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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

Jun 13, 2020

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  • 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 ADOLESCENCEPersistent 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

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