Transcript Substance Misuse - Dr Hawkins

Background etc
Alcohol and drugs....rising evidence of
neurobiological and social vulnerability, versus
purely ‘behavioural and morally objectionable’
Brain circuitry and reward centres, euphoria with
drugs focussed around brain areas involved in
natural reward (food, sex and imbibing fluid)
Background etc
Tolerance (delayed and rapid) and sensitisation (cocaine
seizures and psychosis)
Withdrawal manifestations of established homeostatic
changes in the brain caused by chronic use. Potentially
lethal in alcohol and hypnotics. The use of long acting
substances to manage withdrawal.
Dependence. All those which cause dependence share
action on reward centres. Specifically DA in the nucleus
accumbens. DA crucial but also 5HT, Opioids, GABA and
Glutamate
1960’s prevalence massive increase social movements etc (1975
70% of USA adolescents tried drugs by end of high school)
Late 70’s downward trend. Increased appreciation of harm.
80’s and 90’s climbed again (prevention programmes waned,
attention and finance focussed on terrorist threats) Cannabis,
inahalants, LSD, cocaine, heroin
Late 90’s all declined except one...Ecstasy
Late 2000’s estasy declining and other designers and ‘legal highs’
increasing.
Risk Factors (JAACAP 1997)
Genetic
SUD high in children of parents with
Alcohol misuse. This could be direct
inheritance or an association with ASPD
in parents leading to conduct disorder,
aggression and SUD in children
Risk Factors (JAACAP 1997)
Individual
Difficulties with planning, attention,
abstract reasoning, foresight, judgement,
self monitoring and motor control.
These factors seem similar to ADHD with
CD to me
Risk Factors (JAACAP 1997)
Family
Maternal depression and anxiety.
High rates of parental SUD
Risk Factors (JAACAP 1997)
Peer relationships
Less significant than previously thought
in predicting drug use or misuse.
Association may be because substance
misusers select similar friendship groups
Resilience Factors (JAACAP 1997)
Intelligence
Problem solving ability
Social facility
Positive self esteem
Supportive family relationships
Positive role models
Affect regulation
Groups particularly at risk :
Young Offenders
Looked After Children
Young Homeless
Children whose parents misuse drugs
Those who truant or are excluded from school
Young people involved in prostitution
Teenage mothers
Young People with Mental Health Problems
Care Leavers
Abused children
Family disintegration
(Health Advisory Service 1996)
Co-morbidity is the rule ......
Major
depression
25-50%
ADHD
20-30%
Conduct
Disorder
50% plus
Bulimia
10-20%
Anxiety
disorders
20-30%
Treatment
CBT and Motivational Interviewing are the
thing.
•ADHD significant risk factor for SM
•Risk higher is co-morbid Conduct Disorder
•Risk very high for cocaine and nicotine
•Stimulant Rx does not increase SM, it may
protect from it
•Stimulants can be used
•Long acting stimulants best
•Atomoxetine little abuse potential
•Tricyclics and clonidine high risks and low
evidence
Dysthymia and major depression common
Adult studies SSRI’s help in reducing depression
and alcohol misuse
2 open studies of FLX in young people showed
reduction in craving and frequency and severity
of alcohol misuse
FLX has a good safety profile even in nonabstinent adolescents with poly-drug misuse
(Lohman 2002)
Depression and SM
RCT of FLX and CBT versus PLAC and
CBT
N=126. Age 13-19 with major depression and substance abuse or
dependence
Randomised : 20mg FLX or PLAC for 16 weeks
Both 20 sessions CBT
Weekly drug screens and CDRS
Mean CDRS scores significantly down in both groups. More in FLX
group
Drug use decreased in both groups : No difference
Riggs et al Univ of Colorado 1997
Practical suggestions :
Ideally wait 4 weeks after detoxification before
medication
But early treatment with SSRI’s can make a
difference
Use of CBT and SSRI’s may help both SM and
depression
Not yet enough evidence to suggest routine use of
SSRIs to reduce alcohol misuse in Young People
SM and PTSD
Very often missed self medication common
BDZ dependence is common
Transfer to long acting BDZ
Consider trial of SSRI or Mirtazapine
In anxiety disorders and SUD, the presence of PTSD features
predicts good outcome with SSRI’s
Alcohol abuse not uncommon
Specific PTSD treatment often required after management of SM
SM and Psychosis
Lithium in Bipolar and co-morbid alcohol and
cannabis use : significant reduction in SM (Geller et
al 1998)
Open study CLOZ reduces SM in schizophrenia and
comorbid SM
Specific treatments for SM like Motivational
Enhancement effective in Schizophrenia
15 year old girl. Referred by her drugs worker.
Young person requests a psychiatric view of her
difficulties
Alcohol use is heavy and harmful bottle vodka per
day.
Cannabis use daily for 4 years
Intermittent E’s, Amphet and Cocaine
Separate up and think about assessment. What are
you looking for
Post traumatic symptoms numbing,
vigilance, arousal, flashbacks, insomnia
Depressive symptoms
School failure
What do you do next ?
Family separation when 7. Lived with
mother and sister. Mother’s new partner
avoided. No relationship built.
2 suicide attempts aged 7 and 9. One by
stuffing tissues into her mouth and one by
throwing self into swimming pool
What else do you want to know
As a child was physically abused by father
Watched mother being physically and
sexually abused by father
Father terrifying man
Although lives abroad still uses young
person to manipulate her mother
How are you going to treat her ?
Does alright. Good work with drug and
alcohol worker
Engages with individual therapist
Then sudden deterioration. Why ?
What kind of thing would you look for
Trip out to party with friend
Frightening experience where 4 adult men
try to have sex with her a friend
She fights her way out but friend is raped in
front of her
You want to give her an antidepressant
Which one and why
What are your concerns