Treatment of Substance Abuse in Adolescents CSAM

Transcription

1 Review of Assessment and Treatment of Substance Abuse in Adolescents Marc Fishman MD Johns Hopkins University Dept of Psychiatry Mountain Manor Treatment Center, Baltimore MD CSAM 10/28/10

2 Disclosures Maryland Treatment Centers: equity interest, salary International Center for Health Concerns: consultant Center for Substance Abuse Treatment: treatment grants National Institute on Drug Abuse: research grants Patients and insurance companies: some Patients and insurance companies: some pay, some don t

3 A Whirlwind Survey of Topics Scope of the problem Developmental vulnerability Assessment Treatment and treatment effectiveness Special populations and co-morbidity Opioids Depression ADHD Practical treatment approaches

4 The Public View of Our Patients

5 Scope of the Problem

6 Relationship between Past Month Substance Use and Age Alcohol Use Tobacco Use Binge Alcohol use Any Illicit Drug Use Marijuana Use Source: Dennis (2002) and 1998 NHSDA.

7 The Younger They Start, The Longer They Use usin50%60% ercent still ng P 100% 90% 80% 70% Age of 60% First Use under 15 40% longer 30% % 10% 21+ 0% Years from first use to 1+ years of abstinence Source: Dennis et al., 2005

8 The Sooner we Intervene, The Quicker they get better ercent still usin ng P 100% Years to first 90% Treatment 80% Admission 70% 20 or 60% more 50% 57% years 40% quicker 30% 20% 10 to 19 years 10% 0% 0 to years Years from first use to 1+ years of abstinence Source: Dennis et al., 2005

9 The Growing Incidence of Adolescent Marijuana Use: Adolescent Initiation Rising Adult Initiation Relatively Stable Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: SAMHSA.

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11 Binge Drinking By Age Episodes Per Person Per Year Age Age Age Age Age > 54 Behavioral Risk Factor Surveillance System (CDC telephone survey) - Naimi et al; 2003

12 Heroin Use (MTF) Annual Use Prevalence 8 th and 12 th Graders ( ) 8th Graders 12th Graders nt Perce '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05

13 Non-Medical Prescription Opioid Use MTF: Annual Use Prevalence 12 th Graders, th Graders nt Perce '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05

14 Misuse of Stimulants (MPH) in the General Population: High School Author, Year Population Drug Illicitly Used Percentage Who Used in the Past Year McCabe, th grade students MPH th grade students th grade students 5.0 Grades = A 2.6 Grades = B 3.9 Grades = C 6.4 MPH=methylphenidate. McCabe SE et al. J Adolesc Health. 2004;35:

15 Other substances (Polysubstance use is the rule) Cocaine Methamphetamine Ecstasy Hallucinogens Benzodiazepines Rohypnol Dextromethorphan Steroids Caffeine Nicotine Inhalants Anything else you can think of

16 Proportion of Population In Need Receiving SUD Treatment 30% 25% 20% 15% 10% 5% 0% Age Age Age Age Age Age 65+

17 Developmental Vulnerability

18 Does Development Matter? Probability of Having 1 or More Dependence Symptom(s) as an Adult Based on Age of First Use 30% 25% 20% 15% 10% < > 17 5% 0% Lifetime Tobacco Users Lifetime Alcohol Users Lifetime Marijuana Users Dennis & McGeary. Data from 1995 National Household Survey on Drug Abuse

19 Adolescent Brains and Development Functional development through maturation and morphology Dynamic change through age 25 Synaptic connectivity through experience

20 Developmental Problems Delays in affective regulation: hypertrophy and immaturity of emotional responses Increased adventurousness and excitement-seeking Immaturity in motivation Different sensitivity to intoxication Delays in executive function Treatment = habilitation, not rehabilitation

21 Adolescents have different sensitivity to alcohol intoxication Compared to adults, adolescents show Decreased dysphoria with hangover Decreased sedation, motor impairment with acute intoxication Increased social facilitation with intoxication Increased memory disruption

22 Executive Function: Interference and Impulse Inhibition Name these colors: Yellow Green Blue Red

23 Assessment

24 Screening CRAFFT (1) C- Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? R- Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A - Do you ever use alcohol/drugs while you are by yourself, ALONE?

25 Screening CRAFFT (2) F - Do you ever FORGET things you did while using alcohol or drugs? F - Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? T - Have you gotten into TROUBLE while you were using alcohol or drugs?

26 Evaluation (adolescent elements) Outside informants Developmental trajectory Family context Assets and vulnerabilities Likely role in assisting (or impeding) recovery Peers and adolescent culture Personal assets and goals Therapeutic alliance: as an adult you are one of them

27 Treatment and Treatment Effectiveness

28 Some Evidence Based Substance Abuse Treatment Modalities Motivational enhancement therapy (MET) Cognitive behavioral therapy (CBT) Residential treatments, including short term acute and long term TC Strategic family therapies (MST, MDFT, BSFT) Contingency management Community interventions (assertive, school-based, home-based) Psychiatric assessment and treatment, including medications as needed Juvenile justice mandate and collaboration 12 Step induction

29 Per Quarter r Day ys Abstinent Cannabis Youth Treatment (CYT) Increased Days Abstinent and Percent in Recovery (no use or problems while in community) 90 Days Abstinent 80 Percent in Recovery Intake % 80% 70% 60% 50% 40% 30% 20% 10% 0% % in Reco overy at the End of the Quarter Source: Dennis et al., 2004

30 Alternative Arm Outcomes: Does Treatment Type Matter? Day ys of cann nabis Us se 50 5 Tx Post ttx Tx* Post ttx nce Substan ms (0-16) t Month Problem Past P Months from Intake Months from Intake MET/CBT5 ACRA MDFT 0 * (p<.05)

31 Heroin and Prescription Opioids

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33 Opioids: Prescription analgesics

34 100% ATM Baltimore Site Substance Using Days Heroin Users vs Others 90% 80% Heroin Users 70% Other 60% 50% 40% 30% 20% 10% 0% Baseline 3 Mos. 6 Mos. 9 Mos. 12 Mos.

35 Journal of the Journal of the American Medical Association, 2008

36 CTN Adolescent and Young Adult Buprenorphine Study Opioid Positive Urines: 12 weeks Bup vs Detox (Woody et al, JAMA 2008)

37 Additional youth-relevant substances

38 Inhalants Volatile vapors from household products glue, spray paint, solvents (toluene), propellants, p nitrous oxide, etc Sudden death from arrhythmia and anoxia, bone marrow suppression, seizures hepatotoxicity, delirium, MS-like CNS toxicity

39 Dextromethorphan OTC cough and cold remedies DXM Triple-C Skittles Robo-tripping PCP or ketamine-like NMDA antagonist effect, κ-agonisti t Hallucinations, delirium, HTN, tachycardia, ataxia, agitation, seizures

40 Steroids Athletic performance, body image Oral and injectable Acne, elevated lipids, hepatotoxicity, HTN, severe affective instability, gynecomastia, testicular atrophy

41 Energy drinks Caffeine Insomnia, irritability, withdrawal headaches Severe caffeine toxicity usually self limiting Possible synergistic effects with ETOH

42 Psychiatric Comorbidity

43 Substance Use Severity Related to Other Problems 100% 80% 71% 60% 40% 20% 0% 30% 22% Health Problem Distress* 42% 13% Acute Mental Distress* 25% Past Year Dependence (n=278) * p<.05 Source :Tims FM et al. Addiction. 2002;97(suppl1): % Acute Traumatic Distress* 57% 22% Attention Deficit Hyperactivity Disorder* Other (n=322) 37% Conduct Disorder*

44 Meeting DSM-IV Criteria for Current Psychiatric Disorders * * * * Denotes statistical significance * Denotes approaching significance Results based on The Diagnostic interview for children and adolescents (DICA)

45 Depression

46 Past Year Major Depression Associated with Initiation of Substances 30% 29.2 Past Year 25% MDE 20% No Past Year MDE 15% % Among youth 12-17: Past year initiation of alcohol % Past year initiation of illicit drugs - 7.6% Past year major % depression - 8.8% 0% Initiated Alcohol Initiated Illicit Drugs SAMHSA. National Survey on Drug Use and Health. NSDUH Report 5-07 (2005 data).

47 Depressive Symptoms Correlate with Substance Use Outcomes % Substanc ce using days 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline BDI <11 Baseline BDI > 11 Baseline 3 Mos. 6 Mos. 9 Mos. 12 Mos

48 Reductions in substance use associated with reductions in depression responder non-responder baseline week 9 week 13 week 17 Both Placebo (p<.0001) and Fluoxetine (p<.0003) Responders have significant pre-post reduction whereas Non-Responders in each group do not Responders differ significantly from Non-Responders (p <.02) Riggs et al.

49 Depression Affective instability prominent Depression most common cause (not bipolar) Irritability Lability Over-reactivityreactivity Treatment improves outcome

50 ADHD

51 Onset of Substance Abuse in Untreated ADHD Adults* P <0.05 vs control obability Pr ADHD (n=120) 0.2 Control (n=268) * Retrospectively derived. Wilens TE et al. J Nerv Ment Dis. 1997;185: Age of Onset

52 Medication Treatment for ADHD and Future Drug Use negative positive Huss, 2003 * Barkley, 2002 Molina, 1999 Loney, 1999 * Huss, 1999 Biederman, 1999 * Lambert, Odds Ratio *Indicates P<0.05. Slide courtesy of Dr. Timothy Wilens. Wilens TE et al. Pediatrics. 2003;111:

53 Treatment of attention problems with active substance use ADHD common but differential of inattention broad Depression Intoxication (esp MJ) Demoralization and stress Stimulants improve attention but often problematic Exacerbation of prominent affective instability Very reinforcing

54 Stimulant use for ADHD with co-morbid SUD Treat ADHD, continue stimulants if doing well, but consider other non- stimulant Rx Bupropion SNRIs Use long acting preparations OROS methylphenidate also not crushable Watch for dose escalation

55 Rx Stimulant Use and Substance Abuse in Detroit Middle and High Schools McCabe SE et al. Subst Use Misuse. 2004;39:

56 Practical Treatment Approaches for Adolescents

57 Practical Treatment Approaches 95% is just showing up

58 Developmentally Informed Treatment Practical Approaches Remember that adolescents rely on the support of adults, but also acknowledge striving for autonomy Emphasize adolescent learning styles, using energetic and fun activities while preserving therapeutic content Management of disruptive behavior is expected and essential, balancing limits and looseness Acknowledge normative attraction of thrill-seeking, risk, deviance Emphasize rewards and praise Emphasize prosocial alternatives to drug use Weave a safety net of supports: families (or surrogates) Relationship, relationship, relationship.

59 Practical Treatment Approaches: Maintain Credibility

60 Hypothetical Miracle Cures

61 What we re up against - The culture Drug dealing just to get by Stack your money till it gets sky high Kids sing, kids sing We weren t supposed to make it past 25 Joke s on you we re still alive Throw your hands up in the air, and say We don t care what people say - Kanye West

62 We Need More Treatment!