Approaching Epidemic? Adolescent Opioid Use

1. Approaching Epidemic? Adolescent Opioid Use Lisa M. Paradis, LIMHP, LADC Chemical Use Program Assistant Director Boys Town Center for Behavioral Health

2. Disclosure

3. Introductions • Bio • Audience make-up- Who’s in the house? • Law Enforcement/ Medical Professionals/ Clinicians

4. Breakout Overview • Adolescence- Smells like Teen Spirit? • You Say Opiate, I Say Opioid • Signs and Symptoms of Adolescent Opioid Use • This is your brain on opioids • Nature vs. Nurture • Protective vs. Risk Factors • Theories of Addiction • Taking Action

5. Smells Like Teen Spirit? • Adolescence • Bio • Psycho • Social • Brain Changes http://www.brainfacts.org/thinking-sensing-and-behaving/childhood-and-adolescence/2016/the-workings-of-the-adolescent-brain-091616

6. Adolescent Brain Development • The adolescent brain remains under construction until age 25. • The adolescent brain develops from back to front- pre-frontal cortex is the last to mylenate • A biological reason why teens often act impulsively or fail to think decisions out 0-5= Nurturance 10-20= Supervision

7. Impact to Physical & Social Development • Using substances during these critical development years can have a lasting impact on the structure within the brain • Values and morals can be significantly altered with the onset and continued use of substances • Social Influences are significantly important during this developmental phase • PREVENTION & EARLY INTERVENTION IS KEY!

8. You say Opiate, I say Opioid

10. Symptoms/ Signs of Opioid Use • Decreased sex drive • Constipation • Menstrual irregularities • Seizures • Coma • Euphoria • Unconsciousness • Pain relief • Constricted pupils • Droopy eyelids • Watery eyes • Clammy/itchy skin • Loss of appetite • Sniffles/ cough • Nausea/ vomiting • Lethargy • Drowsiness/ nodding • Scars (injection sites) • Lowered: heart rate, blood pressure, body temperature

11. Pupils

12. Drastic changes in mood Abnormal sustained fatigue or bursts of energy Change in sleep or appetite Decline in personal hygiene Withdrawal from family, friends Change in friends or activities Loss of jobs Aggressive behavior Unaccounted for blocks of time Unexplained loss of money or possessions Decline in school attendance or performance Legal involvement Signs of Drug Use

13. Strong or sudden interest in drug information/ culture/ etc. Missing prescription bottles in the family home Complaints of unmanageable pain Loss of interest in previously important hobbies Strong over/under reaction to criticism or simple request

15. Roughly 99% of heroin users eventually inject the drug. • The second most injected drug is meth (85% of users move towards injection) • Heroin as the shortest incubation period= 6 months- from initial use to injection • Injection= Elevated Health Risks • Hepatitis C • HIV

16. Fentanyl It is fat soluble= enters the brain quickly Increases risk for addiction and overdose Fentanyl is easily produced from legally available precursor chemicals Fentanyl has recently been mixed into heroin or cocaine. Fentanyl’s higher potency= significantly increases the risk for overdose Fentanyl is often found in other counterfeit pills because it is cheap and easy to produce. About 500, 000 pills can be manufactured from 1kg of fentanyl ($3-5K in China)= $1.5 million sales

17. Fentanyl Both used and unused patches have been injected, Smoked, snorted, or taken orally with fatal consequences Fentanyl patches are 50- 100x more powerful than morphine and 20-40x more powerful than heroin

18. Carfentanil 100x stronger than Fentanyl and 10,000x stronger than morphine Used as a large game tranquilizer in veterinary medicine 2mg can knock out a 2000lb elephant! Bonds tightly to the opiate receptor and Narcan has difficulty dislodging it. Dangerous to users as well as medical responders as this substance can be absorbed through the skin as well as inhaled Protective gear is a must! As little as 1 mcg can affect a human Overdose may require a larger dose of Naloxone (Narcan)

19. Kratom • Mitagyna speciose- a tropical evergreen tree in the coffee family whose leaves have been used for centuries in South Asian countries as a stimulant and pain reliever. • DEA have either banned or considered banning this substance • Use of kratom for those attempting to discontinue use of opioids- craving management • Powder, tablets, liquids, gum/resin, concentrated extracts, drug patch

20. Kratom • Kratom forms have an influence on opioid receptors, acting as partial agonists with mu-opioid receptors • Cessation of kratom use can produce physical withdrawal similar to opioid withdrawal • CDC reports kratom abuse to lead to agitation, irritability, tachycardia, nausea, drowsiness, and hypertension

21. Opioid Overdose

22. Adolescent Opioid Overdose Deaths • There have been 9,000 teen deaths since 1999 • Deaths decreased in 2008-2009 due to changes in prescriber habits; however, deaths related to fentanyl and heroin increased due to limited availability of prescriptions • 148 of the 9,000 were intentional murders (CDC) • 40% of these deaths occurred at HOME!

23. Narcan A naloxone (generic) aerosol formula. Easy to administer A single activation of Narcan Nasal Spray directed into a nostril restores respiration near instantly. No needles required Will work whether or not the subject is breathing when administered Cost varies- $130-140 (two doses) Available at most pharmacies

24. This is your brain on • https://youtu.be/aF4GtW5B3uc • https://www.youtube.com/watch?v=IhfZ7ZPPRQA

25. Brain

26. Distribution of Opiate Receptors • Opiate receptors are distributed in distinct patterns in the brain. • Highest densities of opiate receptors are concentrated in areas involved in pain pathways • Dense in substansiagelatinosaof the spinal cord, where sensory nerves make first contact • Also concentrated in the medial area of the thalamus: conveys sensory input associated with deep pain • Dense in the limbic system: a major regulator of emotional behavior- explains euphoria

27. Opiate binding sites in the brain

28. Brain

30. SubstansiaGelatinosa

31. Opiate Receptors

33. Nature vs. Nurture • Biology • Regardless of the drug involved= 50% of the risk of addiction is genetic • Certain variations of certain genes can increase the risk of developing addiction • Genes can increase or reduce risk • Opiate addiction- OPRM1 (normative) OPRM1A118G (addictive) • Environment • Upbringing and exposure to stress are factors that can trump genetics • Enriched environment reduces risk • Severe early life stress dramatically increases the risk of addiction • Greater trauma exposure= increased risk • Increased cortisol associated with early trauma-prolonged into adulthood results in adrenal exhaustion and auto immunity concerns • Boys who experienced 6 or more childhood traumas were 46x greater risk of becoming an IV addict (ACE Study)

34. Risk Factors • Opiates= They work! • Pain as the 5th Vital Sign Relieve stress Action on the mu receptor in the amygdala Feeling of being warm, fed, and cared for Dissociation from negative feeling states Cognitively intact Dopamine high and enhanced sense of well-being Limited availability of treatment resources

35. Protective Factors • Enriched Environment • Improved education and awareness of medical, legal, clinical professionals • Earlier detection, prevention, intervention • Nebraska Prescription Drug Monitoring Program

36. Addiction Loop Tolerance develops Without the drug= overwhelmed by negative emotions and acute abstinence syndrome (feeling like crud) Dopamine is replaced by glutamate and drug seeking behaviors I over E (Intellect over Emotion) turns into E over I (Emotion over Intellect) Neural alterations limit the ability to adapt to new information (stop taking drugs in spite of adverse consequences) and strengthens the power of drug learned associations

37. Triggers Cravings Urges Use

38. First step is liking the drug (easing emotional distress) Endorphins and enkaphalins relieve stress by making you feel warm, safe, fed, and loved If you are a trauma survivor these drugs are especially appealing as they reinforce the connection between the drug and life’s fundamental comforts Secondly- another feedback loop begins involving the unconscious brain and HOMEOSTASIS When opioid levels become too high the brain releases cortisol reducing dopamine levels and causing feelings of irritability and discontent The Locus Coeruleus (LC) puts out more norepinephrine to counteract CNS depression

39. Locus Coeruleus

40. Opioid Abstinence Syndrome • Increased anxiety followed by: • Increased norandrenergic activity • Typically begins 10-12 hours after last dose • Peaks at 2-3 days • Lasts 7-10 days

41. Opioid Abstinence Syndrome • Users Experience: • A hyper-aroused state (fight or flight) • Increased • Heart rate • Blood pressure • Restlessness • Tremors • Hypervigilance • Dilated pupils • Worst Case of the flu imaginable • Nausea/ vomiting • Runny nose • Cold (cannot get warm), shivering • Tearing • Diarrhea

42. Opioid Abstinence Syndrome • MAT (Medication Assisted Treatment) • Clonidine (lowers blood pressure) • Trazedone, Remeron (for insomnia) • Zofran (for nausea) • Buprenorphine (used primarily for initial withdrawal) • Suboxone (combination of burprenorphine and Naloxone) • Methadone (only prescribed through formalized clinic) • Naltrexone (more for maintenance) Pregnancy- Methadone was approved until 2010 when new research indicated Buprenorphine was better suited to reducing withdrawal symptoms in newborns • COWS (Clinical Opiate Withdrawal Scale)

43. What Can You do?

44. What Can You Do? Putting it all together- understanding the bio-psycho-social connection- what you see may be impacted by forces even adolescents cannot manage (biology/ predisposition/ physical addiction) Have the tough conversations Knowing what to look for-and how to intervene Treatment Levels of Care Triggers/Cravings/ Urges cycle

45. Levels of Treatment • Assessment • Education • Outpatient (Individual, Family, Group) • Intensive Outpatient • Partial Hospitalization • Clinically Managed Residential Treatment Programs • Medically Managed Residential Treatment Programs

46. Stages of Change

47. Theories of Addiction • Disease Model • Life Process Model • Process Model of Addiction • Process Model of Recovery • Harm Reduction

48. Disease Model vs. Life Process Model • Your addiction is a way of coping with life experience • You focus on problems and not labels • Improved control and relapse reduction are accepted • Your primary social supports are work, family, friends • Your treatment or group support evolves over life • Your addiction is inbred (genetic) • You must accept your identity as an addict/alcoholic • Total abstinence is the only successful resolution • Your primary social supports are fellow addicts • You need the same treatment and group support forever

49. Process Model of Addiction

50. Recovery Model of Addiction