substance use and adolescence

Substance Use and Adolescence

Edward S. Yuzda, MD, MSc, FRCPC (Psychiatry)Claude Ranger Mental Health ClinicDec. 9th/04

Outline

Historical Perspectives Terminology Types of Substances Diagnoses (DSM-IV) Epidemiology Etiology Risk Factors Course and Prognosis Treatment

Historical Perspective

Since the first accidental discovery of beer and wine millennia ago, humankind has utilized substances for their psychoactive properties

The personality of the culture intertwined with and was influenced by the drug of choice for that era

Terminology

Drug vs.Substance Legal vs. illegal Addiction Substance Dependence Biological vs. Psychological

Dependence

Types of Substances

Central Nervous Depressants– Alcohol– Cannabis– Sedative/hypnotics/anxiolytics– Opioid analgesics– Inhalants (ie. Glue/gasoline)

Types of Substances

Central Nervous Stimulants– Amphetamines– Caffeine– Cocaine– Nicotine– Ecstasy (mixed stimulant/hallucinogen)

Types of Substances

Hallucinogens– LSD– Mescaline– PCP

Types of Substances

Other– Gamma hydoxy butyrate (date rape drug)– Nitrite inhalants– Nitrous oxide– Kava– Betel nut– Nutmeg– Antihistamines– Antiparkinsonian drugs

Alcohol

By far the most common cause of substance related disorders in Canada

50% of all fatal MVAs involve alcohol 25% of all suicides involve alcohol 1.5 oz. Spirits = 5 oz. Table wine = 12 oz. Beer = 3

oz. Fortified wine (13.6 grams of alcohol) Intoxication can lead to blackouts/trauma/tolerance/

psychiatric symptoms

Amphetamine and Amphetamine-Like Drugs

Drastic increase in its use in 12-17 year olds over the past decade

Largely due to the popularity of the rave culture and designer rave drugs

Amphetamine related deaths have tripled in the 90’s

Serious psychiatric effects include psychotic symptoms

Caffeine

Most widely used psychoactive substance in the world

Present in pop/OTC medications/ chocolate/’pep’ pills Meets criteria for abuse potential:

– Positive reinforcer– Discriminated from placebo– Tolerance/withdrawal

(yet not recognized by DSM-IV) Largely associated with anxiety disorders

Cannabis

Most common illicit substance Earliest recorded use (500BC) Analgesic/anticonvulsant/hypnotic/anti-glaucoma/

appetite stimulant 5% of people over age 12 have used cannabis within

the past month Use is on the rise after two decades of decrease Good social drug Controversy exists with regards to its psychiatric

adverse effects (psychosis?/amotivation syndrome?)

Nicotine

An overlooked addiction 1 billion users worldwide Second to no other drug in its addictive

potential Use has steadily declined in the Western

world secondary to extensive public education campaigns

Its use is a risk factor for use of other drugs

Diagnoses (DSM-IV)

Substance Use Disorders Substance-Induced Disorders

Substance Use DisordersSubstance Abuse CriteriaA) A maladaptive pattern of substance use leading to clinically

significant impairment or distress, as manifested by any of the following criteria within a 12 month period:

1) symptoms lead to a failure to fulfill a major life role or obligation at work, home school

2) Repeatedly demonstrates intoxication when engaged in hazardous activities

3) Legal problems

4) cont’d use despite recurrent interpersonal/social consequence

B) Never met criteria for substance dependence

Substance Use DisordersSubstance Dependence CriteriaA) Three or more of the following occurring at any time during a

within a 12 month period:

1) Tolerance

2) Dependence

3) Takes larger quantities for longer times

4) Persistent unsuccessful efforts to cut down

5) Great deal of time spent trying to acquire the substance

6) All of daily activities are spent trying to obtain, use or recover from the effects of the substance

7) Cont’d use despite recurrent interpersonal/social problems

Specify with/without physiological dependence

Epidemiology 37% of people report to having used an illicit

substance 66% for people aged 16-25 15% of people over 28 have a serious

substance use problem– 2/3 alcohol– 1/3 other drugs

3.3% of 15 year olds meet criteria for substance abuse or dependence

The total cost of substance use problems is estimated at $200 billion/year

Epidemiology (cont’d)

Male>Female

Alcohol use : White=Hispanic>Black

Marijuana use: Black>White


Use in past 12 months:

Alcohol – 59.6%

Nicotine – 27.6%

Cannabis– 24.9%

LSD – 7.6%

Hallucinogens - 10.1%

Stimulants – 6.6%

Methamphetamine – 3.6%Ecstasy – 3.1%Cocaine – 2.7%Crack – 2.2%PCP – 2.0%Heroin – 1.8%Glue – 1.5%

Epidemiology (cont’d)Alcohol use (in past 12 months)

12th grade – 79.2%10th grade – 71.8%8th grade – 55.3%

Alcohol ‘Drunk’ (in past 12 months)12th grade – 61.8%10th grade – 48.5%8th grade – 26.8%

Alcohol ‘regular use’12th grade – 30.2%10th grade – 24.0%8th grade – 15.6%


Cigarette use (in past 30 days)

12th grade – 34%

10th grade – 30%

8th grade – 21%

Daily use

12th grade – 22.2%


Illicit drug use (in past 12 months)

12th grade – 40%

10th grade – 38%

8th grade – 24%


Marijuana use (in past 12 months)

12th grade – 36%

8th grade – 18%

Daily Marijuana use

12th grade – 5%


LSD use (in past 12 months)

12th grade – 9%

8th grade – 4%


Amphetamine use (in past 12 months)

12th grade – 10%

8th grade – 9%

Methamphetamine use (in past 12 months)

12th grade – 2.8%

Ecstasy use (in past 12 months)

12th grade – 5%


Heroine use (in past 12 months)

12th grade – 1%

8th grade – 1.6%


Cocaine use (in past 12 months)

12th grade – 4.9%

8th grade – 3%

Crack use (in past 12 months)

12th grade – 2.1%

8th grade – 1.8%

Number of people age 12 or older that have used illicit drugs in the past month (U.S.)

10

15

20

25

30

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95

Number of

millions

Year

Etiology

Psychological Cultural Genetic Neurochemical

Individual-related Risk Factors

Early age of onset Presence of early childhood behavioral

problems Poor academic performance Risk-taking behaviors Favorable beliefs about substance use Shorter attention spans Increased impulsivity Increased irritability/emotionality

Family-related Risk Factors

Favorable beliefs about substance use in parents

Parental tolerance of substance use Lack of closeness and attachment

between adolescent and parent Lack of discipline/supervision by parent Parental substance use

Peer-related Risk Factors

Peer substance use Favorable peer attitudes to use Greater orientation of adolescents to

peers as opposed to parents

Community-related Risk Factors

Low SE status High population density High crime rate

Natural History

Most adolescents try ‘gateway’ drugs (such as cigarettes or alcohol) which are legal and more accessible

such ‘gateway’ drugs then can lead to illicit drug use

Evaluation of a substance use problem

Evaluation includes:– Substance-use related behaviors– Observation of other psychiatric problems– School/vocational functioning– Family functioning– Social competency– Leisure activities– Medical status

Clinical indicators of a substance use problem

Psychosocial/behavioral– Change in school performance– Involvement in illegal activities– Sexual acting out (ie. Prostitution)– Increased demands for money– Change in peer group/involvement– Driving under the influence

Clinical indicators of a substance use problem (cont’d)

Medical– Frequent injuries– Suicide attempts– Sudden weight changes– Chronic respiratory symptoms– Gastrointestinal complaints– Insomnia– Infections– Anxiety– Depression– Sexually transmitted diseases


Historical– Parental use– Estrangement from family– Poor quality relations in the family– Abuse/neglect– Psychiatric disorders– Early age of first use of substances


Psychosocial behavioral– Change in school performance– Involvement in illegal activies– Sexual acting out (ie. Prostitution)– Increased demands for money– Change in peer group/involvement– Driving under the influence

Psychiatric Disorders Commonly Associated with Substance use disorders

Oppositional defiant disorder Conduct disorder ADHD Mood disorders Anxiety disorders Bulimia nervosa Schizophrenia Personality disorders

Course and Prognosis

Most adolescents who use substances do not go on to develop problems

Levels of use often peak in late adolescence Life events such as career attainment,

education, marriage, parenthood tend to decrease substance use

Despite such maturational processes, substance use can disrupt the ability of adolescents to negotiate these tasks

Treatment

Young and socially stable patients have a better prognosis

Treatment can be divided into four phases:– Assessment and referral– Detoxification and withdrawal management– Active treatment– Continuing care

Treatment (cont’d)

Biological– Supportive medical measures– Treatment of withdrawal symptoms– Replacement pharmacological therapies

(ie. Methadone)– Treat psychiatric co morbidities (ie.

depression/ADHD/ etc.)


Psychological– Twelve step programs (AA/NA)– Motivational interviewing– Cognitive behavioral therapy


Social– Residential Programs : total control of adolescents

environment– Intensive outpatient programs

Program characteristics associated with better outcomes include: – longer duration of Tx– available follow-up care– family involvement– social services


PreventionDirect vs. General (ie. Public health education

campaigns)

Successful prevention programs:

target salient risk factors

skills-oriented

follow-up available

culturally-oriented towards the targeted community

substance use and adolescence

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