ADOLESCENT SUBSTANCE ABUSEAnne Cristine D. Guevarra, MD

Child Psychiatry Rotator

Adolescent substance abuse• DSM-5 does not separate the diagnoses of substance

abuse from substance dependence • combined substance use criteria including both abuse and

withdrawal phenomena may strengthen the validity of the disorder in adolescents

Psychosocial risk factors• Parent modeling of substance use• Family conflict• Lack of parental supervision• Peer relationships• Individual stressful life events

Protective risk factors• Stable family life• Strong parent–child bond• Consistent parental supervision• Investment in academic achievement• Peer group that models prosocial family and school

behaviors

Epidemiology• Approximately one of five adolescents have used

marijuana or hashish• Approximately one third of adolescents have used

cigarettes by age 17 years• By 13 years of age, 1/3 of boys and almost ¼ of girls

have tried alcohol• By 18 years of age, 92% of males and 73% of females

reported trying alcohol, and 4% reported using alcohol daily

• Of high school seniors, 41% reported using marijuana; 2% reported using the drug daily

Filipinos using illegal drugs has decreased to 6.7 million from around 10 million in 2001 based on the 2004 survey results of the Dangerous Drugs Board (DDB)

Philippine Drug Enforcement Agency (PDEA)

Office of the Senate: Press Release, May 8, 2006

National Institute on Drug Abuse, 2012

National Institute on Drug Abuse, 2012

National Institute on Drug Abuse, 2012

Nicotine• Nicotine is one of the most addictive substances known; it

involves cholinergic receptors, and enhancing acetylcholine, serotonin, and β-endorphin release.

• Young teens who smoke cigarettes are also exposed to other drugs more frequently than nonsmoking peers.

• Psychoactive agent of tobacco• Agonist at the nicotinic subtype of Ach receptors in the

CNS• 25% of inhaled nicotine reaches the bloodstream• Half-life: 2 hours

Nicotine

• Positive and addictive by • reinforcing the dopaminergic pathway projecting from the ventral

tegmental area to the cerebral cortex and the limbic system• causes an increase in the concentrations of circulating NE and E• causes an increase in the release of vasopressin, endorphin,

ACTH and cortisol (contribute to the basic stimulatory effects of nicotine)

• Highly toxic alkaloid• 0.5mg: 1 stick of cigarette• 60mg: fatal secondary to respiratory paralysis

Nicotine: Adverse Effects

• Low dose: nausea, vomiting, salivation, pallor, weakness, abdominal pain, diarrhea, dizziness, headache, increased blood pressure, tachycardia, tremor, and cold sweats

• High dose: inability to concentrate, confusion, and sensory disturbances, decreased REM

• Pregnancy: increased incidence of LBW and Persistent pulmonary hypertension

Nicotine Toxicity

Griesler, P.C., et al. Comorbid psychiatric disorders and nicotine dependence in adolescence. Addiction 106(5):1010–1020, 2011

Nicotine Dependence Linked to Higher Rates of Mental Disorders Among Teens, March 2012, NIDA.

Drinking• Follows adult demographic drinking patterns• Whites >> other groups• Roman Catholics least likely nondrinkers• More than 1/3 of adolescents are treated in pediatric

trauma center for alcohol or drug use• Four most common cause of death 10-24 years of age

• 37% motor vehicle accidents• 14% homicide• 12% suicide• 12% other injuries or accidents

Alcohol• 72.5% of high school students had tried at least one alcoholic drink

• 24.2% reported an episode of heavy drinking in the month preceding the survey

• 39% of adolescents have used alcohol before 8th grade

• 70% at 8th grade

• A significant problem for 10 – 20% of adolescents• Ages 13 -17 years, 3 million problem drinkers• 300,000 with alcohol dependence• Gap between male and female alcohol consumers is

narrowing

Mechanism of Action• no single molecular target • Enhanced: ion channel activities associated with the

nicotinic acetylcholineserotonin 5-hydroxytryptamine3 (5-HT3,) and GABA type A (GABAA) receptors

• Inhibited: ion channel activities associated with glutamate receptors and voltage-gated calcium channels

• Short-term: intercalating itself into membranes and, thus, increasing fluidity of the membranes

• long-term: membranes become rigid or stiff• The fluidity of the membranes is critical to normal

functioning of receptors, ion channels, and other membrane-bound functional proteins.

Alcohol• May diminish hippocampal brain volume• Compromised cognitive function, especially attention

CIWA-ArThe Clinical Institute Withdrawal Assessment for Alcohol measures 10 categories of symptoms, with a range of scores in each. The maximal score is 67.

Minimal-to-mild withdrawal symptoms result in a total score below 8; moderate withdrawal symptoms (marked autonomic arousal), in a total score of 8 to 15; and severe withdrawal symptoms, in a total score of more than 15.

High scores are predictive of seizures and delirium.

N Engl J Med 2003;348:1786-95

• Adolescents with alcoholism show rates of 50% or higher for additional psychiatric disorders, especially mood disorders.

• A recent survey of adolescents who used alcohol found that more than 80% met criteria for another disorder. • depressive disorders• disruptive behavior disorders• drug use disorders

Marijuana• most widely used drugs by young people in developed

countries, and recently it has become highly used globally. • used by 3.9% of people worldwide (15 - 64 years)• most commonly used illicit drug among high school

students in the United States

• 10% become daily users

• 20 – 30% become weekly users• “gateway drug,” because the strongest predictor of

future cocaine use is frequent marijuana use during adolescence

• 10% in 8th grade, 23% in 10th grade, 36% in 12th grade students

Marijuana• Short-term effects:

• impairment in memory and learning• distorted perception• diminished problem-solving ability• loss of coordination• increased heart rate• anxietyand panic attacks

• Withdrawal symptoms: • Insomnia• Irritability• Restlessness• drug craving• depressed mood• nervousness followed by anxiety, tremors, nausea, muscle twitches• Increased sweating, myalgia, and general malaise

Marijuana• Short-term effects: of the active ingredient in marijuana,

tetrahydrocannabinol (THC), include impairment in memory and learning, distorted perception, diminished problem-solving ability, loss of coordination, increased heart rate, anxiety, and panic attacks

Marijuana• Withdrawal syndrome begins 24 hours after the last use,

peaks at 2 to 4 days, and diminishes after 2 weeks• associated with increased risk of psychiatric disorders• Acute & Chronic use changes in cerebral blood flow to

certain brain regions• Chronic use poor cognitive functioning (verbal learning,

memory, attention)• Those who had used marijuana by 18 years of age were

2.4 times more likely to develop schizophrenia

Marijuana

• Risks:• Motor vehicle accidents• Impaired respiratory function• Increased risk of cardiovascular disease• Increased risk for psychotic symptoms and disorders

Cocaine• The annual cocaine use reported by high school seniors

decreased more than 30% between 1990 and 2000. • 0.5% of 8th grade, 1% of 10th grade, and 2% of 12th

grade students• Prevalence rates for crack cocaine use, however, is

increasing and is most common among those between the ages of 18 and 25.

Cocaine• Sniffed, snorted, injected, smoked• Crack is the term given to cocaine after it has been

changed to a free base for smoking• Effects:

• constriction of peripheral blood vessels• dilated pupils• hyperthermia • increased heart rate• hypertension

• High doses or prolonged use of cocaine can induce paranoid thinking.

• There is immediate risk of death secondary to cardiac arrest or from seizures followed by respiratory arrest.

Cocaine• In contrast to stimulants used to treat ADHD, such as

methylphenidate, cocaine quickly crosses the blood–brain barrier and moves off the dopamine transporter within 20 minutes; methylphenidate remains bound to dopamine for long periods.

CRACK USERS SHOW HIGH RATES OF ANTISOCIAL PERSONALITY DISORDER, ENGAGEMENT IN ILLEGAL ACTIVITIES AND OTHER PSYCHOSOCIAL PROBLEMS

Paim Kessler FH, Barbosa Terra M, Faller S, Ravy Stolf A, Carolina Peuker A, Benzano D, Pechansky F 

Objectives• To compare three groups of Brazilian psychoactive

substance (PAS) abuse patients in terms of psychiatric comorbidities and severity of psychosocial problems

738 Current PAS abusers

293Crack cocaine

126Powder cocaine

319Non-cocaine PAS

Sixth version of the Addiction Severity Index (ASI-6):

Findings• Crack and powder cocaine users were significantly

younger than non-cocaine PAS users• Crack users presented a higher rate of antisocial

personality disorder (25%) than powder cocaine (9%) and non-cocaine PAS users (9%),

Crack users vs. Non-cocaine PAS users

• ASI-6 summary scores• significantly higher rate of occupational, family, and legal problems

and reported more illegal and violent activities such as burglary and theft (23%) and threatening or assaulting (32%) than non-cocaine PAS users.

Opiods• A survey of 7,374 high school seniors found that 12.9%

reported nonmedical use of opioids. Of users, more than 37% reported intranasal administration of prescription opioids.

• Death from an overdose: respiratory arrest from the respiratory depressant effect

• symptoms of overdose: marked unresponsiveness, coma, slow respiration, hypothermia, hypotension, and bradycardia

Opioids: Adverse Effects

• clinical triad of coma, pinpoint pupils, and respiratory depression• opioid overdose as a primary diagnosis• inspect the patient's body for needle tracks in the arms, legs,

ankles, groin, and even the dorsal vein of the penis

Opioids: Adverse Effects

Heroin• Heroin, a derivative of morphine, is produced from a poppy

plant. • Usually appears as a white or brown powder that can be

snorted, but more commonly, it is used intravenously. • Withdrawal symptoms:

• Restlessness• muscle and bone pain• Insomnia• Diarrhea• Vomiting• Cold flashes with goose bumps• Kicking movements

• Withdrawal occurs within a few hours after use; symptoms peak between 48 and 72 hours later and remit within about a week.

Smyth, B. et al. Years of potential life lost among heroin addicts 33 years after treatment. Preventive Medicine 44(4):369-374, 2007Reduced Longevity Among Male Heroin Abusers, 1962-1997, June 2008, NIDA.

Crystal Methamphetamine• Crystal methamphetamine, or “ice,” was at a relative low

level of use in adolescence about one decade ago of 0.5 percent, and has steadily increased to a recent rate of 1.5 percent among 12th graders.

Lysergic Acid Diethylamide (LSD)• Lysergic acid diethylamide is reportedly used by 2.7% of

8th grade students, 5.6% of 10th grade students, and 8.8% of 12th grade students.

• Of 12th grade students, 0.1% report daily use.

• The current LSD rates are lower than rates of LSD use during the past two decades.

Lysergic Acid Diethylamide (LSD)• LSD is odorless, colorless, and has a slightly bitter taste. Higher

doses of LSD can produce visual hallucinations and delusions and, in some cases, panic.

• The sensations experienced after ingestion of LSD usually diminish after 12 hours. Flashbacks can occur up to 1 year after use.

• LSD can produce tolerance.

• Substance use is related to a variety of high-risk behaviors, including early sexual experimentation, risky driving, destruction of property, stealing, “heavy metal” or alternative music, and, occasionally, preoccupation with cults or Satanism.

• Adolescents with inadequate social skills may use a substance as a modality to join a peer group. In some cases, adolescents begin their substance use at home with their parents, who also use substances to enhance their social interactions.

• Although no evidence indicates what determines a typical adolescent user of alcohol or drugs, many substance users seem to have underlying social skills deficits, academic difficulties, and less than optimal peer relationships.

Club Drugs• MDMA, GHB, Rohypnol, and ketamine. • GHB, Rohypnol (a benzodiazepine), and ketamine (an

anesthetic) are primarily depressants and can be added to drinks without detection because they are often colorless, tasteless, and odorless. DATE RAPE

• MDMA is a derivative of methamphetamine, a synthetic with both stimulant and hallucinogenic properties• can inhibit serotonin and dopamine reuptake• can result in dry mouth, increased heart rate, fatigue, muscle

spasm, and hyperthermia.

3,4-Methylenedioxymethamphetamine (MDMA)• The popularity of MDMA has increased over the last

decade, and current rates of use in the United States are in the range of about 5% for 10th graders and 8% of 12th graders

• Despite that, the perceived harmfulness of this drug has increased over the last decade to almost 50% among 12th graders.

• Accidental adolescent deaths have been associated with the use of MDMA.

3,4-Methylenedioxymethamphetamine (MDMA)

• MDMA is a derivative of methamphetamine, a synthetic with both stimulant and hallucinogenic properties.

• MDMA can inhibit serotonin and dopamine reuptake. MDMA can result in dry mouth, increased heart rate, fatigue, muscle spasm, and hyperthermia.

Gamma-Hydroxybutyrate (GHB)• Gamma-hydroxybutyrate, a club drug, has been found in

surveys to have an annual prevalence rate of 1.1% for 8th graders, 1.0% rate for 10th graders, and a 1.6% rate of use for 12th graders.

Ketamine (Ketalar)• Ketamine, another club drug, was found recently to have

a rate of 1.3% annual prevalence for 8th graders, 2.1% for 10th graders, and 2.5% rate for 12th graders.

Flunitrazepam (Rohypnol)• Flunitrazepam (Rohypnol), a third club drug, has been

found to have an annual prevalence rate of about 1% for all high school grades combined.

Club Drugs• Primarily depressants and can be added to drinks without

detection because they are often colorless, tasteless, and odorless.

• The Drug-Induced Rape Prevention and Punishment Act was passed after these drugs were found to be associated with date rape.

Anabolic Steroids• Despite reported knowledge of the risks of anabolic

steroids among high school students, surveys over the last 5 years found rates of anabolic steroid use to be 1.6% among 8th graders and 2.1 among 10th graders. Up to 45% of 10th and 12th graders reported knowledge of the risks of anabolic steroids; however, over the last decade it appears that high school seniors reported less disapproval of their use.

Anabolic steroids (testosterone containing)

• testosterone-like hormones • exhibit various degrees of anabolic (muscle building) and androgenic (masculinizing) effects

• treatment of hypogonadal men, the wasting syndrome associated with human immunodeficiency virus (HIV) infection, and a few specific diseases such as hereditary angioedema and Fanconi's anemia.

Mode of Action • from cholesterol• eugonadal male: physiological dosages of testosterone has no net gain in testosterone concentrations because exogenously administered AAS shut down endogenous testosterone production via feedback inhibition of the hypothalamic-pituitary-gonadal axis.

• illicit users: supraphysiological effects(10 to 100 times the therapeutic dosages)

• Oral and injected

Inhalants• The use of inhalants in the form of glue, aerosols, and

gasoline is relatively more common among younger than older adolescents. Among 8th grade, 10th grade, and 12th grade students, 17.6, 15.7, and 17.6%, respectively, report using inhalants; 0.2% of 8th grade students, 0.1% of 10th grade students, and 0.2% of 12th grade students report daily use of inhalants.

REVIEW ARTICLE by Edward Press, Alan K. Done

SOLVENT SNIFFING: Physiologic Effects and Community Control Measures for Intoxication from the Intentional Inhalation of Organic Solvents II

• The vapors of a wide variety of organic solvents contained in such products as glues, paint thinner, fingernail polish removers, and cleaning and lighter fluids are being used by juveniles for the deliberate induction of intoxication

• Sniffing provides a chemical escape from reality which is more adaptable, and therefore more readily accepted, by young children than are such other intoxicating practices as alcohol ingestion or the use of narcotic drugs.

• Among sniffers as among all juveniles apprehended by the police, there is a great preponderance of boys over girls, and the majority are in their early "teens,”. Although some are as young as 7 to 8 years of age. Although sniffers usually had prior histories of scholastic under achievement, intelligence per se bore little positive relation to the adoption of the habit.

• In some studies, but not in others, sniffers of toluene have been found to have an

abnormal incidence of vague neurological signs, hepatomegaly, eosinophilia, and, rarely, acute intracranical hypertension.

Multiple Substance Use• Among adolescents enrolled in substance abuse

treatment programs, 96% are polydrug users; 97% of adolescents who abuse drugs also use alcohol.

Genetic Factors• The concordance for alcoholism is reportedly higher

among monozygotic than dizygotic twins. • One twin study of drug users showed that the drug abuse

concordance for male monozygotic twins was twice that for dizygotic twins.

• Studies of children of alcoholics reared away from their biological homes have shown that these children have about a 25 percent chance of becoming alcoholics.

Psychosocial Factors• Among adolescents, substance use, particularly marijuana use, is

strongly influenced by peers, and especially for those adolescents who report using marijuana for relaxation

• Escape from stress and a social activity • There are data to suggest, however, that marijuana use is also

associated with both social anxiety disorder and depressive symptoms.

• Among young adolescents who start using alcohol, tobacco, and marijuana at an early age, data suggest that they often come from families with low parental supervision.

• The risk of early initiation of substances is greatest for children below 11 years of age

Increased parental supervision during middle childhood years may diminish drug and alcohol sampling and ultimately diminish the risk of using marijuana, cocaine, or inhalants in the future.

Comorbidity• higher in relatives of youth with depression and anxiety

disorders• mood disorders are common among those with

alcoholism• strong link between early antisocial behavior, conduct

disorder, and substance abuse

Early intervention with children who show early signs of social deviance and antisocial behavior may conceivably impede the processes that contribute to later substance abuse.

Diagnosis & Clinical Features

• Substance use refers to a maladaptive pattern of substance use leading to clinically significant impairment or distress, manifest by one or more of the following symptoms within a 12-month period:• recurrent substance use in situations that causes physical danger

to the user• recurrent substance use in the face of obvious impairment in

school or work situations• recurrent substance use despite resulting legal problems• recurrent substance use despite social or interpersonal problems.

According to the DSM-5, substance-related disorders include the following three categories:

Diagnosis & Clinical Features

• Substance intoxication refers to the development of a reversible, substance-specific syndrome caused by use of a substance. Clinically significant maladaptive behavioral or psychological changes must be present.

• Substance withdrawal refers to a substance-specific syndrome caused by the cessation of, or reduction in, prolonged substance use. The substance-specific syndrome causes clinically significant distress or impairs social or occupational functioning.

According to the DSM-5, substance-related disorders include the following three categories:

Treatment• Effective screening and identification• Brief intervention motivational interviewing, with the goal

of helping the student to gain motivation for behavioral change; referred for more intensive treatment if needed

• Child and Adolescent Levels of Care Utilization Services (CALOCUS)

Child and Adolescent Levels of Care Utilization Services (CALOCUS)

• Level 0: Basic services (prevention)• Level 1: Recovery maintenance (relapse prevention)• Level 2: Outpatient (once per week visits)• Level 3: Intensive outpatient (2 or more visits per week)• Level 4: Intensive integrated services (day treatment,

partial hospitalization, wraparound services)• Level 5: Nonsecure, 24-hour medically monitored service

(group home, residential treatment facility)• Level 6: Secure 24-hour medical management (inpatient

psychiatric or highly programmed residential facility)

• Cognitive-behavioral approaches to psychotherapy for adolescents with substance use generally require that adolescents be motivated to participate in treatment and refrain from further substance use. The therapy focuses on relapse prevention and maintaining abstinence.

• Psychopharmacological interventions for adolescent alcohol and drug users are still in their early stages.

• Because comorbidity influences treatment outcome, it is important to pay attention to other disorders, such as mood disorders, anxiety disorders, conduct disorder, or ADHD during the treatment of substance use disorders.

Legislation: The legal drinking age and the minimum age of purchase of tobacco is 18 in the Philippines.

Alcohol use: According to 2003 figures, among 18–24 year olds, 7.3% were heavy episodic drinkers (13.6% males and 0.9% females). Youth who were out of school accounted for a greater number of drinkers.

2003–2004 GSHS —18.9% of surveyed students were 13 years old or younger when they had their first drink of alcohol; 23.6% drank alcohol in the past 30 days; and 24.3% had engaged in heavy drinking.