Engaging Youth in Treatment in The New Era of Legalized Marijuana

Transcription

1 Engaging Youth in Treatment in The New Era of Legalized Marijuana James McKowen, PhD Clinical Director Addiction Recovery Management Service (ARMS) Department of Psychiatry, Harvard Medical School Massachusetts General Hospital

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

3 Scenario I: Johnny Smith: 16 y/o high school student Caught at school with weed for 2 nd time Smokes several times a week (probably more) Sells to his friends Not doing great at school, misses classes, doesn t do homework Disrespectful at home, doesn t care about Football practice anymore, changed friend group Sees no problems with weed or smoking Teachers and parents see changes in his personality

4 Scenario II: Malika Jones: 17 y/o HS student On Saturday night, Dad smelled pot in her room when she had a sleep over with two friends Malika doesn t think pot is that big of a deal Doing pretty well in school, on varsity swim team, has good friends Some moodiness a few times a month, seems less close with mom recently Malika s older brother had a problem with alcohol in college

5 What to do? Do we respond to these two scenario s the same? Are they right? Is weed that big of a deal for a teen? Cannabis is legal in MA, does this matter? What should parents do? Are there any treatments that can help?

6 My favorite quotes from teens: It s not a drug, it s a plant. It s legal, and your generation smoked tons of it. It s not addictive anyway It s a medicine so can t be that bad. Everyone smokes it. You should try it!

7 What to do? Are they right? Is weed that big of a deal for a teen?

8 Cannabis use is common SAMHSA, 2017

9 Past month use by age group

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12 Percent of users who Become addicted Prevalence of Dependence by drug use type Comparative Prevalence of Dependence Among Different Drug Users % 5 0 Tobacco Heroin Cocaine Alcohol Stimulant Cannabis Analgesics Pshychedelics * * Source: Anthony et al. Exp. Clin. Psychopharmacol. 2(3), pp (1994)

13 And cannabis use is more addictive for teens 17% Slide courtesy of John K. Kelly

14 Marijuana plants have been bred to be significantly more potent Volkow 2014

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16 Adolescent marijuana use is inversely related to perceived risk Volkow 2014

17 Vulnerability of the teen brain

18 THC receptors in brain

19 Drugs Can be Chemical Imposters (THC mimics a natural brain chemical) Brain s Chemical Drug Anandamide THC

20 Longitudinal Impacts: NZ Study

21 Effects of THC on Brain Structure: Animal Studies Structural changes occur in brain regions after exposure to THC, especially in the nucleus accumbens (NAc) Kolb et al, Synapse 2006

22 307 depressed outpatients using and not using cannabis 40.7% had used cannabis in the 30 days prior to the study start depression sxs cannabis use over 6 months of tx Cannabis use improvement in depression and anxiety during 6 months of tx No differences in trajectories according to whether patients used cannabis medically or recreationally Bahorik, et al., 2017

23 % with schizophreniform disorder at age 26 Adolescent Cannabis Use Increases the Risk for Adult Psychosis in Genetically Vulnerable Individuals no adolescent cannabis use adolescent cannabis use Met/Met Val/Met Val/Val COMT Genotype Source: Caspi, A. et al., Biol. Psychiatry, 57: ; 2005.

24 Marijuana and Aggression Anecdotal in clinic Yes Data is mixed White, 1998: 4 waves of data assessed 12 y/o 28 years Adolescent MJ predicted later aggression Early aggression didn t predict later MJ use Lui, 2013: Early aggression, in boys, predicts MJ use only Ansell, 2015: Smarphone readings: MJ and Aggression not related During withdrawal phase: more supportive data: Budney, 2003: During withdrawal peak 2-6 days up to 20 days Millin 2008: y/o, anger increased in 1 st two weeks, up to 3 rd week.

25 What to do? Cannabis is legal in MA, does this matter?

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27 Does legalization affect use?

28 What about states post-legalization?

29 Review: Medical MJ & Youth Mixed data on medical MJ Pacula et al, 2015 & Anderson et al, Mixed evidence if increases use among teens - Teens do access medical MJ - Price tended to fall as much as 25-40% - Decrease alcohol consumption used inter-changeably - Increased traffic accidents w/ combo alcohol and MJ - Use of other drugs unclear. Not long enough to know for recreational

30 What to do? What should parents do?

31 Substance Use Patterns are on a Continuum On a weekly or more regular basis Limited Use Regular Use Problematic Use Use Disorder Infrequent and in social settings Emergence of a pattern of use

32 Substance Use Disorder Severity Diagnosis of mild, moderate, or severe substance use disorder is based on the number of criteria endorsed over past year Mild (2 to 3) Moderate (4 to 5) Severe (6+)

33 Typical Warning Signs: Changes in moodiness, irritability, anger, aggressive behavior, sleep changes New or sudden onset depression, anxiety, panic attacks Incoherence, forgetfulness, slurred speech Clumsiness, poor balance, lack of coordination Rapid speech, uncharacteristic talkativeness, restlessness Thefts, things missing/sold, or sudden requests for money Decreased motivation and lack of interest in former activities, such as school clubs and sports New friends replace old friends hanging out with that crowd. Problems at school, such as discipline issues, poor grades and unexplained absences Appearance blood shot eyes, glassy eyes, seemingly tired a lot Odor windows open, spray, vyzene bottles Unusual trash cans w/ holes, straws, razors, broken mirrors, paraphernalia found Social media messages/photos

34 Review our two scenarios? Typical, problematic, or disorder level use? Johnny? Malika? Treatment for both?

35 When to intervene: Use is more than typical, or very young onset experimentation <14 Grades down, problems with behavior, changes in personality, finding paraphernalia, trust your gut Start with conversation, try and understand Set some expectations and see if this changes behavior Talk to school, see if teachers have noticed anything If concerned, get an evaluation/professional opinion: Pediatrician/Primary care doctor School guidance counselor/psychologist Outpatient program May need specialty treatment + urine screen (THC level) If they refuse seek parent guidance

36 What to do? Are there any treatments that can help?

37 Very few teens/young adults engage in treatment 21% of youth need treatment for a substance use disorder (SAMHSA, 2009) 96% do not perceive the need to attend treatment (SAMHSA, 2009) Only 10% of youth with substance use disorders enter treatment (NSDUH, 2013) Only half finish treatment with mean length of time in treatment is 50 days (Dennis, 2005)

38 There are unique risks and opportunities associated with early onset substance use disorders Risks Associated with Early Onset SUD Opportunities Associated with Early Onset SUD It takes longer to get >1 year sobriety Earlier entry into treatment predicts shorter period from first use to > 1 year abstinence Onset <15 years old more likely to be actively using 30 years later than onset >21 years old

39 Tools to support change: A Village Mental health Substance Use Medication Therapy Individual therapy Group therapy Family therapy Family Peers/mutual help Living environment Sober Supports Structure School Support Work/volunteering Activities/Sports

40 Many youth do not think they have a problem and certainly do not need treatment! Engage Them in Care: Motivational Interviewing Contingency Management ACRA therapy Family & Parent training

41 Strain on families: Ordinary people faced with coping with an enormous stressor typical coping is compromised Lee, 2011 compared to controls: greater levels of depression, stress, & isolation Oreo, Parents have grief reaction avoidance, distress, all leading to worse parent-child interaction Handley, 2008 youth addiction worsens parent substance use in those with low parent social support

42 Community Reinforcement and Family Training (CRAFT) Targeted to caregivers to help motivate youth with SUD to engage in treatment Goals: Empower with knowledge and a plan Improve communication, problemsolving, understanding Teach principals of contingency management to reinforce behavioral change Enhance parental self-care Meyers 1996

43 MGH: ARMS Program Treats teens 26 year olds and their parents Patient centered care: motivational model Evidence-based psychosocial treatments Medication Treatment for Substance Use Recovery Coach Parent Program Toxicology screening

44 Engaging Youth at ARMS Referral Rapidly engage capitalize on motivational window Risk Adjusted Intake Process dual dx evaluation Meet and greet option Modify intake length/content Recovery Coach engagement Treatment Evidence-base youth treatments ACRA, MI, CBT, DBT Match treatment to readiness Support functional goals not just substance outcome Medication: suboxone/vivitrol/psychiatric medications

45 Parent Education & Treatment Free 8 Week Psychoeducation & Skills Group Free Long-term Parent after care group Parent coaching Individual parent coaching: CRAFT, directive, skills focused

46 Thank you ARMS: Youth aged and/or their parents Intake Appointment: Insurance-based program including Masshealth

47 Resources Is your teen using? Youth Central Intake helpline Massachusetts Helpline or call Narcan Overdose w/drawal drug Free: Parents: Learn2cope.org and Al-Anon