substance use and adolescence
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Substance Use and Adolescence. Edward S. Yuzda, MD, MSc, FRCPC (Psychiatry) Claude Ranger Mental Health Clinic Dec. 9 th /04. Outline. Historical Perspectives Terminology Types of Substances Diagnoses (DSM-IV) Epidemiology Etiology Risk Factors Course and Prognosis Treatment. - PowerPoint PPT PresentationTRANSCRIPT
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Substance Use and Adolescence
Edward S. Yuzda, MD, MSc, FRCPC (Psychiatry)Claude Ranger Mental Health ClinicDec. 9th/04
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Outline
Historical Perspectives Terminology Types of Substances Diagnoses (DSM-IV) Epidemiology Etiology Risk Factors Course and Prognosis Treatment
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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
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Terminology
Drug vs.Substance Legal vs. illegal Addiction Substance Dependence Biological vs. Psychological
Dependence
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Types of Substances
Central Nervous Depressants– Alcohol– Cannabis– Sedative/hypnotics/anxiolytics– Opioid analgesics– Inhalants (ie. Glue/gasoline)
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Types of Substances
Central Nervous Stimulants– Amphetamines– Caffeine– Cocaine– Nicotine– Ecstasy (mixed stimulant/hallucinogen)
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Types of Substances
Hallucinogens– LSD– Mescaline– PCP
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Types of Substances
Other– Gamma hydoxy butyrate (date rape drug)– Nitrite inhalants– Nitrous oxide– Kava– Betel nut– Nutmeg– Antihistamines– Antiparkinsonian drugs
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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
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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
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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
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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?)
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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
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Diagnoses (DSM-IV)
Substance Use Disorders Substance-Induced Disorders
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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
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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
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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
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Epidemiology (cont’d)
Male>Female
Alcohol use : White=Hispanic>Black
Marijuana use: Black>White
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Epidemiology (cont’d)
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%
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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%
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Epidemiology (cont’d)
Cigarette use (in past 30 days)
12th grade – 34%
10th grade – 30%
8th grade – 21%
Daily use
12th grade – 22.2%
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Epidemiology (cont’d)
Illicit drug use (in past 12 months)
12th grade – 40%
10th grade – 38%
8th grade – 24%
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Epidemiology (cont’d)
Marijuana use (in past 12 months)
12th grade – 36%
8th grade – 18%
Daily Marijuana use
12th grade – 5%
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Epidemiology (cont’d)
LSD use (in past 12 months)
12th grade – 9%
8th grade – 4%
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Epidemiology (cont’d)
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%
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Epidemiology (cont’d)
Heroine use (in past 12 months)
12th grade – 1%
8th grade – 1.6%
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Epidemiology (cont’d)
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%
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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
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Etiology
Psychological Cultural Genetic Neurochemical
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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
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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
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Peer-related Risk Factors
Peer substance use Favorable peer attitudes to use Greater orientation of adolescents to
peers as opposed to parents
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Community-related Risk Factors
Low SE status High population density High crime rate
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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
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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
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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
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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
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Clinical indicators of a substance use problem (cont’d)
Historical– Parental use– Estrangement from family– Poor quality relations in the family– Abuse/neglect– Psychiatric disorders– Early age of first use of substances
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Clinical indicators of a substance use problem (cont’d)
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
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Psychiatric Disorders Commonly Associated with Substance use disorders
Oppositional defiant disorder Conduct disorder ADHD Mood disorders Anxiety disorders Bulimia nervosa Schizophrenia Personality disorders
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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
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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
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Treatment (cont’d)
Biological– Supportive medical measures– Treatment of withdrawal symptoms– Replacement pharmacological therapies
(ie. Methadone)– Treat psychiatric co morbidities (ie.
depression/ADHD/ etc.)
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Treatment (cont’d)
Psychological– Twelve step programs (AA/NA)– Motivational interviewing– Cognitive behavioral therapy
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Treatment (cont’d)
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
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Treatment (cont’d)
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
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Q + A