Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington

Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington Co-Director, Adolescent Substance Abuse Program Seattle Children’s Hospital PAL Conference, Laramie, WY; 3/24/12

Objectives • Participants will learn about the prevalence and patterns of substance use and substance use disorders (SUDs) in adolescents • Participants will become familiar with common screening and assessment tools of SUDs in adolescents • Participants will be able to describe and utilize common treatment options for SUDs in adolescents

Disclosure • No conflict of interest to report • Off-label discussion of medications

Overview • Definitions • Prevalence • Screening: the Adolescent Perspective and Risk and Protective Factors • Assessment • Treatment • Co-Occurring Disorders • Questions and Answers

Substance-Related Disorders • Substances covered in DSM IV-TR: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine, Sedative/Hypnotic/Anxiolytic, Other/Unknown • Substance Use Disorders (SUDs) = Substance Abuse or Dependence • Substance-Induced Disorders = Substance Intoxication or Withdrawal • Nicotine & Polysubstance: No Abuse • Caffeine: No Abuse or Dependence

Substance Abuse • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring at anytime within a 12-month period: • Recurrent use resulting in a failure to fulfill major role obligations at work, school or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance • Never met criteria for dependence

Substance Dependence • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance: “a need for markedly increased amounts of the substance to achieve intoxication or desired effect” or “markedly diminished effect with continued use of the same amount of the substance” • Withdrawal: “the characteristic withdrawal syndrome for the substance” or “the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

Substance Dependence • Substance is often taken in larger amounts or over a longer period than intended • Persistent desire or unsuccessful efforts to cut down or control substance use • Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover • Important social, occupational, or recreational activities are given up or reduced • Substance use is continued despite knowledge of persistent or recurrent physical or psychological problem caused or exacerbated by substance

Dependence Specifiers • With Physiological Dependence • Without Physiological Dependence Course Specifiers • Early Full Remission • Early Partial Remission • Sustained Full Remission • Sustained Partial Remission • On Agonist Therapy • In a Controlled Environment

Polysubstance Dependence • Repeatedly using at least 3 groups of substances (not including caffeine or nicotine) • Dependence criteria were met as a group but not for any specific substance • Most commonly in individuals where the substance use is highly prevalent but the drugs of choice frequently changed

DSM 5: Substance Use Disorders • 11 criteria: replaced “legal problem” with “craving or a strong desire or urge to use a specific substance” • New Severity Specifiers • Moderate: 2-3 criteria positive • Severe: 4 or more criteria positive • Same Course Specifiers as DSM IV-TR • Potentially identify problematic use earlier and lead to proper intervention

Frequently Asked Question # 1 • How common is substance use in adolescents? • Who is using? • What are they using?

Quiz #1 • How common is substance use? In a class of 100 high school seniors, how many have tried the following during their lifetime: • Cigarettes? • Alcohol? • Illicit Drugs? • Illicit Drugs other than Cannabis?

Prevalence of Substance Use • Monitoring The Future (MTF) Study • www.monitoringthefuture.org • NIDA funded national study • Middle/high school, college, young adults • 40,000+ adolescents from 300+ sites • Survey behaviors/attitudes on substance use • Annual follow-up survey to graduating class

MTF Lifetime Prevalence: 2011

Summary of MTF Trend Findings • Male generally more drug use • College-bound adolescents use less • Regional variation is quite complex & changing • Population density is not a predictor of use • Socioeconomic class difference mostly small • Whites ≥ Hispanics > African Americans: Hispanics in 8th grade higher in most categories but may have higher drop-out rate and earlier initiation to account for lower numbers in 12th grade

Quiz #2 • In adolescents ages 12-17: • How common is Substance Abuse? • How common is Substance Dependence?

Prevalence of SUDs • National Household Survey on Drug Use and Health (NHSDUH) • http://oas.samhsa.gov/nsduh.htm • Formerly NHSDA(buse) • Youth 12-17 years old: survey use and abuse • 8% classified with SUDs in 2005 (3.1% Abuse, 4.9% Dependence): 8.3% for males, 7.8% for females • 7.3% classified with SUDs in 2010 (4.5% Alcohol, 4.7% Illicit drugs): 6.9% for males, 7.7% for females

Prevalence of SUDs • National Comorbidity Survey-Adolescent Supplement ( NCS-A): Merikangas et al, JAACAP 2010 • Youth 13-18 years old: diagnostic survey • 11.4 classified with SUDs: (6.4% Alcohol, 8.9% Illicit drugs): 12.5% for males, 10.2% for females • SUDs rates by age group: • 13-14: 3.7% • 15-16: 12.2% • 17-18: 22.3%

NHSDUH 2010: SUDs Pattern • Most Common Types of Substance Used: Alcohol > Marijuana > Pain Relievers > Cocaine > Others (methamphetamine, heroin, hallucinogen) • Polysubstance use is common • Reflected in most treatment studies and clinical trials (O’Brien et al 2005)

Summary: Epidemiological Studies • Experimentation is normative but consequences can be severe and far-ranging • Abuse is the exception: look for early initiation and heavy use • “Gateway Theory”: Cigarettes Alcohol  Cannabis  Other illicit drugs

Frequently Asked Question #2 • How do I know whether my patient is using too much or not? (i.e., Is he/she just a typical teenager or someone who needs an intervention or assessment)

Tasks of Adolescence • Emancipation/surrender of childhood • Identity formation • Sexual • Intellectual • Moral • Spiritual • Ethnic • Functional role in society

Risk Factors for SUDs Newcomb 1997 • Four generic domains • Cultural/Societal • Interpersonal: family and peers • Psychobehavioral • Biogenetic • Relevance modified by age, gender, and ethnicity

Mediating Factors • Early experimentation • Substance-Dependent parents • Substance-Abusing siblings • Conduct disturbances • Deviant and substance-abusing peers • Sensation-seeking temperament • Impulse and self-control problems

Mediating Factors • Poor parental supervision • Heavy drug-use neighborhoods • School problems • Social skills deficits • Parents with poor parenting skills • Victims of trauma, abuse and neglect

Riggs’ Developmental Pathways to Adolescent Mental Health, Substance Problems IQ; academic performance; female hobby; empathic gatekeeper Resilience Substance Use Abuse Dependence IMPEDES DEVELOPMENT • Coping skills • Social /interpersonal skills • Communication skills • Identity, values consolidation • Affect identification/regulation • Self-Efficacy/external locus control • Cognitive development • Pro-social network PEERS Antisocial; drug-using School Truancy, failure, HS dropout Family SUD, abuse, neglect Genetics Attachment 0 10 5 15 20 Fetal Exposure Drugs/Alcohol ADHD ODD CD ASP Depression Individual

Quiz #3 • What is the screening instrument recommended by the American Academy of Pediatrics for adolescents with substance use disorders?

Screening/Testing • CRAFFT (Knight 2002): screening; 2 or more of the following indicate significant problem • Car • Relax • Alone • Family/friends • Forget • Trouble • Drug testing: urine or other modalities

Frequently Asked Question #3 • What do I do if my patient is in need of an assessment or intervention? • What happens at a chemical dependency assessment? Who performs the assessment?

Chemical Dependency Assessment • Usually performed by Substance Abuse Counselors/Chemical Dependency Professionals (CDPs) • Assessment usually consists of a clinical interview that addresses the 6 dimensions of American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC)

Quiz # 4 • How many dimensions of the ASAM PPC can you name?

ASAM PPC Dimensions • I: Acute intoxication and/or withdrawal potential • II: Biomedical conditions and complications • III: Emotional, behavioral, or cognitive conditions and complications • IV: Readiness to Change • V: Relapse, continued use, or continued problem potential • VI: Recovery environment

Quiz # 5 • Can you name the 4 different levels of chemical dependency treatment identified in the ASAM PPC?

ASAM PPC Levels • Level 0.5: Early Intervention • Level I: Outpatient Services: <9hours/week • Level II: Intensive outpatient (9-19 hours/week)/ Partial hospitalization (>20 hours/week) • Level III: residential/inpatient services (e.g., imminent risk in relapse, continued use or recovery environment) • Level IV: medically managed intensive inpatient services (e.g., imminent risk in D1, D2, or D3)

Psychiatric Assessment • Multiple domains: Timeline approach • Psychiatric/behavioral • Family • School/Vocational • Recreational/Leisure • Medical • Collateral, collateral, collateral!!! • Toxicology

Peers • Deviancy • Substance Use • Gang Riggs’ Lifetime Timeline Longitudinal Developmental History • Pre-natal; attachment School • LD; special education • Behavior problems • Academic performance • Family • Abuse, neglect, conflict, SUD • Family management • Parental monitoring Pre-natal Attachment Adolescent Adult School-age College-age Substance Use • Onset, experimentation • For all substances used >5x • Progression to regular use • Peak use • Current use (last month) • Last use Onset and Progression of Psychiatric Symptoms • ODD/CD • ADHD • Depression • Mania /hypomania • Anxiety (SAD, PTSD, GAD, OCD) • Psychosis

Frequently Asked Question #4 • How do I get my patient into treatment? • What happens when my patient is in treatment in Washington State?

Outpatient/Intensive Outpatient Services • Non-residential programs providing chemical dependency assessments, alcohol/drug free counseling services and education for youth age 10 to 20 • Designed to screen, assess, diagnose, and treat misuse, abuse, and addiction to alcohol and other drugs

Detox/Stabilization Services • Services providing at-risk, runaway, homeless youth age 13-17 a safe, temporary, and protective environment • Criteria: experiencing crisis related to the harmful effects of intoxication and/or withdrawal from alcohol and other drugs, in conjunction with an emotional or behavioral crisis • Typical length of stay: 1-5 days

Inpatient Treatment • Programs designed for “chemically dependent” youth age 13-17 • Services include intensive individual, group, and family counseling, education, school activities, recreation, recovery support groups, and connection to continuing treatment in the home community

Levels of Inpatient Services Level 1 • Primary addiction problems requiring less clinical intervention and behavior management Level 2 • Co-occurring emotional and mental health problems, youth resistant to treatment, or high probability to run from treatment Recovery House • Continued residential stay after completing primary inpatient treatment

NHSDUH 2010: Treatment Needs • Overall: 1.8 million youths aged 12-17 (7.5% of sample population) needed treatment -> 138,000 youths received treatment at a specialty facility (7.6% of youths who needed treatment) • Most treatment occurred in outpatient settings

Barriers to Treatment • Five most often reported reasons for not receiving treatment (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) • Not ready to stop using (40.2%) • Cost or insurance barriers (32.9%) • Stigma (e.g., negative opinions from neighbors and community, negative effect on job) (22.8%) • Can handle the problem without treatment (9.9%) • Did not know where to go (9.3%)

Barriers to Treatment • Five most often reported reasons for not receiving treatment despite seeking treatment: (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) • Cost or insurance barriers (45.2%) • Not ready to stop using (30.3%) • Treatment not needed (15.5%) • Stigma (15.0%) • No Transportation/Inconvenient (8.4%)

Additional Complications in Adolescent SUD Treatment • Polysubstance use: typically alcohol and marijuana, occasional cocaine or opiates (Winters et al 2000; Kaminer et al 2002; Henggeler et al 1996) • High rates of comorbid psychiatric disorders (Armstrong et al 2002) • High rates of substance abuse in immediate families (Henggeler et al 1996; Winters et al 2000) • Developmental vulnerability • Involvement in multiple systems: legal, school, and medical problems may present first • High attrition rate: 50-80% (Henggeler et al 1996)

Frequently Asked Questions #5 • Does treatment work? (e.g., “I’ve known people who have been through rehab many times but they are still addicted”)

Why Treatment • Inconsistent outcomes after treatment prior to 1990’s(Catalano et al. 1992) • Treatment might escalate problems(Kaminer 2005; Dishion et al 1999) • Recent reviews show psychosocial treatment is better than no treatment(Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006) • Effective early intervention is critical and can be preventive in later years(Grant & Dawson 1997; Santisteban et al. 2003; NHSDUH series)

Treatment Evaluation Studies: Older Studies • Older studies tend to be evaluations of four types of programs • “Minnesota Model”: comprehensive 4-6 week inpatient program using 12-Step • Outpatient drug-free programs: individual and group with some family counseling • “Therapeutic Community”: 6-12 months residential program using 12-Step • Outward Bound or life skills training programs: 3-4 weeks wilderness program focusing on challenges of survival and group interdependency

Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington