Alcohol Issues and What’s New on the Streets Smoked or Salted

1. Alcohol Issues andWhat’s New on the StreetsSmoked or Salted National Tribal Best Practices 2012 Anthony Dekker, DO Chief, Addiction Medicine Fort Belvoir Community Hospital Anthony.dekker.civ@health.mil Credit Erik Gunderson MD and Martha Wunsch, MD 2012 NTBP SLC

2. Disclosure • Anthony Dekker, DO has presented numerous programs on Chronic Pain Management and Addiction Medicine. The opinions of Dr Dekker are not necessarily the opinions of the DoD, Indian Health Service or the USPHS. Dr Dekker has no conflicts to report. 2012 NTBP SLC

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4. Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2008 81.7% of pain relievers obtained from friend/relative for free were obtained from one doctor. 1.6% were obtained from a drug dealer. 70% of Prescription Pain Relievers Used Non-Medically Come from Friends or Relatives Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown. Source: NSDUH 2008 2012 NTBP SLC 4 4

5. Question • Is early intoxication at age 15 correlated with an increase in the likelihood of alcohol dependence? • A. Yes • B. No 2012 NTBP SLC

6. Age at Onset of Alcohol USE • First use of alcohol at under 15 y.o. predicts a fourfold increase in lifetime risk for alcohol dependence • Data gathered from US general population • Each year that first use is delayed results in decreased risk of alcohol dependence • Native American communities have varying but LOWER age at onset 2012 NTBP SLC

7. Age at First INTOXICATION 2012 NTBP SLC

8. Age at onset of alcohol DEPENDENCE • 2001-2002 NIAAA study • 40.000 face to face interviews • 4778 alcohol-dependent patients • 15% diagnosable <18 y.o. • 47% diagnosable <21 y.o. • 66% diagnosable <25 y.o. • Earlier onset predicts LESS likelihood of ever seeking treatment and MORE severe course 2012 NTBP SLC

9. American Indians/Alaska Natives (AI/AN) adolescents and substance abuse • AI/AN adolescents have significantly higher rates of alcohol/drug use compared to other ethnic/racial groups in the U.S.(Dixon et al. 2007; Schinke et al. 2000; Spicer et al. 2003). • AI/AN also have the highest rates of commercialized tobacco use compared to other ethnic/racial groups in the U.S. • AI/AN youth experience more severe health, mental health, and social consequences related to alcohol/drug use including depression, conduct disorder, posttraumatic stress disorder, and suicidiality. • AI/AN youth have an earlier onset of drug/alcohol use compared to non-Native youth (Schinke et al. 2000; Spicer et al. 2003, Dixon, 2007). 2012 Symposia Medicus Pediatrics Conference

10. Effects of alcohol/drug abuse among AI/AN adolescents • 78% of AI aged 12-17 have tried alcohol, compared with 53% of the general population (Cabape and Howley 1992; Spicer et al. 2003, Dixon, 2007). • 51-62% of AI youths have tried marijuana as compared to 28-50% from other racial/ethnic groups, although rates varied accordingly to tribe (IHS, 2005; NIAAA, 2002). • Deaths attributable to alcoholism among AI adolescents and young adults, ages 15-24 are more than 15 times the general U.S. population (Mitchell et al., 2004*). 2012 Symposia Medicus Pediatrics Conference

11. Contributing factors of substance abuse among AI/AN adolescents • Low socioeconomic status • Family structure • Parental monitoring • History of family substance abuse • Neglect • Trauma • Urbanicity • Child abuse • Co-occurring mental health problems • Violence Exposure (Stiffman et al., 2007) 2012 Symposia Medicus Pediatrics Conference

12. Historical Trauma and AI/AN Cultural Identity • Many U.S. historical actions, i.e., removals and relocation acts, have resulted in a fragmented AI/AN community • Many AI/ANs may have “lost” some of their cultural identity. • Lost of cultural identity may contribute to increased drug and alcohol use. • Conversely, strong cultural identification may help youth and adults to be less likely to use drugs/alcohol. • AI adolescents who identify with Indian culture may be less likely to be involved in alcohol use than those who lack this sense of identity. 2012 Symposia Medicus Pediatrics Conference

13. Neurobiology of Alcohol • Ralph Hingson, Boston University School of Public Health and its Youth Alcohol Prevention Center. "This analysis suggests that interventions that delay drinking onset may not only reduce the acute consequences of drinking among youth, but may help reduce alcohol dependence among adolescents and adults" 2012 NTBP SLC

14. Findings • 47% of who drank before age 14 developed alcohol dependence compared to 9% of those who started after age 21. • Survey with 43,000 adults • Reference:Hingson, R. W., Heeren, T., Winter, M. R. (2006) Age at Drinking Onset and Alcohol Dependence Age at Onset, Duration, and Severity. Arch Pediatr Adolesc Med., 160(7): 739-746. 2012 NTBP SLC

15. Neurology of Addiction 2012 NTBP SLC

16. Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2008 Felt They Needed Treatment and Did Not Make an Effort Did Not Feel They Needed Treatment (766,000) 95.2% 1.1% (19.8 Million) Felt They Needed Treatment and Did Make an Effort (233,000) 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use 2012 NTBP SLC 16 16 Source: NSDUH 2008

17. Youth Risk Behavioral Survey 1 • Behaviors that contribute to unintentional injuries and violence; • Tobacco use; • Alcohol and other drug use; • Sexual behaviors that contribute to unintended pregnancy and STDs, including human immunodeficiency virus (HIV) infection; • Unhealthy dietary behaviors • Physical inactivity. 1Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance — United States, 2009. MMWR 2010;59(No. SS-5). 2012 NTBP SLC

18. Tobacco • 19.5% (15-28%): smoked cigarettes at least 1 day during the last 30 days. • 50.8% tried to quit smoking cigarettes during the last 12 months. • Among the smokers (19.5%), 7.8% of students had smoked more than 10 cigarettes per day in the last 30 days YRBS 2009 2012 NTBP SLC

19. Alcohol • Nationwide, 72.5% of students had had at least one drink of alcohol on at least 1 day during their life (i.e., ever drank alcohol) • Females 74.2 %; Males 70.8 % • Nationwide, 41.8% of students had had at least one drink of alcohol in the last 30 days (i.e., current alcohol use) • 24.2% of students had had five or more drinks of alcohol in a row (i.e., within a couple of hours) in the last 30 days (i.e., binge drinking) 2012 NTBP SLC YRBS 2009

20. High School Students Consumed Five or More Drinks of Alcohol in a Row in the Past 30 Days* 23% Decline Since 1991 Lowest level since tracking began in 1991 YRBS 2009 2012 NTBP SLC

21. Cannabis • Nationwide, 36.8% of students had used marijuana one or more times during their life (i.e., ever used) • Nationwide, 20.8% of students had used marijuana one or more times during the last 30 days (i.e., current marijuana use) • What will happen in the medical marijuana states/districts? YRBS 2009 2012 NTBP SLC

22. Misuse of Prescription Medications • Nationwide, 20.2% of students had taken prescription drugs without a doctor’s prescription one or more times during their life • Oxycontin™, Percocet™, Vicodin™, Adderall™, Ritalin™, or Xanax™ • Lowest Use among Black Females (10.3 %) • Highest rates of Use among Male 12th Graders (27.2 %) YRBS 2009 2012 NTBP SLC

23. Evertook prescription drugs (e.g., Oxycontin™, Percocet™,Vicodin™, Adderall™, Ritalin™, or Xanax™) without a doctor’s prescription YRBS 2009 2012 NTBP SLC

24. Monitoring the Future2 46,500 students in the 8th, 10th, and 12th grade; 396 secondary schools 1. Usage levels for the various drugs by asking “On how many occasions (if any) have you used marijuana (a) in your lifetime? (b) during the past 12 months? (c) during the last 30 days” 2. Perceived risk is measured by a question asking “How much do you think people risk harming themselves (physically or in other ways), if they” “try marijuana once or twice,” 3. Disapproval is measured by the question “Do YOU disapprove of people doing each of the following?” 4. Availability Perceived availability is measured by the question “How difficult do you think it would be for you to get each of the following types of drugs, if you wanted some?” 2Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2011). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2010. 2012 NTBP SLC

25. Sedative Use & Availability Monitoring the Future, University of Michigan 2010 2012 NTBP SLC

26. Narcotics…other than heroin Monitoring the Future, University of Michigan 2010 2012 NTBP SLC

27. Narcotics…other than heroin Monitoring the Future, University of Michigan 2010 2012 NTBP SLC

28. NFLIS Narcotic Analgesics2006 Regional Distribution

29. NFLIS Benzodiazepines2006 Regional Distribution

30. Alcohol Use Monitoring the Future, University of Michigan 2010 2012 NTBP SLC

31. Alcohol: Disapproval and Availability Monitoring the Future, University of Michigan 2010 2012 NTBP SLC

32. New Initiates to Illicit Drug Use3 3 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41. 2011. 2012 NTBP SLC

33. Past Month Use, Illicit Drugs, Youths Aged 12 to 17: 2002-2010 NSDUH, SAMHSA, 2010 2012 NTBP SLC

34. Current Alcohol Use among Persons Aged 12 to 20, by Age: 2002-2010 NSDUH, SAMHSA 2010 2012 NTBP SLC

35. Summary • High School Students: Alcohol, tobacco, and cannabis are available and >>> use than prescription medications. • In 2010 NSDUH Average age at first nonmedical use of any psychotherapeutics (recent initiates) was 22.3 years. • Ask and be Aware that some teens are using as young as middle school. 2012 NTBP SLC

36. Starting the Conversation • Build in Time Alone: Prepare parents for meeting alone (10-12 years old) and allow the child to choose when parent leaves the room. • Discuss confidentiality. Describe what you will discuss and legal boundaries with parents and children. Know your state laws. • Be on their side. Explain that you talk to all of your teens about alcohol to help keep them healthy. 2012 NTBP SLC

37. H.E.A.D.S.S.S.5,6 • Home • Education • Activities and Employment • Drugs (and alcohol) • Suicidality • Sexuality • Safety and Eating 2012 NTBP SLC

38. Home • Where do you live? How long have you lived there? Who lives at home with you? Deployment Hx? Do you have any pets? Do you feel safe at home? Do you feel safe in your neighborhood? Are there any guns or other weapons at home? How are they stored? Do you have access to them? 2012 NTBP SLC

39. Education • Where do you go to school? Have you changed schools recently? What grade are you in? What do you like or not like about school? What is your favorite or least favorite class? Do you feel safe at school? What are your grades like? What were your grades like last year? Do you have an IEP (individual education plan) in place? What do you want to do after finishing school? 2012 NTBP SLC

40. Activities/Employment • What do you do for fun? What do you and your friends do together? Do you have a best friend? Are you in any clubs or teams? Do you have a job? What is your workplace environment like? Do you drive? 2012 NTBP SLC

41. Eating Habits • Do you exercise? Do you feel comfortable with your body or weight? Do you feel comfortable with your eating habits? Do you ever think about ways to lose weight? Do you ever eat in secret? Do you have a goal weight? What has been your highest weight? Your lowest weight? Have you ever thrown up to lose weight? Do you use diet pills or laxatives? 2012 NTBP SLC

42. Drugs • Do any of your friends smoke or drink? Do you know anyone who smokes or drinks? Have you ever tried? Have you ever used other drugs (pills without a prescription, cocaine, methamphetamine, ecstasy, heroin)? Have you ever used needles? How often do you drink or use drugs? Have you ever had a blackout? Have you ever done anything you later regretted when drinking? 2012 NTBP SLC

43. Suicidality • Have you ever been so sad you thought about hurting yourself? Have you ever tried? Do you feel sad now? Have you ever run away from home? Have you ever cut yourself intentionally? 2012 NTBP SLC

44. Sexuality • Have you ever dated anyone? Boys, girls, or both? How old is he or she? Do you like your boyfriend or girlfriend? Do you feel safe with him or her? Does your boyfriend or girlfriend ever get jealous? Has he or she ever hit you or pushed you? 2012 NTBP SLC

45. “Yes” to dating • Have you ever kissed anyone? Have you ever had sex? Oral sex? Anal sex? How many sexual partners have you had? How old were you when you first had sex? • Has anyone ever touched you in a way you did not want to be touched or forced you to do something you did not want to do sexually? 2012 NTBP SLC

46. “Yes” to sexual encounters • When did you last have sexual intercourse? Did you use a condom with your last sexual encounter? Have you ever had a sexually transmitted infection? Have you ever been tested for HIV? Have you ever been pregnant? Have you ever traded money or drugs for sex? 2012 NTBP SLC

47. CRAFFT7 • Two or more positive answers indicate a positive screen • Validated among adolescents, inner city and suburban sites, Boston Childrens’ Hospital • Car, Relax, Alone, Forget, Friends, Trouble 2012 NTBP SLC

48. “C” • Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? 2012 NTBP SLC

49. “R” • Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? 2012 NTBP SLC

50. “A” • Do you ever use alcohol or drugs while you are by yourself, ALONE? 2012 NTBP SLC