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Adolescent Substance Abuse
Anthony Dekker, D.O.
SWRSAC 2000
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“We live in a decadent age. Young people no longer respect their parents. They are rude and impatient. They frequent taverns and have no self-respect.”
Inscription on Egyptian tombcirca 3000 B.C.
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• “Monitoring the Future” Study:
– NIDA, University of MichiganSince 1975, high school seniorsSince 1991, also 8th & 10th graders
• Those in school use less
• White seniors use > Hispanic > Black
• Peak drug use late 1970s - 1981
ADOLESCENT SUBSTANCE ABUSE
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• 54.7% of seniors had ever used any illicit drug ( 0.6)
• 25.9% used in past month ( 0.3)• 43% believe > 5 drinks 1-2 times a
weekend is risky ()• 25% believe marijuana use once or
twice is risky ()
SUBSTANCE ABUSE TRENDS1999 MONITORING THE FUTURE
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Lifetime 30 days Daily
Alcohol 80.0 51.0 3.4
Cigarettes 64.6 34.6 23.1
Smokeless 23.4 8.4 2.9
tobacco
Marijuana 49.7 23.1 6.0
MONITORING THE FUTURE1999 PREVALENCE OF USE (%)U.S. HIGH SCHOOL SENIORS
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Lifetime 30 days Daily
Stimulants 16.3 4.5 0.3
Inhalants 15.4 2.0 0.2
Hallucinogens 13.7 3.5 0.1
MONITORING THE FUTURE1999 PREVALENCE OF USE (%)U.S. HIGH SCHOOL SENIORS
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Lifetime 30 days Daily
Cocaine 9.8 2.6 0.2
Crack 4.6 1.1 0.2
Heroin 2.0 0.5 0.1
Steroids 2.9 0.9 0.2
Barbiturates 8.9 2.6 0.2
MONITORING THE FUTURE1999 PREVALENCE OF USE (%)U.S. HIGH SCHOOL SENIORS
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• Childhood: parent use and behaviors, attitude, parenting, coping styles, family dysfunction, prevention efforts
• Adolescence: parent use & role-modeling, family expectations, permissiveness, tolerance of teen use & peer group, teen/peer ATOD* use & behaviors; HEADSSS
ANTICIPATORY GUIDANCEFAMILY CONTEXT
* alcohol, tobacco, and other drugs
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• + Family history of alcoholism, addiction or antisocial behavior
• Family modeling of substance use behaviors
• Poor parenting skills, family dysfunction
• Permissive attitude toward teen use household conflict, family chaos
• Child abuse or neglect (physical, sexual)
POTENTIAL RISK FACTORSGENETIC AND FAMILY FACTORS
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interest in school and achievement, early academic failure
self-esteem religious activity• Rebelliousness and social alienation• Early antisocial behavior, delinquency• Psychopathology, esp. depression• Early risk behaviors: ATOD, sex
POTENTIAL RISK FACTORSPERSONAL FACTORS
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• Perceived peer ATOD use, best friend ATOD use
• Ethnic or cultural influences
• Community/neighborhood deterioration/ disorganization
• Easy access, early access
• Advertising and media portrayal
POTENTIAL RISK FACTORSENVIRONMENTAL FACTORS
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• Substance Abuse• Depression• Other Psychological Issues
DIFFERENTIAL DIAGNOSIS FOR A WIDE RANGE OF PSYCHOSOCIAL PATHOLOGY
& ADOLESCENT DYSFUNCTIONS
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• Provider-patient-family trust triangle• Breach
– Presents harm to self or others– Required by law
Maintain privacy and confidentiality
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Provider
privacycommunicationconfidentiality
TRUST RELATIONSHIP
parent child/teen
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• Interview: – relate and just ask
• Tools: – mnemonics and questionnaires:– HEADSSS
• Refer for specific assessment and testing
SCREENING & ASSESSMENT
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Thorough psychosocial history is vital• Confidentiality and informed consent• Indications
– identify user for treatment referral– monitor drug use while under treatment– emergency diagnosis for altered states
• Random, covert or parent requested testing– AAP opposes– adversarial, breaches trust and alliance– does not identify pattern or dependency
URINE DRUG SCREEN
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• Knowledge of techniques, limitations• Urine collection under observation• Urine temp, pH, specific gravity• Legal or forensic
– confidentiality, chain of command– careful labeling, storage– confirmatory testing - GC/MS
URINE DRUG SCREENINSURING ACCURACY
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• Anabolic steroids– p.o. 4 weeks– i.m. 6 weeks
• Amphetamines/ < 48 hours methamphetamines• Barbiturates
– short acting 24 hours– long acting 2-3 weeks
URINE DRUG SCREENDURATION OF DETECTION
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• Cocaine metabolites 2-4 days• Inhalants or LSD undetectable• Marijuana 3-30 days• Methadone 3 days• Opiates 2 days• Phencyclidine 1 week
URINE DRUG SCREENDURATION OF DETECTION
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• PATIENT NOT USING– Affirm decision not to use– Anticipatory guidance
• PATIENT USING/LOWER RISK– State your concern– Elicit patient’s understanding of use. Dispel myths– Assess readiness to change– Negotiate plan and follow up
SYNTHESIS AND PROCESS
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• PATIENT USING/HIGHER RISK– State your concern– Elicit patient’s understanding of use. Dispel myths– Assess readiness to change– Prepare patient/family for referral– Negotiate plan and follow up
SYNTHESIS AND PROCESS
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is an interpersonal interaction whose primary impact is motivational, working to trigger a decision and commitment to change
BRIEF INTERVENTION
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Pre-contemplationContemplation
Action PlanImplementationMaintenance
RecoveryRelapse
MOTIVATIONAL INTERVIEWING
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• is a particular way to help people recognize and do something about their present or potential behavioral problems, including AODA use
• motivates a person to resolve ambivalence and to get moving along the path of change
MOTIVATIONAL INTERVIEWING
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• Express empathy• Develop discrepancy• Avoid argumentation• Roll with resistance• Support self-efficacy
PRINCIPLES OFMOTIVATIONAL INTERVIEWING
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• Practitioner uncertain or inexperienced• Frequent, regular or compulsive use• Concurrent psychopathology• Impaired function: school, legal, work or social (family, peers, etc.)• Certain circumstances: imminent health risk, behavior presents danger to self or
others• Inability to use or maintain abstinence
WHEN IS REFERRAL NEEDED?
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• Local chapter of national groups:– SADD, MADD, NFP, Safe Rides, DARE
• Focus: awareness, education, action– positive peer role-modeling– promote parent involvement– various projects: hotlines, safe rides, lobby, media i.e., SADD “Contract for Life”
COMMUNITY-BASED INITIATIVES
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• Teens more often abuse multiple drugs– smorgasbord vs. drug of choice
• Multiple drug use/overdose effects are more difficult to interpret and treat
• Street drugs often misrepresented– toxic on other than alleged drug– overdose represents drug combination
SUBSTANCE ABUSEGENERAL ISSUES
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• Nicotine effects and addiction, “gateway” drug• Teen users more likely to become smokers• Leukoplakia; various oral cancers: gum, mouth, pharynx, larynx, esophagus• Periodontal disease: gingivitis, recession• Tooth and filling staining, abrasion of teeth, caries, halitosis• Hypertension, vasoconstriction
SMOKELESS TOBACCOHEALTH CONSEQUENCES
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• Solvents– industrial or household– art or office supply
• Gases– in household or commercial products– household aerosol propellants– medical anesthetic gases
• Nitrites– aliphatic nitrites
CATEGORIES OF INHALANTS
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• ACUTE: – anesthesia, intoxication, quick “drunk”– initial excitement turns to drowsiness– disinhibition, lightheaded, agitation, HA– ataxia, dizzy, disoriented, dysarthria, weakness, nystagmus, loss of
consciousness– sensitization to endogenous catecholamines
GENERAL INHALANT EFFECTS
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• CHRONIC: – weight loss– muscle weakness– general disorientation– inattentiveness– lack of coordination
GENERAL INHALANT EFFECTS
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• IRREVERSIBLE: – Hearing loss– Peripheral neuropathies or limb spasms– CNS or brain damage– Hematologic: dyscrasias
ADVERSE INHALANT EFFECTS
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• POTENTIALLY REVERSIBLE: – Renal toxicity– Hepatotoxicity– Respiratory distress– Hematologic: methemoglobenemia
ADVERSE INHALANT EFFECTS
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• Blood oxygen depletion/suffocation• Cardiac toxicity: ventricular fibrillation, arrhythmia, arrest• Gastric content aspiration• Trauma• Nitrite use in HIV+ may risk of Kaposi sarcoma
INHALANT-ASSOCIATED DEATH
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• Synthetic derivatives of testosterone: po, IM• Lay beliefs: muscular capacity, LBM, body fat, strength/endurance, hastens recovery from exercise,
allows more frequent and higher-intensity workouts• Research limited, generally inconclusive• Injection adds risks of hepatitis, HIV
ANDROGENIC ANABOLIC STEROIDS
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HISTORY• Athletic appearing person, physical or psychological
complaint• Obsessive interest in health, exercise, weight lifting• School or work difficulties
DIAGNOSING ANABOLICSTEROID USE
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HISTORY• Behavior changes: aggressiveness (“roid rage”),
hyperactivity, irritability, cyclic mood swings, anxiety, panic, suicidal ideation, auditory hallucination, paranoid/ grandiose delusions
DIAGNOSING ANABOLICSTEROID USE
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HISTORY• Drug history: denies steroid use;
consumes vitamins, nutritional supplements(Creatine); limits other drug use
DIAGNOSING ANABOLICSTEROID USE
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PHYSICAL EXAM• Generally muscular• Paradoxical lack 2o sex characteristics• Female: hirsutism, deep and coarse voice, breast
atrophy, clitoral hypertrophy, acne, male-pattern baldness
DIAGNOSING ANABOLICSTEROID USE
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PHYSICAL EXAM• Male: gynecomastia, testicular atrophy, acne, increased male-pattern
baldness• May complain: sore tendons, difficult voiding• May find: edema, jaundice• Adolescents: premature virilization with stunted growth (epiphyseal closure)
DIAGNOSING ANABOLICSTEROID USE
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HDL, LDL and triglycerides LH, FSH TSH, thyroxin, TBG liver enzymes: alk phos, LDH, SGOT, SGPT glucose hematocrit
ANABOLIC STEROID USEPOSSIBLE LABORATORY EVIDENCE
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• Any psychiatric symptoms/disorders: anxiety, depression, suicidal, paranoid, hallucinations
• Tremors, muscle twitches, seizures• Arrhythmia, MI, CVA, sudden death• Nasal congestion, perforated nasal septum• Nausea, vomiting, abdominal pain• Physical and mental exhaustion
ADVERSE COCAINE EFFECTS