Adolescent Substance Abusemedia-ns.mghcpd.org.s3.amazonaws.com/child-psychopharm...Massachusetts General Hospital for Children Harvard Medical School 0 5 10 15 Alcohol abuse/dependence

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Adolescent Substance AbuseTimothy E. Wilens, M.D.

Chief, Division of Child & Adolescent Psychiatry, (Co) Director of Center for Addiction Medicine,

Massachusetts General HospitalMassachusetts General Hospital for Children

Harvard Medical School

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Alcoholabuse/dependence

Drugabuse/dependence

Any substance usedisorder

Merikangas et al. J.Am.Acad.Child Adolesc.Psychiatry, 2010;49(10):980-989

Lifetime Prevalence of DSM-IV Substance Use

Disorders Disorders in the National Comorbidity

Survey-Adolescent (NCS-A)

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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

SAMHSA, 2008 National Survey on Drug Use and Health (September 2009)

70%

From

friends

and

family

family

Sources of Pain Relievers for Most Recent

Nonmedical Use Among Past Users

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Age at Onset of DSM-IV Drug

Abuse and Dependence

Compton et al. Arch Gen Psychiatry/ Vol 64, May 2007; 45(11): 1294 - 1303

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Juvenile SUD: Overview

• Definitions

– Use - at least once [often stratified in reports as past 30d, past year]

– Misuse - emergence of pattern of use

– Substance Use Disorder (DSM V) - pattern of misuse with impairment and/or consequences, inability to control use, use despite consequences, physiological symptoms

• Graded mild-severe

• No differentiation between abuse vs dependence

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Photo courtesy of the NIDA Web site. From

A Slide Teaching Packet: The Brain and the

Actions of Cocaine, Opiates, and Marijuana.

Inhibitions

Major Brain Circuits Involved in Addiction

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Substance Mechanism of Action

Alcohol GABA, opioid agonist; NMDA antagonist

Cocaine Blocks re-uptake of dopamine

Amphetamines Stimulate dopamine release

PCP, ketamine NMDA antagonist

Opioids Mu, delta, and kappa agonism

Cannabis CB1 agonist

MDMA (“ecstasy”) 5HT release and re-uptake inhibition; mild DA and NE reuptake inhibition

LSD (“Acid”) 5HT2a agonism leading to increased glutamate?

(Adapted from Textbook of SUD Tx: Galanter; APA Press 2013)

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Juvenile SUD: Risk and Protective Factors

Familial - runs in families

Genetic – 50% accounted for by “genes”

Environmental – Values, patterns, availability

Self medication – Symptoms, affect intolerance

(Wilens et al., 2000; 2002, 2005, 2013; Nunes et al. 2003; Rhee et al. 2003; Yule et al. AJA 2013)

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Wong SS, Wilens TE..

Pediatrics.

2017;140(5):e20171818

Medical Cannabinoids in Children and Adolescents: A Systematic Review

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Note: Boldface figures indicate significant results. Dashes indicate analyses were not performed because

of a limited number of data points.

Groenman AP et al. J Am Acad Child Adolesc Psychiatry. 2017

Jul;56(7):556-569

Child Psychopathology Increases Risk for Later SUD

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Life

tim

e P

reva

len

ce

Persistent BPD vs. Control: p=0.001;

Persistent BPD vs. Non-Persistent BPD: p=0.2;

Non-Persistent BPD vs. Controls: p=0.2

Development of SUD in Adolescent Bipolar Disorder

Wilens et al. J Clin Psych 2016

Bipolar

Control

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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

(Jackson, Yule, Wilens; Adolescent SUD in Handbook of

Adolescent Medicine, 2nd Edition, 2017)

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Screening Adolescents for Drugs and Alcohol:S2BI (Levy et al, Pediatrics 2016)

In the past year, how many times have you used:

• Tobacco?

• Alcohol?

• Marijuana?

STOP if all “Never.”

Otherwise, CONTINUE.

• Prescription drugs that were not prescribed for you (such as pain medication or Adderall)?

• Illegal Drugs (such as cocaine or Ecstasy)?

• Inhalants (such as nitrous oxide)?

• Herbs or synthetic drugs (such as salvia, “K2”, or bath salts)?

https://www.drugabuse.gov/ast/s2bi/#/

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Screening Adolescents for Drugs and Alcohol

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 thins 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?

• Two or more yes answers on the CRAFFT suggest a serious problem and a need for further assessment

(Knight et al., Arch Pediatr Adolesc Med 1999: 153: 591-6)

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Documentation

According to Group Health’s standards for substance use disorder

documentation, clinical staff may and should document the following

information related to substance use:

• Patient disclosures about substance use, abuse, or dependence.

• Patient disclosures about current or past chemical dependency

treatment.

• Completed screening tools including:

- Adolescent substance use screening tool (CRAFFT) and CRAFFT results.

- Others

- A DSM diagnosis of substance abuse or dependence and the pertinent

clinical information that supports the diagnosis.

- Referrals for a chemical dependency evaluation (includes all levels of

care, behavioral, medical, inpatient, partial, outpatient).

Protection of chemical dependency information begins at the start of a

treatment program, not at the time of screening, identification, or referral

(as outlined in confidentiality regulation 42 CFR Part 2).

Adapted from Group Health Guidelines

www.ghc.org/all-sites/guidelines/drug-adolescent.pdf

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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

• Alcoholics Anonymous/Narcotics Anonymous for teens

• Rational Recovery

• Avoid “tough love” as initial step

(Jackson, Yule, Wilens; Adolescent SUD in Handbook of Adolescent Medicine, 2nd Edition, Springer, 2017)

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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

• Coping skills

• Reduce SUD “cues”

• Relapse prevention (eg reducing cues, balance in life)

(Wilens, McKowen & Kane Contemp Peds 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 et al. 2010; Yule and Wilens, Curr Psych. 2015; 14(4): 36-39, 47-51.Jackson, Yule, Wilens;

Adolescent SUD in Handbook of Adolescent Medicine, 2nd Edition, Springer, 2017)

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Pharmacotherapies to Reduce Urge or Cravings

• Nicotine– Nicotine patch (most effective in teens), inhaled

nicotine, nicotine gum, nicotine lozenges– Bupropion (Wellbutrin, Zyban)– Varenicline (nicotinic modulator)– Cytisine (acacia seed extract, nicotinic partial

agonist)-used in Europe– Experimental: Riminobant (Cannabinoid type I

receptor antagonist); nicotinic partial/full agonists-various nicotinic subunits

– E-cigs not recommended (e.g. may encourage cig use)

(Lerman et al. J Clin Oncol 2005:23-311-323; Basil et al. Psychiatry 12:2005:49-52; West et al. NEJM

2011:365: 1193-200; Dutra and Glants, JAMA Pediatrics, 2014: 168: 610-617).

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Pharmacotherapies to Reduce Urge or Cravings

• Alcohol– Naltrexone (Rivea) -reduces alcoholic drinking: dosing 25-50 mg

BID to TID– Acamprosate (Campral) -helps with abstinence: dosing 333 mg 1-

2 TID– Topirimate (Topamax) -helps reduce alcoholic drinking, maintain

abstinence: dosing <300 mg /day– Odansetron (Zofran) -helps reduce urges and drinking in early

onset alcohol use disorders; 2-8 mg/day– Baclofen -GABA derivative, anecdotally reported to reduce

drinking urges and edginess; 10-20 mg/day– Dilsufiram (Antabuse)- reaction to alcohol (use for passes, highly

motivated youth); blocks aldehyde dehydrogenase

(Lerman et al. J Clin Oncol 2005:23-311-323; Basil et al. Psychiatry 12:2005:49-52; Johnson et al. JAMA 2007; 298:1641-

1651; Niederhofer &Staffen: Eur Child Adolesc Psychiatry:12:144148 2003; Deas D. et al., JAACAP 2005. 15:723-728; ADD

RECENT REFERENCE)

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Pharmacotherapy for Marijuana Use Disorders

• N-Acetyl Cysteine (NAC)-natraceutical-dosing 1200 mg BID (RCT; Grey et al. Am J Psych 2012)

• Buspirone (pilot RCT; McRae-Clark et al., 2009)

• Gabapentin (pilot RCT; Mason et al., 2012)

• Topirimate (adult addiction studies)

• Rimonabant- experimental (CB-1 receptor blocker; EU approval and withdrawal: mood/SI) (Huestis MA, et al.

Psychopharm 2007)

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Young people SUD- Comorbidity

• ADHD – Consider addressing both conditions– Low level substance use–> continue to treat ADHD– More severe SUD –> address SUD first, if possible– Can treat ADHD through SUD (nonstim, XR stims only)

• Depression – Co-treat Depression and SUD– May need to improve SUD to see residual mood symptoms

• Anxiety– Address SUD initially, then anxiety– Can treat anxiety through SUD (use SSRI/SNRI, buspirone)

• Severe Mood Dysregulation– Treat mood dysregulation and SUD simultaneously– Use safer agents (e.g. SGAs for mood)

For review, see (Gignac et al. 2010; Yule and Wilens, Curr Psych. 2015; 14(4): 36-39,

47-51.Jackson, Yule, Wilens; Adolescent SUD in Handbook of Adolescent Medicine, 2nd

Edition, Springer, 2017)

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Juvenile SUD: Confidentiality

• Need to discuss SUD with patient & 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

(Gignac, Waxmonsky and Wilens, Adol SA, in Child Adoles Psychopharm, 2010; Jackson, Yule,

Wilens; Adolescent SUD in Handbook of Adolescent Medicine, 2nd Edition, Springer, 2017)

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Juvenile SUD: Summary

• Juvenile SUD is commonly comorbid with psychopathology

• Screening, discussion, and documentation constitute components of care of these youth

• Treatment of psych may reduce ultimate SUD

• Treatment of comorbid youth requires both SUD and psych intervention

• Pharmacotherapy can be effective in youth with SUD problems