7/5/2019 · 2019-07-05 · 7/5/2019 2 take home points •nicotine use via vaping and marijuana use...
TRANSCRIPT
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SUBSTANCE USE AND YOUTH:REFINING YOUR SCREENING AND COUNSELING IN THE AGE OF JUUL, CANNABIS LEGALIZATION, AND THE OPIATE EPIDEMIC
JACK RUSLEY, MD, MHS
COLBY COLLEGE – PROGRESS IN PEDIATRICS
JULY 9, 2019
DISCLOSURES
• I have no financial interest in or affiliation with any commercial supporter to disclose.
OBJECTIVES
• By the end, I hope you will have:
• Identified three main epidemiologic trends in adolescent substance use
• Identified at least one strategy to address each of your three most common challenges to
screening for substance use among adolescents
• Improve your comfort with counseling adolescents about substance use, including emerging
substances
• Picked one strength-based approach to working with adolescents
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TAKE HOME POINTS
• Nicotine use via vaping and marijuana use are on the rise, all others in decline
• Adolescence is a vulnerable period because of neuro-developmental and psychosocial
reasons
• Primary care screening of all adolescents for substance use in a confidential way is
important, and requires thoughtful implementation
• Using strength-based, motivational-interviewing will 1) increase your effectiveness and 2)
help you stay focused, and 3) preserve the patient-clinician relationship.
ONE VIEW OF ADOLESCENTS
https://www.youtube.com/watch?v=2DqKz1w6Lug
“Risky”
“Self-centered”
“Bad kids”
Lecturing
“You should”
Rushing
Ignoring
Not screening
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A DIFFERENT VIEW OF ADOLESCENTS
WHY ARE ADOLESCENTS VULNERABLE?
ADOLESCENTS AS:
• Seekers of knowledge and experiences
• Naturally resilient in the face of
adversity
• Motivated to live up to expectations of
trusted adults and peers
• Experts on themselves and their bodies
• Looking for ways to control their lives
and contribute to the world
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ADOLESCENTS AS SUPERHEROES
Source: Syfy.com
STRENGTH-BASED APPROACHES
• Strengths buffer against the effects of stress
and other external factors
• Strength-based approaches work to build:
• Resilience
• Self-efficacy and self-regulation
• Future orientation
• Not a substitute for addressing problems at
other levels (i.e. family, community, society)https://developingchild.harvard.edu/resources/
inbrief-the-science-of-resilience/
DIAGNOSIS OF SUBSTANCE USE DISORDERS
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• Impacts the dopamine
pathway, leading to “high”
• “Rewires” by up/down
regulating receptors
• Leads to tolerance (needing
more to get same effect)
• Lead to withdrawal (feeling
horrible when drug is
removed)
WHAT MAKES IT A DRUG?
• Medical illness
• Clinically significant impairments:
• Health, social function
• Cognitive, behavioral, psychological symptoms
• Mild, moderate, severe (addiction)
• Temporary or chronic
• Develop over time
• Lead to changes in the brain
• Extremely stigmatized
SUBSTANCE USE DISORDER
Surgeon General Report, 2016 https://drugabuse.com/library/addiction-stigma/
• Lack of control
• Difficulty quitting
• Excessive time using
• Restricted activities, hobbies
• Cravings
• Failure to fulfill obligations
• Use despite hazardous situations
• Use despite physical, psychological
problems
• Tolerance
• Withdrawal
DSM-V: SUBSTANCE USE DISORDER
Severity:
0-1 = no SUD
2-3 = mild
4-5 = moderate
≥6 = severe
APA, 2013
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CONTEXT AND TRENDS IN ADOLESCENT SUBSTANCE USE
MTF, 2017; HHS.gov
Youth continue to use marijuana,
nicotine, and alcohol more than
other substances
Alcohol and “combustible” cigarette
use is trending down
Marijuana use is trending up
12 grade students, Past 30 Day Use, 2007 v 2017
Marijuana use
continues to slowly
trended higher
Marijuana use is
now more common
than combustible
cigarette use
MTF, 2017
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Tetrahydrocannabinol
(THC) is a psychoactive
component of marijuana.
THC potency in marijuana
has increased greatly since
the 1990s.
Cannabidiol (CBD) is also
found in marijuana and
many other products.
Freeman, 2015; DiForti, 2009
Public opinion about marijuana
legalization has flipped As perceived risk goes down, use goes
up among adolescents
ELECTRONIC NICOTINE DELIVERY SYSTEMS (ENDS)
Contain highly addictive nicotine
Flavors appeal to youth
Available online without ID
Easy to hide
Highly marketed as safe
alternative to cigarettes Sources: CDC, tobacco.stanford.edu, AAP Richmond Center
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ENDS FAR OUTPACE COMBUSTIBLES
% of high
school
students
who used
in past 30
days
Gentzke, CDC, 2019
Use of ENDS is
increasing rapidly
among youth
HEALTH CONCERNS WITH ENDS
Addiction to nicotine
Effects on developing brain
The number of nicotinic receptors (in yellow and red)
is significantly increased in the smoker compared to
the non-smoker. (From Perry et al., 1999)
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HEALTH CONCERNS WITH ENDS
Addiction to nicotine
Effects on developing brain
Vaporized chemicals include
known carcinogens
HEALTH CONCERNS WITH ENDS
Addiction to nicotine
Effects on developing brain
Vaporized chemicals include known
carcinogens
Cases of explosions, fires leading
to serious injuries
Growing evidence
that most
adolescents use
ENDS first, and
that around 1/3
start smoking
combustible
products
Sources: AAP Richmond Center,
Surgeon General Report, 2017
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FDA APPROVED ENDS CESSATION TOOLS FOR ADULTS OR CHILDREN
ALCOHOL
• Still has huge impact on youth
• 4300 deaths per year
• 119,000 ER visits in 2013
• $24 billion in economic costs
• 11% of all alcohol consumed
• Increases chances of a wide variety
of poor outcomes
or
BINGE DRINKING
• 4-5 or more drinks
in 2 hours
• Most common
pattern in youth
• Trended down
over time, now
leveled off
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OPIATE EPIDEMIC
More deadly than peak rates of HIV,
gun violence, or motor vehicle
collisions
Death rate has quadrupled since
1999
Likely leading to drop in life
expectancy
https://www.cdc.gov/injury/wisqars/leadingcauses.html
https://www.cdc.gov/drugoverdose/data/analysis.html
OPIATES AND OVERDOSE
Most adults begin use as youth
Most who die have overdosed
multiple times
Photo: People.com
MOST OPIATES ON STREET COME FROM US
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MEDICATION ASSISTED TREATMENT (MAT)
• Detoxification:
• Eases discomfort associated with withdrawal. Can be achieved with opioids or non-opioid
“comfort meds” (i.e. clonidine)
• Maintenance:
• Prevents relapse through supervised substitution or blockage of targeted receptors
• Buprenorphine, methadone, naltrexone ER
• MAT for adolescents with opiate use disorders
• effective and recommended by the AAP
• less than a third of adolescents with OUD receive MAT (Hadland, JAMA Peds, 2017)
• adolescent-focused treatment programs are few and far between
MAIN TRENDS
• Youth continue to use marijuana, nicotine, and alcohol more than other substances
• Cigarette use continues to wane, but has been replaced by marijuana (slowly
increasing) and electronic nicotine delivery systems (ENDS, rapidly increasing)
• Alcohol use continues to manifest mostly as binge drinking for adolescents, but has
gradually decreased since the 1990s
• Most adults with opiate use disorders started using as youth with prescription
painkillers (i.e. oxycodone)
SCREENING FOR SUBSTANCE USE AMONG ADOLESCENTS
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“Pediatricians play a key role in preventing and curtailing adolescent substance use
and associated harm, whether through direct patient care practices,
multidisciplinary collaboration, or supporting of parenting and community efforts.”
TURN AND TALK
• How do you ask adolescents about substance use now?
• Whom do you ask?
• Whom don’t you ask?
• What questions do you ask?
• Which substances do you ask about? Which do you NOT ask about?
• How does your approach change depending on age/development, if at all?
• What screening form do you use, if any?
• Is it on a tablet or paper?
• Is it possible or likely that parents can see responses?
• Who reviews the form?
SCREENING: WHERE ON THE MOUNTAIN IS YOUR PATIENT?
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SCREENING TO BRIEF INTERVENTION (S2BI)
Nackers, 2015
ASSESS FOR PROBLEMS
DON’T FORGET THE CAR QUESTION!
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WHEN THEY SCREEN POSITIVE, PROBE FOR DETAILS
• Frequency and form
• How much (cost vs quantity)
• How often (typical day or typical week)
• How consumed (vape, smoke, eat, inject, etc)
• How getting it (from where/who/how paying for it)
• History of use
• When did you use most recently?
• How old were you when you first tried it, used
regularly?
• Factors driving use (most
important!)
• Triggers or reasons for use
• How it makes them feel (why
still using)
• Depression, anxiety, trauma
• Brief: 3-5 minutes
• Conversation, not a lecture
• Motivational interviewing approach
• FOCUS IS: encouraging healthy choices, increasing motivation to
change
• FOCUS IS NOT: moral/legal issues, convincing/persuading
BRIEF INTERVENTIONS (BI) AND ADOLESCENTS
• Pediatricians are effective agents to deliver interventions
• They are rated more positively when they discuss substance use
• Primary care BI delays initiation, decreases use
• Emergency room BI reduces use, reduces associated problems,
and is cost-effective
• It works across types of risk behaviors, diseases, ages including
parents!
BI BY PEDIATRICIANS WORKS
Levy, 2016; Erikson, 2005
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• Key principles
• Collaboration
• Evocation/empowerment
• Autonomy
• Key strategies
• Express empathy
• Develop discrepancy
• Roll with resistance
• Avoid argumentation
• Support self-efficacy
MOTIVATIONAL INTERVIEWING (MI)
WHY DO WE HESITATE TO DO MI?
Lecturing is…
Faster?
Easier?
DEVELOPING DISCREPANCY
• What is teen doing?
• When are they using (e.g. before
school or job)?
• Problems while high, trying to
obtain drug?
• Done anything they regretted
while high, in effort to obtain drug?
• How often are they getting high,
trying to obtain drug?
• What does teen want to be
doing?
• Getting job
• Going to college
• Playing sports
• Engaging in relationships
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• SUMMARIZE: “It sounds like you really want to go to college, but since
you started smoking marijuana every day before you go to school and also
between 4th and 5th periods, you have noticed your grades have gotten
worse.”
• ADVICE: “Only you can decide whether or not you decide to quit
smoking. As your doctor, I do recommend you quit for your health.”
• EDUCATE: “We know when teens smoke daily, they are at risk for a lot
of problems that impact them at school, like…”
SAMPLE BI STATEMENT
• “I know you said you feel like you could stop if you wanted because it is
not a problem for you.”
• “What do you think about stopping for just two weeks? You can make a
follow-up appointment to see me and then we can discuss how that went
for you.”
THE CHALLENGE
Hoover Adger Approach; Levy. Pediatrics, 2015.
THE FOLLOW UP
• When they return:
• If quit Congratulate, ask about positive effects, difficulty of quitting
• If still using discuss triggers and why ongoing use
• Ongoing motivational interviewing
• Planting seed that MJ use may be a problem they cannot control
without assistance
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CASES
• Split into groups of two
• Taller person is the adolescent in Case 1
• You get some guidance from script on how to respond
• Be guarded, but not confrontational!
• Shorter person is the PCP in Case 1
• Practice your MI skills
• Don’t try to “do it right”, just listen!
• Then, switch in Case 2!
CLINICIAN, PARENT, AND YOUTH RESOURCES
• See handout
LOCAL RESOURCES
SAHMSA Behavioral Health Treatment Services Locator
https://findtreatment.samhsa.gov/
Maine Department of Health and Human
Serviceshttps://www.maine.gov/dhhs/samhs/gethelp/
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OBJECTIVES REVISITED
• Take a moment to complete your assessment and evaluation!
• Identified three main epidemiologic trends in adolescent substance use
• Identified at least one strategy to address each of your three most common challenges to
screening for substance use among adolescents
• Improve your comfort with counseling adolescents about substance use, including emerging
substances
• Picked one strength-based approach to working with adolescents
TAKE HOME POINTS
• Nicotine use via vaping and marijuana use are on the rise, all others in decline
• Adolescence is a vulnerable period because of neuro-developmental and psychosocial
reasons
• Primary care screening of all adolescents for substance use in a confidential way is
important, and requires thoughtful implementation
• Using strength-based, motivational-interviewing will 1) increase your effectiveness and 2)
help you stay focused, and 3) preserve the patient-clinician relationship.
• Beletsky L, Rich JD, Walley AY. (2012). Prevention of fatal opioid overdose. JAMA, 308(18): 1863-1864.
• Casey BJ, Getz S, Galvan A. (2008). The adolescent brain. Development Review, 28(1): 62-77.
• DekabanAS. (1978). Change in brain weights during the span of human life: Relation of brain weights to body heights and
body weights. Annals Neurology, 4(4): 345-356.
• Gogtay N, Giedd JN, Lusk L, Hayashi KM, Greenstein D, Vaituzis AC, Nugent TF 3rd, Herman DH, Clasen LS, Toga AW,
Rapoport JL, Thompson PM. (2004). Dynamic mapping of human cortical development during childhood through early
adulthood. Proceedings of the National Academy of Sciences of the United States of America, 101(21): 8174-8179.
• Gowing L, Ali R, White J. (2004). Buprenorphine for the management of opioid withdrawal. Cochrane Database of Systematic
Reviews, Oct 18;(4):CD002025.
• Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. (2013). Monitoring the Future national results on drug use: 2012
Overview, Key Findings on Adolescent Drug Use. Ann Arbor: Institute for Social Research, The University of Michigan.
Available online at: http://monitoringthefuture.org/pubs/monographs/mtf-overview2012.pdf
REFERENCES - 1
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REFERENCES - II
• Marsch LA, Bickel WK, Badger GJ, Stothart ME, Quesnel KJ, Stanger C, Brooklyn J. (2005). Comparison of pharmacological
treatments for opioid-dependent adolescents: a randomized controlled trial. Archives of General Psychiatry, 62(10): 1157-
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• NSDUH. Substance Abuse and Mental Health Services Administration. (2013). Results from the 2013 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Available online at
https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf
• Roozen HG, de Waart R, van der Windt DA, van den Brink W, de Jong CA, KerkhofAJ. (2006). A systematic review of the
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in the United States: Results from the 2016 National Survey on Drug Use and Health, 7(1), 877–726. Retrieved from
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• Brody, G. H., Yu, T., Miller, G. E., & Chen, E. (2016). Resilience in Adolescence, Health, and Psychosocial Outcomes. Pediatrics,
138(6), e20161042. https://doi.org/10.1542/peds.2016-1042
• Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household
dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics, 111(3), 564–72. Retrieved from
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the Future 2015. Retrieved from http://monitoringthefuture.org/pubs/monographs/mtf-overview2015.pdf
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• 9 out of 10 adolescents with SUD did not receive treatment at any
facility
• 52% of facilities admitted adolescent clients , only 32% of all facilities
offered “programs or groups” for adolescents
THERE IS A LARGE GAP BETWEEN NEED FOR SUD TREATMENT AND VIABLE OPTIONS FOR YOUTH
Mericle, 2015
DrugTime frame for + urine assay
acute exp (chronic)
False positives
(false positivity varies by assay)
Amphetamine 1 to 2 days (2 to 4 days) Poor specificity due to structural similarity of many drugs, herbs,
medications (i.e. nasal decongestants, bupropion, selegiline, propranolol,
atenolol.)
Benzodiazepines 1 to 5 days (most)
2 to 30 days for diazepam
Oxaprozin
Cocaine 2 days (7 days) Coca tea, Coca leaves
GHB <24 hours Endogenous neurotransmitter naturally present in minute quantities.
Ketamine 1 to 3 days
LSD 1 to 3 days
Marijuana 1 to 3 days (>1 mo) Hemp-containing foods.
Opioids 1 to 3 days Poppy seeds
Methadone 1 to 5 days Doxylamine
Propoxyphene 3 to 10 days
PCP 4 to 7 days Dextromethorphan, diphenhydramine, doxylamine, ketamine, tramadol, venlafaxine
URINE DRUG TESTING
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