adolescent substance abuse anthony dekker, d.o. swrsac 2000
TRANSCRIPT
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 tombcirca 3000 B.C.
• “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
• 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
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
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
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
• 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
• + 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
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
• 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
• Substance Abuse• Depression• Other Psychological Issues
DIFFERENTIAL DIAGNOSIS FOR A WIDE RANGE OF PSYCHOSOCIAL PATHOLOGY
& ADOLESCENT DYSFUNCTIONS
• Provider-patient-family trust triangle• Breach
– Presents harm to self or others– Required by law
Maintain privacy and confidentiality
Provider
privacycommunicationconfidentiality
TRUST RELATIONSHIP
parent child/teen
• Interview: – relate and just ask
• Tools: – mnemonics and questionnaires:– HEADSSS
• Refer for specific assessment and testing
SCREENING & ASSESSMENT
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
• 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
• 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
• 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
• 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
SYNTHESIS AND PROCESS
is an interpersonal interaction whose primary impact is motivational, working to trigger a decision and commitment to change
BRIEF INTERVENTION
Pre-contemplationContemplation
Action PlanImplementationMaintenance
RecoveryRelapse
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
MOTIVATIONAL INTERVIEWING
• Express empathy• Develop discrepancy• Avoid argumentation• Roll with resistance• Support self-efficacy
PRINCIPLES OFMOTIVATIONAL INTERVIEWING
• 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?
• 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
• 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
• 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
• 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
• 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
GENERAL 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
ADVERSE INHALANT EFFECTS
• 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
• 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
HISTORY• Athletic appearing person, physical or psychological
complaint• Obsessive interest in health, exercise, weight lifting• School or work difficulties
DIAGNOSING ANABOLICSTEROID USE
HISTORY• Behavior changes: aggressiveness (“roid rage”),
hyperactivity, irritability, cyclic mood swings, anxiety, panic, suicidal ideation, auditory hallucination, paranoid/ grandiose delusions
DIAGNOSING ANABOLICSTEROID USE
HISTORY• Drug history: denies steroid use;
consumes vitamins, nutritional supplements(Creatine); limits other drug use
DIAGNOSING ANABOLICSTEROID 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 ANABOLICSTEROID 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)
DIAGNOSING ANABOLICSTEROID USE
HDL, LDL and triglycerides LH, FSH TSH, thyroxin, TBG liver enzymes: alk phos, LDH, SGOT, SGPT glucose hematocrit
ANABOLIC STEROID USEPOSSIBLE LABORATORY EVIDENCE
• 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