Transcript Drug Overdose in the Adolescent Laos

Drug Overdose
in the
Adolescent
Carla Laos MD, FAAP
Pediatric Emergency Medicine Physician
Objectives
• Provide epidemiology surrounding adolescents and
overdose and suicide
• Discuss the medical effects of various ingestions
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Skittles Parties
Marijuana, Synthetic marijuana
Alcohol
Huffing
OTC medications ( Nyquil, Listerine, Corcidin)
• Role of social media with adolescents and
substance abuse
• Lack of media coverage
Suicide
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Suicide  3rd leading cause of death 15y-19y
1950-1990 suicide rate increased by 300%
1990-2013 suicide rate decreased by 20%
2013: 1748 suicides, true number may be higher
Successful, Males: Females  6:1
Unsuccessful, Female: Males  2:1
National Youth Risk Behavior Survey:
o 9-12 graders
o 24% of students had seriously considered attempting suicide during
previous year.
Fixed Risk Factors for
Suicide
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Family history of suicide or suicide attempts
History of adoption
Male gender
Parental mental health problems
Lesbian, gay, bisexual or questioning sexual identity
History of physical or sexual abuse
Previous suicide attempt
Risk Factors for Suicide
• Psychosocial stresses
o Conflicts with parents
o Breakup of a relationship
• 15 y/o male with self inflicted wounds, large X on chest
o School difficulties/failure
o Social isolation (bullying)
• 14 year old male with ‘Everyone hates me’ etched into his
chest/abdomen
• Long term high levels of community violence may
increase conduct/emotional problems and add to
suicide risk for exposed youth
Mental Health Risk
Factors for Suicide
• Sleep disturbances
• Depression, bipolar
• Substance intoxication and substance use disorders
o Alcohol use/alcoholism (a/w 50% of suicides)
o 15 year old dropped off by friends at DCMC, unconscious for unknown period
of time. DOA.
• PTSD, Panic attacks, psychosis
• History of aggression, impulsivity, severe anger
• Pathologic internet use
• More than 90% of adolescent suicide victims met criteria
for a psychiatric order before their death
Social and Environmental
Risk Factors
• Bullying
• Impaired parent-child relationship
• Living outside the home (homeless, corrections
facility, group home)
• School difficulties
• Not working or attending school
• Legal or romantic difficulties
Nonsuicidal Self-injury
(NSSI)
• By definition, does not included intent to die
• NSSI is a risk factor for suicide attempts and suicidal
ideation
• (Include pics)
Bullying
• Aggressive or deliberately harmful behavior that is:
o Between peers
o Repeated over time
o Involves an imbalance of power (physical strength or popularity)
• 4 categories:
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Direct-physical (assault, theft)
Direct verbal (threats, insults, name calling)
Indirect relational (social exclusion, rumors)
Cyberbullying
• 16 year old female ingestion of Tylenol due to spreading of
naked pics on social media
Bullying
• Clear relationship between bullying and suicidal
ideation in children and adolescents
• Bullying predicts future mental health problems
Internet Use
• Pathologic internet use correlates with SI and NSSI
• Video games & intenet > 5 hours a/w depression
and SI/SA
• Suicide related seraches a/w completed suicides
among young adults
• Participation in online forums can be dangerous
o Attempts made by susceptible individuals encouraged by
conversations
Leading Methods of
Suicide (15-19y)
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Suffocation (42%)
Discharge of firearms (42%)
Poisoning (6%)
Falling (3%)
Alcohol
• Most widely used psychoactive drug in the USA.
• Financial cost to society is $166.5 billion/year
(medical treatment, rehabilitation therapy, lost
earnings, car crashes)
• Societal double standard:
o “Parents will say, ‘My kid may be drinking, but at
least he’s not doing drugs.’
Alcohol & Teens
• An adolescent may employ similar logic to gain
permission to drink alcohol.
• “C’mon, Dad, the three of us are just gonna split a
six-pack while watching the playoffs at Andy’s
house. How come you and your friends get to do it
and we can’t? Besides, it’s not like I’m smoking
weed or shooting up heroin. It’s just beer.”
• Address the glaring contradictions in our society.
Candor will be appreciated. Here is an example of
what you might say:
Alcohol and Teens
“It does seem hypocritical... we say it’s okay for adults to
drink but not to smoke marijuana. Maybe nobody should
use alcohol at all, but it’s such a part of our culture that
I don’t see us going back to the days of Prohibition.
“Until you turn twenty-one, you are not to drink, if for
no other reason than it is against the law. Once you’re of
legal age, then it will be your decision whether or not to
use alcohol. Illicit drugs, you are never to take; I don’t
care how old you are.”
Alcohol & the Teenage
Brain
Short Term Effects:
• Difficulty making good decisions
• Less aware that behavior inappropriate or risky
• More likely to engage in risky behavior
• Less likely to recognize potential behavior
Long Term Effects:
• Alcohol during teen years can interfere with
development and change the brain
• Negative effects on information processing/learning
• Increases risk of alcohol use disorder later in life
Alcohol & Teens
• Additional Long-Term Effects
o Blackouts, memory loss
o Vitamin deficiencies
o Malnutrition
o Suppression of immune system
o Hormonal deficiencies, sexual dysfunction,
infertility
o Inflammation of the pancreas (pancreatitis)
o Alcoholic hepatitis
o Alcoholic cirrhosis
o Cardiovascular disease and stroke
Alcohol & Teens
• Alcohol-withdrawal delirium, or delirium tremens:
o Can range in intensity from mild irritability and
sleeplessness, to frightening hallucinations and delusions
Alcohol & Teens
• Statistics from the National Council on Alcoholism
and Drug Dependence:
o Alcohol use invovled in about half of all sexual assaults
involving adolescents and college students, including date
rape.
o One in six teens—admit to having experienced alcoholinduced blackouts, where they could not recall the events
of the previous evening.
Alcohol & Teens
• Sexually active teens who overindulge are less likely
to protect themselves against pregnancy and
sexually transmitted diseases.
• Stated simply, they are too besotted to take the
necessary precautions before having intercourse.
• The fact that heavy drinking wears down the
immune system adds to their risk of contracting a
sexually transmitted disease (STD).
Huffing/Sniffing
• According to national surveys, inhaling dangerous
products is becoming one of the most widespread
problems in the country.
• Household products such as gasoline are readily
available,
• Has resulted in a significant rise in the number teens
and young adults abusing this substance.
Huffing/Sniffing
• Long-Term Health Risks:
• Mental deterioration, chronic injury to the nervous
system are the principal health dangers of chronic
abuse of solvents, including gasoline.
• This leads to other health issues, such as:
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Problems with attention, memory, and problem-solving
Muscle weakness
Tremor
Balance problems
Mood changes
Dementia
Nephritis and tubular necrosis
Certain cancers
Inhalants
• Inhalants
• Young people today can face strong peer pressure
to try drugs, including a group of substances called
inhalants. Inhalant abuse is particularly a problem
with younger teens, but even children as young as 5
or 6 years may try inhalants.
• Inhalants have the special risk of being deadly any
time they are used—even the first time.
Inhalants
• Types of inhalants
• More than 1,000 products typically found around
the house can be misused as inhalants to get high.
Because these products are commonly found in
homes, offices, and classrooms, they are legal,
cheap, easy to get, and easy to hide. Nearly 1 in 10
eighth graders have tried inhalants.
• There are 3 general types of inhalants: solvents and
fuels, nitrous oxide, and volatile nitrites.
Inhalants
• Solvents are household or industrial products that
contain liquid or aerosol, including glues and adhesives,
• Nearly all products in pressurized spray cans can be
abused, including hair spray, deodorants, computer
cleaners, and spray paint.
• Fuels inhaled for abuse: butane, propane, gasoline,
octane boosters, and refrigerants.
• Nitrous oxide or laughing gas is usually diverted from
medical use or is found in whipping cream chargers
(steel cylinder or cartridge filled with nitrous oxide used
with whipping cream dispenser).
• Volatile nitrites found in air fresheners are mostly tried by
older teens who believe this drug will enhance sexual
function.
Inhalants
• How inhalants are used
• Abuse called solvent abuse, huffing, sniffing, glue
sniffing, or volatile substance abuse.
• Users will
o Sniff, huff (breathe in fumes from a rag soaked with
chemicals), or inhale directly from product cans or other
containers that hold inhalants.
o Spray inhalants into a bag or an empty container like a
soda can and inhale them.
o Medical gases like nitrous oxide are often put into balloons.
o Spray or pour inhalants onto a cloth or piece of clothing,
then inhale deeply from the fabric.
Inhalants
• How inhalant use affects health
• Contain chemicals never meant for people to
inhale.
• Even the first use can result in death.
• Heart is sensitive to inhalant effects, leading to
abnormal heart rhythms and sudden death.
• Can cause permanent brain damage.
• High happens fast, lasts few seconds to minutes,
unless the user inhales repeatedly.
• At first, inhalant users feel stimulated, but very soon
feel dizzy and may slur their speech/ stumble.
Sometimes users think they see things that are not
there.
Inhalants
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Short-term effects include
Excitement, no inhibition, impulsive behavior
Double vision, dizziness, unsteady walking
Sneezing, coughing, runny nose, red eyes
Slurred speech, nausea, vomiting
Sleepiness, headache, passing out
Death
Inhalants
• Long-term effects from brain and nerve damage
include
• Trouble with attention, poor problem-solving
• Muscle weakness and tremor
• Balance problems
• Poor memory, mood changes, dementia
Marijuana
• Marijuana use affects health and well-being
• School
• Marijuana users have a hard time thinking clearly,
concentrating, remembering things, and solving
problems. Frequent marijuana use often causes
grades to drop. Users often lose interest in school
and may quit.
Marijuana
• Driving and physical activity
• Marijuana impairs judgment, complex motor skills,
and the ability to judge speed and time. Those who
drive or take other risks after smoking marijuana are
much more likely to be injured or killed.
• Sexual health
• Teens who smoke marijuana are more likely to take
sexual risks and have unwanted or unprotected sex.
Marijuana
• Long-term health
• Teens' bodies and brains are still growing and
maturing, so smoking anything, including marijuana,
is not good for lung health. Marijuana use may also
lead to addiction or mental health problems (ie,
depression, anxiety or schizophrenia).
Cough & Cold Medicines
• Dexamethorphan acts onsame receptors as
ketamine or PCP
• Causes hallucinations
• Codeine binds to same receptors as heroin
• Both codeine and DXM increase dopamine in the
brain’s reward pathway
Cough and Cold
Medicines
• Abuse of DXM can cause:
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Loss of coordination
Paresthesias
Nausea
Elevated BP, HR
Rarely, hypoxia, causing brain damage when DXM taken with
decongestants
• Abuse of Promethazine- Codeine Cough syrup
o Bradycardia
o Slowed breathing ( high doses can lead to overdose and death)
• These medications even more dangerous when
taken with other drugs
Protective Factors
• Religious involvement
• Connection between teen and parents, school and
peers
Approaching the
Adolescent
• No data indicate that inquiry about suicide
precipitates the behavior.
• Suicidal thoughts or comments should never be
dismissed.
• Behavioral problems that may be manifestations of
masked depression
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Truancy
Academic deterioration
Running away
Defiance of authorities
Drug/Alcohol abuse
Delinquency
Sexual acting out
Approaching the
Adolescent
• Screen patients for suicide, mood disorders and
substance abuse/dependence
• Ask about emotional difficulties, use of
drugs/alcohol
• Assess level of danger to self/others
• Where resources lacking, others encouraged to
obtain extra training and become competent in
providing an in depth assessment
Role of Media
• Youth may imitate suicidal behavior seen on
television
• Media coverage of an adolescent’s suicide may
lead to cluster suicides
o Additional deaths directly proportional to
amount/duration/prominence of media coverage
Management of the
Suicidal Adolescent
• Management depends on risk
• Adolescents at high risk:
o Plan or recent suicide attempt
o Stated current intent to kill themselves
o Recent SI or behavior accompanied by current
agitation/hopelessness
o Impulsivity and profoundly dysphoric mood a/w bipolar,
depression, psychosis or a substance abuse disorder
• Those who seem at low risk, joke, or seek help
for repeated somatic complaints may be asking
for help.
Management of the
Suicidal Adolescent
• Moderate or high risk of suicide or attempt:
o Immediate mental health professional evaluation
o Options include hospitalization, transfer to emergency
department, same day evaluation by MH professional
• Consider psychiatric hospitalization
Previous attempts
High degree of intent to commit suicide
Serious depression or other psychiatric illness
Engage in substance abuse/have active substance use
disorder
o Low impulse control
o Families unwilling to commit to counseling
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Careful of the ‘Suicide
Gesture’
• This term should not be used.
• Adolescent who took 8 Motrin tablets:
o May have thought it was lethal and may do something more
lethal the next time
o May hae known dose was not lethal and took the pills as a
rehearsal for a lethal attempt
• The benefit of the doubt is generally on safety in
the management of the suicidal adolescent
References
• Suicide and Suicide Attempts in Adolescents,
Committee on Adolescents. Pediatrics Apr 2000, 105
(4) 871-874; DOI
• Suicide and Suicide Attempts in Adolescents
• Committee on Adolescence. Pediatrics Jul 2016,
138 (1) e20161420; DOI: 10.1542/peds.2016-14204
• National Institute of Mental Health (best practices
for media and online reporting of deaths by suicide)
• Teens.drugabuse.gov
• National Institute on Drug Abuse (NIDA)
drugabuse.gov