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Psychopharmacology of Psychopharmacology of Adolescent Addiction Adolescent Addiction

& & Co-Morbid Psychiatric Co-Morbid Psychiatric

Disorders.Disorders.

Dr. Patricia Byrne.Dr. Patricia Byrne.

Lecture OverviewLecture Overview

Part 1 Part 1

Substitution and Detoxification of Substitution and Detoxification of Adolescent Addiction Adolescent Addiction 

Part 2 Part 2

Managing Co-morbid Psychiatric Managing Co-morbid Psychiatric Disorders.Disorders.

Drugs of AbuseDrugs of Abuse

Opiates – Heroin, Morphine, Codeine, Opiates – Heroin, Morphine, Codeine, Methadone.Methadone.

Cocaine, ‘Crack’ cocaine.Cocaine, ‘Crack’ cocaine. Amphetamines – Esctasy, Speed.Amphetamines – Esctasy, Speed. Hallucinogens – LSD, Magic Mushrooms.Hallucinogens – LSD, Magic Mushrooms. Benzodiazepines.Benzodiazepines. Sedative medications – hypnotics, Sedative medications – hypnotics,

antidepressants, antipsychotics.antidepressants, antipsychotics. Cannabis.Cannabis. Alcohol.Alcohol.

OpiatesOpiates Heroin - ‘gear’, ‘smack’, ‘junk’.Heroin - ‘gear’, ‘smack’, ‘junk’. Smoked ‘chasing’, skin popped or intravenous Smoked ‘chasing’, skin popped or intravenous

use ‘banging’.use ‘banging’. Sold in ‘bags’ or else by weight ‘an Sold in ‘bags’ or else by weight ‘an 1/81/8thth (oz)’ (oz)’

Ireland a bag size of pea costs €20 ‘a score’. Ireland a bag size of pea costs €20 ‘a score’. Use can range from ½ bag to 7-9 bags a day.Use can range from ½ bag to 7-9 bags a day. Purity and size of bags differ!!!Purity and size of bags differ!!!‘‘in Scotland the bags were twice as big and three in Scotland the bags were twice as big and three

times as strong..’ &times as strong..’ &‘‘I had to inject in the UK as the stuff wasn’t as I had to inject in the UK as the stuff wasn’t as

good.’good.’

Treatment of Opiate Abuse in Treatment of Opiate Abuse in Adolescents.Adolescents.

1.1. History, M.S.E, Physical exam including History, M.S.E, Physical exam including dentition, Inv. – FBC, LFT, U&E, Viral screen.dentition, Inv. – FBC, LFT, U&E, Viral screen.

2.2. Confirm dependence. – 3 urines at 3-4 day Confirm dependence. – 3 urines at 3-4 day intervals. 6-AM * is a specific metabolite intervals. 6-AM * is a specific metabolite present for about 12 hours after heroin use.present for about 12 hours after heroin use.

3.3. Assess motivation –young person or others?Assess motivation –young person or others?

4.4. Assess supports.Assess supports.

5.5. Treatment plan – biopsychosocial.Treatment plan – biopsychosocial.* 6 - acetyl morphine* 6 - acetyl morphine

SubstitutionSubstitution

Replacing heroin with an alternative agent, Replacing heroin with an alternative agent, aiming for aiming for harm reductionharm reduction..

Substitution strategiesSubstitution strategies– Methadone – opiate agonist.Methadone – opiate agonist.– Buprenorphine – partial opiate agonist.Buprenorphine – partial opiate agonist.– Heroin – some evidence for Heroin – some evidence for adultsadults who fail who fail optimal optimal

MMT > 6 months.MMT > 6 months.– Psychosocial treatments add benefit to opiate Psychosocial treatments add benefit to opiate

replacement, but are not effective on their own.replacement, but are not effective on their own.– Naltrexone (opiate antagonist) first requires Naltrexone (opiate antagonist) first requires

detoxification from opiates.detoxification from opiates.

Methadone Maintenance Methadone Maintenance Treatment (MMT) in Treatment (MMT) in

AdolescentsAdolescents In AdultsIn Adults

– MMT improves health and reduces illicit heroin use, MMT improves health and reduces illicit heroin use, infectious diseases transmission and overdose infectious diseases transmission and overdose death (1).death (1).

– MMT doses 60-100mg/day are more effective in MMT doses 60-100mg/day are more effective in retaining patients and reducing heroin and cocaine retaining patients and reducing heroin and cocaine use during treatment (2) (in an use during treatment (2) (in an opiateopiate dependantdependant population).population).

Licencing – UK ‘adults’, Ireland 18 +, US 18+Licencing – UK ‘adults’, Ireland 18 +, US 18+ Limits evidence base in adolescents – used Limits evidence base in adolescents – used

with caution on basis of clear benefit in adults. with caution on basis of clear benefit in adults.

MMT in AdolescentsMMT in Adolescents

‘‘Full’ opiate agonist, low lethal dose, highly Full’ opiate agonist, low lethal dose, highly dependence forming, long half life. dependence forming, long half life.

Changes in a persons tolerance for opiates Changes in a persons tolerance for opiates occur when commencing treatment, occur when commencing treatment, increasing or decreasing doses.increasing or decreasing doses.

This must be explained as the risk of This must be explained as the risk of overdose is increased at these times.overdose is increased at these times.

If a person missed 2 or more days of MMT If a person missed 2 or more days of MMT their tolerance may have reduced and even a their tolerance may have reduced and even a stable dose must be reviewed and reduced.stable dose must be reviewed and reduced.

MMT in AdolescentsMMT in Adolescents Full informed consent, ensuring they are able to Full informed consent, ensuring they are able to

explain back the risk of overdose. Consent from explain back the risk of overdose. Consent from parent / legal gaurdian.parent / legal gaurdian.

Beware over-reporting of opiate use, Beware over-reporting of opiate use, polysubstance misuse, co-morbid alcohol or polysubstance misuse, co-morbid alcohol or benzodiazepine abuse.benzodiazepine abuse.

Once daily supervised dose, green syrup Once daily supervised dose, green syrup 1mg/1ml. Y.P.P. twice weekly supervised urine 1mg/1ml. Y.P.P. twice weekly supervised urine samples.samples.

Dose - titrate according to signs and symptoms of Dose - titrate according to signs and symptoms of opiate withdrawal. Start low e.g. 20 mg & go opiate withdrawal. Start low e.g. 20 mg & go slow, max increase 10mg a day.slow, max increase 10mg a day.

BuprenorphineBuprenorphine

Licence - UK 16 +years, Ireland >15 years Licence - UK 16 +years, Ireland >15 years under specialist supervision only.under specialist supervision only.

Sublingual tablet – may take 10-15 minutes to Sublingual tablet – may take 10-15 minutes to dissolve.dissolve.

Partial agonist at Partial agonist at receptor, high affinity and receptor, high affinity and slow release. Antagonist for slow release. Antagonist for - reduces - reduces withdrawal symptoms. Eases detoxification?withdrawal symptoms. Eases detoxification?

Partial agonist – improves safety compared to Partial agonist – improves safety compared to methadone, but may not be suitable for those methadone, but may not be suitable for those requiring higher replacement levels (=> 40mg requiring higher replacement levels (=> 40mg methadone)methadone)

‘‘Precipiated Withdrawal’Precipiated Withdrawal’ High affinity – buprenorphine will bind High affinity – buprenorphine will bind

preferentially to opiate receptors over methadone preferentially to opiate receptors over methadone or heroin, displacing them from the receptors. or heroin, displacing them from the receptors.

Partial agonist – lower intrinsic activity at the Partial agonist – lower intrinsic activity at the opiate receptor than heroin or methadone. opiate receptor than heroin or methadone.

If someone takes their first dose of buprenorphine If someone takes their first dose of buprenorphine and they are still under the influence of opiates, and they are still under the influence of opiates, buprenorphine will displace the opiate and bind to buprenorphine will displace the opiate and bind to the receptor. the receptor.

This will result in a sudden drop in activity at the This will result in a sudden drop in activity at the opiate receptor, inducing withdrawal symptoms opiate receptor, inducing withdrawal symptoms after 20-30 minutes.after 20-30 minutes.

Precipiatated WithdrawalPrecipiatated Withdrawal

A person commencing buprenorphine must A person commencing buprenorphine must understand this concept, and should not have understand this concept, and should not have the first dose of buprenorphine within 12-18 the first dose of buprenorphine within 12-18 hours of last heroin use, or within 24 hours of hours of last heroin use, or within 24 hours of last methadone use.last methadone use.

Ideally the person should present in the early Ideally the person should present in the early stages of withdrawal, and be supervised for 1 stages of withdrawal, and be supervised for 1 hour after the first trial dose of 2 mg, after hour after the first trial dose of 2 mg, after which a second dose of 2 mg can be which a second dose of 2 mg can be administered.administered.

BuprenorhineBuprenorhine Once stabilized on buprenorphine a person will Once stabilized on buprenorphine a person will

experience reduced effect of illicit opiate use as experience reduced effect of illicit opiate use as receptors are already bound by buprenorphine.receptors are already bound by buprenorphine.

Half life increases with dose.Half life increases with dose. Low dose (2-4 mg) T ½ 12 hours, high Low dose (2-4 mg) T ½ 12 hours, high

dose (16-32 mg) T ½ 48-72 hours. At higher dose (16-32 mg) T ½ 48-72 hours. At higher doses can be administered every 2 - 3 days doses can be administered every 2 - 3 days (max 36mg at one time).(max 36mg at one time).

Diversion and IV use in Australia & France. Diversion and IV use in Australia & France. Awaiting Buprenorphine / Naloxone preparation.Awaiting Buprenorphine / Naloxone preparation.

Buprenorphine vs MethadoneBuprenorphine vs Methadone

Bell compared treatment retention in Bell compared treatment retention in adolescents with buprenorphine or adolescents with buprenorphine or methadone – MMT appears more methadone – MMT appears more effective at preventing premature drop effective at preventing premature drop out (3).out (3).

Consider opiate tolerance, duration of Consider opiate tolerance, duration of dependence, oral or IV drug use, ability dependence, oral or IV drug use, ability to present close to or in withdrawal.to present close to or in withdrawal.

DetoxificationDetoxification

Withdrawal strategiesWithdrawal strategies1.1. Tapered opioid agonist reduction -Tapered opioid agonist reduction -

Methadone / Buprenorphine.Methadone / Buprenorphine. 2.2. Adrenergic agonists - Clonidine, Adrenergic agonists - Clonidine,

Lofexidine. Reduces withdrawal Lofexidine. Reduces withdrawal symptoms via non opioid mechanisms.symptoms via non opioid mechanisms.

3.3. Opioid antagonist - Naltrexone + Opioid antagonist - Naltrexone + adrenergic agonist (minimal sedation).adrenergic agonist (minimal sedation).

4.4. Opioid antagonist plus heavy Opioid antagonist plus heavy sedation/anesthesia – RRx3 of sedation/anesthesia – RRx3 of complications (4).complications (4).

DetoxificationDetoxification RCT comparing clonidine with buprenorphine. RCT comparing clonidine with buprenorphine.

36 adolescents, 13-18 years, 28 day detox. 36 adolescents, 13-18 years, 28 day detox. (5). (5).

Counselling 3 times weekly, contingency Counselling 3 times weekly, contingency management, all offered treatment with management, all offered treatment with naltrexone following withdrawal.naltrexone following withdrawal.

Retention – 72% bup. vs. 39% clon.Retention – 72% bup. vs. 39% clon. Opiate neg. urines – 64% bup. vs. 32% clon.Opiate neg. urines – 64% bup. vs. 32% clon. HIV risk behaviour –decreased in both HIV risk behaviour –decreased in both

groups (self-report).groups (self-report). Naltrexone started – 61% bup. vs. 5% clon.Naltrexone started – 61% bup. vs. 5% clon.

CocaineCocaine Rapid intoxication, withdrawal effects include Rapid intoxication, withdrawal effects include

depressed mood, lethargy, irritability, anorexia, depressed mood, lethargy, irritability, anorexia, disturbed sleep pattern, craving. disturbed sleep pattern, craving.

Acute use – increases dopamine, serotonin and Acute use – increases dopamine, serotonin and noradrenaline levels by blocking reuptake inhibitors. noradrenaline levels by blocking reuptake inhibitors.

Chronic use leads to depletion of dopamine, and Chronic use leads to depletion of dopamine, and down-regulation of monoamine system.down-regulation of monoamine system.

Treatments complicated by high drop out rates. Treatments complicated by high drop out rates. Dopamine agonists, Carbamazepine, & Dopamine agonists, Carbamazepine, & Antidepressants all tried, no evidence of benefit (6). Antidepressants all tried, no evidence of benefit (6). YPP use MI / CBT, linked to contingency YPP use MI / CBT, linked to contingency management system.management system.

AmphetaminesAmphetamines

Includes amphetamines ‘Speed’ and Ecstasy. Includes amphetamines ‘Speed’ and Ecstasy. ESPAD 2003 survey of 16 year olds: lifetime ESPAD 2003 survey of 16 year olds: lifetime use - < 1% amphetamines, 5-8 % Esctasy. use - < 1% amphetamines, 5-8 % Esctasy.

Cohrane review - Fluoxetine – Short term Cohrane review - Fluoxetine – Short term reduced craving, no effect on use. No reduced craving, no effect on use. No bio/psycho/social treatment has found to be bio/psycho/social treatment has found to be effective (7).effective (7).

Withdrawal – common >80%, intense craving. Withdrawal – common >80%, intense craving. No studies to guide treatment (8).No studies to guide treatment (8).

Psychosis - antipsychotic medications can Psychosis - antipsychotic medications can reduce agitation (9). Treat as psychosis.reduce agitation (9). Treat as psychosis.

BenzodiazepinesBenzodiazepines ‘‘Sleepers, downers, blueys, roche’.Sleepers, downers, blueys, roche’. Often early onset of abuse. Frequently Often early onset of abuse. Frequently

polysubstance misuse.polysubstance misuse. Quantity and type can be measured on urine Quantity and type can be measured on urine

samples.samples. YPP links to contingency management, MI, YPP links to contingency management, MI,

education regarding effects of reducing dose.education regarding effects of reducing dose. Prescribed detoxification in community is difficult as Prescribed detoxification in community is difficult as

easy availability leads to ongoing illicit use. If easy availability leads to ongoing illicit use. If motivated may detox themselves.motivated may detox themselves.

Inpatient detoxification rarely required, Inpatient detoxification rarely required, carbamazepine useful adjunct (10). carbamazepine useful adjunct (10).

Zzzzz drugs…Zzzzz drugs…

Drugs that have sedative properties are Drugs that have sedative properties are open to abuse – zopiclone, zolpidem & open to abuse – zopiclone, zolpidem & zotepine.zotepine.

Sedative antidepressants – e.g. Sedative antidepressants – e.g. mirtazepine (zipsin), dothiepin mirtazepine (zipsin), dothiepin (prothiaden) reports of abuse in MMT (prothiaden) reports of abuse in MMT population.population.

Sedative antipsychotics – e.g. Sedative antipsychotics – e.g. olanzapine, chlorpromazine. olanzapine, chlorpromazine.

CannabisCannabis Hash, blow, weed, skunk …Hash, blow, weed, skunk … Smoked or ingested.Smoked or ingested. Most commonly used illicit drug among Most commonly used illicit drug among

adolescents – ESPAD 2003 survey 16 yr olds, adolescents – ESPAD 2003 survey 16 yr olds, lifetime use 38-40% in RoI and U.K., 20% use in lifetime use 38-40% in RoI and U.K., 20% use in previous 30 days.previous 30 days.

Differing strengths ‘skunk’ or ‘hydro’ have much Differing strengths ‘skunk’ or ‘hydro’ have much higher levels of THC.higher levels of THC.

Early onset use, low percieved harm.Early onset use, low percieved harm. Serious mental health risks – amotivational Serious mental health risks – amotivational

syndrome, RRx2 psychosis, increased with syndrome, RRx2 psychosis, increased with heavier use and earlier age use (11). heavier use and earlier age use (11).

CannabisCannabis No pharmacological treatment options.No pharmacological treatment options. Cochrane Review psychological therapyCochrane Review psychological therapy

– CBT individual & group. CBT individual & group. – Brief individual Motivational Interviewing (MI). Brief individual Motivational Interviewing (MI).

OutcomeOutcome– Brief MI effective in reducing use.Brief MI effective in reducing use.– Extended (9+ sessions) ind. CBT > brief ind. MI.Extended (9+ sessions) ind. CBT > brief ind. MI.– Contingency management (token economy) may Contingency management (token economy) may

improve outcomes in both groups. (12)improve outcomes in both groups. (12) YPP Psycho-education, MI, Contingency YPP Psycho-education, MI, Contingency

Management.Management.

AlcoholAlcohol Alcohol major role in society and peer group Alcohol major role in society and peer group

interactions. Patterns of drinking often binge interactions. Patterns of drinking often binge rather than daily dependence.rather than daily dependence.

ESPAD 2003 16 yr oldsESPAD 2003 16 yr olds RoIRoI UKUK

Lifetime UseLifetime Use 42%42% 47%47%

Binge (>5 drinks) in last 30 daysBinge (>5 drinks) in last 30 days 31%31% 29%29%

Drunkenness > 20 times Drunkenness > 20 times 32%32% 27%27%

AlcoholAlcohol

Non confrontaional approach, explore Non confrontaional approach, explore alternative options for adolescents. alternative options for adolescents.

MI useful in allowing adolescent to MI useful in allowing adolescent to explore effects of alcohol and become explore effects of alcohol and become motivated for chnge. motivated for chnge.

CBT approaches can be used to CBT approaches can be used to recognise high risk situations, problem recognise high risk situations, problem solve and form an individual relapse solve and form an individual relapse prevention plan.prevention plan.

Alcohol TreatmentsAlcohol Treatments In adults AA, 12 step facilitation (TSF) and In adults AA, 12 step facilitation (TSF) and

psychosocial treatments all benefit (13).psychosocial treatments all benefit (13). Adolescents – may be useful, concerns re identity as Adolescents – may be useful, concerns re identity as

an ‘addict’.an ‘addict’. If inpatient stabilization and detoxification required, If inpatient stabilization and detoxification required,

benzodiazepines +/- carbamezepine Need plan of benzodiazepines +/- carbamezepine Need plan of psychosocial support for discharge.psychosocial support for discharge.

Relapse preventionRelapse prevention– Acamprosate – no evidence for adolescent use.Acamprosate – no evidence for adolescent use.– Disulfiram – only 2 case reports in adolescents, Disulfiram – only 2 case reports in adolescents,

11stst abstinent x 4/12, 2 abstinent x 4/12, 2ndnd non-compliant non-compliant (14). (14). Requires high motivation, understanding of Requires high motivation, understanding of adverse effects if drinks – greatly limits use.adverse effects if drinks – greatly limits use.

Co-morbid Pyschiatric Co-morbid Pyschiatric DisordersDisorders

Estimated that 2/3Estimated that 2/3rdsrds of adolescents with Substance of adolescents with Substance Use Disorders (SUD) have co-morbid psychiatratric Use Disorders (SUD) have co-morbid psychiatratric disorder(s).disorder(s).

Increasingly adolescents who present to CAMHS also Increasingly adolescents who present to CAMHS also use/misuse substances.use/misuse substances.

Direction of causality - substance use to self-medicate Direction of causality - substance use to self-medicate distressing symptoms, distressing symptoms, or or psychiatric symptoms as a psychiatric symptoms as a result of substance misuse. Often unclear.result of substance misuse. Often unclear.

Major co-morbid disorders are ADHD, Conduct Major co-morbid disorders are ADHD, Conduct Disorder, Anxiety Disorders, Mood Disorders and Disorder, Anxiety Disorders, Mood Disorders and Psychosis.Psychosis.

Treatment DilemmasTreatment Dilemmas Do we treat SUD or Psychiatric D/O, or both?Do we treat SUD or Psychiatric D/O, or both? Where do we treat – CAMHS or specialist Where do we treat – CAMHS or specialist

adolsecent addiction service?adolsecent addiction service? How do we treat? Limited studies on co-morbid How do we treat? Limited studies on co-morbid

population -> combine evidence for each disorder population -> combine evidence for each disorder to form an individual plan. to form an individual plan.

Pharmacological options limited in adolescents.Pharmacological options limited in adolescents. Adolescents who substance misuse tend to Adolescents who substance misuse tend to

require even higher levels of social and require even higher levels of social and motivational support to engage with motivational support to engage with pharmacological and psychological treatments.pharmacological and psychological treatments.

ADHD & Conduct DisorderADHD & Conduct Disorder

ADHD increases the risk of SUD X 2 (15).ADHD increases the risk of SUD X 2 (15). ADHD/Conduct disorder increases this risk ADHD/Conduct disorder increases this risk

even further – need to diagnose and treat even further – need to diagnose and treat ADHD optimally to prevent complications.ADHD optimally to prevent complications.

Study showed improvement in SUD and Study showed improvement in SUD and ADHD symptoms in adolescents and young ADHD symptoms in adolescents and young adults treated with Methylphenidate (16), and adults treated with Methylphenidate (16), and also study showed improvement in adults with also study showed improvement in adults with childhood onsetchildhood onset ADHDADHD and SUD (17). and SUD (17).

Anxiety DisordersAnxiety Disorders Most common disorder in adolescence. Substance Most common disorder in adolescence. Substance

misuse may be a strong avoiding & reinforcing misuse may be a strong avoiding & reinforcing strategy to self-treat social phobia, GAD, and PTSD. strategy to self-treat social phobia, GAD, and PTSD. If not recognised outcome for both disorders reduced.If not recognised outcome for both disorders reduced.

Anxiety disorders often present with co-morbid Anxiety disorders often present with co-morbid depressive symptoms or disorders. depressive symptoms or disorders.

Consider psychological treatment (MI followed by Consider psychological treatment (MI followed by CBT), treat SUD as appropriate. CBT), treat SUD as appropriate.

If these measures fail, consider fluoxetine with If these measures fail, consider fluoxetine with caution. Avoid paroxetine, venlafaxine & sedative caution. Avoid paroxetine, venlafaxine & sedative agents, and monitor for emergent suicidality. agents, and monitor for emergent suicidality.

Depressive DisorderDepressive Disorder Diagnosis complicated by SUD – ‘primary’ or ‘secondary’. Diagnosis complicated by SUD – ‘primary’ or ‘secondary’.

Depression may also increase the severity of SUD.Depression may also increase the severity of SUD.

Ability to engage in CBT reduced by substance misuse, Ability to engage in CBT reduced by substance misuse, ability to engage in treatment for SUD reduced by low ability to engage in treatment for SUD reduced by low mood.mood.

Study of adolescent inpatients on a dual diagnosis unit - Study of adolescent inpatients on a dual diagnosis unit - 31% MDD, those with ‘secondary depression’ did not remit 31% MDD, those with ‘secondary depression’ did not remit with abstinence (18). with abstinence (18).

Fluoxetine has been shown to reduce depressive symptoms Fluoxetine has been shown to reduce depressive symptoms and SUD in substance abusing adolescents. 3 year follow and SUD in substance abusing adolescents. 3 year follow up suggests worse outcome for MDD than SUD (19). up suggests worse outcome for MDD than SUD (19).

BPADBPAD Very difficult to diagnose in adolescents, especially if Very difficult to diagnose in adolescents, especially if

abusing stimulant drugs.abusing stimulant drugs. Age of onset important – US studies youths with Age of onset important – US studies youths with

adolescent onset BPAD had 8.8 times the risk of SUD adolescent onset BPAD had 8.8 times the risk of SUD compared to youths with Child Onset BPAD (20).compared to youths with Child Onset BPAD (20).

Mood stabilizer response rates in adolescents Mood stabilizer response rates in adolescents Valproate 53%, lithium 38%, carbamazepine 38% Valproate 53%, lithium 38%, carbamazepine 38% (21).(21).

Co-morbid SUD & BPAD – Geller showed improved Co-morbid SUD & BPAD – Geller showed improved overall functioning and reduced SU in double blind overall functioning and reduced SU in double blind placebo study of lithium (22).placebo study of lithium (22).

PsychosisPsychosis

Early onset schizophrenia outcome poor. SUD Early onset schizophrenia outcome poor. SUD worsens short and long term outcome.worsens short and long term outcome.

Major concern is evidence of RR X 2 of Major concern is evidence of RR X 2 of developing psychosis associated with early developing psychosis associated with early onset cannabis use (11).onset cannabis use (11).

Treatment complicated as lack of insight and Treatment complicated as lack of insight and amotivation is a feature of both disorders. amotivation is a feature of both disorders.

Treat psychosis, during periods of remission Treat psychosis, during periods of remission psycho-educate re SUD, use psychological psycho-educate re SUD, use psychological and pharmacological disorders as appropriate.and pharmacological disorders as appropriate.

SUD & Psychiatric Co-SUD & Psychiatric Co-morbidity, a summary…morbidity, a summary…

Always be open to dual diagnosis, use careful Always be open to dual diagnosis, use careful history taking to understand the interaction history taking to understand the interaction between the disorders from the clinical view between the disorders from the clinical view andand the adolescent’s view. the adolescent’s view.

Support the adolescent in becoming Support the adolescent in becoming motivated to engage in treatment.motivated to engage in treatment.

Parallel treatment often required, intense Parallel treatment often required, intense pyschosocial support always required.pyschosocial support always required.

Recommended reading and references Recommended reading and references are included in your delegate pack.are included in your delegate pack.

Thank you.Thank you.