Substance Abuse Disorders in Adolescents; Assessment and Treatment Studies

1. Brittany Baker, LMSW Substance Abuse Disorders in Adolescents; Assessment and Treatment Studies

2. Prevalence and Importance • The rate of any current substance use disorder was only slightly greater than that estimated for independent mood disorders, 9.35%, representing 19.4 million US adults. • Arch Gen Psychiatry. 2004;61(8):807-816 • It is estimated that 9 percent of children in this country (6 million) live with at least one parent who abuses alcohol or other drugs • (Substance Abuse and Mental Health Services Administration [SAMHSA], 2003). • Studies indicate that between one-third and two-thirds of child maltreatment cases involve substance use to some degree • (HHS, 1999). • According to the legislature, in 2009, the economic costs of alcohol and drub abuse was worth discussion. • $254.7 billion annually with $97.7 billion due to drug abuse

3. Are kids doing drugs too? • Short answer, yes. • Longer answer, according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA) the following was true in 2013 for teens aged 12-17: • On an average day, • 881,684 smoked cigarettes • 646,707 smoked marijuana • 457,672 drank alcohol

4. Why are they using? • In recent decades the perceived risk of harm to self has declined, resulting in higher usage. • The consequences? • Higher Death Rates. • 18% of drivers ages 16-20, drive under the influence. • According to the Youth Risk Behavior Surveillance System conducted by CDC, unintentional injuries, such as MVAs cause 29% of deaths in adolescents, %0% of these deaths were alcohol related. • Higher STD Contraction Rates. • Higher drug usage has been linked to higher percentage of STD contraction. This is because adolescents are more apt to be impulsive during use and have multiple sex partners. • Higher Juvenile Delinquency Rates. • currently approximately 52% of males in the juvenile system are linked to drug or alcohol use.

5. Substance Use and Environment • Many adolescents who are considered to be using drugs are likely to suffer from other medical, mental health, or environmental stressors: • Depression, Anxiety, Eating Disorders • Parent-Child Conflict, Social Incompetency • Loss and Grief • Academic Failure • Social Workers are trained to look at the entire picture of a case, this is why we are better than LPCs and LCDCs. 

6. Assessing • What are you assessing • Introducing substances • What is it? • Why is it used? • What does current use look like? • Process of Assessing • What are they reporting • What are they not reporting • What is observable

7. Assessing • What do they report? • Name of Substance (street or clinical, past and/or current use) • When started • How frequent • At what amount per use • For how long at current rate • Last use • Attempts at sobriety • Longest sobriety

8. Assessing • What may NOT be reported by patient • Family History • Hereditary factor • Get family reports • Some patients will underreport. • This is for numerous reasons (i.e guilt, shame, avoidance of prosecution) • One Australian study found number one factor of underreporting to be full time employment, most likely fear of termination • However, remain cautious because family member may not understand situation in its entity. • Medical conditions • Liver disease, heart conditions • Use your Senses/Intuition • Appearance, smell

9. Introducing Substances • Alcohol • Found in: • Beer, Wine, Liquor • Why people intake: • Increased sociability, self esteem, euphoria • Cope with mood disorders i.e. depression • Signs of current use: • Flushed face, slurred speech, unsteady gait, distinct smell

10. Introducing Substances • Cannabis • preparation of the Cannabis plant for either recreational or medicinal purposes. • Common Names • hashish, weed, pot, marajuana • Why people intake: • Lower anxiety, euphoria • Signs of current use: • Impaired cognition, slower reaction time, reddened eyes, distinct smell, inappropriate affect/laughing

11. Introducing Substances • Opioids • Common Names: • Heroin, morphine, vicodin, hydrocodone, oxycotin, narco, codeine • Why People Intake: • Decreased perception or reaction to pain • Signs of current use: • Constricted pupils, unbalanced gait, slurred speech, difficulty staying awake

12. Introducing Substances • Benzodiazepines • Decreases excitability of neurons, resulting in lower communication and a “relaxed” feeling • Common Names: • “Downers”, Xanax, also BARS, Ativan, Klonopin, Valium, • Why Intake: • Decrease anxiety, agitation, insomnia • Signs of current use: • Similar to those of opioid abuse

13. Introducing Substances • Stimulants • Amphetamines, Methamphetamines, Cocaine • Street Names: • ADHD meds, meth, dust, crack, coke • Why Intake: • Increase concentration, energy, weight loss • Signs of current use: • Dilated pupils, restlessness, increase heart rate, insomnia, high anxiety, possible paranoia, extreme weight loss quickly, open pores on face.

14. Introducing Substances • New and Upcoming Drugs • K-2 • A synthetic form of marijuana known to cause long-term psychosis • Bath Salts • A group of designer drugs, crushed, resembling Epson salt, but chemically resembling cocaine or amphetamine. • Krokodil • A synthetic form of opiate similar to heroin, and MUCH cheaper, hence its rise in use. ($150 vs $6)

15. Faces of Substance Use

16. DSM Changes from IV to V • DSM-IV has specified substance “abuse” and “dependence” with the ability for the clinician to specify the substance type and notate the state of remission, if applicable. • DSM-V has removed these terms and replaced it with substance “use”, allowing the clinician to specify the severity of the use. • The purpose of this appears to be to help minimize the stigma related to “abusing” or “misusing” substances and being an “addict” because of physical dependence. • This prompts the discussion as to how addiction is seen by society and treated in psychiatry.

17. DSM-V Substance Use Criteria • In order to be diagnosed with Substance Use Disorder the patient must meet at least 2 of the 11 criteria for the diagnosis. the criteria are very similar to those outlined in DSM-IV for abuse and dependence combined. A patient meeting 2-3 if the criteria indicates mild substance use disorder, meeting 4-5 criteria indicates moderate, and 6-7 indicates severe (APA, 2013). • Diagnostic Criteria • Continuing to use opioids despite negative personal consequences • Repeatedly unable to carry out major obligations at work, school, or home due to opioid use • Recurrent use of opioids in physically hazardous situations • Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use • Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount • Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal • Using greater amounts or using over a longer time period than intended • Persistent desire or unsuccessful efforts to cut down or control opioid use • Spending a lot of time obtaining, using, or recovering from using opioids • Stopping or reducing important social, occupational, or recreational activities due to opioid use • Consistant use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids • Craving or a strong desire to use opioids (*Note - This is a new criterion added since the DSM-IV-TR)

18. DSM-V Substance Induced Disorders • Many substances are known to lead to “substance induced” mental health states • i.e. K-2 is well known to create “substance induced psychosis”. • After initial sobriety is achieved, sometimes psychosis does not revert. This is because K-2 appears to actively change the physiological cells of the brain in some. • i.e. some stimulants can push a diagnosed Bipolar person into a “state” of mania. • This person may remain in state of mania and require medication management to recenter

19. Initial Treatment • Initially, the adolescent may require detoxification due to dependence on the drug. • Some drug dependencies may require inpatient treatment during initial detox due to withdrawal symptoms. • Shakiness, vomiting, dizziness, racing heart beat, higher blood pressure, possibility of seizures. • There are medications that can aid with symptoms of withdrawal • ETOH: Librium, Valium* • Opiate: Catapres (Clonodine)*, Robaxin

20. Current Modailities • CBT/Behavior Modification • Most program and treatment modalities incorporate a foundation of CBT/BM. • Identifying reason for use/consequences of use • The “cue” for use; i.e. paraphilia • The results of use; i.e. DUI, probation • Changing the behavior • Seeing positive results • Changing the thought process • Motivational Intervention, Contingency Management, and Relapse Prevention are running themes of most studies.

21. Current Modalities • 12-Step • “Minnesota Model” • Adaptation of the 12 step program leading to the baseline of 28 days for rehab. This is the current length of stay seen as sufficient by most insurance companies. • Family Systems/Therapy • Old Style Paradigm • Second Paradigm • Third Paradigm *added the importance of peer group to treatment

22. Current Modalities • Treatment is seen as most effective when monotherapeutic models are combined: • Adolescent brains are not as matured as adults and require creative manipulation of skills to be successful. • Individualized treatment and accountability are key. • Kids have to “buy in” to what you are teaching.

23. Characteristics of Successful Treatment Programs • Important Program Characteristics for Success: • Skills Development • General Life Skills • Staffing • Recovering “users” • Peer Monitoring • Social Learning/Accountability • Conflict Resolution • Linked to social skills • Family Involvement • Support • Community Involvement • Options

24. Specific Programming • Seven Challenges • Listed and supported as an evidenced-based treatment from SAMSHA this incororates the following elements: • We decided to open up and talk honestly about ourselves and about alcohol and other drugs. • We looked at what we liked about alcohol and other drugs, and why we were using them • We looked at our use of alcohol or other drugs to see if it has caused harm or could cause harm. • We looked at our responsibility and the responsibility of others for our problems. • We thought about where we seemed to be headed, where we wanted to go, and what we wanted to accomplish. • We made thoughtful decisions about our lives and about our use of alcohol and other drugs. • We followed through on our decisions about our lives and drug use. If we saw problems, we went back to earlier challenges and mastered them

25. Specific Programming • Cannabis Youth Treatment (CYT) • Motivational/CBT Enhancement • Family Support Network • Community Reinforcement • Skills Enhancement • Problem Solving, Anger Management, Communication, Planning, Cravings, Relapse Prevention

26. Additional Programming; Preventing Relapse • Diversion Models/Drug Courts for Adolescents • Intensive Community Supervision • Day/Evening Treatment • Tracking/Monitoring • Mentor Tutoring • Work Apprenticeship • Restitution • Community Service/Volunteer Work • Medication Management • While mainly used in adults, some medications can be used to help management relapse prevention: • ETOH: Antabuse, Campral • Opiates: Suboxone, Methadone

27. References • Bridget F. Grant, PhD, PhD; Frederick S. Stinson, PhD; Deborah A. Dawson, PhD; S. Patricia Chou, PhD; Mary C. Dufour, MD, MPH; Wilson Compton, MD; Roger P. Pickering, MS; Kenneth Kaplan, BS. Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry; 61(8):807-816 • Child Welfare Information Gateway. 2009. Parental substance use and the child welfare system. Bulletins for Professionals. • Hanson, R. F., Self-Brown, S., Fricker-Elhai, A. E., Kilpatrick, D. G., Saunders, B. E., & Resnick, H. S. (2006). The relations between family environment and violence exposure among youth: Findings from the National Survey of Adolescents. Child Maltreatment 11(1), 3-15. • McGregor, Kiah and Makkai, Toni. Self-reported Drug Use: How Prevalent is Under-reporting? Australian Institute of Criminology. Issues and Trends of Criminology. June 2003. No.260

28. References • State legislature. 2009. The council of state governments resolution supporting state legislative mental health caucuses. • Substance Abuse and Mental Health Services Administration. (2003). Children living with substance-abusing or substance-dependent parents. (National Household Survey on Drug Abuse). Rockville, MD: Office of Applied Studies. Retrieved January 28, 2008, from www.oas.samhsa.gov/2k3/children/children.htm • Treatment Centers.NET. July 2012. Signs and symptoms of drug abuse. http://www.treatment-centers.net/signs-and-symptoms.html. • McHugh, Katharyn. 2011. “Cognitive-Behavioral Therapy for Substance Use Disorders” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/ • CYT.http://www.uclaisap.org/dmhcod/assets/Transition%20Age%20Youth/Resources/Adolescent%20Brief%20Treatment%20Manual%20Order%20Form.pdf • http://sevenchallenges.com • Substance use by adolescents on an average day is alarming • SAMHSAhttp://www.samhsa.gov/newsroom/advisories/1308285320.aspx

29. Questions?