Substance Use Substance Use
Dec 25, 2015
Substance UseSubstance Use
Why do adolescents use Why do adolescents use substances?substances?
CuriosityCuriosity
Boredom Boredom
Fit in with peers/peer pressureFit in with peers/peer pressure
Normal adolescent explorationNormal adolescent exploration
2004 National Survey on Drug Use and 2004 National Survey on Drug Use and HealthHealth (SAMHSA, 2005)(SAMHSA, 2005)
Alcohol – Prevalence increases with ageAlcohol – Prevalence increases with age– 2% of 12 year olds use alcohol2% of 12 year olds use alcohol– 36% of 17 year olds36% of 17 year olds– Peaks at 71% at age 21 Peaks at 71% at age 21
Tobacco Tobacco – 15.2% of adolescents between ages 12 & 17 15.2% of adolescents between ages 12 & 17
report using tobaccoreport using tobacco– Males are more likely to use tobacco than Males are more likely to use tobacco than
females, but females are more likely to smoke females, but females are more likely to smoke than malesthan males
2004 National Survey on Drug Use and 2004 National Survey on Drug Use and HealthHealth (SAMHSA, 2005)(SAMHSA, 2005)
Illegal Drugs – 11.6% of adolescents between Illegal Drugs – 11.6% of adolescents between 12 & 17 (4.2% between ages 12 & 13) use illegal 12 & 17 (4.2% between ages 12 & 13) use illegal drugs (other than alcohol and tobacco)drugs (other than alcohol and tobacco)– Use is high among boys than girls Use is high among boys than girls – Boys are more likely to use marijuana than girlsBoys are more likely to use marijuana than girls– Girls are more likely to use prescription drugsGirls are more likely to use prescription drugs
Inhalants – the only drug whose use decreases Inhalants – the only drug whose use decreases during adolescence during adolescence – 4.1% at age 134.1% at age 13– 2.2% at age 152.2% at age 15– 1.5% at age 171.5% at age 17
Annual Numbers of New Users of Annual Numbers of New Users of Marijuana: 1965–2002 Marijuana: 1965–2002
Source: SAMHSA
Annual Numbers of New Nonmedical Annual Numbers of New Nonmedical Users of Pain Relievers: 1965–2002Users of Pain Relievers: 1965–2002
Source: SAMHSA
Annual Numbers of New Users of Annual Numbers of New Users of Ecstasy, LSD, and PCP: 1965–2002Ecstasy, LSD, and PCP: 1965–2002
Source: SAMHSA
Associated ConcernsAssociated Concerns
Physical problemsPhysical problems– Heart problemsHeart problems
– Liver functioning/Hepatitis CLiver functioning/Hepatitis C
– Neuronal/brain damageNeuronal/brain damage
– Overdose/deathOverdose/death
Associated ConcernsAssociated Concerns
Social/BehavioralSocial/Behavioral– Impact on educationImpact on education
Increased likelihood of being diagnosed with a learning Increased likelihood of being diagnosed with a learning disabilitydisability
Impaired concentrationImpaired concentration
Behavioral disruptionsBehavioral disruptions
TruancyTruancy
School Drop outSchool Drop out
– Correlated with Correlated with Increased AggressivenessIncreased Aggressiveness
Limited frustration toleranceLimited frustration tolerance
DelinquencyDelinquency
Past Month Illicit Drug Use among Youths Aged Past Month Illicit Drug Use among Youths Aged 12 to 17, by Participation in Delinquent 12 to 17, by Participation in Delinquent
BehaviorsBehaviors
Associated ConcernsAssociated Concerns
Most common co-morbid disordersMost common co-morbid disorders– Conduct disorderConduct disorder
– ADHDADHD
– Depression/Bi-polar DisorderDepression/Bi-polar Disorder
– Learning DisordersLearning Disorders
Substance Abuse History - DSMSubstance Abuse History - DSM
DSM-III (1980) DSM-III (1980) – Prior to DSM-III diagnosis consisted of “addiction”Prior to DSM-III diagnosis consisted of “addiction”– ““Abuse” and “Dependence” replaced “addiction” in Abuse” and “Dependence” replaced “addiction” in
DSM-IIIDSM-III
DSM-III-R (1987)DSM-III-R (1987)– Dependence criteria reorganized to fit Edwards & Dependence criteria reorganized to fit Edwards &
Gross “Alcohol Dependence Syndrome”, from their Gross “Alcohol Dependence Syndrome”, from their observations of patientsobservations of patients
– Abuse was a residual category for people who had a Abuse was a residual category for people who had a problem but did not meet the criteria for dependenceproblem but did not meet the criteria for dependence
Substance Abuse History - DSMSubstance Abuse History - DSM
DSM-IV (1994)DSM-IV (1994)
– Criteria were again reorganizedCriteria were again reorganized
– Abuse designed to serve as its own Abuse designed to serve as its own independent diagnosisindependent diagnosis
– Physiological vs. psychological dependencePhysiological vs. psychological dependence
DSM-IV Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
(2) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the
substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work
performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
B. The individual has never met criteria for Substance Dependence for the same class of substance.
DSM-IV Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring during a 12-month period:
1. Tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve
intoxication b. markedly diminished effect with continued use of the same amount of the
substance 2. Withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance b. the same (or related) substance is taken to relieve or avoid withdrawal
symptoms 3. The substance is often taken in larger Amounts or over a longer period than was
intended 4. There is a persistent desire or unsuccessful efforts to cut down or Control substance
use 5. A great deal of Time is spent in activities necessary to obtain the substance (e.g.,
visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
6. Important social, occupational, or recreational activities are given up or reduced because of substance use
7. The substance use is continued despite Knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (e.g., cocaine-induced depression, or ulcer from drinking)
DSM-IV Drug Categories DSM-IV Drug Categories
AlcoholAlcohol
Amphetamine & Amphetamine &
Amphetamine-likeAmphetamine-like
CaffeineCaffeine
Cannabis Cannabis
CocaineCocaine
HallucinogenHallucinogen
InhalantInhalant
NicotineNicotine
OpioidOpioid
Phencyclidine & Phencyclidine &
phencyclidine-likephencyclidine-like
Sedative, hypnotic, Sedative, hypnotic,
anxiolyticanxiolytic
PolysubstancePolysubstance
Other Other
Problems with the DSM-IV Substance Use Problems with the DSM-IV Substance Use Criteria when used with Children and Criteria when used with Children and
AdolescentsAdolescentsAbuse criteria are composed of how an individual interacts with his or her environment.
Requiring three or more dependence criteria for the dependence diagnosis – about 1/3 of adolescent “regular” alcohol users “fall through the
cracks” because they meet only one or two criteria (called diagnostic orphans)
– about 1/5 of adult regular drinkers are diagnostic orphans.
Should substance use during adolescence even be categorized as a disorder because of how common it is for adolescents to use alcohol and other substances
Should substance use during adolescence even be categorized as a disorder because of how common it is
for adolescents to use alcohol and other substances?
Regardless of how common substance use is, adolescents who meet the criteria of abuse: continued use in spite of the problems that use causes, are still using in a pathological manner.
Assessing Substance UseAssessing Substance Use
Clinical interviews (child/parent/others)Clinical interviews (child/parent/others)
Self-Report InventoriesSelf-Report Inventories– Substance Abuse Subtle Screening Inventory Substance Abuse Subtle Screening Inventory
(SASSI)(SASSI)– MMPI-A McCarthy ScaleMMPI-A McCarthy Scale
Drug TestsDrug Tests– UrineUrine– Blood/Cerebrospinal fluidBlood/Cerebrospinal fluid– HairHair
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
MedicationsMedications– AlcoholAlcohol
LibriumLibrium
Antabuse Antabuse
NaltrexoneNaltrexone
– Heroine/opioidsHeroine/opioids Methadone Methadone
Buprenorphine Buprenorphine
– CocaineCocaine Ibogaine Ibogaine
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
MedicationsMedications– Anti-depressantsAnti-depressants
– Mood stabilizersMood stabilizers
– Anti-anxiety medicationsAnti-anxiety medications
– Anti-psychoticsAnti-psychotics
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
Behavioral and Cognitive-Behavioral Behavioral and Cognitive-Behavioral TreatmentsTreatments– Behavioral TherapyBehavioral Therapy
Create new associationsCreate new associations
Change behaviorsChange behaviors
Antabuse Antabuse
– Rational Emotive TherapyRational Emotive TherapyDevelop an internal locus of controlDevelop an internal locus of control
Dispute irrational beliefsDispute irrational beliefs
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
Group TherapyGroup Therapy– The most effective form of therapy for The most effective form of therapy for
adolescent substance abuseadolescent substance abuse– May be mixed gender or single genderMay be mixed gender or single gender– Groups are for both support and for treatmentGroups are for both support and for treatment– Should focus on social skills training, coping Should focus on social skills training, coping
skills, refusal skills, and self-awareness as skills, refusal skills, and self-awareness as well as addiction treatment and educationwell as addiction treatment and education
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
Support groupsSupport groups– Alcoholics Anonymous (AA) and Narcotics Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) Anonymous (NA) No facilitatorNo facilitator
Adolescents should attend adolescent groups, not Adolescents should attend adolescent groups, not adult groups!adult groups!
– SMART Recovery (Self-Management and SMART Recovery (Self-Management and Recovery Training)Recovery Training)
Uses an adult facilitatorUses an adult facilitator
Treatment of Adolescent Treatment of Adolescent Substance Use DisordersSubstance Use Disorders
Residential TreatmentResidential Treatment– Generally 30 to 90 days for adolescentsGenerally 30 to 90 days for adolescents– Usually rely on AA/NA as well as traditional Usually rely on AA/NA as well as traditional
group therapiesgroup therapies– Therapeutic Community Therapeutic Community
Levels of TreatmentLevels of Treatment
Outpatient TreatmentOutpatient Treatment1.1. Traditional OutpatientTraditional Outpatient
– Individual therapyIndividual therapy– Group TherapyGroup Therapy– Family TherapyFamily Therapy
2.2. Intensive Outpatient ProgramsIntensive Outpatient Programs– Individual and group therapyIndividual and group therapy– Family and family groupsFamily and family groups
3.3. Partial HospitalizationPartial Hospitalization
Levels of TreatmentLevels of Treatment
Medically Monitored Medically Monitored 4.4. DetoxificationDetoxification
– Staffed by counselors, sometimes nursesStaffed by counselors, sometimes nurses– Not really “treatment”, but “drying out”Not really “treatment”, but “drying out”– Not meant to be the last stop of treatmentNot meant to be the last stop of treatment
5.5. RehabilitationRehabilitation– Staffed by counselors, therapists, nurseStaffed by counselors, therapists, nurse– Doctor is “on-call” and consults with staffDoctor is “on-call” and consults with staff
Levels of TreatmentLevels of Treatment
Medically ManagedMedically Managed6.6. DetoxificationDetoxification
– Usually a hospital settingUsually a hospital setting– Staffed by nurses and doctorsStaffed by nurses and doctors
7.7. RehabilitationRehabilitation– Usually in hospital settingUsually in hospital setting– Staffed by nurses and doctorsStaffed by nurses and doctors– Usually shorter-term than medically monitored Usually shorter-term than medically monitored
rehab, but can also be long-termrehab, but can also be long-term
PreventionPrevention rather than rather than TreatmentTreatment
Treatment has limited success; prevention Treatment has limited success; prevention is cheaper and more effectiveis cheaper and more effectiveD.A.R.E.D.A.R.E.– Not found to be effectiveNot found to be effective– Actually found to positively correlate with Actually found to positively correlate with
substance use substance use
Life Skills TrainingLife Skills Training– Evidence-based prevention programEvidence-based prevention program– School-based/community-based groupsSchool-based/community-based groups– Cognitive-behavioral based treatmentCognitive-behavioral based treatment