Altered States: Altered States: Alcohol and Substance Use Alcohol and Substance Use and Abuse in Adolescentsand Abuse in Adolescents

Jess P. Shatkin, MD, MPHJess P. Shatkin, MD, MPH

Vice Chair for EducationVice Chair for Education

NYU Child Study CenterNYU Child Study Center

Director of Undergraduate StudiesDirector of Undergraduate Studies

Child & Adolescent Mental Health Studies (CAMS)Child & Adolescent Mental Health Studies (CAMS)

New York University College of Arts & ScienceNew York University College of Arts & Science

Associate Professor of Child & Adolescent Psychiatry & Associate Professor of Child & Adolescent Psychiatry & PediatricsPediatrics

New York University School of MedicineNew York University School of Medicine

OutlineOutline Defining Drug Use vs. AbuseDefining Drug Use vs. Abuse Who uses drugs – what do they use and Who uses drugs – what do they use and

when do they start?when do they start? The power of the pressThe power of the press Why drugs are addicting (and the Why drugs are addicting (and the

Dopamine theory)Dopamine theory) Negative health consequences of drug useNegative health consequences of drug use Risk/Protective factorsRisk/Protective factors Monitoring & talking to kids about drugsMonitoring & talking to kids about drugs Guidelines for reasonable choicesGuidelines for reasonable choices

Sexual ActivitySexual Activity

EatingEating

GamblingGambling

Drugs and AlcoholDrugs and Alcohol

When does use become When does use become abuse?abuse?

What constitutes What constitutes ““normalnormal”” substance use?substance use?

The Universal Desire to Alter The Universal Desire to Alter ConsciousnessConsciousness

When does it start?When does it start? What does it look like?What does it look like? What forms does it take?What forms does it take?

What does it mean to be What does it mean to be ““addictedaddicted””??

Addiction: Addiction: a cluster of cognitive, affective, a cluster of cognitive, affective, behavioral, and physiologic signs that behavioral, and physiologic signs that indicate compulsive use of a substance and indicate compulsive use of a substance and inability to control intake despite negative inability to control intake despite negative consequences (e.g., medical illness, failure consequences (e.g., medical illness, failure in life roles, interpersonal difficulties).in life roles, interpersonal difficulties).

Dependence:Dependence: upon cessation of drug, an upon cessation of drug, an individual experiences pathological signs individual experiences pathological signs and symptoms (e.g., tolerance and and symptoms (e.g., tolerance and withdrawal).withdrawal).

And the 2And the 2ndnd Most Traded Most Traded Commodity in the World is…Commodity in the World is…

CAFFEINE!!!CAFFEINE!!!

Costs of Substance AbuseCosts of Substance Abuse EconomicEconomic Alcohol misuse: $167 billionAlcohol misuse: $167 billion Tobacco misuse: $138 billionTobacco misuse: $138 billion Drug Abuse: $110 billionDrug Abuse: $110 billion HealthcareHealthcare Tobacco misuse: $80 billionTobacco misuse: $80 billion Alcohol misuse: $23 billionAlcohol misuse: $23 billion Drug Abuse: $12 billionDrug Abuse: $12 billion Costs disproportionately affect the Costs disproportionately affect the 15-4415-44 age age

group, in contrast to most other costly group, in contrast to most other costly healthcare problems which are concentrated in healthcare problems which are concentrated in the older populationthe older population

– Source: RWJ foundation 2001 based on 1995 estimatesSource: RWJ foundation 2001 based on 1995 estimates

Consequences of Consequences of Adolescent Substance UseAdolescent Substance Use

Association with:Association with: High-risk sexual behavior with increased High-risk sexual behavior with increased

risk ofrisk of– RapeRape– STDsSTDs– Unintended pregnancyUnintended pregnancy

Health Problems: short and long-termHealth Problems: short and long-term Motor vehicle accidentsMotor vehicle accidents SuicideSuicide HomicideHomicide

Preventable Causes of DeathPreventable Causes of Death(McGinnis, JAMA, Nov. 10, 1993)(McGinnis, JAMA, Nov. 10, 1993)

Cause Estimated No. % of total Deaths

Tobacco 400,000 19

Diet/Activity 300,000 14

Alcohol 100,000 5

Microbial Agents 90,000 4

Toxic Agents 60,000 3

Firearms 35,000 2

Sexual Behavior 30,000 1

Motor Vehicles 25,000 1

Illicit Drug Use 25,000 <1

TOTAL 1,060,000 50

How Common is Addiction?How Common is Addiction? 10-20% of the population will at some point 10-20% of the population will at some point

have an addictionhave an addiction Approximately 10% of individuals with Approximately 10% of individuals with

Substance Dependence (including alcohol) Substance Dependence (including alcohol) commit suicide (most often in the context of a commit suicide (most often in the context of a mood disorder)mood disorder)

An estimated 22 million Americans in 2002 An estimated 22 million Americans in 2002 were classified with substance dependence or were classified with substance dependence or abuse (9.4 percent of the total population aged abuse (9.4 percent of the total population aged 12 or older). Of these, 3.2 million were 12 or older). Of these, 3.2 million were classified with dependence on or abuse of both classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not dependent on or abused illicit drugs but not alcohol, and 14.9 million were dependent on or alcohol, and 14.9 million were dependent on or abused alcohol but not illicit drugs.abused alcohol but not illicit drugs.

2002; National Survey on Drug Use and Health 2002; National Survey on Drug Use and Health

EpidemiologyEpidemiology About 9% of adolescents, aged 12 – 17 years, About 9% of adolescents, aged 12 – 17 years,

are classified as needing treatment for are classified as needing treatment for alcohol and substance abuse (SAMHSA, 2010)alcohol and substance abuse (SAMHSA, 2010)

Greater use in adolescence translates into Greater use in adolescence translates into greater use as an adult (e.g., the earlier you greater use as an adult (e.g., the earlier you start, the more likely it is to persist into later start, the more likely it is to persist into later life)life)

Gay, lesbian, and bisexual youth report more Gay, lesbian, and bisexual youth report more SUDS use than heterosexual youthSUDS use than heterosexual youth– Females more likely than males among GLB youth Females more likely than males among GLB youth

to use and males more than females among to use and males more than females among heterosexual youthheterosexual youth

Past Month Illicit Drug UsePast Month Illicit Drug UseBy Age (2002) By Age (2002)

Past Month Illicit Drug UsePast Month Illicit Drug UseBy Age (2010) By Age (2010)

Where Do Kids Use Drugs?Where Do Kids Use Drugs?

Illicit Drug Use (2010)Illicit Drug Use (2010)

An estimated 22.6 million Americans, or 8.9% of the An estimated 22.6 million Americans, or 8.9% of the population aged 12 or older, were illicit drug userspopulation aged 12 or older, were illicit drug users

Marijuana was the most commonly used illicit drug Marijuana was the most commonly used illicit drug with a rate of 6.9% (17.4 million)with a rate of 6.9% (17.4 million)

1.5 million people (0.6%) used cocaine, 25% of 1.5 million people (0.6%) used cocaine, 25% of whom used crackwhom used crack

Hallucinogens were used by 1.2 million people Hallucinogens were used by 1.2 million people (0.5%), over half of whom used Ecstasy(0.5%), over half of whom used Ecstasy

There were an estimated 166,000 current heroin There were an estimated 166,000 current heroin usersusers

An estimated 7 million people, or 2.7% of the An estimated 7 million people, or 2.7% of the population aged 12 or older, abused population aged 12 or older, abused psychotherapeutic drugspsychotherapeutic drugs

SubstanceUse- 2009MTF

8th 10th 12th 8th 10th 12th 8th 10th 12th

Alcohol37% 59% 72% 30% 53% 66% 15% 30% 44%

Cigarettes 20% 33% 44% - - - 7% 13% 20%

Any IllicitSubstance

20% 36% 47% 15% 29% 37% 8% 18% 23%

Cannabis 16% 32% 42% 12% 27% 33% 7% 16% 21%

Amphetamineor meth-Amphetamine

8% 13% 12% 5% 9% 9% 3% 4% 4%

Inhalants 15% 12% 10% 8% 6% 3% 4% 2% 1%

Lifetime Annual 30-day

SubstanceUse- 2009MTF

8th 10th 12th 8th 10th 12th 8th 10th 12th

Tranquilizers4% 7% 9% 3% 5% 6% 1% 2% 3%

Hallucinogens 5% 9% 10% 3% 6% 7% 1.4% 2% 2%

CocaineCrack

7% 11% 14% 4% 6% 8% 2% 2% 3%

MDMA(Ecstasy)

2% 6% 7% 1% 3.7% 4.3% 0.6% 1.3% 1.8%

Steroids 1% 1% 2% 0.8% 0.8% 1.5% 0.5% 0.5% 1%

Heroin 1.3% 1.5% 1.2% 0.7% 0.9% 0.7% 0.4% 0.4% 0.4%

Narcotics (other than heroin)

- - 13% - - 9% - - 4.1%

Lifetime Annual 30-day

Epidemiology (MTF - annual Epidemiology (MTF - annual prevalence of any illicit drug prevalence of any illicit drug

use)use)1979

1992 1997 2007 2009

12th grade

55% 27% 42% 36% 37%

10th grade

20% 39% 28% 29%

8th grade

13% 22% 13% 15%

Epidemiology (MTF - annual Epidemiology (MTF - annual prevalence of cannabis use)prevalence of cannabis use)

1979 1992

1997 2007 2009

12th grade

50% 22% 39% 32% 33%

10th grade

15% 35% 25% 27%

8th grade

7% 18% 10% 12%

Epidemiology (MTF - annual Epidemiology (MTF - annual prevalence of alcohol use)prevalence of alcohol use)

1979 1992

1997 2007 2009

12th grade

77% 75% 66% 66%

10th grade

70% 65% 56% 53%

8th grade

54% 46% 32% 30%

Epidemiology (MTF - annual Epidemiology (MTF - annual prevalence of binge drinking)prevalence of binge drinking)

1979 1992

1997 2007 2009

12th grade

50% 53% 46% 47%

10th grade

37% 41% 34% 31%

8th grade

18% 18% 13% 12%

Epidemiology (MTF - lifetime Epidemiology (MTF - lifetime prevalence of tobacco use)prevalence of tobacco use)

1979 1992

1997 2007 2009

12th grade

74% 62% 65% 46% 44%

10th grade

54% 60% 35% 33%

8th grade

45% 47% 22% 20%

Epidemiology (MTF - 30 day Epidemiology (MTF - 30 day prevalence of tobacco use)prevalence of tobacco use)

1979 1992

1997 2007 2009

12th grade

34% 28% 37% 22% 20%

10th grade

22% 30% 14% 13%

8th grade

16% 19% 7% 6.5%

Epidemiology (MTF - Epidemiology (MTF - annual prevalence of annual prevalence of narcotics other than narcotics other than

heroin)heroin)

1979

1992

1997 2007 2009

12th grade

6% 3% 6% 9% 9%

Epidemiology: Use Epidemiology: Use DisordersDisorders Nationwide diagnostic telephone Nationwide diagnostic telephone

interview (Kilpatrick 2000)interview (Kilpatrick 2000) 4000 adolescents4000 adolescents Among 17 year oldsAmong 17 year olds

– 10% alcohol abuse or dependence10% alcohol abuse or dependence– 7% cannabis abuse or dependence7% cannabis abuse or dependence– 2% 2% ‘‘hard drughard drug’’ abuse or dependence abuse or dependence

12-1712-17– 4% alcohol abuse or dependence4% alcohol abuse or dependence– 4% cannabis abuse or dependence4% cannabis abuse or dependence– 1% 1% ‘‘hard drughard drug’’ abuse or dependence abuse or dependence

Past month tobacco use among youths age 12-17 from 2008 NSDUH

Current Alcohol use among persons aged 12-20 from 2008

NSDUH

And in Europe?And in Europe? European School Survey Project on Alcohol and European School Survey Project on Alcohol and

Other Drugs, 2007Other Drugs, 2007 A large majority of European countries have higher A large majority of European countries have higher

intoxication rates and binge drinking (e.g., 5 or intoxication rates and binge drinking (e.g., 5 or more drinks in a row) rates than the united states.  more drinks in a row) rates than the united states. 

Data collected from 15 and 16 year-olds in 35 Data collected from 15 and 16 year-olds in 35 European countries showed that European European countries showed that European adolescents drink more often, drink more heavily, adolescents drink more often, drink more heavily, and get drunk more often than American and get drunk more often than American adolescents do.  adolescents do. 

In the US, 22% binge drank in the past 30 days; in In the US, 22% binge drank in the past 30 days; in Denmark, that figure was 60%; in Germany 57%; in Denmark, that figure was 60%; in Germany 57%; in Britain 54%; in Italy 34%; and in France 28%.  Britain 54%; in Italy 34%; and in France 28%. 

Intoxication rates for the last 30 days for US Intoxication rates for the last 30 days for US adolescents was 18%, compared with 61% in adolescents was 18%, compared with 61% in Denmark, 53% in Ireland, 48% in Austria, and 46% Denmark, 53% in Ireland, 48% in Austria, and 46% in Britain. in Britain. 

Influence of Early Use (Drugs)Influence of Early Use (Drugs)Dramatic relationship between age Dramatic relationship between age

of first drug use and subsequent of first drug use and subsequent drug abuse/dependence drug abuse/dependence (SAMHSA, (SAMHSA, 2007)2007)

Early first use (Early first use (≤13≤13) ) triples odds triples odds of drug dependence in adulthood of drug dependence in adulthood compared to first use >21compared to first use >21

Strongest predictor of drug use is Strongest predictor of drug use is prior drug useprior drug use

Influence of Early Alcohol Influence of Early Alcohol UseUse Dramatic relationship between age of first alcohol Dramatic relationship between age of first alcohol

use and subsequent alcohol abuse/dependenceuse and subsequent alcohol abuse/dependence

Early first use (Early first use (≤15≤15) ) increases the rate of increases the rate of subsequent alcohol abuse/dependence by subsequent alcohol abuse/dependence by 6 fold6 fold compared to those who first compared to those who first ≥21 (SAMHSA, 2003)≥21 (SAMHSA, 2003)

Each year drinking onset is delayed, risk of Each year drinking onset is delayed, risk of alcohol dependence is reduced by 14%alcohol dependence is reduced by 14%

CONCLUSION: CONCLUSION: If risk factors discovered If risk factors discovered and treated early and drug initiation and treated early and drug initiation delayed delayed adolescent SUDS can be adolescent SUDS can be prevented!prevented!

Percentages of Past Year Alcohol Dependence or Abuse among Adults

Aged 21 or Older, by Age at First Use: NSDUH 2003

Use, Binge Use & Heavy Use, Use, Binge Use & Heavy Use, 20102010

Types of Drugs Used 2002 Types of Drugs Used 2002 (Aged 12 or Older) (Aged 12 or Older)

                                                                                                                                                                                                                                                                                                                                                                       

Use of Selected Illicit Drugs Use of Selected Illicit Drugs among Persons Aged 12 or among Persons Aged 12 or

Older (2002)Older (2002)

Hey, man, should you be Hey, man, should you be driving?driving?

In 2002, an estimated 11 million people In 2002, an estimated 11 million people reported driving under the influence of an reported driving under the influence of an illicit drug during the past year. This illicit drug during the past year. This corresponds to 4.7 percent of the corresponds to 4.7 percent of the population aged 12 or older. The rate was population aged 12 or older. The rate was 10 percent or greater for each age from 17 10 percent or greater for each age from 17 to 25, with 21 year olds reporting the to 25, with 21 year olds reporting the highest rate of any age (18.0 percent). highest rate of any age (18.0 percent). Among adults aged 26 or older, the rate Among adults aged 26 or older, the rate was 3.0 percent. was 3.0 percent.

About 1 in 7 Americans aged 12 or older in About 1 in 7 Americans aged 12 or older in 2002 (14.2 percent, or 33.5 million persons) 2002 (14.2 percent, or 33.5 million persons) drove under the influence of alcohol at least drove under the influence of alcohol at least once in the 12 months prior to the once in the 12 months prior to the interview. interview.

More About DrivingMore About Driving According to a report by the National According to a report by the National

Institute on Drug Abuse, in 2006 30% of high Institute on Drug Abuse, in 2006 30% of high school seniors reported driving after drinking school seniors reported driving after drinking heavily or using drugs, or riding in a car heavily or using drugs, or riding in a car whose driver had been drinking heavily or whose driver had been drinking heavily or using drugs, at least once in the prior 2 using drugs, at least once in the prior 2 weeks. weeks.

Males were more likely than females to drive Males were more likely than females to drive after heavy drinking or marijuana use. after heavy drinking or marijuana use.

Only 20 percent of those students with an A Only 20 percent of those students with an A or A- GPA exposed themselves to these or A- GPA exposed themselves to these situations as opposed to almost 39 percent situations as opposed to almost 39 percent with a GPA of B- or below. with a GPA of B- or below.

Driving Under the Influence of Driving Under the Influence of Alcohol in the Past Year among Alcohol in the Past Year among

Persons Aged 16 or Older, by Age: Persons Aged 16 or Older, by Age: 20102010

MarijuanaMarijuana Marijuana is the most widely used illicit Marijuana is the most widely used illicit

drug, and it is usually the first drug used drug, and it is usually the first drug used by persons who use illicit drugsby persons who use illicit drugs

The number of annual marijuana initiates The number of annual marijuana initiates increased from 1.5 million in 1991 to increased from 1.5 million in 1991 to around 2.5 million from 1996. There has around 2.5 million from 1996. There has been no significant change in the number been no significant change in the number since 1996. An estimated 2.4 million since 1996. An estimated 2.4 million persons used marijuana for the first time persons used marijuana for the first time in 2000, the most recent estimate in 2000, the most recent estimate available. available.

The The ““GatewayGateway”” to Marijuana to Marijuana

First Illicit Drug Used Among New First Illicit Drug Used Among New Initiates Aged 12 and Over, 2010Initiates Aged 12 and Over, 2010

Neurobiology of Specific Drugs of Neurobiology of Specific Drugs of Abuse: Abuse: Addictive SpectrumAddictive Spectrum

Percent who try a drug ever and become Percent who try a drug ever and become dependent:dependent:– Nicotine: 32%Nicotine: 32%– Heroin: 23%Heroin: 23%– Crack, IV cocaine: 23%Crack, IV cocaine: 23%– Intranasal cocaine: 17%Intranasal cocaine: 17%– Alcohol: 15%Alcohol: 15%– Cannabis: 9%Cannabis: 9%– Sedative-Hypnotics: 9%Sedative-Hypnotics: 9%– Psychedelics 4.9%Psychedelics 4.9%– Inhalants: 3.7%Inhalants: 3.7%

Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence onAnthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence ontobacco, alcohol, controlled substances, and inhalants: basic findings from the Nationaltobacco, alcohol, controlled substances, and inhalants: basic findings from the National

Comorbidity Survey. Comorbidity Survey. Exp Clin Psychopharmacol.Exp Clin Psychopharmacol. 1994;2:244-268 1994;2:244-268

Past Month Cigarette Use among Past Month Cigarette Use among Persons Aged 12 or Older, by Age: Persons Aged 12 or Older, by Age:

20102010

The Good News: The Good News: Tobacco Rates are DecliningTobacco Rates are Declining

Marijuana First Use By AgeMarijuana First Use By Age

Mean Age at First Use, 2010Mean Age at First Use, 2010

Prescription DrugsPrescription Drugs More teens abuse prescription drugs than any More teens abuse prescription drugs than any

illicit drug except marijuana. illicit drug except marijuana. 13% of adolescents and 31% of young adults 13% of adolescents and 31% of young adults

report non-medical use of Rx drugs (lifetime, report non-medical use of Rx drugs (lifetime, SAMHSA 2007, NSDUG)SAMHSA 2007, NSDUG)

The majority of teens who abuse prescription The majority of teens who abuse prescription drugs get them easily and for free, primarily from drugs get them easily and for free, primarily from friends and relatives. friends and relatives.

There has been a dramatic increase in the number There has been a dramatic increase in the number of poisonings and even deaths associated with the of poisonings and even deaths associated with the abuse of prescription and OTC drugs. abuse of prescription and OTC drugs.

The prescription drugs most commonly abused by The prescription drugs most commonly abused by teens are painkillers, prescribed to treat pain; teens are painkillers, prescribed to treat pain; sedative-hypnotics, such as sleeping pills or anti-sedative-hypnotics, such as sleeping pills or anti-anxiety drugs; and stimulants, mainly prescribed anxiety drugs; and stimulants, mainly prescribed to treat attention-deficit hyperactivity disorder to treat attention-deficit hyperactivity disorder (ADHD). (ADHD).

Over the Counter DrugsOver the Counter Drugs The cough suppressant dextromethorphan (DXM) is The cough suppressant dextromethorphan (DXM) is

found in more than 140 over-the-counter (OTC) found in more than 140 over-the-counter (OTC) cough and cold medications. cough and cold medications.

Based on SAMHSA's National Survey on Drug Use Based on SAMHSA's National Survey on Drug Use and Health, in 2006 about 3.1 million persons aged and Health, in 2006 about 3.1 million persons aged 12 to 25 (5.3%) had ever abused an over-the-12 to 25 (5.3%) had ever abused an over-the-counter cough and cold medication to get high.counter cough and cold medication to get high.

Among youths aged 12 to 17, females were more Among youths aged 12 to 17, females were more likely than males to have misused OTC cough and likely than males to have misused OTC cough and cold medications in the past year, but among young cold medications in the past year, but among young adults aged 18 to 25, males were more likely than adults aged 18 to 25, males were more likely than females to have misused these medications.females to have misused these medications.

Among persons aged 12 to 25 who had misused an Among persons aged 12 to 25 who had misused an OTC cough and cold medication in the past year, OTC cough and cold medication in the past year, 30.5 percent misused a NyQuil® product, 18.1 30.5 percent misused a NyQuil® product, 18.1 percent misused a Coricidin® product, and 17.8 percent misused a Coricidin® product, and 17.8 percent misused a Robitussin® productpercent misused a Robitussin® product

The Role of Popular MediaThe Role of Popular Media Films devoted principally to drugs or drug Films devoted principally to drugs or drug

rehabilitation have over the past 25 years rehabilitation have over the past 25 years amounted to only 1 to 2 percent of the total amounted to only 1 to 2 percent of the total number of films released, and no upward number of films released, and no upward trend has been observed during the '90s trend has been observed during the '90s

About 10 to 15 percent of movies released About 10 to 15 percent of movies released portray drug use or have drug contentportray drug use or have drug content

People People magazinemagazine has published about 20 has published about 20 articles a year dealing with marijuana, with articles a year dealing with marijuana, with no recent upsurge in frequencyno recent upsurge in frequency

The percentage of articles in The percentage of articles in Rolling Stone Rolling Stone mentioning marijuana use has shown an mentioning marijuana use has shown an upward trend during the 1990s, though it has upward trend during the 1990s, though it has averaged less than 10 percentaveraged less than 10 percent

Welcome to the MoviesWelcome to the Movies

16 of the most popular R-rated films in the mid-1980s contained alcohol 16 of the most popular R-rated films in the mid-1980s contained alcohol use and averaged 16 episodes per film (Greenberg et al, 1993). use and averaged 16 episodes per film (Greenberg et al, 1993).

93% of the 200 most popular video rentals from 1996 – 97 depicted 93% of the 200 most popular video rentals from 1996 – 97 depicted alcohol use, and 22% depicted illicit drugs (Roberts et al, 1999). alcohol use, and 22% depicted illicit drugs (Roberts et al, 1999). – Over one-quarter of these films depicted graphic portrayals of drug preparation and/or Over one-quarter of these films depicted graphic portrayals of drug preparation and/or

ingestion. ingestion. – Few of these movies gave any indication as to the reason for drug use among the Few of these movies gave any indication as to the reason for drug use among the

characters. characters. – Fewer than 50% of the films portrayed short-term consequences of substance abuse, and Fewer than 50% of the films portrayed short-term consequences of substance abuse, and

only 12% depicted long-term consequences. only 12% depicted long-term consequences.

Films between 1960 and 1990 showed characters smoking at a rate of Films between 1960 and 1990 showed characters smoking at a rate of three-times the national average for American adults (Hazan et al, 1994). three-times the national average for American adults (Hazan et al, 1994).

Among the top 25 grossing films each year between 1988 and 1997, over Among the top 25 grossing films each year between 1988 and 1997, over 75% of them contained tobacco use. Likewise, nearly 90% of the 200 most 75% of them contained tobacco use. Likewise, nearly 90% of the 200 most popular movie rentals from 1996 – 97 depicted tobacco use (Roberts et al, popular movie rentals from 1996 – 97 depicted tobacco use (Roberts et al, 1999). 1999). – These films tend to portray smoking in a positive fashion, and the characters who smoke These films tend to portray smoking in a positive fashion, and the characters who smoke

are sexier and more romantic than other characters in the films (McIntosh et al, 1998). are sexier and more romantic than other characters in the films (McIntosh et al, 1998).

Another study reviewed all G-rated animated feature films released Another study reviewed all G-rated animated feature films released between 1937 and 2000 and found that 47% portrayed alcohol use and between 1937 and 2000 and found that 47% portrayed alcohol use and 43% portrayed tobacco use (Thompson and Yokota, 2001). 43% portrayed tobacco use (Thompson and Yokota, 2001).

MusicMusic Primack et al (2008) analyzed the 279 most popular songs of Primack et al (2008) analyzed the 279 most popular songs of

2005 according to Billboard magazine for references to 2005 according to Billboard magazine for references to substance of abuse. substance of abuse.

They found that one in three popular songs contains explicit They found that one in three popular songs contains explicit references to drug or alcohol use. Teenagers listen to an references to drug or alcohol use. Teenagers listen to an average of nearly 2.5 hours of music per day, which means average of nearly 2.5 hours of music per day, which means that they are receiving about 35 references to substance that they are receiving about 35 references to substance abuse for every hour of music they listen to. abuse for every hour of music they listen to.

Whether a song contained a reference to drugs or alcohol Whether a song contained a reference to drugs or alcohol varied by genre. Only 9% of pop songs had lyrics relating to varied by genre. Only 9% of pop songs had lyrics relating to drugs or alcohol, 14% for rock songs, 20% for R&B and hip-drugs or alcohol, 14% for rock songs, 20% for R&B and hip-hop songs, 36% for country songs, and 77% for rap songs. hop songs, 36% for country songs, and 77% for rap songs.

The researchers concluded that the average adolescent is The researchers concluded that the average adolescent is exposed to approximately 84 references to explicit exposed to approximately 84 references to explicit substance use daily in popular songs, and this exposure substance use daily in popular songs, and this exposure varies widely by musical genre. varies widely by musical genre.

The substance use depicted in popular music is frequently The substance use depicted in popular music is frequently motivated by peer acceptance and sex, and it has highly motivated by peer acceptance and sex, and it has highly positive associations and consequences.positive associations and consequences.

Why do people take drugs?Why do people take drugs? They want to feel better, ease physical They want to feel better, ease physical

and emotional painand emotional pain They want to fit in (peer pressure)They want to fit in (peer pressure) They want to challenge parental They want to challenge parental

authority & escape parental pressureauthority & escape parental pressure They want to forget their troublesThey want to forget their troubles They want to relaxThey want to relax They want to satisfy their curiosityThey want to satisfy their curiosity They want to have funThey want to have fun They want to take a risk They want to take a risk The media influenced themThe media influenced them

Dopamine Made Me Do ItDopamine Made Me Do It

They want to increase their Dopamine They want to increase their Dopamine (DA) in the limbic circuit (nucleus (DA) in the limbic circuit (nucleus accumbens)?accumbens)?– DA is a neurotransmitter that helps to DA is a neurotransmitter that helps to

regulate motivation of behaviors necessary regulate motivation of behaviors necessary for survivalfor survival Food intake increases DA, which feels good, so Food intake increases DA, which feels good, so

we seek it outwe seek it out Sexual behavior increases DASexual behavior increases DA Social interaction increases DASocial interaction increases DA And so do drugs of abuse, and this is crucial to And so do drugs of abuse, and this is crucial to

their reinforcing/addictive effectstheir reinforcing/addictive effects

The Limbic SystemThe Limbic System

Dopamine Dopamine NeurotransmissionNeurotransmission

Neurons and ReceptorsNeurons and Receptors

PET Scan TechnologyPET Scan Technology Positron Emission Tomography (PET) Positron Emission Tomography (PET)

scans derive physiological images scans derive physiological images based upon the detection of radiation based upon the detection of radiation from the emission of positronsfrom the emission of positrons

Short half-life radioactive chemicals are Short half-life radioactive chemicals are injected into the person or animal, injected into the person or animal, which are chosen b/c of their affinity for which are chosen b/c of their affinity for a certain part of the body a certain part of the body

These radioactive chemicals then These radioactive chemicals then naturally and rapidly degrade and naturally and rapidly degrade and images are taken, showing images are taken, showing ““hothot”” and and ““coldcold”” spots, which indicate the amount spots, which indicate the amount of physiologic activityof physiologic activity

PET ScannerPET Scanner

D2 Receptor ChangesD2 Receptor Changes

D2 Receptor Decrease D2 Receptor Decrease in Cocaine Addictionin Cocaine Addiction

D2 Receptor Decreases in D2 Receptor Decreases in Drugs of AbuseDrugs of Abuse

Why Does D2 Receptor Density Why Does D2 Receptor Density Matter?Matter?

DA cells turn our attention to what is salient DA cells turn our attention to what is salient (fun, sad, important for survival, aversive, (fun, sad, important for survival, aversive, etc.)etc.)

So, if the D2 density is decreased in drug So, if the D2 density is decreased in drug users, they will then experience less of a users, they will then experience less of a ““signalsignal”” from the firing of DA neurons in a from the firing of DA neurons in a given situation, or…given situation, or…

Natural reinforcers (e.g., food, sex, getting an Natural reinforcers (e.g., food, sex, getting an ““AA ”” on an exam, etc.) are less rewarding than on an exam, etc.) are less rewarding than they would otherwise be b/c the changes in they would otherwise be b/c the changes in DA are not large enough to signal them as DA are not large enough to signal them as salient stimulisalient stimuli

Okay, so which came first?...The Okay, so which came first?...The low receptor density or the low receptor density or the

addiction?addiction?

ConclusionConclusion Low levels of receptors may make Low levels of receptors may make

individuals more vulnerable to taking individuals more vulnerable to taking drugs b/c the experience is pleasant drugs b/c the experience is pleasant (which increases the probability of (which increases the probability of trying it again), or…trying it again), or…

High levels of receptors may protect High levels of receptors may protect against drug abuse b/c the reaction to against drug abuse b/c the reaction to the drugs tends to be aversive (which the drugs tends to be aversive (which decreases the probability of trying it decreases the probability of trying it again)again)

What About Drugs?What About Drugs? Increases in DA in the synapse are 5-10x greater Increases in DA in the synapse are 5-10x greater

with drugs than with natural reinforcerswith drugs than with natural reinforcers Moreover, drugs like cocaine, amphetamine, & Moreover, drugs like cocaine, amphetamine, &

methamphetamine block the reuptake transporter, methamphetamine block the reuptake transporter, so DA stays in the synapse longer than with natural so DA stays in the synapse longer than with natural reinforcersreinforcers

Thus, despite the fact that the number of receptors Thus, despite the fact that the number of receptors is decreased in drug abusers, the probability of is decreased in drug abusers, the probability of interaction between DA and receptors is very large, interaction between DA and receptors is very large, not only b/c the DA concentration is very high but not only b/c the DA concentration is very high but b/c it stays in the synapse longerb/c it stays in the synapse longer

So, the drug abuser learns that while natural So, the drug abuser learns that while natural reinforcers are no longer able to produce a salient reinforcers are no longer able to produce a salient ““feel goodfeel good”” signal, drugs of abuse do; this fact drives signal, drugs of abuse do; this fact drives and motivates subsequent behaviorand motivates subsequent behavior

But is Dopamine Enough But is Dopamine Enough to Explain Addiction?to Explain Addiction?

NoNo If you were to give drugs to a person If you were to give drugs to a person

who is not addicted, you would see an who is not addicted, you would see an increase in DA in his/her brain that increase in DA in his/her brain that would be equal to or even larger than would be equal to or even larger than that seen in the brain of an addicted that seen in the brain of an addicted individualindividual

So, the ability of drugs of abuse to So, the ability of drugs of abuse to increase DA does not by itself explain increase DA does not by itself explain the process of addictionthe process of addiction

So, what other factors are So, what other factors are important?important?

One study looked at rhesus monkeys One study looked at rhesus monkeys each raised in isolation & D2 levels each raised in isolation & D2 levels were measuredwere measured

The monkeys were then placed in a The monkeys were then placed in a group and a social hierarchy was group and a social hierarchy was allowed to developallowed to develop

Dominant monkeys had higher D2 Dominant monkeys had higher D2 levels, but it wasnlevels, but it wasn’’t predetermined t predetermined (e.g., they didn(e.g., they didn’’t have higher D2 levels t have higher D2 levels prior to being placed in the group)prior to being placed in the group)

EnvironmentEnvironment

So, the environment somehow So, the environment somehow triggered higher D2 levels in the triggered higher D2 levels in the dominant monkeysdominant monkeys

By the way, the subordinate animals By the way, the subordinate animals with low D2 receptor density readily with low D2 receptor density readily self-administered high doses of self-administered high doses of cocainecocaine

Other Factors That May Have Other Factors That May Have an Impact Upon Addictionan Impact Upon Addiction

Association with deviant peer groupAssociation with deviant peer group Parental neglectParental neglect History of physical/sexual/emotional abuseHistory of physical/sexual/emotional abuse Low verbal intelligence & educationLow verbal intelligence & education Lower Socioeconomic Background (poverty)Lower Socioeconomic Background (poverty) Neighborhood disorganization & violenceNeighborhood disorganization & violence Parent history of antisocial traitsParent history of antisocial traits Family history of substance abuse/dependenceFamily history of substance abuse/dependence Early first use (<15 y/o)Early first use (<15 y/o) Chronic pain and disabilityChronic pain and disability Psychiatric diagnosisPsychiatric diagnosis

Adolescent VulnerabilityAdolescent Vulnerability Adolescent compared with adult rats are Adolescent compared with adult rats are

less sensitive to the social, motor, sedation, less sensitive to the social, motor, sedation, acute withdrawal, and acute withdrawal, and ““hangoverhangover”” effects of effects of EtOHEtOH– Important b/c these effects serve as cues to Important b/c these effects serve as cues to

limit intake in adultslimit intake in adults In contrast, adolescents appear to be more In contrast, adolescents appear to be more

sensitive to neurotoxic effectssensitive to neurotoxic effects– e.g., greater hippocampal memory deficits, e.g., greater hippocampal memory deficits,

smaller frontal and hippocampal volumes, and smaller frontal and hippocampal volumes, and modification of brain circuitry (increased modification of brain circuitry (increased dendritic spine size, which may stabilize dendritic spine size, which may stabilize addictive behavior)addictive behavior)

Risk Factors for Teen Drug Risk Factors for Teen Drug AbuseAbuse

The younger one is at initiation of drug and alcohol use or The younger one is at initiation of drug and alcohol use or experimentation, the greater the risk for adult abuse and experimentation, the greater the risk for adult abuse and dependence (Chen et al, 2009). dependence (Chen et al, 2009).

Other risk factors include early aggressive behavior, lack of Other risk factors include early aggressive behavior, lack of parental supervision, drug availability, and poverty. parental supervision, drug availability, and poverty. Association with peers who abuse drugs is perhaps the most Association with peers who abuse drugs is perhaps the most robust predictor of adolescent substance abuse (NIDA, 2008; robust predictor of adolescent substance abuse (NIDA, 2008; Rowe et al, 2004). Rowe et al, 2004).

Difficult temperament, lack of self-control, and aggressive Difficult temperament, lack of self-control, and aggressive behavior are risk factors noted in infancy. Family conflict, lack behavior are risk factors noted in infancy. Family conflict, lack of nurturing and attachment, and caregiver drug abuse are of nurturing and attachment, and caregiver drug abuse are also frequently cited as risks for later substance abuse. also frequently cited as risks for later substance abuse.

In addition, individuals who abuse alcohol and drugs have high In addition, individuals who abuse alcohol and drugs have high rates of physical, sexual, and emotional abuse, often live in rates of physical, sexual, and emotional abuse, often live in disorganized and violent neighborhoods, have frequent disorganized and violent neighborhoods, have frequent psychiatric diagnoses, and high rates of chronic pain and psychiatric diagnoses, and high rates of chronic pain and disability. disability.

Rapid, Rapid, earlyearly physical and social changes physical and social changes that create emotion-based motivationsthat create emotion-based motivations

Gradual, Gradual, laterlater development of affect development of affect regulation and maturation of regulation and maturation of cognitive/self-control skillscognitive/self-control skills

Emotional CapacityDrives and emotions, sensation seeking, risk taking, sensitivity to rewards, low self control

Cognitive CapacityPlanning, logic, reasoning, inhibitory control, problem-solving skills, capacity for understanding long-term consequences of behavior

Brain Reward PathwaysBrain Reward Pathways

Source: Messing RO. In: Harrison’s Principles of Internal Medicine. 2001:2557-2561.

•The VTA-nucleus accumbens pathway is activated by all drugs of dependence

•This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex

Ventral tegmental area (VTA)

Nucleus accumbens

Risk Factors: Family & PeersRisk Factors: Family & Peers Chaotic home environments especially Chaotic home environments especially

parentalparentalsubstance use & mental illnesssubstance use & mental illness

Lack of parental monitoring or involvement Lack of parental monitoring or involvement especially with kids with difficult especially with kids with difficult temperaments and conduct disorderstemperaments and conduct disorders

Parental Permissiveness Parental Permissiveness Lack of mutual attachments and nurturingLack of mutual attachments and nurturing Use by siblingsUse by siblings Verbal, physical, emotional abuseVerbal, physical, emotional abuse Peer substance usePeer substance use Affiliation with deviant peer groupAffiliation with deviant peer group

Risk Factors: Risk Factors: Environmental/CulturalEnvironmental/Cultural

Perceptions of approval of drug using Perceptions of approval of drug using behaviors in school, peer, and community behaviors in school, peer, and community environmentsenvironments

Drug availabilityDrug availability Trafficking patternsTrafficking patterns Urban settingsUrban settings HomelessnessHomelessness Low Socioeconomic statusLow Socioeconomic status Media Promotion of useMedia Promotion of use Negative attitude toward youthNegative attitude toward youth Community Codependency and secrecyCommunity Codependency and secrecy

Risk Factors: Life EventsRisk Factors: Life Events

School/academic failureSchool/academic failurePoor social coping skillsPoor social coping skillsAbuse or neglectAbuse or neglectExposure to violenceExposure to violenceVictimization by AssaultVictimization by Assault

Risk and TransitionsRisk and Transitions Most vulnerable periods: transition from Most vulnerable periods: transition from

one developmental stage to anotherone developmental stage to another Elementary Elementary middle school: social middle school: social

challenges (i.e. peers): Likely to encounter challenges (i.e. peers): Likely to encounter drugs for 1drugs for 1stst time time

Entering High school: social, psychological, Entering High school: social, psychological, educational challengeseducational challenges

Other transition risk periods:Other transition risk periods:– Entering college Entering college – Entering workforceEntering workforce– MarriageMarriage

Protective FactorsProtective Factors Strong bonds with familyStrong bonds with family Parental monitoring Parental monitoring

– Clear rules of conduct within the familyClear rules of conduct within the family– Involvement of parents in childrenInvolvement of parents in children’’s livess lives

Success in school performanceSuccess in school performance Strong bonds with pro-social institutionsStrong bonds with pro-social institutions

– FamilyFamily– SchoolSchool– Religions organizations or spiritual practiceReligions organizations or spiritual practice

Exposure to use prevention programsExposure to use prevention programs Adoption of conventional norms about drug Adoption of conventional norms about drug

abuseabuse

Psychiatric ComorbiditiesPsychiatric Comorbidities

Typically run from 50 – 90%Typically run from 50 – 90%– Anxiety 50%Anxiety 50%– Depression 20 – 60%Depression 20 – 60%– ADHD 30 – 60%ADHD 30 – 60%– ODD/Conduct Disorder 40 – 50%ODD/Conduct Disorder 40 – 50%

The Impact of Education on The Impact of Education on Cigarette UseCigarette Use

More About EducationMore About Education

Education is also associated with drug Education is also associated with drug abuseabuse

Illicit drug use is lower for college Illicit drug use is lower for college graduates (5.1%) than those who do not graduates (5.1%) than those who do not graduate from high school (9.3%), high graduate from high school (9.3%), high school graduates (8.6%), and those with school graduates (8.6%), and those with some college (8.9%). some college (8.9%).

By contrast, college graduates are more By contrast, college graduates are more likely to try illicit drugs in their lifetime likely to try illicit drugs in their lifetime than adults who have not completed high than adults who have not completed high school (52% vs. 36%) (SAMHSA, 2008b). school (52% vs. 36%) (SAMHSA, 2008b).

Health Effects of AlcoholHealth Effects of Alcohol DehydrationDehydration Addiction Addiction Accidents and injuryAccidents and injury Depression and psychosisDepression and psychosis UlcersUlcers Cancer of mouth/throat/stomachCancer of mouth/throat/stomach CirrhosisCirrhosis Brain damageBrain damage Pancreatic damagePancreatic damage Decreased fertilityDecreased fertility Fetal alcohol syndromeFetal alcohol syndrome High blood pressureHigh blood pressure Increase risk of breast cancerIncrease risk of breast cancer

““TypesTypes”” of Abusers of Abusers Type A alcoholics have a later onset, fewer childhood risk Type A alcoholics have a later onset, fewer childhood risk

factors, less severe dependence, less psychopathological factors, less severe dependence, less psychopathological dysfunction, and better treatment outcomes than Type B. dysfunction, and better treatment outcomes than Type B.

Type B alcoholics have more childhood risk factors, a Type B alcoholics have more childhood risk factors, a family history of alcoholism, early onset of alcohol related family history of alcoholism, early onset of alcohol related problems, more severe dependence, polydrug use, a more problems, more severe dependence, polydrug use, a more chronic treatment history, greater psychopathological chronic treatment history, greater psychopathological dysfunction, and more stress (Babor et al, 1992)dysfunction, and more stress (Babor et al, 1992)

This typology has been replicated with adult drug abusers, This typology has been replicated with adult drug abusers, suggesting the same impact with early onset drug abuse. suggesting the same impact with early onset drug abuse.

Similarly, the earlier an adolescent begins abusing Similarly, the earlier an adolescent begins abusing substances, the greater the likelihood of conduct problems substances, the greater the likelihood of conduct problems and family dysfunction and the more likely one is to and family dysfunction and the more likely one is to experience chronic problems into adulthood (Zucker et al, experience chronic problems into adulthood (Zucker et al, 1996). 1996).

Health Effects of DrugsHealth Effects of Drugs

Specific to the type of drug, but in general:Specific to the type of drug, but in general:– Brain damageBrain damage– High blood pressureHigh blood pressure– StrokeStroke– Cardiac arrestCardiac arrest– Cancer Cancer – AddictionAddiction– Accidents and injuryAccidents and injury– Depression and PsychosisDepression and Psychosis

Neurotoxicity of DrugsNeurotoxicity of Drugs

Methamphetamine is known to cause Methamphetamine is known to cause cell damage and even DA neuron cell cell damage and even DA neuron cell death in animalsdeath in animals

Methamphetamine abusers are also Methamphetamine abusers are also known to have significant reductions known to have significant reductions in D2 transportersin D2 transporters

The lower the number of D2 The lower the number of D2 transporters, the worse addicts transporters, the worse addicts perform in gross motor speed, fine perform in gross motor speed, fine motor tasks, and memory functionmotor tasks, and memory function

Long-Term Follow-UpLong-Term Follow-Up Long-term follow-up studies of alcoholics have found that Long-term follow-up studies of alcoholics have found that

20% or more eventually become permanently abstinent, 20% or more eventually become permanently abstinent, generally after a major life stressor, such as incarceration generally after a major life stressor, such as incarceration or life-threatening complications related to alcohol abuse. or life-threatening complications related to alcohol abuse.

Relapse rates are particularly high during the first 12 Relapse rates are particularly high during the first 12 months of abstinence (American Psychiatric Association, months of abstinence (American Psychiatric Association, 2000). 2000).

A recent 25-year longitudinal study of adolescents who A recent 25-year longitudinal study of adolescents who began using marijuana prior to 21 years-of-age found that began using marijuana prior to 21 years-of-age found that high levels of cannabis use in adolescence was related to high levels of cannabis use in adolescence was related to worse educational outcomes, lower income, greater welfare worse educational outcomes, lower income, greater welfare dependence and unemployment, and less relationship and dependence and unemployment, and less relationship and general life satisfaction (Fergusson and Boden, 2008). general life satisfaction (Fergusson and Boden, 2008).

All manner of risky behavior, including early sexual activity, All manner of risky behavior, including early sexual activity, accidents and motor vehicle accidents, violence, and accidents and motor vehicle accidents, violence, and school drop-out, are more common among teens who school drop-out, are more common among teens who abuse drugs and alcohol (Weinberg et al, 1998).abuse drugs and alcohol (Weinberg et al, 1998).

Is there recovery?Is there recovery?

After about 9 months of After about 9 months of detoxification (abstinence), addicts detoxification (abstinence), addicts seem to recover roughly their full seem to recover roughly their full complement of D2 receptorscomplement of D2 receptors

There is a less marked trend, There is a less marked trend, however, toward recovery of motor however, toward recovery of motor and memory functionand memory function

Hey, what about smoking?Hey, what about smoking?

Nicotine is known to be highly addictiveNicotine is known to be highly addictive Smokers have a higher probability of Smokers have a higher probability of

developing lung cancer, along with many developing lung cancer, along with many other cancers (numerous carcinogens other cancers (numerous carcinogens have been found in cigarette smoke)have been found in cigarette smoke)

PET scans have been used to measure PET scans have been used to measure levels of monoamine oxidase, which helps levels of monoamine oxidase, which helps the brain to metabolize catecholamines the brain to metabolize catecholamines and helps the body to detoxify substancesand helps the body to detoxify substances

Assessment of Substance Assessment of Substance UseUse

Less than half of pediatricians screen Less than half of pediatricians screen adolescents for tobacco, EtOH, and adolescents for tobacco, EtOH, and drug usedrug use

Fewer than one-quarter of Fewer than one-quarter of pediatricians report that they are pediatricians report that they are comfortable asking about these issues comfortable asking about these issues

No similar studies of child and No similar studies of child and adolescent psychiatristsadolescent psychiatrists

– Halperin-Felsher et al, 2000; Price et al, 2001Halperin-Felsher et al, 2000; Price et al, 2001

Assessment of Substance Use Assessment of Substance Use (2)(2)

Simply asking about the frequency and Simply asking about the frequency and quantity of use has not shown great quantity of use has not shown great validityvalidity

Asking about use (yes/no) can be Asking about use (yes/no) can be effective but not for quantity of useeffective but not for quantity of use

Well designed and validated self-report Well designed and validated self-report measures are better screeners for measures are better screeners for problem severityproblem severity

Screening ToolsScreening Tools CRAFFTCRAFFT

– Public domainPublic domain– 6 items6 items– Administered verbally during routine visitAdministered verbally during routine visit

C – Have you ever gotten into a C – Have you ever gotten into a carcar driven by someone (including yourself) driven by someone (including yourself) who was who was ““highhigh”” or using EtOH or drugs? or using EtOH or drugs?

R – Do you use EtOH or drugs to R – Do you use EtOH or drugs to relaxrelax?? A – Do you ever use EtOH or drugs A – Do you ever use EtOH or drugs

while you are by yourself, while you are by yourself, alonealone??

CRAFFT continued…CRAFFT continued… F – Has any F – Has any friendfriend, , family memberfamily member, or , or

other person ever thought you had a other person ever thought you had a problem with EtOH or drugs?problem with EtOH or drugs?

F – Do you ever F – Do you ever forgetforget (or regret) things (or regret) things you did while using?you did while using?

T – Have you ever gotten into T – Have you ever gotten into troubletrouble while using EtOH or drugs, or done while using EtOH or drugs, or done something you would not normally do something you would not normally do (break the laws, rules or curfew; engage (break the laws, rules or curfew; engage in risk behavior to you or others)?in risk behavior to you or others)?

Warning Signs (1) Warning Signs (1) Changes in school performance Changes in school performance

– Falling gradesFalling grades– Skipping SchoolSkipping School– TardinessTardiness

Changes in peer groupChanges in peer group– Hanging out with drug-using, antisocial, older Hanging out with drug-using, antisocial, older

friendsfriends Breaking Rules: home, school, communityBreaking Rules: home, school, community Affect changes: Mood swings, depression, irritability, Affect changes: Mood swings, depression, irritability,

anger, negative attitudeanger, negative attitude Activity Level: Sudden increases or decreasesActivity Level: Sudden increases or decreases Withdrawal from family: secretivenessWithdrawal from family: secretiveness Changes in physical appearanceChanges in physical appearance

– Weight lossWeight loss– Lack of cleanlinessLack of cleanliness– Strange smellsStrange smells

Warning Signs (2) Warning Signs (2) Eyes: red, watery, glassyEyes: red, watery, glassy Nose: runny and not due to allergies or Nose: runny and not due to allergies or

coldcold Eating/Sleeping habits: changesEating/Sleeping habits: changes Decreased motivation in pleasure teen Decreased motivation in pleasure teen

activities: sports, hobbiesactivities: sports, hobbies Anti-social behavior: lying, stealingAnti-social behavior: lying, stealing Using street or drug languageUsing street or drug language Possession of drug paraphernaliaPossession of drug paraphernalia Cigarette SmokingCigarette Smoking

Warning Signs (3) Warning Signs (3)

Initiation of drug use before 12 or Initiation of drug use before 12 or 1313

Daily or weeks use of at least one Daily or weeks use of at least one drugdrug

Poly-drug usePoly-drug use

Sources of Adolescent SUDS Sources of Adolescent SUDS Treatment ReferralsTreatment Referrals

Criminal Justice System: 44%Criminal Justice System: 44%School/Community Agency: School/Community Agency:

22%22%Self/Family: 17%Self/Family: 17%Substance abuse treatment Substance abuse treatment

agency: 5%agency: 5%Other Health care provider: 5%Other Health care provider: 5%Other: 16%Other: 16%

Treatment of AddictionTreatment of Addiction The five key steps:The five key steps:

(1)(1) DetoxificationDetoxification

(2)(2) Inpatient hospitalizationInpatient hospitalization

(3)(3) Therapeutic CommunityTherapeutic Community(a)(a) Isolate, learn to cope, function, socializeIsolate, learn to cope, function, socialize

(b)(b) E.g., Wilderness programs (increasing admissions)E.g., Wilderness programs (increasing admissions)

(c)(c) Therapeutic community sees SUDS as a behavioral and Therapeutic community sees SUDS as a behavioral and personality problem and community as the change agentpersonality problem and community as the change agent

(4)(4) ……or…Minnesota Modelor…Minnesota Model(a)(a) Incorporates individual and group psychotherapy (e.g., AA)Incorporates individual and group psychotherapy (e.g., AA)

(b)(b) MM views SUDS as a disease and the counselor as the MM views SUDS as a disease and the counselor as the treatment directortreatment director

(5)(5) Outpatient treatmentOutpatient treatment(1)(1) Family/group/individual therapy; ER/crisis Family/group/individual therapy; ER/crisis

(6)(6) Self-help programsSelf-help programs

Family TherapyFamily Therapy Many forms have proven efficacious Many forms have proven efficacious

(Deas, 2008; Liddle et al, 2009; (Deas, 2008; Liddle et al, 2009; Santisteban et al, 2006):Santisteban et al, 2006):– Multidimensional Family TherapyMultidimensional Family Therapy– Brief Strategic Family TherapyBrief Strategic Family Therapy– Multisystemic TherapyMultisystemic Therapy– Purdue Brief Family TherapyPurdue Brief Family Therapy– Various forms of family therapy Various forms of family therapy

integrated with Cognitive Behavior integrated with Cognitive Behavior Therapy (CBT)Therapy (CBT)

Motivational InterviewingMotivational Interviewing MI is a brief treatment designed to increase an MI is a brief treatment designed to increase an

individualindividual’’s motivation to make changes about s motivation to make changes about substance abuse and aspects of his life that substance abuse and aspects of his life that trigger or perpetuate SUDStrigger or perpetuate SUDS

Successful with teens and adultsSuccessful with teens and adults 4 major therapeutic principles:4 major therapeutic principles:

(1)(1) Employ empathy to listen and accept the individualEmploy empathy to listen and accept the individual

(2)(2) Develop discrepancy between his behavior and his Develop discrepancy between his behavior and his greater values and goals as a way to motivate changegreater values and goals as a way to motivate change

(3)(3) Roll with resistance and do not argue with the patient Roll with resistance and do not argue with the patient or directly oppose the resistance; rather reframe the or directly oppose the resistance; rather reframe the resistance to create a new perspectiveresistance to create a new perspective

(4)(4) Support self-efficacy by encouraging the patientSupport self-efficacy by encouraging the patient’’s s belief in himselfbelief in himself

Self-Help ProgramsSelf-Help Programs

AA is the prototypicalAA is the prototypical Problems with 12-step programs in Problems with 12-step programs in

adolescents:adolescents:(1)(1)Rely upon voluntary participationRely upon voluntary participation

(2)(2)First step (admission of powerlessness)First step (admission of powerlessness)

(3)(3)Hitting Hitting ““rock bottomrock bottom””

Pharmacologic Treatments Pharmacologic Treatments AlcoholAlcohol

– Disulfiram: Behavior de-conditioningDisulfiram: Behavior de-conditioning– Naltrexone (oral and Vivitrol): blunts reward cravingNaltrexone (oral and Vivitrol): blunts reward craving– Acamprosate: blunts relief cravingAcamprosate: blunts relief craving– Others to consider (non-FDA approved: Topiramate, Others to consider (non-FDA approved: Topiramate,

BaclofenBaclofen TobaccoTobacco

– Replacement therapiesReplacement therapies Nicotine Replacement Therapies: short-acting (ie. Nicotine Replacement Therapies: short-acting (ie.

gum, inhalers); long-acting (i.e. patch)gum, inhalers); long-acting (i.e. patch) Varenicline: long-acting partial alpha4, beta2 Varenicline: long-acting partial alpha4, beta2

nicotinic cholinergic receptor (NAR) agonistnicotinic cholinergic receptor (NAR) agonist– OtherOther

Wellbutrin: increased DA/NE & NAR antagonist and Wellbutrin: increased DA/NE & NAR antagonist and works independent of anti-depressant propertiesworks independent of anti-depressant properties

Non-FDA approved: Clonidine, NortryptilineNon-FDA approved: Clonidine, Nortryptiline

Pharmacologic Treatments Pharmacologic Treatments OpiatesOpiates

– Replacement therapiesReplacement therapiesMethadone: long acting mu agonistMethadone: long acting mu agonistBuprenorphine: long-acting partial Buprenorphine: long-acting partial mu agonist; kappa antagonistmu agonist; kappa antagonist

– Non-opioid treatmentsNon-opioid treatmentsClonidineClonidineNaltrexoneNaltrexone

Treatment OutcomesTreatment Outcomes Predictors of RelapsePredictors of Relapse

– Higher rates than for adultsHigher rates than for adults– Peer influencePeer influence– Lack of pro-social activitiesLack of pro-social activities– Drug cravingDrug craving

Predictors of SuccessPredictors of Success– Parental involvementParental involvement– Compliance with after-careCompliance with after-care– Treatment CompletionTreatment Completion

Treatment OutcomesTreatment Outcomes Across all types of treatment programs, Across all types of treatment programs,

both inpatient and outpatient, slightly both inpatient and outpatient, slightly more than 1/3 of adolescents maintain more than 1/3 of adolescents maintain abstinence at 6 months and slightly less abstinence at 6 months and slightly less than 1/3 after 12 monthsthan 1/3 after 12 months

Factors most closely related to good Factors most closely related to good outcome include completing the outcome include completing the treatment program, low pretreatment treatment program, low pretreatment substance use, and peer, parent, and substance use, and peer, parent, and social support of nonusesocial support of nonuse

(Williams and Chang, 2000)(Williams and Chang, 2000)

"All substances are poisons; there is none which is not a poison. The right dose differentiates a poison…."

--Paracelsus (1493-1541)

Guidelines for Reasonable Guidelines for Reasonable ChoicesChoices