Transcript Substance Use and Adolesence

Substance Use and Adolescence
Edward S. Yuzda, MD, MSc, FRCPC (Psychiatry)
Claude Ranger Mental Health Clinic
Dec. 9th/04
Outline
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Historical Perspectives
Terminology
Types of Substances
Diagnoses (DSM-IV)
Epidemiology
Etiology
Risk Factors
Course and Prognosis
Treatment
Historical Perspective
Since the first accidental discovery of
beer and wine millennia ago,
humankind has utilized substances for
their psychoactive properties
 The personality of the culture
intertwined with and was influenced by
the drug of choice for that era
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Terminology
Drug vs.Substance
 Legal vs. illegal
 Addiction
 Substance Dependence
 Biological vs. Psychological
Dependence
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Types of Substances
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Central Nervous Depressants
– Alcohol
– Cannabis
– Sedative/hypnotics/anxiolytics
– Opioid analgesics
– Inhalants (ie. Glue/gasoline)
Types of Substances
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Central Nervous Stimulants
– Amphetamines
– Caffeine
– Cocaine
– Nicotine
– Ecstasy (mixed stimulant/hallucinogen)
Types of Substances
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Hallucinogens
– LSD
– Mescaline
– PCP
Types of Substances
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Other
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Gamma hydoxy butyrate (date rape drug)
Nitrite inhalants
Nitrous oxide
Kava
Betel nut
Nutmeg
Antihistamines
Antiparkinsonian drugs
Alcohol
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By far the most common cause of substance related
disorders in Canada
50% of all fatal MVAs involve alcohol
25% of all suicides involve alcohol
1.5 oz. Spirits = 5 oz. Table wine = 12 oz. Beer = 3
oz. Fortified wine (13.6 grams of alcohol)
Intoxication can lead to blackouts/trauma/tolerance/
psychiatric symptoms
Amphetamine and Amphetamine-Like Drugs
Drastic increase in its use in 12-17 year
olds over the past decade
 Largely due to the popularity of the rave
culture and designer rave drugs
 Amphetamine related deaths have
tripled in the 90’s
 Serious psychiatric effects include
psychotic symptoms
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Caffeine
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Most widely used psychoactive substance in the
world
 Present in pop/OTC medications/ chocolate/’pep’ pills
 Meets criteria for abuse potential:
– Positive reinforcer
– Discriminated from placebo
– Tolerance/withdrawal
(yet not recognized by DSM-IV)
 Largely associated with anxiety disorders
Cannabis
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Most common illicit substance
 Earliest recorded use (500BC)
 Analgesic/anticonvulsant/hypnotic/anti-glaucoma/
appetite stimulant
 5% of people over age 12 have used cannabis within
the past month
 Use is on the rise after two decades of decrease
 Good social drug
 Controversy exists with regards to its psychiatric
adverse effects (psychosis?/amotivation syndrome?)
Nicotine
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An overlooked addiction
1 billion users worldwide
Second to no other drug in its addictive
potential
Use has steadily declined in the Western
world secondary to extensive public
education campaigns
Its use is a risk factor for use of other drugs
Diagnoses (DSM-IV)
Substance Use Disorders
 Substance-Induced Disorders
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Substance Use Disorders
Substance Abuse Criteria
A) A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by any of the
following criteria within a 12 month period:
1) symptoms lead to a failure to fulfill a major life role or
obligation at work, home school
2) Repeatedly demonstrates intoxication when engaged in
hazardous activities
3) Legal problems
4) cont’d use despite recurrent interpersonal/social
consequence
B) Never met criteria for substance dependence
Substance Use Disorders
Substance Dependence Criteria
A) Three or more of the following occurring at any time during a
within a 12 month period:
1) Tolerance
2) Dependence
3) Takes larger quantities for longer times
4) Persistent unsuccessful efforts to cut down
5) Great deal of time spent trying to acquire the substance
6) All of daily activities are spent trying to obtain, use or
recover from the effects of the substance
7) Cont’d use despite recurrent interpersonal/social problems
Specify with/without physiological dependence
Epidemiology
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37% of people report to having used an illicit
substance
 66% for people aged 16-25
 15% of people over 28 have a serious
substance use problem
– 2/3 alcohol
– 1/3 other drugs
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3.3% of 15 year olds meet criteria for
substance abuse or dependence
 The total cost of substance use problems is
estimated at $200 billion/year
Epidemiology (cont’d)
Male>Female
Alcohol use : White=Hispanic>Black
Marijuana use: Black>White
Epidemiology (cont’d)
Use in past 12 months:
Alcohol – 59.6%
Nicotine – 27.6%
Cannabis– 24.9%
LSD – 7.6%
Hallucinogens - 10.1%
Stimulants – 6.6%
Methamphetamine – 3.6%
Ecstasy – 3.1%
Cocaine – 2.7%
Crack – 2.2%
PCP – 2.0%
Heroin – 1.8%
Glue – 1.5%
Epidemiology (cont’d)
Alcohol use (in past 12 months)
12th grade – 79.2%
10th grade – 71.8%
8th grade – 55.3%
Alcohol ‘Drunk’ (in past 12 months)
12th grade – 61.8%
10th grade – 48.5%
8th grade – 26.8%
Alcohol ‘regular use’
12th grade – 30.2%
10th grade – 24.0%
8th grade – 15.6%
Epidemiology (cont’d)
Cigarette use (in past 30 days)
12th grade – 34%
10th grade – 30%
8th grade – 21%
Daily use
12th grade – 22.2%
Epidemiology (cont’d)
Illicit drug use (in past 12 months)
12th grade – 40%
10th grade – 38%
8th grade – 24%
Epidemiology (cont’d)
Marijuana use (in past 12 months)
12th grade – 36%
8th grade – 18%
Daily Marijuana use
12th grade – 5%
Epidemiology (cont’d)
LSD use (in past 12 months)
12th grade – 9%
8th grade – 4%
Epidemiology (cont’d)
Amphetamine use (in past 12 months)
12th grade – 10%
8th grade – 9%
Methamphetamine use (in past 12 months)
12th grade – 2.8%
Ecstasy use (in past 12 months)
12th grade – 5%
Epidemiology (cont’d)
Heroine use (in past 12 months)
12th grade – 1%
8th grade – 1.6%
Epidemiology (cont’d)
Cocaine use (in past 12 months)
12th grade – 4.9%
8th grade – 3%
Crack use (in past 12 months)
12th grade – 2.1%
8th grade – 1.8%
Number of people age 12 or older that have used
illicit drugs in the past month (U.S.)
30
25
Number
of
20
millions
15
10
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95
Year
Etiology
Psychological
 Cultural
 Genetic
 Neurochemical
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Individual-related Risk Factors
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Early age of onset
Presence of early childhood behavioral
problems
Poor academic performance
Risk-taking behaviors
Favorable beliefs about substance use
Shorter attention spans
Increased impulsivity
Increased irritability/emotionality
Family-related Risk Factors
Favorable beliefs about substance use
in parents
 Parental tolerance of substance use
 Lack of closeness and attachment
between adolescent and parent
 Lack of discipline/supervision by parent
 Parental substance use
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Peer-related Risk Factors
Peer substance use
 Favorable peer attitudes to use
 Greater orientation of adolescents to
peers as opposed to parents
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Community-related Risk Factors
Low SE status
 High population density
 High crime rate
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Natural History
Most adolescents try ‘gateway’ drugs
(such as cigarettes or alcohol) which
are legal and more accessible
 such ‘gateway’ drugs then can lead to
illicit drug use
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Evaluation of a substance use
problem
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Evaluation includes:
– Substance-use related behaviors
– Observation of other psychiatric problems
– School/vocational functioning
– Family functioning
– Social competency
– Leisure activities
– Medical status
Clinical indicators of a substance use
problem
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Psychosocial/behavioral
– Change in school performance
– Involvement in illegal activities
– Sexual acting out (ie. Prostitution)
– Increased demands for money
– Change in peer group/involvement
– Driving under the influence
Clinical indicators of a substance use
problem (cont’d)
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Medical
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Frequent injuries
Suicide attempts
Sudden weight changes
Chronic respiratory symptoms
Gastrointestinal complaints
Insomnia
Infections
Anxiety
Depression
Sexually transmitted diseases
Clinical indicators of a substance use
problem (cont’d)
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Historical
– Parental use
– Estrangement from family
– Poor quality relations in the family
– Abuse/neglect
– Psychiatric disorders
– Early age of first use of substances
Clinical indicators of a substance use
problem (cont’d)
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Psychosocial behavioral
– Change in school performance
– Involvement in illegal activies
– Sexual acting out (ie. Prostitution)
– Increased demands for money
– Change in peer group/involvement
– Driving under the influence
Psychiatric Disorders Commonly Associated
with Substance use disorders
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Oppositional defiant disorder
Conduct disorder
ADHD
Mood disorders
Anxiety disorders
Bulimia nervosa
Schizophrenia
Personality disorders
Course and Prognosis
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Most adolescents who use substances do not
go on to develop problems
 Levels of use often peak in late adolescence
 Life events such as career attainment,
education, marriage, parenthood tend to
decrease substance use
 Despite such maturational processes,
substance use can disrupt the ability of
adolescents to negotiate these tasks
Treatment
Young and socially stable patients have
a better prognosis
 Treatment can be divided into four
phases:
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– Assessment and referral
– Detoxification and withdrawal management
– Active treatment
– Continuing care
Treatment (cont’d)
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Biological
– Supportive medical measures
– Treatment of withdrawal symptoms
– Replacement pharmacological therapies
(ie. Methadone)
– Treat psychiatric co morbidities (ie.
depression/ADHD/ etc.)
Treatment (cont’d)
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Psychological
– Twelve step programs (AA/NA)
– Motivational interviewing
– Cognitive behavioral therapy
Treatment (cont’d)
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Social
– Residential Programs : total control of adolescents
environment
– Intensive outpatient programs
 Program characteristics associated with better
outcomes include:
– longer duration of Tx
– available follow-up care
– family involvement
– social services
Treatment (cont’d)
Prevention
Direct vs. General (ie. Public health education
campaigns)
Successful prevention programs:
target salient risk factors
skills-oriented
follow-up available
culturally-oriented towards the targeted community
Q+A