Tackling Teen Alcohol Use- The Six Gs Cathy McDonald, MD, MPH Alameda County ATOD Provider Network Thunder Road 510-653-5040.

Tackling Teen Alcohol Tackling Teen Alcohol Use- The Six G’sUse- The Six G’s

Cathy McDonald, MD, MPHCathy McDonald, MD, MPHAlameda County ATOD Provider NetworkAlameda County ATOD Provider Network

Thunder RoadThunder Road

510-653-5040510-653-5040

Teen Alcohol UseTeen Alcohol Use

Scope of the problemScope of the problem Alcohol Effect on Teen BrainAlcohol Effect on Teen Brain Genetics & environmentGenetics & environment Addiction Stage/ Addiction Stage/

DependenceDependence Pediatrician’s RolePediatrician’s Role Screening & InterventionScreening & Intervention

The ProblemThe ProblemData: NationalData: National

MONITORING THE FUTURE 2007

55%72%12th

41%62%10th

18%39%8th

Been Drunk

ever

Any Use

Grade

The ProblemThe ProblemData: StateData: State

California Student Survey 2005-2006 Past 30 days

Grade Any Binge 5+ drinks

7th 12% 5%

9th 24% 12%

11th 36% 21%

The ProblemThe ProblemData: StateData: State

California Student Survey 2005-2006

Grade 2 + criteria dependence

Drove or Driver Under Influence

7th

9th 5% 20%

11th 13% 30%

The scope of the The scope of the problemproblem

Adult Alcohol dependence 5% M 2% FAdult Alcohol dependence 5% M 2% F 7000 teens <16 take first drink every 7000 teens <16 take first drink every

day (SAMSHA 2004)day (SAMSHA 2004) 20% of US alcohol used by teens20% of US alcohol used by teens 31% traffic deaths in teens alcohol 31% traffic deaths in teens alcohol

related (15-2related (15-20) NHTSA 2006 ( 77% of 0) NHTSA 2006 ( 77% of these unrestrained)these unrestrained)

CA Blood Alcohol < .01% <21 ZERO CA Blood Alcohol < .01% <21 ZERO TOLERANCETOLERANCE

The scope of the The scope of the problemproblem 1995 survey 30% 4th-6th graders peer pressure to 1995 survey 30% 4th-6th graders peer pressure to

drink beerdrink beer

70% 12-20 no alcohol past month70% 12-20 no alcohol past month 15% binge drink any month15% binge drink any month

– State-Men 5 or > drinks (women 4 or >) in a row once in past month

– Monitoring the Future-5 or > drinks in a row in previous 2 weeks Male and female

2% 14-20 buy alcohol on line2% 14-20 buy alcohol on line 8% adults ever shoulder tap-19% 21-8% adults ever shoulder tap-19% 21-

30 yo men30 yo men

What is a drinkWhat is a drink

12oz can of beer=12oz can of beer= 5 oz glass of wine=5 oz glass of wine= 1.25 oz shot 80 proof hard liquor1.25 oz shot 80 proof hard liquor Alcohol poisoning: depends on how much, how Alcohol poisoning: depends on how much, how

strong, how fast, how empty the stomach isstrong, how fast, how empty the stomach is

180 lb male 5 beers + 4 shots in 3 hours=.144 180 lb male 5 beers + 4 shots in 3 hours=.144 BACBAC

180 lb male 1 beer .02 BAC out of zero tolerance180 lb male 1 beer .02 BAC out of zero tolerance

180 lb male 4 drinks .08 BAC180 lb male 4 drinks .08 BAC

BAC decreases by .01 % every 40 minutesBAC decreases by .01 % every 40 minutes

Alcohol’s effect on Alcohol’s effect on adolescent brainadolescent brain

Slides from Ken Winters, Slides from Ken Winters, Ph.D.Ph.D.

Associate ProfessorAssociate Professor Director of the Center for Director of the Center for

Adolescent Substance Abuse Adolescent Substance Abuse ResearchResearch

University of MinnesotaUniversity of Minnesota

, PhD

An Immature Brain An Immature Brain = =

Less Brakes on the “Go” Less Brakes on the “Go” SystemSystem

• Growth of the brain’s nerve Growth of the brain’s nerve cells (neurons) occurs through cells (neurons) occurs through late childhood late childhood • 1,000,000,000,000,000 possible 1,000,000,000,000,000 possible

connections.connections.• Around Around 1111 – GIRLS; – GIRLS; 12½12½ - BOYS: - BOYS:

• Some of these connections Some of these connections are pruned off.are pruned off.

Construction AheadConstruction Ahead

• When the pruning is complete, the When the pruning is complete, the brain is faster and more efficient.brain is faster and more efficient.

• But…But… during the pruning process, during the pruning process, the brain is not functioning at full the brain is not functioning at full capacitycapacity

Construction AheadConstruction Ahead

Emerging Science: Teen Brains Are Emerging Science: Teen Brains Are

StillStill

“Under Construction”“Under Construction”• New insights about:New insights about:

•Why teenagers take risks and Why teenagers take risks and show poor judgmentshow poor judgment

•How teenagers may be highly How teenagers may be highly vulnerable to substance abusevulnerable to substance abuse

• These findings can help These findings can help parents, parents,

policy makerspolicy makers

Judgment Gets BetterJudgment Gets Betterwith Agewith Age

• By age 18, the adolescent’s judgement By age 18, the adolescent’s judgement for for structured challengesstructured challenges is roughly is roughly equal to that of adults.equal to that of adults.

• But judgement that But judgement that involves resisting involves resisting impulses or delaying gratificationimpulses or delaying gratification is still is still under construction during late under construction during late adolescence and early adulthood until adolescence and early adulthood until 24yo24yo

• Sensory and physical activities Sensory and physical activities benefit from earlier “back of the benefit from earlier “back of the brain” development brain” development

• Complex, judgment-demanding Complex, judgment-demanding thinking are compromised by later thinking are compromised by later “front of the brain” development“front of the brain” development

Implications of Arrested Implications of Arrested Development for Development for Adolescent Adolescent BehaviorBehavior

1615

9

4.22.6

0

5

10

15

20

<12 yrs 12-14 yrs 15-17 yrs 18-20 yrs 21+ yrs

Age Started Drinking

%

Fewer Problems in ThoseWho Start Later

.. Percentages of Past Year Percentages of Past Year Alcohol Use Alcohol Use Disorder (Abuse or DependenceDisorder (Abuse or Dependence) Among ) Among Adults Aged 21 or Older, by Age of First Adults Aged 21 or Older, by Age of First Use Use (SAMHSA, 2004)(SAMHSA, 2004)

0

10

20

30

40

50

60

70

80

90

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EastWestNorth

2.2. Survey Data Suggest that Survey Data Suggest that Adolescents Are Less Sensitive to Adolescents Are Less Sensitive to Alcohol’s EffectsAlcohol’s Effects

148

26 2430 32

0

20

40

60

80

100

8th Graders 10th Graders 12th Graders

5+ drinks in row, past 2 weeks

Been drunk past month

Monitoring the Future, 2001

Less sensitive

Adolescents continue Adolescents continue to be less sensitive in to be less sensitive in 20072007GradeGrade 5+ drinks in 5+ drinks in

a row last 2 a row last 2 weeksweeks

Drunk in last Drunk in last monthmonth

8th8th 10%10% 5%5%

10th10th 22%22% 18%18%

12th12th 26%26% 29%29%

Are adolescents more Are adolescents more susceptible to alcohol than susceptible to alcohol than

adults?adults?1. Epidemiological data1. Epidemiological data

2.2. Adolescent rats are Adolescent rats are less sensitiveless sensitive to to the sedative and motor impairment the sedative and motor impairment effects of effects of intoxication.intoxication.

3.3. Adolescent rats are Adolescent rats are more sensitivemore sensitive to to the social disinhibition effects of the social disinhibition effects of alcohol. alcohol.

#2 and #3 : May contribute to binge drinking and increased risk to alcohol dependence.

Are adolescents more Are adolescents more susceptible to alcohol than susceptible to alcohol than

adults?adults?1. Epidemiological evidence1. Epidemiological evidence

2. Adolescent rats are 2. Adolescent rats are less sensitiveless sensitive to the to the sedative and motor impairment effects of sedative and motor impairment effects of intoxication.intoxication.

3. Adolescent rats are 3. Adolescent rats are more sensitivemore sensitive to the to the social disinhibition effects of alcohol.social disinhibition effects of alcohol.

4.4. Alcohol produces Alcohol produces greater greater cognitive disruptionscognitive disruptions in in adolescent rats.adolescent rats.

Human Data: Alcohol’s Human Data: Alcohol’s EffectsEffects(Brown, 2002; Wuethrich, 2001)(Brown, 2002; Wuethrich, 2001)

4.4. Adolescents with a Adolescents with a history of extensive history of extensive use….use….

Hippocampus volume (10%)Hippocampus volume (10%)

brain activity during memory brain activity during memory taskstasks

converts informat

ion to memory

Not known if restoration or recovery will occur.

Evidence in support that youth are Evidence in support that youth are highly vulnerable to the effects of highly vulnerable to the effects of alcoholalcohol

1.1. Greater rates of alcohol use Greater rates of alcohol use disorders at earlier ages disorders at earlier ages

2.2. Reduced sensitivity to Reduced sensitivity to

intoxicationintoxication

3.3. Increased social disinhibitionIncreased social disinhibition

4.4. Increased cognitive disruptionIncreased cognitive disruption

SUMMARY

Impact of genetics and Impact of genetics and environmentenvironment GeneticsGenetics

sons of alcoholics 25% risksons of alcoholics 25% riskdaughters increased riskdaughters increased risk

EnvironmentEnvironmentalcohol responsible for 50% marital violencealcohol responsible for 50% marital violence35-70% child abuse35-70% child abuse

Youth at High RiskYouth at High RiskFH alcoholismFH alcoholismDelinquentDelinquentlearning disabilities including ADHDlearning disabilities including ADHDpsychosomatic complaintspsychosomatic complaintsFamily antisocial behaviorFamily antisocial behaviorpoor parentingpoor parenting

Impact of environmentImpact of environment

Family Attitude and availabilityFamily Attitude and availability– Home is primary place for early useHome is primary place for early use– Some at meals -no big dealSome at meals -no big deal– Often availableOften available

Media Messages & societal norms-Conveys adult Media Messages & societal norms-Conveys adult statusstatus– Advertised widely-seen in tv and moviesAdvertised widely-seen in tv and movies– Ads linked to sociability, elegance, good looks, Ads linked to sociability, elegance, good looks,

success, relaxation, romance, advertisingsuccess, relaxation, romance, advertising– 56% of 5th -12th graders say ads encourage to 56% of 5th -12th graders say ads encourage to

drinkdrink– Hundreds of websites promote drinkingHundreds of websites promote drinking– Conveys maturity, bravado, masculinityConveys maturity, bravado, masculinity

Impact of EnvironmentImpact of Environment

Family and CommunityFamily and Community– RewardReward– After workAfter work– CelebrateCelebrate– sportssports

Stages of Use / AbuseStages of Use / Abuse

Potential-impulsive, available,peer drivenPotential-impulsive, available,peer driven Stage IStage I Experimentation Experimentation Stage IIStage II Active seeking Active seeking Stage IIIStage III PreoccupationPreoccupation Stage IVStage IV Addiction- withdrawal, Addiction- withdrawal,

shame, remorse, depression, shame, remorse, depression, powerlessness, unmanageablitypowerlessness, unmanageablity

Potential for big consequences earlyPotential for big consequences early

DSMIV criteria for DSMIV criteria for alcohol dependencealcohol dependence Three of the following present in 12 months

Using more/same but less effective-tolerance

Withdrawal symptoms: shaky or uncomfortable

Using more than care to Want to cut down but not able Lots of time spent getting, using and

recovering Important activities given up due to use Continue inspite of physical / mental

consequence

Screening tools for Screening tools for ATOD once use ATOD once use recognized recognized CRAFFTCRAFFT

– CCarar– RRelaxelax– AAlonelone

FFamily / Friendsamily / Friends FForgetorget TTroublerouble

Two or more yes -there is a problem- needs further evaluation

Pediatrician’s Role: Pediatrician’s Role: PreventionPrevention Prenatal visit √FH alcoholism-urge 12 Prenatal visit √FH alcoholism-urge 12

step support AA/Alanon- Be alert for step support AA/Alanon- Be alert for COA or fetal alcohol syndromeCOA or fetal alcohol syndrome

Adolescence Adolescence – store alcohol & meds away from kidsstore alcohol & meds away from kids– Set firm rules about expectationsSet firm rules about expectations– Urge family to discuss risks-judgement Urge family to discuss risks-judgement

problemsproblems– Child of alcoholic discuss with family, Child of alcoholic discuss with family,

discuss genetic risks, alateen (problem list discuss genetic risks, alateen (problem list prenatal)prenatal)

Pediatrician’s RolePediatrician’s RoleWhen to considerWhen to consider Parent concernedParent concerned FU ER visit or hospitalization for injuryFU ER visit or hospitalization for injury Occasionally ulcerOccasionally ulcer High suspicion with other drug thc, nicotineHigh suspicion with other drug thc, nicotine Teen who is sex active (Teen who is sex active ( rate) rate) History of rapeHistory of rape Alcohol poisoning in ERAlcohol poisoning in ER Major change in behavior-grades dropMajor change in behavior-grades drop Teen in recovery who relapsesTeen in recovery who relapses

Pediatricians Role:Pediatricians Role:Start Counseling EarlyStart Counseling Early 8-12 years old8-12 years old Incorporate into HEEADSSS-Home, Incorporate into HEEADSSS-Home,

education,eating, activities,Drugs education,eating, activities,Drugs alcohol tobacco, suicidality sex,safetyalcohol tobacco, suicidality sex,safety

Incorporate into SSHADESS-Strengths, Incorporate into SSHADESS-Strengths, school, home,activities, drugs, school, home,activities, drugs, emotions, sex, safetyemotions, sex, safety

Start early if FH alcohol And/or High risk Start early if FH alcohol And/or High risk youthyouth

Pediatrician’s Role:Pediatrician’s Role:How to ask How to ask Family useFamily use Friend useFriend use Own use: not -how much do you use?- rather Own use: not -how much do you use?- rather

“I see that some of your family members “I see that some of your family members and/or friends drink, I’m wondering about and/or friends drink, I’m wondering about your drinking”your drinking”

Ask about riding with people who have had a Ask about riding with people who have had a drink, drinking and driving, biking, safe sex drink, drinking and driving, biking, safe sex

How are Peds Doing How are Peds Doing Millstein data 2003 Millstein data 2003 Surveyed 1842 Peds & FP’s-docs ask, Do you Surveyed 1842 Peds & FP’s-docs ask, Do you

use Alcuse AlcPediatricians 23-43% counseling Pediatricians 23-43% counseling Family Practice 14-27% counseling Family Practice 14-27% counseling Intervention increased when perceived Intervention increased when perceived

resources/ skillsresources/ skillsProblems: time and lack of resourcesProblems: time and lack of resourcesGOAL:Increased screening and counselingGOAL:Increased screening and counselingIf all of you do it today in your office at least If all of you do it today in your office at least

one person would be likely to be protected one person would be likely to be protected from an alcohol related adverse eventfrom an alcohol related adverse event

How are Peds Doing How are Peds Doing Millstein data 2003Millstein data 2003Professional guides AAP, Gaps recommend alcohol screening all teensProfessional guides AAP, Gaps recommend alcohol screening all teens<25% sample screened all adolescents<25% sample screened all adolescentsScreening for alcohol use in family and peers recommended typical Screening for alcohol use in family and peers recommended typical

physician does this in only a minority of patientsphysician does this in only a minority of patientsScreening for alcohol use in Motor Vehicles is done even less oftenScreening for alcohol use in Motor Vehicles is done even less often<1/3 adhered to recommendation all teens be educated even though <1/3 adhered to recommendation all teens be educated even though

teens see docs as credible source of infoteens see docs as credible source of infoYounger teens less likely than older :conflict with use dataYounger teens less likely than older :conflict with use data

1/3 8th graders in school had had a drink 1/3 8th graders in school had had a drink 1/7 8th graders have been drunk1/7 8th graders have been drunk

Solutions- time and training- knowledge Solutions- time and training- knowledge of resourcesof resources

Millstein Counseling Millstein Counseling levels identifiedlevels identified Low level counseling-general risks, risk of Low level counseling-general risks, risk of

abuse, risk of injury (warning drink & drive, abuse, risk of injury (warning drink & drive, boat, swim, physical or sex abuse by boat, swim, physical or sex abuse by acquaintance, unsafe sex)acquaintance, unsafe sex)

Medium level counselingMedium level counseling– Advising drinkers to stop and encouraging non-Advising drinkers to stop and encouraging non-

drinkers to maintain abstinencedrinkers to maintain abstinence Aim for High level counselingAim for High level counseling

– Information about common teen alcohol Information about common teen alcohol situationssituations

– Normative info on teens who don’t drinkNormative info on teens who don’t drink– Practicing refusal skillsPracticing refusal skills

Using the 6 G’s with Using the 6 G’s with teensteens GENETIC

– Family members drink more than they should?

– Feel scared when family drink?

GROUP– Where hang with friends?– What do for fun with friends?– When at friends - how often parent present

Heyman, R. Contemporary Pediatrics June 2007

Using the 6 G’s with Using the 6 G’s with teensteens GIVE- someone likely to try to give to teen

– Have you been at parties where people your age and or older drinking and drugging (D& D)?

– Do your friends prefer drinking to other activities?– Ever feel weird cause the only one at party not D&D?– Ever offered D&D ? How handled? Refusal skills

GET-willing to get – Are you the kind who like to live on the edge?– Do you think people have more or less fun when D&D?– Are you curious how D&D affect your body?– What do you think about underage D & D

Using the 6 G’s with Using the 6 G’s with teensteens GREAT-get great physical & mental danger

– What do you know about D&D effect on Young brain vs older?

– What know about how D&D affect judgment /thinking?– Know anyone who’s life has been harmed by D& D -

alcohol poisoning, attacked, injured in moving vehicle, cirrhosis, blackout etc.

GUIDANCE- grasp parent and societal– What’s your idea why grownups don’t want young

people to use alcohol?– What’s your sense of where your parents stand?– What know about consequences -parents- school-legal

if choose to D&D?ALSO CAN USE WITH PARENTS-handouts in article

Use existing resources Use existing resources young teensyoung teens

Adolescent Health Working Group Adolescent Health Working Group Behavioral Health an Adolescent Behavioral Health an Adolescent Provider Toolkit. Contains the Provider Toolkit. Contains the Crafft. Also contains multiple tools Crafft. Also contains multiple tools to use with teens related to stress to use with teens related to stress management and coping. Stress management and coping. Stress is often at the core of substance is often at the core of substance use in teens.use in teens.

Use existing resources and Use existing resources and opportunities-older teensopportunities-older teensCA DMV PARENT TEEN TRAINING CA DMV PARENT TEEN TRAINING GUIDE 2006GUIDE 2006

Advises parents discuss 4 questions with kids:Advises parents discuss 4 questions with kids:1. Being driven home from a party by friend 1. Being driven home from a party by friend who is now under influence who is now under influence 2. Date intoxicated at party and insists on 2. Date intoxicated at party and insists on driving.driving.3. Riding in car with older teens-one using 3. Riding in car with older teens-one using alcohol and offers to you.alcohol and offers to you.4. Told teen no alcohol-went to party and 4. Told teen no alcohol-went to party and wine served and feeling strange from the wine served and feeling strange from the wine- it’s late- teen afraid to drive home - wine- it’s late- teen afraid to drive home - not sure if he should call parents.not sure if he should call parents.

Teen in hospital who Teen in hospital who is regular drinker-is regular drinker-rarely needs rarely needs withdrawal medswithdrawal meds Assess magnitude of drinking Assess what happens if stops for a day or two-

does s/he get shaky? Is s/he doing prescription drugs- benzodiazepans

can be a problem if withdrawing from both. - If don’t believe client check drug screen asking for benzo’s

Shaking and jitteriness are late symptoms after _1-2days

If concerned monitor with alcohol withdrawal checklist (Web Source Royal Brisbane Hospital)

Very rarely are meds necessary

CasesCases

16 yo female glass of wine at 16 yo female glass of wine at party with friends. Drank 2 times party with friends. Drank 2 times in last year-Max 1 drink. Parents in last year-Max 1 drink. Parents rule no drinking. They don’t know. rule no drinking. They don’t know.

Friends parents supplied the Friends parents supplied the liquor at the partyliquor at the party

Aware of effect on judgement if Aware of effect on judgement if kept drinkingkept drinking

CasesCases

15 year old female 6 beers a day 15 year old female 6 beers a day for the last year. FH of alcoholism for the last year. FH of alcoholism in dad still drinking. Multiple black in dad still drinking. Multiple black outs almost every day.outs almost every day.

Source-stealing and shoulder Source-stealing and shoulder tappingtapping

References & References & Resources Resources References: Levy S. et al. Office-based intervention for References: Levy S. et al. Office-based intervention for

adolescent substance abuse. Ped Clinics North AM adolescent substance abuse. Ped Clinics North AM 2002;49:329.2002;49:329.

Millstein,S. et al. Screening and Counseling for Adolescent Millstein,S. et al. Screening and Counseling for Adolescent Alcohol Use… Pediatrics 2003;111:114-122.Alcohol Use… Pediatrics 2003;111:114-122.

Heyman R. Combating Underage Drinking with the 6 g’s. Heyman R. Combating Underage Drinking with the 6 g’s. Contemporary Pediatrics 2007;24 63-99. Contemporary Pediatrics 2007;24 63-99.

www.contemporarypediatrics.comResources: Hopelinks.netResources: Hopelinks.netwww.ahwg.net download Adolescent Provider Toolkit download Adolescent Provider Toolkitwww.drugabuse.govwww.safeyouth.org/scripts/teens/alcohol.aspwww.safeyouth.org/scripts/teens/alcohol.asp