Adolescent Early Intervention and Treatment Summit...Adolescent Early Intervention and Treatment Summit Sacramento, CA November 8-9, 2017 Paula Riggs MD Professor and Director, Division

Adolescent Early Intervention and Treatment Summit

Sacramento, CA November 8-9, 2017

Paula Riggs MDProfessor and Director, Division of Substance Dependence

Department of PsychiatryUniversity Colorado School of Medicine

Developmental Considerations Early Intervention and Substance Treatment in

Adolescents

Developmental Considerations Early Intervention and Substance Treatment in

Adolescents

Disclosures Disclosures ~2~

• Scientific Advisory Board for Smart About Marijuana (SAM)

• Senior Scientific ConsultantCDPHE/NIDA supported RCT of medical cannabis for veterans with service-related, non-treatment responsive PTSD

Learning Objectives Learning Objectives ~3~

Developmental Considerations• Prevention, Early Intervention, and Adolescent Substance

Treatment

Systems-Level Approach• What is “integrated” care and why do we need it?• What would it look like if we had it?• Where are we now?• Where do we need to go from here?• Is there a roadmap to get from here to there?

Learning Objectives Learning Objectives ~4~

Systems-Level Approach• What is “integrated” care and why do we need it?• What would it look like if we had it?• Where are we now?• Where do we go from here?• Is there a roadmap to get from here to there?

Developmental Considerations• Prevention, Early Intervention, and Adolescent Substance

Treatment

~5~

If we could build a behavioral healthcare system from the ground up

…knowing what we know today…….

What would it look like ?

Consensus among researchers and clinicians that addiction and many other psychiatric disorders are neurobiologically-based medical illnesses similar to other chronic medical diseases such as diabetes, cardiovascular disease, hypertension, asthma

Medical advances in the treatment of most chronic diseases involves universal screening, public education, prevention, and early identification of risk factors and interventions to reduce risk

Early intervention at first signs /symptoms of the disease to prevent further progression

Lifestyle and behavior often contribute to disease onset, severity, prognosis

Medical management and treatment require changes in behavior and lifestyle

• Medical model is the roadmap

• Psychiatry –operate as fully functional medical subspecialty providing integratedsubstance/mentalhealth treatment

What is integrated care and what would it look like if we had it?

What is integrated care and what would it look like if we had it?

6

Will you join me

in a brief tour of

that paralleluniverse

~7~

Addiction

Mental Health

Medical Healthcare

funding

This universe is dysfunctional, non-integrated silo’dsystem of care

Medical Healthcare

Cardiology

Endocrinology

Pulmonary surgery

GIPsychiatry

Behavioral Healthcare

(substance/mental health)

Pediatrics

In this parallel universe, psychiatry is fully integrated into mainstream healthcare functioning as multidisciplinary medical subspecialty addressing substance and other psychiatric disorders

What is integrated care and what would it look like if we had it?

What would it look like if we had it?What would it look like if we had it?

8

Universal and regular repeated screening in primary care settings across development/lifespan includingschool-based health clinics (SBHC)

Early identification of risk factors

Effective prevention and risk reduction interventions

Early detection and treatment at first signs/symptoms of illness (e.g. intervention for harmful or risky use)

• Repeated screening in medical settings across development

• Identify those ‘at risk’

• Provide earlier stage treatment to prevent progression

What would it look like if we had it?

Chronic Disease Model of Care provides continuity of care across the continuum of care

What would it look like if we had it?

Chronic Disease Model of Care provides continuity of care across the continuum of care

• Common assessment battery –characterize patients; systematically track patient outcomes (repeated outcome measures)

• Clinicians/practitioners trained in evidence based practice • Continuity of care across the continuum of care• Practice parameters and standards of care are clearly defined and updated to reflect

medical /research advances • Regular and systematic program and performance evaluation; quality improvement

measures

HospitalDetox

ResidentialRehab

IOPRehab Outpatient continuity of care Tele-Monitoring

In this universe substance /mental health treatment looks a lot like prevention, treatment and continuity of care provided for patients with diabetes, cardiovascular disease, and other chronic medical conditions Early

relapse detection

0123456789

Pre During During During Post

Treatment Research Institute

Outcomes In Hypertension, Diabetes, Cardiovascular Disease

Pre During Treatment Post

02468

10

Pre During During During PostTreatment Research Institute

Outcomes In Addiction

Pre During Treatment Post

We have the wrong model!We must adopt a chronic disease model of care consistent with current

research and fully integrated within the medical healthcare system

Very serious use2,300,000 million in treatment

Little to no use

23,000,000With “addiction”

40,000,000“harmful use”

Screening andearly interventions integrated into medical healthcare

PreventionScreening

Where are we now?

< 10 % of those who could benefit from substance treatment receive it

• We’ve primarily developed treatment for the most serious end of the spectrum without a meaningful continuum of care

• Comorbidity is the rule yet, integrated SUD/MH treatment is lacking

Lack early interventions to reduce harmful use in primary care and other medical settings

• School-based health clinics (SBHCs) are underappreciated and under-utilized as primary care settings

• 95% of adolescents with SUD are in still school but universal screening and school-based substance treatment is lacking

SBIRT won’t work until we have > integration

Very serious use2,300,000 million in

treatment

Little to no use

23,000,000with “addiction”

40,000,000“harmful use”EARLY

INTERVENTION

PREVENTION• Universal screening• Early risk identification; risk

reduction

Our “hit rock bottom” approach approach is antithetical to medical advances in treating other chronic diseases

• Effective screening• Brief interventions for at

risk or those with harmful use

Where are we now?

• Clinical workforce shortage

• Lack adequate training

• Poor compensation

• High turnover

• Increase treatment access/availability

• Medical basis of addiction /mental illness will reduce stigma and the need for additional layers of ‘confidentiality’ protection Mental Health

Parity and Addiction Equity Act (2008)

It’s the LAW but still not enforced

Where do we go from here?

Develop or adapt existing evidence based treatments as earlier intervention implemented in medical settings/healthcare systems*

ENCOMPASS

IntegratedTreatmentfor Adolescentsand YoungAdults

Research-based approach to concurrently treating co-occurring psychiatric disorders

Can be feasibly adapted and implementation in community-based substance, outpatient mental health, or school-based settings

Research Practice • MET/CBT, 16 weeks 

• Incentives  paid $25 per visit; free tx* 

Could not apply additional incentives/contingencies to enhance abstinence rates

Psychiatric treatment  Constrained by single 

pharmacotherapy/placebo Could not individually tailor treatment as 

clinically indicated

Relapse prevention/ continuing care

Constrained by research protocol

• MET /CBT 16 weeks

• CM Incentives “fishbowl”

Compliance

Abstinence

Non‐drug alternative activities

Psychiatric treatment

Broader range of options

Psychotherapy 

Pharmacotherapy

Relapse prevention/continuing care 

Involvement in non‐drug alternative activities sustained  drug‐free lifestyle 

School-based adaptation

Developmental Considerations Early Intervention and Substance Treatment in

Adolescents

Developmental Considerations Early Intervention and Substance Treatment in

Adolescents

16

Most substance /psychiatric disorders are pediatric onset • ½ of all psychiatric disorders have an onset before age 15• ¾ onset before 24• Most adults who suffer from chronic addiction started

using as teenagers• National average age of marijuana onset = 14 • 85% of young adult IV heroin users report that they started

with non-medical use of Rx opioids as adolescents• ¾ of new heroin users report antecedent use of Rx opioids

Most childhood-onset psychiatric disorders increase risk for adolescent SUDAdolescent substance abuse increases risk of developing co-occurring psychiatric disorders

17SchoolFamily Peers Community

Pre natal

Birth 5 10 15 20 25

OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES

Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety

Substance Use Disorders

PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic

Teen Intervene

SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT

TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds

Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities

later school start time

School-based –screening, earlier intervention, increase tx access,reduce health disparities

Screening, early tx

18

Moran et al Amer. J Pub Health 2017

Here is a link to the Rescue's youtube page:https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_rescueagency&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=OShb1tsKFwDfD05snvIkYtHH4YNWaKOJOYhW9fl1NqQ&e=

Finally here is a link to a live recorded presentation by Jeff Jordan:https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_watch-3Fv-3D1TPkWVAK3wM-26t-3D3s&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=C8HGyBhPA2RAeDdHhir1l8Xay5CF3semCwKVwTVKJTQ&e=

19

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_rescueagency&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=OShb1tsKFwDfD05snvIkYtHH4YNWaKOJOYhW9fl1NqQ&e=

https://agentsofchangesummit.com/

20SchoolFamily Peers Community

Pre natal

Birth 5 10 15 20 25

OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES

Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety

Substance Use Disorders

PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic

Teen Intervene

SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT

TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds

Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities

later school start time

School-based –screening, earlier intervention, increase tx access,reduce health disparities

Screening, early tx

Pre-natal THC

exposure- “miswiring” fetal brain development-Persistent neurocognitive deficits-lower academic achievement

Tortoriello et al 2014

Fetal Development INFANCY LATENCY PRE-TEEN ADOLESCENCE

Persistent neurocognitive deficits, reduction in IQ comparable to environmental lead exposure

• 4x risk of psychosis• 2x risk depression,

anxiety disorders in young adulthood

• Increases risk of addiction to drugs tried later (5x AUD)

• Deleterious development female reproductive system ; sperm motility

Developmental Considerations Early Intervention and Treatment” MJ Impact on Brain and Neurocognitive Development

Inadvertent ingestion by infants-12 year olds resulted in 17 hospital admissions 2009-2011

NONE prior to 2009

Pediatric MJ Exposures in a Medical MJ State Wang et al JAMA 2013

• Impulse, motor control

• decision-making

• verbal fluency • Short term

memory• Sustained

attention• Response

time• psychosis• Inc. stroke

6 x increase in MJ use among women of childbearing age nationally Wilkinson 2015 NAS, 2017

If there was a neurotoxin in the air or the water that at least 50% of our kids were being exposed to

... and 1/6 of these, exposed at levels associated with significant reductions in IQ, learning problems, academic underachievement, and persistent neurocognitive deficits

Begs the Question?

6-8 point reduction in IQ associated with regular adolescent MJ use comparable to 7.4 point reduction associated with environmental lead exposure (10 mg/dc) Meier et al 2012; Canfield et al 1996

“…IQ declined by 7.4 points as lifetime average blood lead concentrations increased from 1 to 10 μg per deciliter.

24SchoolFamily Peers Community

Pre natal

Birth 5 10 15 20 25

OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES

Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety

Substance Use Disorders

PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic

Teen Intervene

SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT

TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds

Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities

later school start time

School-based –screening, earlier intervention, increase tx access,reduce health disparities

Screening, early tx

5x increase in neonatal opioid abstinence syndrome in past decade

In many states Medicaid only covers maternal treatment for OUD pre-delivery not post-delivery

Peri-natal ADOLESCENCE

• Adolescent-onset substance use increases risk of progression to chronic addiction, opioid, polysubstance, and psychiatric comorbidity

• Psychiatric Disorders • 50% start before age 15• 75% before age 25

• 85% of young adult IV heroin users report that they started with non-medical abuse of Rx opioids during adolescence yet no appreciable increase in adolescent treatment admissions for OUD … suggests they bypass existing treatment

• Need school-based screening, early intervention, treatment

Developmental Considerations for Early Intervention and Treatment Opioid Crisis

• 3/5 overdose deaths in US are opioid-related

• Opioid deaths > MVAs

• 2015- 22,000 deaths (62 /day)

• ¾ new heroin users report antecedent Rx opioid

CDC 2017 Reddy et al Obstet Gynecol 2017

26

Opioid Crisis

27SchoolFamily Peers Community

Pre natal

Birth 5 10 15 20 25

OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES

Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety

Substance Use Disorders

PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic

Teen Intervene

SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT

TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds

Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities

later school start time

School-based –screening, earlier intervention, increase tx access,reduce health disparities

Screening, early tx

PSYCHIATRY

28

With Shared Vision, We Can Get There From Here

THANK YOU FOR YOUR ATTENTION

QUESTIONS?

COMMENTS?

DISCUSSION?

THANK YOU FOR YOUR ATTENTION

QUESTIONS?

COMMENTS?

DISCUSSION?

29