repeat for Emphasis Problems ExperiencedAsk if would Like to ChangeConsider Signed ContractRisk/Harm Reduction

Follow-up

BRIEF NEGOTIATING INTERVIEW

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I _________________ agree to not drink alcohol, use drugs, or

take anyone else’s medication for the next _____ days. I also will not provide drugs, alcohol, or prescription medications for anyone else during this time. In addition, I agree to not drive a motor vehicle while under the influence of drugs or alcohol, nor will I ride with a driver who has been

drinking

or using drugs. I will come to my follow-up appointment with ______________on ___________. Signed, ________________________ Date: ____________________ SIGNED CONTRACT

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http://www.youtube.com/watch?v=fX90j4jD9Sc

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http://withcarson.org/http://awareawakealive.org

https://awareawakealive.org/educate/911-lifeline-legislationCARSON

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Local Examples

Austin Travis County Integral Care (ATCIC) Free evening groups 512-804-3101, CFSInfro@atcic.org, http://atcic.org/content/adolescent-substance-use-Phoenix Academy www.phoenixhouse.org

Inpatient

Shoal Creek http://www.seton.net/locations/shoal_creek/ Austin Oaks http://austinoakshospital.com/Children’s Optimal Health www.childrensoptimalhealth.orgPrivate therapists, psychiatristsOthershttp://www.cleaninvestmentsinc.comhttp://parc.memorialhermann.org/locations/austin-outpatient-rehab/http://starlite.crchealth.com/http://www.summersky.us/

RESOURCES

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Online

http://familymed.uthscsa.edu/sstart/resourcesOPEN.aspSubstance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians COMMITTEE ON SUBSTANCE ABUSED Pediatrics originally published online October 31, 2011; DOI: 10.1542/peds.2011-1754Quick Guide for Physicians http://store.samhsa.gov/shin/content//SMA12-3597/SMA12-3597.pdf

Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/RESOURCES

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17 YO in your office for WCC

Sister seeing your partner and in therapyMom upset, wanting to speak with you aloneSmoking MJ dailyDoesn’t think is problemAttending school, has counselor likes, wants to be a chefHas girlfriend who stays soberFamily chaos

JULIO