Celia Neavel MD FSAHM Director Center for Adolescent Health Peoples Community Clinic Kirsten Gibbs Nieto MD Internal Medicine amp Pediatric Hospitalist Dell Childrens amp University Medical Center Brackenridge ID: 916770
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Slide1
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
Slide2Case 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
Slide317 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
Slide4Smoking 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
Slide5Monitoring the Future (MTF) Survey 2013
Slide6Bath Salts 0.9%
10.5% in 2005
6.9% in 2006
11.4% in 2011
15%
(K2/Spice)
Slide7Slide8NIDA Monitoring the Future Survey 2013
Alcohol use among teens remains at historically low levels
Slide9Now Fewer Teens Smoke Cigarettes than Marijuana
Slide102008
2013
8
th5.8%
7%
10
th
13.8%
18%
12
th
19.4%
22.7%
Slide11AISD Student Substance Abuse & Safety Survey 2013
Slide12You can find data on the specific schools in your area…
Slide13AISD Survey 2013
Slide14Slide15AISD High School Students
Self Reporting Marijuana Use
2012-13
Slide16AISD Middle School Students
Self Reporting Marijuana Use
2012-13
Slide17“I’ve Never Heard of that Drug!”
NIDA EMERGING TRENDS
Slide18Update Local Drugs of Abuse
Contributed by John Abraham DO, Child and Adolescent PsychiatristCollaboracare and Phoenix Academy
Slide19New 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
Slide20A 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”
Slide21Stimulants
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
Slide22Bath 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
Slide23Heroin
Starting to make a comebackOften starts with Rx opiate abuse that becomes too expensiveHydrocodone pills cost $5 to $15 on the street
Slide24Prescription 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
Slide25Inhalants
“Duster” air can computer duster = easy and cheap way to get high
Slide26Others “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.
Slide27Prescription 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
Slide28Assess 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
Slide29“
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
Slide301
. 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
Slide31Each “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
Slide32Abuse = 1 or more:
Use causes failure to fulfill obligations work, home, schoolRecurrent Use in Hazardous SettingsRecurrent Legal ProblemsContinued Use Despite Recurrent ProblemsABUSE vs DEPENDENCE
Slide33Dependence = 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
Slide34DRUG
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
Slide35Drug Metabolism and ½ Life
ETOH 1 oz excreted per hourYouth’s Physical ConditionFluid Balance and Hydration StatusRoute and Frequency of Ingestion
VARIABILITIES DRUG SCREENING
Slide36COMPREHENSIVE ASSESSMENT
Home LifeDelinquency HistoryPhysical/Sexual Abuse HistoryMedical StatusLearning Status
In-Depth Psychiatric Status
Environmental RisksEnvironmental Assets/StrengthsSexual BehaviorDevelopmental StatusLeisure & Recreational PreferencesFamily Dynamics
Slide37Screening, 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
Slide38Slide39Slide40Stage
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
Slide41Stage
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
Slide42Summarize Assessment
Repeat for Emphasis Problems ExperiencedAsk if would Like to ChangeConsider Signed ContractRisk/Harm Reduction
Follow-up
BRIEF NEGOTIATING INTERVIEW
Slide43I _________________ 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
Slide44http://www.youtube.com/watch?v=fX90j4jD9Sc
Slide45http://withcarson.org/http://awareawakealive.org
https://awareawakealive.org/educate/911-lifeline-legislationCARSON
Slide46Local 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
Slide47Online
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
Slide4817 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