in partnership with University of California Los Angeles Integrated Substance Abuse Programs Substance Use Adolescent Health and SBIRT Training Objectives By the end of this training participants will be able to ID: 797500
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Slide1
Training Module:
Conrad N. Hilton Foundation Substance Use Prevention Initiativein partnership withUniversity of California, Los Angeles Integrated Substance Abuse Programs
Substance Use, Adolescent Health,
and SBIRT
Slide2Training ObjectivesBy the end of this training, participants will be able to:Describe three ways that substance use can impact the short term health and well-being of adolescents.Explain substance use disorders and their causes
Understand why it is particularly critical to address substance use among adolescentsDescribe two ways other than risk for substance use disorders that substance use puts the long-term health and well-being of adolescents at risk
Describe the SBIRT model
2
Slide3What Psychoactive Substances Do: Trigger DopamineDopamine is the neurotransmitter released when we do things essential for survival (eat, drink, sex)Pleasure/Well-beingSatiationSedation
Psychoactive drugs’ chemical structures stimulate release of dopamine in different parts of the brain3
Slide40
50
100
150
200
0
60
120
180
Time (min)
% of Basal DA Output
NAc
shell
Empty
Box
Feeding
Di
Chiara
2007
FOOD
100
150
200
DA Concentration (% Baseline)
Mounts
Intromissions
Ejaculations
15
0
5
10
Copulation Frequency
Sample
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Scr
Scr
Bas
Female 1 Present
Scr
Female 2 Present
Scr
Fiorino
1999
SEX
Natural Rewards
and Dopamine
Slide5Shoblock
2003; Di
Chiara
1987
Effects of Substances on Dopamine Release
0
100
200
300
400
Time After Cocaine
% of Basal Release
DA
DOPAC
HVA
Accumbens
COCAINE
100
150
200
250
0
1
2
3
4hr
Time After Ethanol
% of Basal Release
0.25
0.5
1
2.5
Accumbens
0
Dose (g/kg
ip
)
ETHANOL
Time After Methamphetamine
% Basal Release
METHAMPHETAMINE
0
1
2
3hr
1500
1000
500
0
Accumbens
0
100
150
200
250
0
1
2
3 hr
Time After Nicotine
% of Basal Release
Accumbens
Caudate
NICOTINE
Accumbens
5
Slide66
Slide7When Substance Use Becomes ProblematicNegative impacts of substance use begin to outweigh the benefitsSubstance effects that are unpleasant or harmfulConsequences of things done while intoxicatedImpact on individual, friends/family, or societyHealth impacts
OverdoseSubstance use disordersImpact on mental healthImpact on physical health7
Slide8The Problematic Aspects of Getting Drunk/High
AlcoholCannabis
Opioids
Stimulants
SedativesInhalants
Mood SwingsXX
X
Impaired Body Movement
X
X
X
X
X
Impaired Cognition, Problem Solving, Judgment
X
X
X
X
X
Memory Problems
X
X
X
X
Drowsiness
X
X
X
X
Anxiety/
Confusion
X
X
X
Paranoia/Panic
X
X
Aggression/
Violence
X
X
X
Psychosis/
Hallucinations
X
X
X
X
8
Slide9Sexual Risk Substance use increases risky sex behavior and chances of contracting HIV among MSM (Boone 2013; Chesney 1998)Binge drinking associated with unintended pregnancy (Naimi 2003)
Injury RiskAlcohol is involved in 60% of fatal falls and over 60% of fire deaths (D’Onofrio 2008)
Alcohol consumption increases risk of violence-related injury (
Cherpitel 2007)
Almost 8% of ED visits in US are attributable to alcohol
(McDonald 2004)35-40% of ED patients have illicit drugs in their system (Vitale 2006)The Problematic Aspects: Bad Decisions9
Slide10The Problematic Aspects: Bad DecisionsImpaired DrivingBlood Alcohol Content (BAC) of .08: Four times risk of a crashBAC of .15: 12 times risk of a crash
Insufficient numbers to draw conclusions for other substances, but we know they impact reaction time and decision makingCrime26% of victims of violence report attacker seemed like they were under the influence of alcohol/drugs
Over half of jail inmates charged with robbery, burglary, motor vehicle theft report using drugs at time of offense 46-49% of probationers say they used alcohol/drugs at time of offense
National Highway Traffic Safety Administration, ND; Bureau of Justice Statistics ND; Smith 2012
10
Slide11The Problematic Aspects:OverdoseAlcoholPoisoning occurs when alcohol shuts down areas of the brain that control basic life-support functions (breathing, heart rate)Can cause brain damage and death
StimulantsImpact heart and blood vessels, leading to heart attacks, strokes, seizuresOpioids
Act on part of the brain that regulates breathingCan cause respiratory depression and death
Increased risk when combined with alcohol or sedatives
11
Slide1212
Slide13The Not Fun Aspects :Substance Use Disorders (SUD)SUD are medical conditions, not a matter of choice or will
There is no biological test, but recognized through behaviorCompulsive substance useLoss of control over substance use
13
Slide14Substance Use DisordersSUDs are brain diseasesChanges in brain structure and function40-60% of SUD vulnerability is genetic (alcohol, tobacco)
Environmental factors also play a key role Exposure to substances
Culture/norms
Relationships (family, friends, school, work) Stress and trauma
14NIDA 2010
Slide15Substance Use DisordersAmerican Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013)Describes 11 diagnostic criteria for SUD
Mild SUD: 2-3 criteriaModerate SUD: 4-5 criteriaSevere SUD: 6 or more criteria
Criteria include impulse control, social impairment, risky use, tolerance/withdrawal
15
Slide16Prolonged Drug Use Changes
The Brain In Fundamental and
Long-Lasting Ways
16
Slide17We Have Evidence That
These Changes Can Be Both
Functional
and
Structural
AND…
17
Slide18DA D2 Receptor Availability
control
addicted
Cocaine
Alcohol
Reward Circuits
DA
DA
DA
DA
DA
DA
Drug Abuser
DA
DA
DA
DA
DA
DA
DA
Reward Circuits
DA
DA
DA
DA
DA
Non-Drug Abuser
Heroin
Meth
Dopamine D2 Receptors are Lower in Addiction
18
Slide19PET Scan of Long-Term Impact of
Methamphetamine
on the Brain
19
Slide20How Brain Changes Link To BehaviorNeurochemical changes impact the dopamine reward pathway—the wiring that makes us naturally want what we need (e.g. food, water)
Brain changes from prolonged use makes us instinctually crave substances as if we need them to survive
20
Slide21Prolonged substance use leads to brain changes that impair cognition and memoryMost developed evidence is from stimulants (was of interest when scanning technology developed)Knowledge of other substances is developing
21
Beyond Craving
Slide22Dopamine Transporters in
Methamphetamine Abusers
p < 0.0002
Normal Control
Methamphetamine Abuser
7
8
9
10
11
12
13
1.0
1.2
1.4
1.6
1.8
2.0
Time Gait
(seconds)
Dopamine Transporter
(Bmax/Kd)
Motor Activity
4
6
8
10
12
14
16
1
1.2
1.4
1.6
1.8
2
Delayed Recall
(words remembered)
Dopamine Transporter
Bmax/Kd
Memory
Volkow
2001.
22
Slide23Control
> MA
4
3
2
0
1
23
Slide24MA >
Control
5
4
2
0
1
3
24
Slide25Brain Activity and Long-Term Use of Other SubstancesAlcoholMay lead to shrinking of brain, deficiencies in fibers that carry information between brain cells. Deficits in frontal lobes (learning, memory) and cerebellum (movement, coordination) Marijuana
For individuals with dependence, lower dopamine release in the striatum, leading to greater emotional withdrawal and inattention (National Institute on Drug Abuse
OpioidsStructural and functional changes in brain regions associated with mood, impulse control, motivation
25
National
Institute on Alcohol and Alcoholism, 2004; National Institute on Drug Abuse 2016; Upadhay 2010
Slide26The brain shows distinct changes after
substance use
that can persist
long after
use
has stopped
SUDs are
chronic
brain
disorders
26
Slide27PET Scan of Long-Term Meth Brain Damage
27
Slide28Substance Use and Mental HealthSelf-medication for mental health problemsImpact substances have on brain and social functioningMany MH disorders are rooted in same parts of brain, same neurotransmitters impacted by psychoactive substances
Common risk factorsGeneticsEnvironment (esp. trauma)
Mertens
2003, Flynn 2008 , NIDA 2012, SAMHSA 2010
Slide29Substance Use and Mental HealthMH DISORDER
SUD POPULATIONNON-SUD POPULATION
Depression
28.51%
2.74%
Anxiety16.87%2.22%Major Psychoses
6.56%
0.38%
43% of people with SUD have a co-occurring mental health disorder
Approx. 70% of people in SUD treatment have a co-occurring mental health disorder
Weiss 1992, Robinson 2011, Martins 2011, SAMHSA 2010
29
Slide30Substance Use and Physical HealthBehavioral risksMore tobacco use: breathing problems/cancerInjections: collapsed veins, infections Intoxication leads to more risky sex behaviorsViolence (pharmacological, systemic)Poverty
Underutilization of healthcare services
30
Boles 2003, McCoy 2001, NIDA 2012b
Slide31Substance Use and Physical HealthDirect medical consequences Effects on heart rateDecreases lung functioningStomach inflammationLiver damageKidney damage/failure
Increased blood pressure/stroke1/3 of people with SUD have a chronic physical condition or disease31
NIDA 2012b,
Reif
2011
Slide32Substance Use Disorders Shorten LifePeople who receive publicly-funded SUD services live 26.1 years less than the general populationNearly 2/3 of excess death due to medical causes
Oregon Department of Human Services 200832
Slide33What does this mean for the people with whom you work?
Slide34Most Substance Use Starts in the Teen/Young Adult Years
67%
1.5%
5.5%
<12
12-17
18-25
>25
26%
First Marijuana Use, (Percent of Initiates
)
Slide35Gogtay
2004; National Institute on Drug Abuse 2007.
Brain Development
Ages 5-20 years
MRI scans of healthy children and teens compressing
15 years of brain development (ages 5–20).
Red indicates more gray matter, blue less gray matter.
Neural connections are pruned
back-to-front.
The prefrontal cortex ("executive" functions), is last to mature.
35
35
Slide36The Interaction between the Developing Nervous System and Substances of Abuse Leads to:
Difficulty in decision making
Difficulty understanding the
consequences of
behavior
Increased vulnerability to memory
and attention
problems
This can lead to:
Increased experimentation
Alcohol and drug addiction
Fiellin
2008
.
36
36
Slide37Young Brains Are Different from Older BrainsAlcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains Adolescent rats are more sensitive to the memory and learning problems than adults
Conversely, they are less susceptible to intoxication (motor impairment and sedation) from alcoholThese factors may lead to higher rates of dependence in these groups
Hiller-
Sturmhöfel 2004
37
37
Slide38Later Onset Substance Use and SUD RiskEarly onset substance use predicts development of SUD The later adolescents start using, the less likely they are to develop SUD
Alcohol: During adolescence, odds of dependence decrease 14% for every year of delayed first useDrugs: Odds of dependence decrease 4-5% for every year of delayed first use
Grant 1997, 1998
38
Slide39We Can’t Treat Our Way Out of This Public Health CrisisApprox. 21.5 million Americans have SUDTraditionally we wait for people to get sick, then
treat themOnly 11% of people with SUD get specialty careOnly 5% of adolescentsEarly detection and prevention are
public health strategies to address SUD
Given the key role of adolescence in the development of SUD, people who work with adolescents can be the
front line in preventing SUD
Center for Behavioral Health Statistics and Quality 201539
Slide40SBIRT:A Population Approach to Prevention/Early InterventionScreening a population to identify individuals who are using substances in a risky or unhealthy way
Brief Intervention to change behaviors and attitudes of individuals who are putting their health at risk with substance use. Sometimes this is one intervention, sometimes a few sessionsReferral to Treatment
for individuals who require specialty care (behavioral, pharmacological treatments)
40
Slide4141
Identify adolescents with SUD and link them with specialty care
(about 5% of adolescents)
Educate adolescents who are using substances
(
approx
11.5% using alcohol, 9.4% using drugs) motivate behavior
change)
What SBIRT Can Accomplish
Slide42Take Away PointsAdolescents are vulnerable to impacts of psychoactive substances Prevention and early intervention for SUD is about more than just substance useReducing risky behaviors and consequences
Reducing mental health and physical problems associated with substance useDecreasing substance use in adolescence can decrease prevalence of SUD in entire US population
4. Service providers who treat adolescents are in prime position to deliver prevention and early intervention services to address the public health crisis of substance use
5. The SBIRT model can be used to identify adolescents who are using substances in a risky manner and facilitate positive change.
42
Slide43Questions? Comments?43
Slide44WORKS CITEDBoles, S. M., & Miotto, K. (2003). Substance abuse and violence: A review of the literature. Aggression and violent behavior
, 8(2), 155-174.
Boone MR, Cook SH, Wilson P. (2013). Substance use and sexual risk behavior in HIV-positive men who have sex with men: an episode-level analysis.
AIDS Behavior 17L1883-1887
.
Bureau of Justice Statistics (ND). Drugs and Crime Facts. http://www.bjs.gov/content/dcf/duc.cfm#to Accessed December 10, 2016. Center for Behavioral Health Statistics and Quality (2015). Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. (HHS Publication No. SMA 15-4927, NSSDUH Series H-50).Cherpitel CJ. (2007) . Alcohol and injuries: a review of international emergency room studies since 1995. Drug and Alcohol Review
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DiChiara
G,
Bassareo
V. (2007) Reward system and addiction: what dopamine does and does not do.
Current Opinions in Pharmacology
7(1):69-76.
DiChiara
G.,
Imperato
A.,
Mulas
A. (1987). Preferential stimulation of dopamine release in the mesolimbic system: a common feature of drugs of abuse. In
Sanlder
M,
Feurstein
C,
Scatton
B (
eds
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interactiosn
in the basal ganglia.
New York: Raven Press, p. 171-182.
D’Onofrio
G et al. (2008). Brief intervention for hazardous and
harrmful
drinkers in the emergency department.
Annals of Emergency medicine 51(6): 742-750.
Fiellin, D. A. (2008). Treatment of adolescent opioid dependence: no quick fix.
JAMA,
300(17), 2057-2059.
Fiorino DF, Phillips AG. (1999). Facilitation of sexual behavior and enhanced dopamine
effluc in the nucleus
accumbens of male rats after D-amphetamine-induced behavioral sensitization.
Journal of Neuroscience 19(1): 456-463.
Flynn, P. M., & Brown, B. S. (2008). Co-occurring disorders in substance abuse treatment: Issues and prospects. Journal of substance abuse treatment
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, N., et. al. (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Sciences, 101
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Grant, B. F., & Dawson, D. A. (1998). Age of onset of drug use and its association with DSM-IV drug abuse and dependence: results from the National Longitudinal Alcohol Epidemiologic Survey.
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Swartzwelder, H. S. (2004). Alcohol's effects on the adolescent brain: what can be learned from animal models.
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44
Slide45WORKS CITEDMcDonald AJ, Wang N, Camargo CA. (2004). US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Archives of Internal Medicine .
164:531-537.Mertens, J. R., Lu, Y. W.,
Parthasarathy
, S., Moore, C., & Weisner
, C. M. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: comparison with matched controls.
Archives of Internal Medicine, 163(20), 2511-2517.Naimi, T. S., Lipscomb, L. E., Brewer, R. D., & Gilbert, B. C. (2003). Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children. Pediatrics,
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National Institute on Alcohol Abuse and Alcoholism (2004). Alcohol’s Damaging Effects on the Brain.
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NIDA. (2007).
Drugs Brains, and Behavior: The Science of Addiction
(NIH Pub No. 07-5605). Downloaded from
http://www.drugabuse.gov/ScienceofAddiction
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National Institute on Drug Abuse (2012) What are Co-Occurring Disorders? https://teens.drugabuse.gov/blog/post/what-are-co-occurring-disorders. Accessed July 22, 2016.
National Institute on Drug Abuse (2012b) Medical Consequences of Drug Abuse https://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse. Accessed January 22, 2016.
National Institute on Drug Abuse (2016) Brain dopamine release reduced in severe marijuana dependence. https://www.drugabuse.gov/news-events/news-releases/2016/03/brain-dopamine-release-reduced-in-severe-marijuana-dependence accessed January 10, 2017.
National Highway Traffic Safety Administration (ND).
Drug and alcohol crash risk study
available http://www.nhtsa.gov/Driving+Safety/Research+&+Evaluation/Alcohol+and+Drug+Use+By+Drivers Accessed December 10, 2016.
Oregon Department of Human Services, Addiction and Mental Health Division (2008)
Measuring Premature Mortality Among Oregonians.
Reif
, S., Larson, M., Cheng, D. M.,
Allensworth
-Davies, D.,
Samet
, J., &
Saitz
, R. (2011). Chronic disease and recent addiction treatment utilization among alcohol and drug dependent adults.
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Robinson, J.,
Sareen
, J., Cox, B. J., & Bolton, J. M. (2011). Role of self-medication in the development of comorbid anxiety and substance use disorders: a longitudinal investigation.
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, J. R., Sullivan, E. B., Maisonneuve, I. M., & Glick, S. D. (2003). Neurochemical and behavioral differences between d-methamphetamine and d-amphetamine in rats.
Psychopharmacology,
165(4), 359-369.Smith PH,
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Leonaard KE, Cornelius JR. (2012). Intimate Partner Violence and Substance Use Disorders: Findings from the National Epidemiological Survey on Alcohol and Related Conditions. Psychology of Addictive Behaviors 26(2): 236-245.
Substance Abuse and Mental Health Services Administration (2010)
Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) Available at http://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-Disorders-Evidence-Based-Practices-EBP-KIT/SMA08-4367
Upadhyay, J.,
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45