Transcript (eg, admit to the use of a fictitious drug).

‫‪Metamphetamine‬‬
‫دکتر طاهره صادقیه‬
‫فوق تخصص روانپزشکی کودک ونوجوان‬
12-14,%
15-17,%
18-20,%
None
8.3
2.2
0.9
Alcohol
17.7
19.9
30.6
Crack/cocaine
1.2
2.4
6.3
Marijuana/hashish
66.7
66.9
37.9
Heroin
0.2
1.2
9.8
Nonprescription
methadone
Other opiates and
synthetics
PCP
0
0
0.1
0.4
0.6
2.5
0.1
0.1
0.4
Hallucinogens
0.1
0.3
0.4
Methamphetamine
2.1
4
8.4
Other amphetamines
0.6
0.9
1.4
Other stimulants
0.2
0.1
0.1
Benzodiazapines
0.2
0.2
0.4
Other tranquilizers
0.1
0.1
0
0
0
0
0.2
0.1
0.2
Barbiturates
Other sedatives or
hypnotics
• The prevalence of substance use and SUDs
increases almost linearly from early to late
adolescence.
• Approximately one in four older adolescents
meets criteria for abuse for at least one
substance, and one in five meets criteria for
SD.
Etiology
• Genetic and Environmental Influences
• Twin and adoption studies have demonstrated
that considerable shared environmental
influences exist for the initiation of substance
use, and that genetic influences become more
apparent when environments allow for their
expression
• Genetic influences on the development of
adolescent SUDs may act through a direct effect
on psychophysiological reactions to substances or
their metabolism,
• or indirectly through genetic effects on
personality traits such as behavioral disinhibition,
which leads to substance experimentation
Externalizing Disorders
• Conduct disorder has consistently been shown
to be a predictor of substance use initiation
and progression toward SUDs.
• Oppositional defiant disorder (ODD) and
attention-deficit hyperactivity disorder
(ADHD) appear to increase risk for developing
SUDs somewhat, although there is controversy
about the magnitude of the effect of ODD or
ADHD due to their comorbidity with CD.
Stage Theory and the Gateway Theory
• Thus, typically a licit substance, such as
alcohol or cigarettes, is used first in a
sequence, followed by marijuana, which is
usually the first illicit substance before
progressing on to use of other illicit
substances
Family and Peer Effects
• Parental drug use, as well as drug use by older
siblings, is a significant risk factor for the
development of adolescent substance use.
However, the mechanism of transmission is
complex, with individual personality
dimensions mediating the effect of sibling and
parent influences
Family and Peer Effects
• while the common notion has been that peers
create peer pressure to consume substances,
most studies support the notion that there
exists a complex process by which individuals
select peer groups, and then in turn influence
these, as well as are influenced by them
Biological Mechanisms in the Etiology
of Substance Use Disorders
• neural adaptations altering the hedonic tone
of individuals. This tone is reset by substance
use so that it is lower over time, resulting in
dysphoria and craving when not using, and
driving the substance dependence cycle
Substance-Specific Risks
• there are differences between substances in terms of
their addictive potential. The time course toward the
development of dependence varies by individual, by
substance, and by route of administration. Some
substances,
• Cocaine—15-16%
Alchol----------12-13%
•
• AMPHETAMIN
• Marijuana----------8%
Table 49.9-1 Domains of Facters Associated with Drug Use
I. Cultural/societal
Laws favorable to drug use
Social norms favorable to drug use
Availability of drugs
Extreme economic deprivations
Neighborhood disorganization
II. Interpersonal
Childhood interpersonal factors
Family alcohol and drug behavior and attitudes
Poor and inconsistent family management practices
Parent personality and other characteristics
Family conflicts
Physical or sexual abuse
Adolescent interpersonal factors
General stressful life events (i.e., relocation)
Peer rejection in school and other contexts
Association with drug-using peers
III. Psychobehavioral
Child and adolescent psychobehavioral influences
Age
Early and persistent behavior problem (including drug use)
Academic failure
Low degree of commitment to school
Postadolescent psychobehavioral factors
Occupational satisfaction and success
Child-rearing demands
Multiple role obligations
Achievement of sex role expectations
Intimate relationship functioning
Educational/financial attainment and security
Psychobehavioral antecedents and consequences throughout life
Alienation, rebelliousness, or antisocial personality
Sensation seeking
Psychopathology (depression, anxiety)
Attitudes favorable to drug use
Cognitive motivations or expectancies for drug use
Inability to delay gratification
IV. Biogenetic
Inherited susceptibility to drug use
Psychophysiological vulnerability to drug effects
Difficulties with risk assessment
• Cognitive immaturity in early adolescence
– Difficulty hypothesising alternative
hampers risk assessment
– Narrow range of solutions
– Avoidant coping style – early teens
futures
• Adolescent omnipotence (Elkind, 1967)
– Invulnerability to adverse consequences of risk
behaviour
• Lack of life experience
• Risk taking is also a normative, healthy
behaviour, used to achieve task of sep/indiv,
identity formation and establishment of peer
relationships
ADOLESCENT DRUG USE
• WHO: Adolescence is a period between the
ages 10-19
Adolescence is a stage of searching;
Searching for identity..
Searching for joy ...
Searching for excitement…
Searching for difference…
Searching for independence……
Adolescence and Brain Immaturity
• The last brain structures to fully mature are
the areas of the cortex related to so-called
executive functions:
- decision making
- inhibition of behaviour
- selective attention
- problem solving and reasoning
Normal brain development : function of
different stages of development
1.
2.
3.
Proliferation of pathways
- makes the brain versatile and able to adapt to
different environments
Pruning of these pathways
- with experience the unused pathways are eliminated,
narrowing the options for behaviour
Myelination (white matter)
- makes the remaining pathways faster and more
efficient
As a result brain has become adapted to environment and
efficient in functioning, but is less able to change in future.
course
• Earlier onset
• More severe sub use
• comorbid
DD
• The most frequent of these are externalizing
disorders, but internalizing disorders are also
more prevalent than in the general population
• 76%--COMORBIDITY
• 68%--disruptive behavior dis
• 32%---mood dis
• 20%---anxiety dis
• Comorbidity -----rule
Methamphetamine
• The racemate amphetamine sulfate
(Benzedrine) treatment of nasal congestion
and asthma.
• In 1937, amphetamine sulfate tablets were
introduced for the treatment of narcolepsy,
postencephalitic parkinsonism, depression,
and lethargy.
• FDA)-approved indications for amphetamine
are limited to attention-deficit/hyperactivity
disorder (ADHD) and narcolepsy; however,
amphetamines are also used in the treatment
of obesity, depression, dysthymia, chronic
fatigue syndrome, acquired immune
deficiency syndrome (AIDS), dementia, and
neurasthenia.
• Preparations
• The major amphetamines currently available and used
in the United States are dextroamphetamine
(Dexedrine), methamphetamine (Desoxyn), a mixed
dextroamphetamine-amphetamine salt (Adderall), and
the
• These drugs go by such street names as ice, crystal,
crystal meth, and speed.
•
the amphetamines are referred to as analeptics,
sympathomimetics, stimulants, and psychostimulants.
• The typical amphetamines are used to
increase performance and to induce a
euphoric feeling, for example, by students
studying for examinations, by long-distance
truck drivers on trips, by business people with
important deadlines, by athletes in
competition, and by soldiers during wartime.
Although not as addictive as cocaine,
amphetamines are nonetheless addictive
drugs.
• Other amphetamine-like substances are
ephedrine, pseudoephedrine, and
phenylpropanolamine (PPA).
• These drugs, PPA in particular, can
dangerously exacerbate hypertension,
precipitate a toxic psychosis, cause intestinal
infarction, or result in death.
• The safety margin for PPA is particularly
narrow, and three to four times the normal
dose can result in life-threatening
hypertension.
• methamphetamine is a potent form of
amphetamine that abusers of the substance
inhale, smoke, or inject intravenously (IV). Its
psychological effects last for hours and are
described as particularly powerful. Unlike
cocaine (which must be imported,
methamphetamine is a synthetic drug that
can be manufactured domestically in illicit
laboratories.
Home Labs
Epidemiology
• The National Household Survey on Drug Abuse
(NHSDA) conducted in 2001 found that 7.1
percent of persons (12 years of age and older)
reported lifetime nonmedical use of stimulants,
• a significant increase since the 4.5 percent found
in the 1997 survey. The highest rates of use in the
past year (1.5 percent) were among 18- to 25year-olds, followed by 12- to 17-year-olds.
• The treatment admission rate for primary
amphetamine abuse in the United States is about
30 per 100,000 people 12 years of age or older.
Amphetamines
• Nonmedical use of stimulants is reported by
approximately 2% of 12-17-year-olds, with
0.6% reporting methamphetamine use
• all socioeconomic groups
• white professionals
• abuse by others, including friends and family
members of the patient receiving the
amphetamine
• the lifetime prevalence of amphetamine
dependence and abuse is 1.5 percent, and the
male to female ratio is 1.
Neuropharmacology
• The classic amphetamines (i.e., dextroamphetamine,
methamphetamine, and methylphenidate) produce
their primary effects by causing the release of
catecholamines, particularly dopamine, from
presynaptic terminals
• The effects are particularly potent for the
dopaminergic neurons projecting from the ventral
tegmental area to the cerebral cortex and the limbic
areas. This pathway has been termed the reward circuit
pathway, and its activation is probably the major
addicting mechanism for the amphetamines
• The designer amphetamines cause the release
of catecholamines (dopamine and
norepinephrine) and of serotonin, the
neurotransmitter implicated as the major
neurochemical pathway for hallucinogens.
Therefore, the clinical effects of designer
amphetamines are a blend of the effects of
classic amphetamines and those of
hallucinogens.
• Substituted Amphetamines
• MDMA (3,4-methylene-dioxymethamphetamine) is
one of a series of substituted amphetamines that also
includes MDEA, MDA (3,4-methylenedioxyamphetamine), DOB (2,5-dimethoxy-4bromoamphetamine), PMA
(paramethoxyamphetamine), and others. These drugs
produce subjective effects resembling those of
amphetamine and LSD (lysergic acid diethylamide), and
in that sense, MDMA and similar analogues may
represent a distinct category of drugs
• Club Drugs
• The use of a certain group of substances popularly called club drugs
is often associated with dance clubs, bars, and all-night dance
parties (raves). The group includes LSD, -³‫خ‬hydroxybutyrate (GHB),
ketamine, methamphetamine, MDMA (ecstasy), and Rohypnol or
“roofies†(flunitrazepam). These substances are not all in the
same drug class, nor do they produce the same physical or
subjective effects. GHB, ketamine, and Rohypnol have been called
date rape drugs because they produce disorienting and sedating
effects, and often users cannot recall what occurred during all or
part of an episode under the influence of the drug. Hence, it is
alleged that these drugs might be surreptitiously placed in a
beverage, or a person might be convinced to take the drug and then
not recall clearly what occurred after ingestion.
Effects
•
•
•
•
•
•
•
•
•
Hyperalert state
Talkative
Restlessness
elevated temp
Anorexia
Nausea
dry mouth
dilated pupils
Sweating
•
•
•
•
•
•
•
•
•
dizziness
hyperactive reflexes
Tremor
Insomnia
AGGRESSION
skin picking(formication)
Hypertension
Tachycardia
arrhythmias
• Its use is associated with major health consequences,
including memory loss, aggression, violence and
psychotic behavior, and neuropsychological deficits
• Similar to cocaine, dependence can develop quickly
and be associated with rapid psychosocial decline.
• The physical effects of acute. Convulsions and seizures
may occur.
•
•
•
•
Table 12.3-2 DSM-IV-TR Diagnostic Criteria for Amphetamine Intoxication
Recent use of amphetamine or a related substance (e.g., methylphenidate).
Clinically significant maladaptive behavioral or psychological changes (e.g.,
euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal
sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment;
or impaired social or occupational functioning) that developed during, or shortly
after, use of amphetamine or a related substance.
Two (or more) of the following, developing during, or shortly after, use of
amphetamine or a related substance:
–
–
–
–
–
–
–
–
–
•
•
tachycardia or bradycardia
apillary dilation
elevated or lowered blood pressure
perspiration or chills
nausea or vomiting
evidence of weight loss
psychomotor agitation or retardation
muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
confusion, seizures, dyskinesias, dystonias, or coma
The symptoms are not due to a general medical condition and are not better
accounted for by another mental disorder.
Specify if:
With perceptual disturbances (From American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC:
American Psychiatric Association; copyright 2000, with permission.)
• Table 12.3-3 DSM-IV-TR Diagnostic Criteria for
Amphetamine Withdrawal
• Cessation of (or reduction in) amphetamine (or a related
substance) use that has been heavy and prolonged.
• Dysphoric mood and two (or more) of the following
physiological changes, developing within a few hours to
several days after Criterion A:
–
–
–
–
–
fatigue
vivid, unpleasant dreams
insomnia or hypersomnia
increased appetite
psychomotor retardation or agitation
• The symptoms in Criterion B cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
• The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder
• Amphetamine Withdrawal
• After amphetamine intoxication, a crash occurs with
symptoms of anxiety, tremulousness, dysphoric mood,
lethargy, fatigue, nightmares (accompanied by rebound
rapid eye movement [REM] sleep), headache, profuse
sweating, muscle cramps, stomach cramps, and
insatiable hunger. The withdrawal symptoms generally
peak in 2 to 4 days and are resolved in 1 week. The
most serious withdrawal symptom is depression, which
can be particularly severe after the sustained use of
high doses of amphetamine and which can be
associated with suicidal ideation or behavior
MYTHS ABOUT DU/DA
• Drug addiction occurs as a result of free will.
You choose to become addicted.
• Drug addiction happens in people who have a
‘weak’ character or lack self-discipline
• Marijuana is not addicting
• People who carry on taking drugs after
treatment are a waste of time and will never
beat their addiction
TABLE 17–5. Urine toxicology
Substance
Half-life, hrs
Detection after last
use, days
Amphetamines
10–15
1–2
Barbiturates
20–96
3–21
Benzodiazepines
20–90
2–9
Cocaine
0.8–6.0
0.2–4 (metabolites)
Amphetamines
• Detection period: 1-2 days
• Positive screening test with:
– amphetamine, dextroamphetamine,
methamphetamine, pseudoephedrine,
phentermine, ephedrine,
phenylpropanolamine, phenylephrine,
selegiline(Parkinson’s med)
• some will dectect MDMA (ecstacy) most
will not
Amphetamines
• Urinary excretion is pH dependent;
acidification can reduce plasma 1/2-life
to 7-8 hours, alkinization may increase
the 1/2-life to over 33 hours
• Lack of specificity of screening test
makes confirmatory test essential
Levels of Assessment
• Screening identifies the need for a
comprehensive assessment and is not a
substitute for an assessment.
Validity of Adolescent Report
• Most youth in drug treatment settings admit
to use of substances; few treatment-seeking
adolescents endorse questions that indicate
blatant faking of responses (e.g., admit to the
use of a fictitious drug).
• Specific populations, especially extremely
antisocial youth, have much higher responses
of "faking good" than clinical samples
(Winters et al. 1991).
• factors at intake such as
• denial, reluctance to self-disclose due to
embarrassment, and wish to avoid sanctions
for use, as well as ability of the adolescent in
treatment to more carefully examine the
extent of substance use.
The Interview
• clinician to be direct, persistent, but
nonjudgmental and respectful of
confidentiality issues.
The Interview
• age at onset, duration, frequency, and route
of ingestion for each individual drug,
including alcohol, tobacco, illicit drugs,
inhalants, over-the-counter medications, and
prescription drugs such as benzodiazepines,
opiates, and stimulants.
• Additional inquiry should cover negative
consequences as well as attempts and
motivation to control use or quit.
• setting of use (time and place),
• alone or with peers,
• and the attitudes of these peers about substance
use.
• Variability in quantity and frequency of periods of
abstinence as well as periods of rapid acceleration of
use and heavy use of particular agents.
• A timeline drug chart or calendar is often useful to
allow the adolescent to report quantity, frequency,
and variability data across time with important dates,
holidays, and other time cues as a guide.
• attitudes and/or expectancies of use, and
motivation(s) or perceived benefits to use.
• usual antecedents to use and consequences of
use.
• Such an analysis may allow a more specific
targeting of relevant antecedents during
treatment. Along with specific attitudes and
beliefs about substance use, the clinician should
also inquire about the adolescent's values and
attitudes in general.
• depression, suicidality, aggression, psychosis,
and treatment history may be sufficient in
order to augment other information in
determining when an adolescent should be
referred for a more detailed, comprehensive
psychiatric evaluation
• The medical history and possible physical
exam search for symptoms and illnesses that
may be related to SUDs and behaviors,
including trauma, pregnancies, HIV/AIDS,
sexually transmitted diseases, infections or
wounds, and possible liver diseases
• School/vocational, peer, and family domains
would emphasize family and peer substance
use and attitudes toward use,
• parental monitoring and supervision,
• family history of SUDs and psychiatric
disorders, and the effect of substance use on
academic and/or vocational functioning.
• Inquiry into recreational or prosocial
activities such as sports, interests, and
hobbies will provide the clinician with
information about the adolescent's social
repertoire and whether this will have to be
targeted for change.
Confidentiality
• Adolescents are more likely to provide
truthful information if they believe that their
information, at least the details, will not be
shared. Prior to the adolescent interview, the
clinician should review exactly what
information the clinician is obliged to share
and with whom
• Typically, a clinician should inform the
adolescent that a threat of danger to self or
others will force the clinician to inform a
responsible adult, usually the parents.
• The clinician should be knowledgeable about
state and federal laws that limit what
information may be released from drug and
alcohol treatment programs.
• Confidentiality statutes include information
about illegal behavior such as selling drugs, who
sells the adolescent drugs, and peer behaviors.
In order for the assessment team to speak with
the adolescent's family, school, or legal staff
members, the adolescent must sign a consent
form.
•
Table 52.5-1. The CRAFFT Questions: A Brief Screening Test for Adolescent
Substance Abuse
•
C Have you ever ridden in a Car driven by someone (including yourself) who was
“high” or had been using alcohol or drugsz
•
R Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
•
A Do you ever use alcohol/drugs while you are by yourself, Alone?
•
F Do your family or Friends ever tell you that you should cut down on your drinking
or drug use?
•
F Do you ever Forget things you did while using alcohol or drugs?
•
T Have you gotten into Trouble while you were using alcohol or drugs?
Treatment
• The primary goal for the treatment of
adolescents with SUDs is achieving and
maintaining abstinence from substance use.
While abstinence should remain the explicit
long-term goal for treatment, a realistic view
recognizes both the chronicity of SUDs in
some populations of adolescents and the
self-limited nature of substance use and
substance use–related problems in others
• psychoeducation about SUDs, which decreases familial
resistance to treatment and increases motivation and
engagement; assisting parents and family to initiate and
maintain efforts to get the adolescent into appropriate
treatment and achieve abstinence;
• assisting parents and family to establish or reestablish
structure with consistent limit setting and careful
monitoring of the adolescent's activities and behavior;
• improving communication among family members; and
getting other family members into treatment and/or
support programs.
The Course of Substance Use Disorders
in Adolescents
• There is considerable individual variability in
the rate of return and extent of posttreatment
substance use among adolescents following
treatment. Although most treated adolescents
return to some substance use following
treatment, treated adolescents generally show
reductions in substance use and problems
over both short- and longer-term follow-up
• Longer-term outcome studies report that
most adolescents show developmentally
limited patterns of substance use and related
problems, although small proportions show
more-chronic high levels of substance
involvement through young adulthood.
• Non pharmacological
Entrance
Discontinution
Maintance
Motivation/family/12 steps/CBT/MATRIX
• The clinician should also consider alternative
agents to psychostimulants, such as
atomoxetine or bupropion, which do not
have abuse potential.
• RITALINE
• IBUDULAST
• NEUROINFLAMATORY ---GLIAL
• ANTIBODI ANTIMETAMPHETAMINE