Transcript Substance Misuse 5th October 2012 Dr F Akerele

Drugs and alcohol
Drugs and alcohol
Scale of the problem
Per capita alcohol consumption doubles in last 50 years
Reducing age of onset of regular drinking
Associated with physical health problems
Associated with neuro-cognitive deficits
Age of onset associated with higher dependency, chaotic
pattern of use & higher lifetime consumption
SM is the single most important factor increasing the risk of
suicide in young people with depression or psychosis
Drugs and alcohol
Key Points
• Drinking increases with age - 14% of 12–13s, 33% of 14–
15s and 62% of 16–17s have drunk alcohol in the last wk
• 54% of pupils aged between 11 and 15 have smoked a
cigarette, drunk alcohol or taken drugs on at least one
occasion
• more pupils had drunk alcohol (45%) than had smoked
cigarettes (27%) or taken drugs (18%).
Drugs and alcohol
• girls have caught up & possibly overtaken boys in binge
drinking
• Beer and lager are the most popular drinks among
under-18s. Spirits, wine and alcopops are also popular
• Ethnic minority teenagers are less likely to drink alcohol.
One in 20 non-white 12-17year-olds are frequent
drinkers compared with one in four whites.
Drugs and alcohol
In 2010, the key survey estimates for 11 to 15 year olds in England
included the following:
• 5% of pupils were regular smokers, equivalent to around 150,000
young people (CI=130,000-170,000)
• 13% had drunk alcohol in the last week, equivalent to around
400,000 young people (CI=370,000-430,000)
• 12% had taken drugs (including volatile substances) in the last year,
equivalent to around 380,000 young people (CI=350,000-410,000)
• 7% had taken drugs in the last month, equivalent to around 200,000
young people (CI=180,000-230,000)
Drugs and alcohol
Risk Factors
• Gateway Hypothesis
Significant association between early onset
cannabis use and subsequent illicit drug
use (Bowen & Horwood, 2006)
Drugs and alcohol
• 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
• Strong genetic link in alcohol (Kendler et al 1999)
Risk Factors
Individual
• Extrovert personality
• Impulsive, risk taking teenager
• Depression, ADHD
Risk Factors
Family + Environmental
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Parental drug & alcohol use
Child maltreatment & abuse
Parental separation & marital conflict
Domestic – poor housing, disharmonious family
Peer influences
Media effect
Drugs and alcohol
• 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
Drugs and alcohol
• Groups particularly at risk :
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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)
Drugs and alcohol
• Resilience Factors (JAACAP 1997)
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Intelligence
Problem solving ability
Social facility
Positive self esteem
Supportive family relationships
Positive role models
Affect regulation
Substance Misuse
Disorder
Substance Misuse
Disorder
ADHD 2030%
Substance Misuse
Disorder
ADHD 2030%
Major
depression
and
dysthymia
25-50%
Substance Misuse
Disorder
ADHD 2030%
Major
depression
and
dysthymia
25-50%
Anxiety inc
PTSD and
phobias 2030%
Substance Misuse
Disorder
ADHD 2030%
Conduct
Disorder >
50%
Major
depression
and
dysthymia
25-50%
Anxiety inc
PTSD and
phobias 2030%
Substance Misuse
Disorder
ADHD 2030%
Conduct
Disorder
> 50%
Major
depression
and
dysthymia
25-50%
Bulimia
10-20%
Anxiety inc
PTSD and
phobias 2030%
Substance Misuse
Disorder
Comorbidity is
the rule rather than
the exception
Drugs and alcohol
ADHD and SM
•ADHD - significant risk factor for SM
•Risk higher if co-morbid Conduct Disorder
•Risk very high for cocaine and nicotine
•Stimulant Rx does not increase SM, it may protect
from it
Drugs and alcohol
ADHD and SM
•Stimulants can be used
•Long acting stimulants best
•Atomoxetine little abuse potential
•Tricyclics and clonidine high risks and low
evidence
Drugs and alcohol
Depression and SM
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
Drugs and alcohol
SM and PTSD
Very often missed - self medication common
BDZ dependence is common
Transfer to long acting BDZ
Consider trial of SSRI or Mirtazapine
Alcohol abuse not uncommon
Specific PTSD treatment often required after management of SM
Drugs and alcohol
SM and Psychosis
Lithium in Bipolar and co-morbid alcohol and cannabis
use : significant reduction in SM (Geller et al 1998)
Open study - Clozapine reduces SM in schizophrenia
and co-morbid SM (Brunette et al - Schizophr Bull 2006)
(Tsaung et al – AJP 1999)
Specific treatments for SM like Motivational
Enhancement effective in Schizophrenia
Drugs and alcohol
Urine testing
Amphetamine
Barbiturates
Benzos
Cocaine
Heroin
Cannabis
PCP
: 2-4 days
: 2-4 days
: Up to 30 days
: 1-3 days
: 1-3 days
: 1-3 days (Infrequent use)
: 30 days (Chronic use)
: 2-7 days ( Acute use)
: 30 days (Chronic Use)
Drugs and alcohol
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
Drugs and alcohol
Post traumatic symptoms numbing, vigilance,
arousal, flashbacks, insomnia
Depressive symptoms
School failure
What do you do next ?
Drugs and alcohol
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
Drugs and alcohol
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 ?
Drugs and alcohol
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
Drugs and alcohol
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