Adolescent Substance Abuse

Anthony Dekker, D.O.

SWRSAC 2000
“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 tomb

circa 3000 B.C.
 ADOLESCENT SUBSTANCE ABUSE

• “Monitoring the Future” Study:

– NIDA, University of Michigan
Since 1975, high school seniors
Since 1991, also 8th & 10th graders
• Those in school use less
• White seniors use > Hispanic > Black
• Peak drug use late 1970s - 1981
 SUBSTANCE ABUSE TRENDS
1999 MONITORING THE FUTURE

• 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 ()
 MONITORING THE FUTURE
1999 PREVALENCE OF USE (%)
U.S. HIGH SCHOOL SENIORS
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 FUTURE
1999 PREVALENCE OF USE (%)
U.S. HIGH SCHOOL SENIORS

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 FUTURE
1999 PREVALENCE OF USE (%)
U.S. HIGH SCHOOL SENIORS
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
 ANTICIPATORY GUIDANCE
FAMILY CONTEXT
• 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 * alcohol, tobacco, and other drugs
 POTENTIAL RISK FACTORS
GENETIC AND FAMILY FACTORS

• + 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 FACTORS
PERSONAL FACTORS
  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 FACTORS
ENVIRONMENTAL FACTORS

• Perceived peer ATOD use, best friend

ATOD use
• Ethnic or cultural influences
• Community/neighborhood deterioration/
disorganization
• Easy access, early access
• Advertising and media portrayal
 DIFFERENTIAL DIAGNOSIS FOR A WIDE
RANGE OF PSYCHOSOCIAL PATHOLOGY
& ADOLESCENT DYSFUNCTIONS

• Substance Abuse
• Depression
• Other Psychological Issues
 Maintain privacy and confidentiality

• Provider-patient-family trust triangle

• Breach
– Presents harm to self or others
– Required by law
 TRUST RELATIONSHIP
Provider

privacy
communication
confidentiality

parent child/teen
 SCREENING & ASSESSMENT

• Interview:
– relate and just ask
• Tools:
– mnemonics and questionnaires:
– HEADSSS
• Refer for specific assessment and testing
 URINE DRUG SCREEN
 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
INSURING ACCURACY
• 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 SCREEN
DURATION OF DETECTION
• 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 SCREEN
DURATION OF DETECTION
• Cocaine metabolites 2-4 days
• Inhalants or LSD undetectable
• Marijuana 3-30 days
• Methadone 3 days
• Opiates 2 days
• Phencyclidine 1 week
 SYNTHESIS AND PROCESS
• 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
• 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
 BRIEF INTERVENTION

is an interpersonal interaction
whose primary impact is
motivational, working to trigger a
decision and commitment to change
MOTIVATIONAL INTERVIEWING
Pre-contemplation
Contemplation
Action Plan
Implementation
Maintenance
Recovery
Relapse
 MOTIVATIONAL INTERVIEWING

• 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
 PRINCIPLES OF
MOTIVATIONAL INTERVIEWING

• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy
 WHEN IS REFERRAL NEEDED?
• 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
 COMMUNITY-BASED INITIATIVES
• 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”
 SUBSTANCE ABUSE
GENERAL ISSUES
• 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
 SMOKELESS TOBACCO
HEALTH CONSEQUENCES
• 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
 CATEGORIES OF INHALANTS
• Solvents
– industrial or household
– art or office supply
• Gases
– in household or commercial products
– household aerosol propellants
– medical anesthetic gases
• Nitrites
– aliphatic nitrites
 GENERAL INHALANT EFFECTS

• 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

• CHRONIC:
– weight loss
– muscle weakness
– general disorientation
– inattentiveness
– lack of coordination
 ADVERSE INHALANT EFFECTS

• IRREVERSIBLE:
– Hearing loss
– Peripheral neuropathies or limb spasms
– CNS or brain damage
– Hematologic: dyscrasias
 ADVERSE INHALANT EFFECTS

• POTENTIALLY REVERSIBLE:
– Renal toxicity
– Hepatotoxicity
– Respiratory distress
– Hematologic: methemoglobenemia
 INHALANT-ASSOCIATED DEATH
• Blood oxygen depletion/suffocation
• Cardiac toxicity: ventricular fibrillation, arrhythmia, arrest
• Gastric content aspiration
• Trauma
• Nitrite use in HIV+ may  risk of Kaposi sarcoma
 ANDROGENIC ANABOLIC STEROIDS
• 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
 DIAGNOSING ANABOLIC
STEROID USE

HISTORY
• Athletic appearing person, physical or psychological
complaint
• Obsessive interest in health, exercise, weight lifting
• School or work difficulties
 DIAGNOSING ANABOLIC
STEROID USE

HISTORY
• Behavior changes: aggressiveness (“roid rage”),
hyperactivity, irritability, cyclic mood swings,
anxiety, panic, suicidal ideation, auditory
hallucination, paranoid/ grandiose delusions
 DIAGNOSING ANABOLIC
STEROID USE

HISTORY
• Drug history: denies steroid use; consumes
vitamins, nutritional
supplements(Creatine); limits other drug use
 DIAGNOSING ANABOLIC
STEROID USE

PHYSICAL EXAM
• Generally muscular
• Paradoxical lack 2o sex characteristics
• Female: hirsutism, deep and coarse voice, breast
atrophy, clitoral hypertrophy, acne, male-pattern baldness
 DIAGNOSING ANABOLIC
STEROID USE
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)
 ANABOLIC STEROID USE
POSSIBLE LABORATORY EVIDENCE
 HDL,  LDL and triglycerides
  LH, FSH
  TSH, thyroxin, TBG
  liver enzymes: alk phos, LDH, SGOT, SGPT
  glucose
  hematocrit
 ADVERSE COCAINE EFFECTS
• 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