Substance Use Disorders in Young People

1. Substance Use Disorders in Young People Christopher Gerhart, MAC, LADAC, CADC, SAP, MTTS, etc.

2. Objectives. At the end of this talk you will be able to: • Identify diagnostic criteria for substance use disorders • Describe the epidemiology of substance-related disorders among young people. • Apply this information to clinical cases • Apply skills to make your practice more alive, dynamic and fun.

3. Normal (Usually) Adult Brain

4. REWARD SYSTEM • Drugs of abuse activate the reward system in the limbic area of the brain—producing powerful feelings of pleasure • Fool brain into thinking that they are necessary for survival

5. REWARD SYSTEM (cont.) • Desire to repeat drug using behavior is strong • Drugs of abuse can/do exert powerful control over behavior because they act directly on the more primitive, survival limbic structures— over-ride the frontal cortex in controlling our behavior

7. PUBERTY Romantic motivation Sexual interest Emotional intensity Sleep cycle changes Appetite Risk for affective disorders (girls) Increase in risk taking, sensation seeking, and novelty seeking AGE/EXPERIENCE Planning Logic, reasoning Inhibitory control Problem solving Understanding consequences Affect regulation Goal setting and pursuit Judgment and abstract thinking ADOLESCENCE

8. A Definition of AddictionAmerican Society of Addiction Medicine A primary, chronic, neuro-biologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Graham, A.W.; Schultz, T.K.; Mayo-Smith, M.F.; Ries, R.K.; and Wilford, B.B. eds. Principles of Addiction Medicine, Third Edition. Chevy Chase, MD: American Society of Addiction Medicine, Inc., 2003.

9. Use of the DSM-5 • The primary purpose of the DSM-5 (Diagnostic and Statistical Manual ofMental Disorders) is to assist trained clinicians in the diagnosis of their patients’ mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual.

10. Substances Frequently Used by Young People • Alcohol • Cannabis • Hallucinogens • Inhalants • Tobacco • Opioids • Sedatives, hypnotics, and anxiolytics • Stimulants • Other

11. 2015 Monitoring the Future Study Prevalence of Past Year Drug Use Among 12th graders * Nonmedical use Categories not mutually exclusive

12. Substance-Related Disorders • Substance Use Disorders • Previously split into abuse or dependence • Involves: impaired control, social impairment, risky use, and pharmacological criteria • Substance-Induced Disorders

13. Substance Use Disorder • Using larger amounts or for longer time than intended • Persistent desire or unsuccessful attempts to cut down or control use • Great deal of time obtaining, using, or recovering • Craving • Fail to fulfill major roles (work, school, home) • Persistent social or interpersonal problems caused by substance use

14. Substance Use Disorder • Important social, occupational, recreational activities given up or reduced • Use in physically hazardous situations • Physical or psychological problems caused by use • Tolerance • Withdrawal

15. Tolerance • Need to use an increased amount of a substance in order to achieve the desired effect OR • Markedly diminished effect with continued use of the same amount of the substance

16. Severity • Depends on # of symptoms • Mild: 2-3 symptoms • Moderate: 4-5 symptoms • Severe: 6 or more symptoms

17. Specifiers • In early remission: no criteria for > 3 months but < 12 months (except craving) • In sustained remission: no criteria for > 12 months (except craving) • In a controlled environment: access to substance restricted (ex. Jail, placement)

18. Substance-Induced Disorders • Intoxication • Withdrawal • Psychotic Disorder • Bipolar Disorder • Depressive Disorder • Anxiety Disorder • Sleep Disorder • Delirium • Neurocognitive • Sexual Dysfunction

19. Changes in the Brain

20. Neuroadaptation Underlying CNS changes that occur following repeated use such that person develops tolerance and/or withdrawal • Pharmacokinetic – adaptation of metabolizing system • Pharmacodynamic – ability of CNS to function despite high blood levels

21. Epidemiology: Prevalence • Start at earlier age (<15yo), more likely to become addicted – ex. alcohol: 18% vs. 4% (if start at 18yo or older) • Rates of abuse vary by age: 1% (12yo) - 25% (21yo) - 1% (65yo)

22. Epidemiology (cont.) • 13 million people require treatment for alcohol • 5.5 million people require treatment for drug use • 2.5% population reported using Rx meds non-medically within past month

23. Epidemiology (cont.) • 40% of hospital admissions are related to alcohol or drug use • 25% of all hospital deaths

24. Epidemiology (cont.) • 100,000 deaths/year • Intoxication is associated with 50% of all motor vehicle accidents, 50% of all domestic violence cases and 50% of all murders

25. Region 6 Profile 1U.S. Census 2010 2U.S. Census 2010 3SAMHSA, NSDUH 2008-2009, Table 19. Dependence on or Abuse of Illicit Drugs or Alcohol in Past Year among Persons Aged 18 or Older. 4SAMHSA, NSDUH 2008-2009, Table 22. Serious Mental Illness in Past Year among Persons Aged 18 or Older, by State. 5CDC, National Vital Statistics System-Mortality (NVSS-M) 2008, per 100,000

26. Source of Marijuana* among 12th Graders in 2012-2015, by State Policy *Categories not mutually exclusive ** Statistically significant difference SOURCE: University of Michigan, 2015 Monitoring the Future Study

27. Etiology • Multiple interacting factors influence using behavior and loss of decisional flexibility • Not all who become dependent experience it same way or are motivated by same factors • Different factors may be more or less important at different stages (drug availability, social acceptance, peer pressure, personality and biology)

28. Etiology • “Brain Disease” – changes in structure and neurochemistry transform voluntary drug-using compulsive • Changes proven but necessary/sufficient? (drug-dependent person changes behavior in response to positive reinforcers) • Psychodynamic: disturbed ego function (inability to deal with reality)

29. Etiology • Self-medication • Alcohol - panic; opioids -anger; amphetamine - depression • Genetic (well-established with alcohol) • Conditioning: behavior maintained by its consequences • Terminate aversive state (pain, anxiety, w/d) • Special status • Euphoria • Secondary reinforcers (ex. Paraphernalia)

30. Etiology • Receptors • Too little endogenous opioid activity (ie low endorphins)or too much endogenous opioid antagonist activity = increased risk of dependence. • Normal endogenous receptor but long-term use modulates, so need exogenous substance to maintain homeostasis. • Neurotransmitters • Opioid • Catecholamines • GABA • Serotonin

31. Learning and Physiological Basis for Dependence • After using drugs or when stop – leads to a depleted state resulting in dysphoria and/or cravings to use, reinforcing the use of more drug. • Response of brain cells is to downregulate receptors and/or decrease production of neurotransmitters that are in excess of normal levels.

32. Comorbidity • Up to 50% of persons that have a substance use disorder also have a comorbid psychiatric disorder • Antisocial PD • Depression • Suicide

33. Insufficient Responses to Behavioral Health IssuesOr, Things That Do Not Work Well For Long 33

34. Treatment • Behavioral Interventions Motivation to change (MI) Group Therapy Individual Therapy Contingency Management Self-Help Recovery Groups (AA) Therapeutic Communities Aversion Therapies Family Involvement/Therapy Twelve-Step Facilitation Relapse Prevention

35. Treatment • Pharmacologic Intervention • Treat Co-Occurring Psychiatric Disorders • 50% will have another psychiatric disorder • Treat Associated Medical Conditions cardiovascular, cancer, endocrine, hepatic, hematologic, infectious, neurologic, nutritional, GI, pulmonary, renal, musculoskeletal

36. The Original Jellinek Curve

37. Devoted himself to finding laws in economics, trying to make it into an exact science. Author of the three-volume Trattato di Sociologia Generale First noticed the 80/20 Rule Pareto’s Law of Principle Vilfredo Pareto 1848 - 1923 Pareto’s 80/20 Rule

38. Examples of the 80/20 Rule • 80% of Pareto’s peas came from 20% of the peapods. • 80% of Italy’s land was owned by 20% of the people • 80% of profit is produced by 20% of employees. • 80% of crime is committed by 20% of the criminals.

39. Prochaska and DiClemente’s Stages of Change Model • Precontemplation (Not yet acknowledging that there is a problem behavior that needs to be changed) • Contemplation  (Acknowledging that there is a problem but not yet ready or sure of  wanting to make a change) • Preparation/Determination (Getting ready to change) • Action (Changing behavior) • Maintenance (Maintaining the behavior change) and • Relapse (Returning to older behaviors and abandoning the new changes)

40. Behavioral Health is Essential to Health 40 By 2020, mental & substance use disorders (M/SUDs) will surpass all physical diseases as a major cause of disability worldwide One-half of U.S. adults will develop at least one mental illness in their lifetime • U.S. 2006: M/SUDs were 3rd most costly health condition behind heart conditions and injury-related disorders • Mental illness and heart diseases alone account for almost 70 percent of lost output/productivity

41. Websites • SAMHSA – www.samhsa.gov • Substance Abuse and Mental Health Services Administration • NIDA – www.drugabuse.gov • National Institute on Drug Abuse • AAAP – www.aaap.org • American Academy of Addiction Psychiatry • ASAM – www.asam.org • American Society of Addiction Medicine