adolescent substance use...
TRANSCRIPT
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ADOLESCENT SUBSTANCE USE DISORDERS
Timothy E. Wilens, MD
Director, Center for Addiction Medicine Chief, Division of Child and Adolescent Psychiatry,
Massachusetts General Hospital Harvard Medical School
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Disclosures* Dr. Wilens has served as a consultant or has received grant support from the
following: • NIH (National Institute on Drug Abuse) • Ironshore, Neurovance (Euthymics), Sunovion, Tris • National Football League (ERM), Minor/Major League Baseball • Bay Cove Human Services, Phoenix House (Clinical Services) • (Co)Edited Straight Talk About Psychiatric Medications for Kids (Guilford
Press); ADHD Across the Lifespan (Cambridge Univ Press); Comprehensive Clinical Psychiatry; Psychopharmacology & Neurotherapeutics (Elsevier)
• Some of the medications discussed may not be FDA approved in the manner in which they are discussed including diagnosis(es), combinations, age groups, dosing, or in context to other disorders (e.g. substance use disorders)
* Past 3 years
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SUDs = substance use disorders. Merikangas KR, et al. J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989.
Lifetime Prevalence of DSM-IV SUDs in the National Comorbidity Survey-Adolescent
0
5
10
15
AlcoholAbuse/Dependence
DrugAbuse/Dependence
Any Substance UseDisorder
Life
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%)
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Johnston LD, et al. Overall, illicit drug use by American teens continues gradual decline in 2007. December 12, 2007. University of Michigan. http://ns.umich.edu/new/releases/6225. Accessed June 11, 2014.
Alcohol: Trends in 30-Day Use, Risk, Disapproval, and Availability
Grades 8, 10, and 12
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*Beginning in 2002, a revised set of questions on other narcotics was introduced, in which pentazocine/naloxone, laudanum, and paregoric were replaced with hydrocodone/acetaminophen, oxycodone, and oxycodone/acetaminophen. Johnston LD, et al. Overall, illicit drug use by American teens continues gradual decline in 2007. December 12, 2007. University of Michigan. http://ns.umich.edu/new/releases/6225. Accessed June 11, 2014.
Other Narcotics: Trends in Annual Use and Availability
Grades 8, 10, and 12
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56%
5%
9% 4% 18%
8%
Free from a friend or relative
Taken from a friend or relative without asking
Bought from a friend or relative
Drug dealer
From one doctor
Other source
70% from
friends and
family Family
SAMHSA. Results from the 2008 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434; 2009.
Sources of Pain Relievers for Most Recent Nonmedical Use among Past Users
www.mghcme.org Wilens TE, et al. J Clin Psych: 2016 (in press)
Rates of SUDs in College Students in Boston who Misuse Stimulants
Misusers
Controls
Substance Use Disorders
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Getting the Jump on the Marijuana Problem
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Compton WM, et al. Arch Gen Psychiatry. 2007;64(5):566-576.
Age at Onset of DSM-IV Drug Abuse and Dependence
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Juvenile SUD: Risk and Protective Factors
• Familial: runs in families
– Higher rates of SUD in children in SUD families
– Twofold to fourfold elevated risk for SUD in offspring
– Exposure to parental SUD influences child SUD
– Higher rates of psychopathology and dysfunction in the children of SUD parents
Wilens TE, et al. J Clin Psychiatry. 2009;70(2):259-265. Wilens TE, et al. Am J Addict. 2002;11(1):41-51. Wilens TE, et al. Am J Addict. 2005;14(2):179-187. Wilens TE, et al. Drug Alcohol Depend. 2013;132(1-2):114-121. Wilson JJ, et al. Child Psychiatry Hum Dev. 2003;34(1):19-34. Rhee SH, et al. Arch Gen Psychiatry. 2003;60(12):1256-1264. Yule AM, et al. Am J Addict. 2013;22(5):460-465.
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Juvenile SUD: Risk and Protective Factors (continued)
• Genetic: vulnerabilities for inherited subtypes
– Genetics account for ca. 50% of risk
– Early-onset (adolescent) SUD associated with heredity (55% males, 73% females)
– Associated with conduct, mood, ADHD
– Sons of male alcoholics are at a ninefold risk for SUD
Kendler KS, et al. Am J Psychiatry. 2014;171(2):209-217.
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Juvenile SUD: Risk and Protective Factors (continued)
• Environmental Exposure: availability, values, modeling/conventionality
– Family exposure
– Peer use
– School exposure
– Community SUD
Yule & Wilens. Psychiatric Times. 2011;XXVIII(10):42-43. Yule AM, et al. Am J Addict. 2013;22(5):460-465. Kendler et al. AM J Psychiatry. 2014; 171(2):209-217
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Juvenile SUD: Risk and Protective Factors (continued)
• Self-esteem issues:
– Poor self-esteem or image linked to later SUD
– Poor ego development linked to SUD
– SUD exacerbates self-esteem issues
• Dynamic issues:
– Self-medication: amelioration of specific symptoms
– Affect tolerance: use of substance to blunt affect states
– Familial patterns and modeling
Khantzian EJ. Am J Addict. 2012;21(3):274-279.
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Costello EJ, et al. J Clin Child Psychol. 1999;28(3):298-311. Buckstein OG, et al. Am J Psychiatry. 1989;146(9):1131-1141. Kandel DB, et al. Arch Gen Psychiatry. 1996;53(1):71-80. Weinberg NZ, et al. J Clin Child Psychol. 1999;28(3):290-297. Kramer TL, et al. J Am Acad Child Adolesc Psychiatry. 2003;42(11):1318-1326. Arata CM, et al. Adolescence. 2003;38(151):567-579.
Juvenile SUD: Overlap with Psychopathology
0
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50
60
70
80
90
100
(-) SA (+) SA
Rate (%)
Rates of Adolescent Psychopathology
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Common Psychopathology in Adolescent SUD
• Conduct disorder
– High risk for SUD (80% to 90%)
– Examine for comorbid mood disorder
• ADHD
– Twofold risk for SUD
– 50% of adolescent SUD with ADHD
– Treatment reduces SUD
• Anxiety/Posttraumatic Stress Disorder (PTSD)
– Twofold risk for SUD
– Anxiety frequent “cue” for substance use
– PTSD precedes or is result of SUD
• Depression
– Twofold risk for SUD (precedes SUD)
Wilens TE, et al. J Am Acad Child Adolesc Psychiatry. 2011;50(6):543-553. Hussong AM, et al. Psychol Addict Behav. 2011;25(3):390-404. Clarke DB, et al. Am J Psychiatry. 2004;161(4):685-691. Riggs PD, et al. Drug Alcohol Depend. 2007;91(2-3):306-311.
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Life
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Persistent BPD vs Control: P = .001 Persistent BPD vs Non-Persistent BPD: P = .2 Non-Persistent BPD vs Controls: P = .2 Bipolar
Control
Wilens TE, et al. Presented at: 59th Annual Meeting of the American Academy of Child & Adolescent Psychiatry; October 23-28, 2012; San Francisco, CA.
Development of SUD in Adolescent Bipolar Disorder
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Juvenile SUD: Diagnostics
• Evaluate medical condition including complications (LFT, STDs)
• Generate differential diagnosis for psychiatric/medical symptoms
• Utilize urine, saliva, or hair toxicology screens
LFT = liver function test STD= sexually transmitted diseases. Gignac M, et al. J Child Adolesc Psychopharmacol. 2005;15(5):742-750.
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Zaman T, et al. www.psychiatry.org/advocacy--newsroom/position-statements. Accessed June 11, 2014.
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Lisdahl KM, et al. Front Psychiatry. 2013;4:53. Grant JE, et al. Drug Alcohol Depend. 2012;121(1-2):159-162. Gruber SA, et al. Exp Clin Psychopharmacol. 2011;19(3):231-242.
Marijuana Adversely Impacts Adolescent Brain Structure and Function
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Screening Adolescents for Drugs and Alcohol
• During the past 12 months did you
A. Drink any alcohol?
B. Smoke any marijuana or hashish?
C. Use anything else to get high?
• If NO: Ask if you have ever ridden in a CAR driven by someone who was high or had been using drugs or alcohol
• If YES: Complete CRAFFT
Knight JR, et al. Arch Pediatr Adolesc Med. 1999;153(6):591-596.
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Screening Adolescents for Drugs and Alcohol (continued)
C Have you ever ridden in a CAR driven by someone who was “high” or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself, ALONE?
F Do you ever FORGET things you did while using alcohol or drugs?
F Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten into TROUBLE while you were using alcohol or drugs?
• ≥2 yes answers on the CRAFFT suggest a serious problem and a need for further assessment
Knight JR, et al. Arch Pediatr Adolesc Med. 1999;153(6):591-596.
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Juvenile SUD: Treatment
• Parent work
– Need for involvement (may start prior to individual teen work)
– Need for increased supervision
– Behavioral management techniques
– Need to monitor SUD and psych treatment
– Establish additional supports
– AA/NA/Al-Anon
– “Tough Love”
AA = Alcoholics Anonymous; NA = Narcotics Anonymous. Wilens TE, et al. Contemporary Pediatrics. November 2013. Kelly et al. J Subst Abuse Treat. 2011;40(4):419-425. Kelly et al. Drug Alcohol Depend. 2010;110:117-125.
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Juvenile SUD: Treatment
• Stabilization of alcohol / drug abuse
– Harm reduction: Lowering use
– Absolute sobriety: None
– Basic self-help philosophy
– Give multiple referrals
– AA/NA for teens
– Rational recovery
– Avoid “Tough Love” as initial step
Yule & Wilens, Curr Psychiatry, 2015. Wilens TE, et al. Contemporary Pediatrics. November 2013.
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Juvenile SUD: Treatment
• Psychotherapy
– Groups: for youth and for their parents
– Motivational interviewing
– Engage/collaborative connection with patient
– Discuss issues that are problematic (don’t focus on SUD)
– Cognitive behavioral modification
– Reduction in impairing behaviors
– Reduce SUD “cues”
– Individual: “Recovery Sensitive Therapist”
– Coping skills (especially for conduct disorder)
– Cognitive / behavioral Tx
– Relapse prevention (eg, reducing cues, balance in life)
Wilens TE, et al. Contemporary Pediatrics. November 2013.
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Psychopharmacologic Strategies with Juvenile Substance Abuse
• Aversive treatment (antimetabolism)
• Reduce urge or craving
• Substitution therapy
• Treat underlying psychiatric comorbidity
• Preventive therapy
Gignac M, et al. J Child Adolesc Psychopharmacol. 2005;15(5):742-750. Simkin DR, et al. Child Adolesc Psychiatr Clin N Am. 2010;19(3):591-608.
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Juvenile SUD: Confidentiality
• Need to discuss SUD with patient and parent
1) Adolescent discussion with parent
2) Practitioner + adolescent discussion with parent(s)
• Need for immediate disclosure
– Dangerousness or severe SUD (eg, IV)
– Incompetent adolescent (e.g. manic, psychotic)
Gignac M, et al. J Child Adolesc Psychopharmacol. 2005;15(5):742-750.
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Juvenile SUD: Practical Take-Away
• Juvenile SUD is commonly comorbid with psychopathology
• Screening, discussion, and documentation constitute components of care of these youth
• Treatment of psychopathology may reduce ultimate SUD
• Treatment of comorbid youth requires both SUD and psych intervention
• Psychotherapy(ies) and pharmacotherapy can be effective in youth with SUD