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PPOC Pediatric Physician’s Organization at Children’s

© Boston Children’s Hospital 2019. All rights reserved. For permission, contact ASAP Project Manager at [email protected]

Adolescent Substance Use: What’s the Deal?

Shannon Mountain-Ray, LICSW

Director of Integrated Substance Use Treatment Adolescent Substance Use and Addition Program – Primary Care (ASAP-PC)

Division of Developmental Medicine Boston Children’s Hospital



Objectives:

• Explain how adolescent brain development creates special vulnerability to developing substance use disorders

• Describe the impact of adolescent substance use on physical and mental health

• Discuss important points to share with patients/caregivers about risks



Adolescent Substance Use and Addiction Program (ASAP):

Division of Developmental Medicine

Boston Children’s Hospital

• Multi-disciplinary team

• Hospital-based – Boston and Waltham

• Outpatient treatment – “from experimentation to addiction”

Comprehensive substance use evaluation Individual Substance Use Counseling

Medication-Assisted Treatment (MAT) Group Therapy

Clinical Drug Testing Parent Guidance

Psychopharmacology



ASAP - Primary Care (ASAP-PC):

• Fully-integrated clinical social worker in primary care setting as part of multi-disciplinary team

• Office-based

• Outpatient treatment – “from experimentation to addiction”

Comprehensive substance use evaluation Individual Substance Use Counseling

Medication-Assisted Treatment (MAT) Parent Guidance

Clinical Drug Testing Referrals, as needed



Case Study: James

James is a 17-year-old boy with no past medical or psychiatric history who is coming in for his annual PE. He is a B+ student finishing 11th grade. He lives with his parents and is an only child. He is a two-sport varsity athlete. James reports occasional drinking with friends on weekends but denies ever using illicit drugs. He is starting to look at colleges.



Management

James comes in for his well-child visit and receives the meningococcal vaccine and TdaP. His PCP congratulates him on his hard work at school and his safe choices about drugs.



Epilogue One week later, James attends an end-of-the-year party with some high school friends. While driving home, James’ car jumps the curb and slams head-on into a tree. James is pronounced dead at the scene. His blood alcohol concentration at autopsy is 0.24.



Leading Causes of Mortality among Persons Ages 10-24 Years, United States, 2014

Motor vehicle crashes 23%

Other unintentional injuries 17%

Suicide 17%

Homicide 14%

TOTAL 71%

The four leading causes of death among adolescents shown above are all linked to alcohol and other drug use.

Source: Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance—United States, 2015. MMWR Surveill Summ 2016;65(No. SS-6):1–174.



Most drug use starts in adolescence

0

2

4

6

8

10

12

Percentage of Past Year Initiates (among persons at risk for initiation)

1.7%

5.9%

9.5% 9.7%

3.4%

0.2%

12-13

14-15

16-17 18-20

21-25 26 and Older



Substances Used by 12th Graders, 2018

Substance Lifetime (%) Past 30

Days (%)

Alcohol 58.5 30.2

Any illicit drug 47.8 24.0

Marijuana 43.6 22.2

Inhalants 4.4 0.7

Hallucinogens 6.6 1.4

Cocaine 3.9 1.2

Amphetamines 8.6 2.4

Heroin 0.80 0.2

Other Narcotics 6.0 1.1

Sources: Monitoring the Future. Trends in Lifetime Prevalence of Use of Various Drugs in Grades 8, 10, and 12. Drug and Alcohol Press Release, 2018

While experimentation with alcohol is common, less than half of 12th graders are current (past 30 days) drinkers. Some kids and adults think that all high schoolers use marijuana, but the truth is that less than half (43.6%) of seniors have ever tried it and only 22.2% are current smokers.



Alcohol-Associated Risk Behaviors of 9th-12th Graders, 2017

The Youth Risk Behavior Survey (YRBS) is a questionnaire administered every other year to high school students across the country.

During the past 30 days:

• 29.8% had at least one drink of alcohol

• 13.5% reported current binge drinking

• 16.5% rode with a driver who had been drinking alcohol

• 5.5% drove when they had been drinking alcohol

Source: United States Department of Health and Human Services, Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance (YRBS) – United States, 2018. Morbidity and Mortality Weekly Report 2015:65(SS-6).



Correlates of Substance Use During Adolescence

Injuries (intentional, unintentional)

Emergency room visits

School failure

Violence

Arrests, incarceration

Sexual assaults

Unprotected intercourse

STIs, including HIV

Alcohol and other drug use is correlated with significant morbidity during adolescence. Note that in the opening case study James did not appear to have a substance use disorder but still experienced major consequences related to use.



Adolescents are developmentally vulnerable to

developing substance use disorders and problems associated with substance use.



Age at first use and later risk

0

10

20

30

40

50

60

<=13 14 15 16 17 18 19 20 >=21

47 45

38

32 28

15 17 11

9

Age at First Drink

% w

ith

Alc

oh

ol D

iso

rde

r

Source: Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence. Arch Pediatr Adolesc Med. 2006;160:739-746.

0

5

10

15

20

13 15 17 19 21+

17 16

11

8

4

Alcohol Marijuana

% w

ith

Mar

iju

ana

Dis

ord

er

Age at First Use



Source: US News & World Report, 2005

The Adolescent

Brain

What’s going

on in there?



Brain weight by age

Source: Dekaban, A.S. and Sadowsky, D. Annals of Neurology, 4:345-356, 1978 Image retrieved from: http://www.pediatricmri.nih.gov/nihpd/info/image_gallery.html#



• Adolescence is a critical period in brain development

• The brain is still developing until approximately age 24 or 25

What we now know

Slide courtesy of Ken Winters, PhD.



Parietal Lobe Frontal Lobe

Occipital Lobe

Cerebellum Temporal

Lobe

Brain Stem

Back Front

How the brain develops

Hippocampus Amygdala Nucleus Accumbens

Prefontal Cortex



Cerebellum



Amygdala



Nucleus accumbens



Prefrontal cortex



Prefrontal Cortex (mature in late

adolescence/early adulthood)

– Impulse control

– Decision-making

– Organizing and planning

– Abstract thought, rational thinking

– Attention, focus

– Working memory

Limbic System (mature in adolescence)

Includes hippocampus and amygdala

– Emotional memory

– Fear response

– Pleasure response

– Fight or Flight

Brain Maturation

Nucleus Accumbens (highly active in adolescence)

– Pleasure center

– Active during pleasurable activities, including feeding, sex and drug use

– Plays a major role in addiction



The Adolescent Brain

Prefontal Cortex

Limbic System:

Hippocampus Amygdala Nucleus Accumbens



Before After



• At about age 11 (girls) and 12½ (boys), this

thickening undergoes pruning (use it or lose it).

• At the same time, myelin sheaths that encase

nerve cells thicken.

• Myelin sheaths are like insulation on a wire; they

make nerve cell transmission faster and more

efficient.

Construction Ahead

Slide courtesy of Ken Winters, PhD.



During adolescence, the brain is working to become an information super-highway



The Reward Pathway

Ventral-Tegmental

Area Source: NIDA



marijuana

Source: NIDA



An Example: Marijuana



What is in Marijuana?

• Contains many cannabinoid chemicals …

– Delta-9-tetrahydrocannabinol (TCH)

– delta-8-tetrahydrocannabinol

– cannabidiol

– cannabinol

– cannabichromene

– cannabigerol

– Etc.

Source: Mechoulam R, Hanus L, The cannabinoid system from the point of view of a chemist. In Marijuana and Madness. ed. Castle, Murray. Cambridge University Press, 2004



What is the active chemical in pot?

• THC (Delta-9-tetrahydrocannabinol) is the main active chemical in marijuana.

• Marijuana’s potency depends on how much THC it contains.

• THC binds to brain’s own cannabinoid receptor sites

32



33

The Brain and Marijuana



Endocannabinoid System: Regulation

• The neuron’s “volume control”: dials down neuron activity when too strong

• Regulates levels of important neurotransmitters affecting pleasure, mood, pain, appetite, sleep, motivation, focus, memory, attention etc. (dopamine, serotonin, endorphins)

• Helps keep neuron activity in balance, not underactive or overactive



Cannabinoid Receptors

Your body produces its own cannabinoid chemical called Anandamide which binds to cannabinoid receptors in your brain



36

Cannabinoid receptors in our brains? Why?

Animal studies show that without Anandamide…

– Experience more pain

– Can’t control appetite

– More anxious

– Less able to cope with stress



37

Source: NIDA

With Marijuana: With Anadamide:

Dopamine release Dopamine release



THC vs. Anandamide

Source: Joy J, Watson SJ, Benson JJ, eds. (1999). Cannabinoids and animal physiology. In: Marijuana and Medicine: Assessing the Science Base. Washington, DC: Division of Neuroscience and Behavioral Health -Institute of Medicine. National Academies Press.



THC vs. Anandamide

• Both dial down neuron activity to change neurotransmitter release

• THC has a MUCH STRONGER, LONGER effect than anandamide on brain cells

• THC interferes with anandamide function, so it can’t do its job to protect and balance cell activity



41

THC Binding Sites



What’s affected by marijuana?



Pleasurable Affects

• Mild Euphoria

• Visual and Auditory Enhancements

• Increased Talking

Adverse Affects

• Decreased Coordination and Reaction Time

• Impaired Ability to Concentrate

• Impaired Memory and Learning



Source: White House Office of National Drug Control Policy (ONDCP), 2014.

Content of THC in marijuana has increased

over time

<4%

>12%

1985 1990 1995 2000 2005 2010 2013

12 10 8 6 4 2 0

% T

HC

45

Overuse/Toxicity

• Mood fluctuations

• Hallucinations

• Depersonalization

• Anxiety and panic

• Paranoia

• Vomiting



Marijuana Withdrawal Symptoms

• Restlessness, anxiety

• Increased irritability, anger, aggression

• Difficulty falling and staying asleep, nightmares/strange dreams

• Decreased appetite

• Weight loss

Source: Budney et al. Arch Gen Psych 58(10):917-924, 2001.



Source: Meier et al. Proceedings of the National Academy of Sciences. 2012



The Dunedin Study (New Zealand) (N=1037)

1 2 3 4 5

Assessment ages

13 yrs (Pre-initiation) 18 yrs 21 yrs 32 yrs 38 yrs

Source: Meier et al. PNAS, 2012



Change in IQ from 13 to 38 years old

49



50

Change in IQ from 13 to 38 years old



• THC reduces hippocampal neuron activation

• With chronic THC exposure, neurons are gradually lost due to continual suppression

• THC users have smaller hippocampuses, and poorer memory

Source: Iversen L. How cannabis works in the brain. In Marijuana and Madness. Ed. Castle & Murray, 2004. Oxford University Press.



52

Teen Working Memory Performance

Source: Jacobsen et al. Impact of cannabis use on brain function in adolescents. Annals NY Acad Sci. 2004.



Long-term effects associated with marijuana use in adolescence

Psychosis1

Depression2,3,4

Anxiety4

Diminished life satisfaction and achievement5,6,7

Cognitive decline8,9

Addiction10,11

Sources: 1. Griffith-Lendering, et al. (2013). 2. Manrique-Garcia, et al. (2012). 3. Fairman BJ & Anthony JC (2012). 4. Patton GC ,et al. (2002). 5. Fergusson DM, Horwood LJ, & Swain-Campbell N (2000). 6. Fergusson DM & Boden JM (2008). 7. Brook JS, et al. (2013). 8. Meier MH, et al. (2012). 9. Zalesky A, et al. (2012). 10. Lopez-Quintero C, et al. (2011). 11. Hall W & Degenhardt L (2009).



The AAP opposes legalization of

marijuana because of the potential harms

to children and adolescents.



Can We Please Stop Pretending Marijuana Is Harmless?

55

By Dr. Sushrut Jangi October 08, 2015

“…underscoring the incredible momentum to legalize marijuana is the misconception that the drug can’t hurt anybody. It can, especially young people.”



Important Points

• The adolescent brain is not fully developed

• The “reward pathway” is highly sensitive during

adolescence increasing susceptibility to developing

addiction

• Substance use during adolescence can change the

developing brain (e.g. neural pathways) increasing

risk for learning, memory and mental health

problems

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