Adolescents And Addiction Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract By the twelfth grade, around half of all high school students have used an illicit drug at least once in their lifetimes. Many other substances, such as aerosol sprays and glues, are even easier for adolescents to obtain and use. Medical professionals need to be aware of the warning signs of an adolescent substance use disorder and the relationship between mental disorders and addiction in order to properly diagnose and treat these young individuals. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1
Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 1 hour. Statement of Learning Need Clinicians working in various health settings are involved with adolescents and need to be informed about how to intervene when a substance use disorder is evident. All health professionals need to be able to identify mental health conditions or other situations associated with a problem of adolescent addiction. Course Purpose To provide health clinicians with knowledge of the issues related to the risks associated with substance use and addiction in adolescents. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2
Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3
1. True or False: According to one study, approximately 80 percent of adolescents have consumed some amount of alcohol before reaching their senior year of high school. a. True. b. False. 2. The following is/are true about drinking alcohol in college: a. It is not widespread phenomenon but when it is present half of those participating binge drink. b. Many teens enter college and start drinking alcohol during their experience there, even if they were not prior alcohol users. c. The negative consequences of such alcohol consumption affect thousands of students and their families each year. d. Answers b. and c. 3. Methylphenidate (Ritalin ) is a prescription drug prescribed for the treatment of ADHD. As a prescription drug a. it does not have the potential to be abused by the teen patient because it is not a stimulant. b. there is potential for abuse of the drug and resulting addiction when it is used inappropriately for a long enough period of time. c. Methylphenidate causes the person taking it to feel lethargic. d. Teens who abuse Ritalin are less likely to misuse other types of drugs. 4. True or False: Alcohol use among underage youth is widespread, and according to one study, over half of kids have tried alcohol by the time they turned 15, with over 70 percent having tried alcohol by the time they have reached age 18. a. True. b. False. 5. Which statement(s) are true about the drug delta-9- tetrahydrocannabinol ( THC ) found in marijuana: a. THC in marijuana affects several specific areas of the brain that can lead to cognitive changes that could potentially be permanent, even if the teen stops using marijuana. b. THC affects coordination and memory, which may make it difficult for a person to make good decisions after using marijuana. c. Studies have shown that people who consistently smoke marijuana starting in their teens have a drop in IQ points that is not regained, even if they quit using it later. d. All of the above. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4
Introduction Substance abuse and addiction, whether to alcohol, illicit drugs, or other substances, is hurtful to someone of any age, but is particularly damaging to adolescents. Teens across various socioeconomic and cultural backgrounds abuse drugs and alcohol. This leads to physical or psychological problems and can also affect a teen s learning abilities, capacity to retain and remember information, and activities and relationships with family and peers. Furthermore, teens that start to use alcohol or tobacco or to experiment with certain types of drugs are at higher risk of moving on to other drugs and further increasing their risks of addiction. Unfortunately, adolescents often engage in potentially harmful behavior before considering the consequences. The growth and maturity that develops during adolescence does not necessarily stay in sync with the physical progress that occurs during this time. In other words, adolescents often experience increased physical growth, the effects of increased hormone secretion and puberty; and, teens are subject to social pressures that result in them potentially making choices that are not always the best for their health and well being. Adolescents and young adults tend to more actively experiment with drugs and alcohol, but these groups are also more likely to develop substance use disorders. 7 Poor habits or even addictions that develop during adolescence can continue to plague a person as an adult, long after the teen years have ended. That is to say, choices that a person makes during adolescence, such as whether to use drugs or alcohol or whether to start smoking, can lead to habits that are not only difficult to break later, but that can cause dangerous complications if they continue into adulthood. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5
Types Of Substance Use Disorders The reasons adolescents develop substance use disorders and addiction on drugs and alcohol are varied and complex, but unfortunately, substance use addiction is more common among teens than many would like to admit. According to the Substance Abuse and Mental Health Services Administration (SAHMSA), over 23 million people over the age of 12 years needed treatment for substance use in 2012. 1 Adolescents are often under significant pressure and are influenced by their peers, family members, and others in the community, all of whom have an effect on whether many teens start to experiment with harmful substances. Whether a substance use disorder takes the form of alcohol, illegal drugs, tobacco, or prescription drugs, teens that use these substances are at risk of the damaging and longterm effects that can last into adulthood. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was developed to assist trained mental health clinicians to diagnose mental and substance use disorders. The DSM-5 chapter, Substance-Related and Addictive Disorders, includes diagnostic criteria and symptoms of a substance use disorder and summarize characteristic signs and symptoms suggestive of an underlying disorder. In the sections below, the DSM-5 changes to the substance use disorders groups and the criteria defining substance use conditions or addictions are discussed. Alcohol Alcohol is one of the most commonly used substances across all age groups. It is legally available for purchase by people over a certain age, which is 21 years old in the United States, and adolescents are not legally eligible to purchase or drink alcohol, regardless of its prominence among this age group. According to the Monitoring the Future study, approximately 80 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6
percent of adolescents have consumed some amount of alcohol by the time they reach their senior year of high school, and half of these teens have taken their first drink by the time they have reached the eighth grade. 2 An adolescent may develop an alcohol use disorder after repeated use. An alcohol use disorder and addiction develops when a person is unable to stop using alcohol despite making attempts to quit; when a person suffers negative symptoms and effects of withdrawal when stopping intake; or when a person is unable to stop drinking alcohol routinely, even though its use is negatively impacting work, school, and relationships. An alcohol use disorder develops when a person uses alcohol and drinks too much or too often; the person may engage in dangerous activities as a result of alcohol intoxication, such as driving while drunk or engaging in unsafe sexual practices. Alcohol addiction involves a craving for alcohol, an inability to stop drinking once starting, increased tolerance to alcohol, requiring more and more of it to achieve the same effects of intoxication, and withdrawal symptoms when not drinking alcohol. 40 Alcohol is a central nervous system depressant, and the adolescent who consumes it may initially feel tired and sluggish, but may also experience euphoria and pleasant or happy feelings. The short-term use of alcohol increases the work of inhibitory neurotransmitters such as GABA and serotonin, which produces these initial effects. Over time, though, alcohol use then increases the work of excitatory transmitters, such as epinephrine and norepinephrine and decreases the effects of inhibitory neurotransmitters. The person then experiences tolerance and requires more drinks to achieve the same effects as was initially felt early on. 40 Increased consumption because of tolerance can eventually lead to a substance use disorder and addiction when the person craves the effects of alcohol and has nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7
a desire to drink and continues to consume alcohol despite negative consequences. The DSM-5 section on Alcohol-Related Disorders defines alcohol use disorder as a problematic pattern of alcohol use leading to clinical significant impairment or distress, as manifested by at least two of the following occurring within a twelve month period, and the criteria are listed as: 77 Alcohol is often taken in larger amounts or over a longer period than was intended; There is a persistent desire of unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. Craving, or a strong desire or urge to use alcohol. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. Recurrent alcohol use in situations in which it is physically hazardous. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbate by alcohol. Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8
A markedly diminished effect with continued use of the same amount of alcohol. Withdrawal as manifested by either of the following: The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms. An alcohol use disorder causes many significant effects to various body systems. Alcohol has been shown to contribute to liver disease, including cirrhosis and hepatitis; gastrointestinal dysfunction, such as esophageal varices and portal hypertension; heart disease, obesity, poor sleep habits, osteoporosis, pneumonia, and certain types of cancer. 40 Both short- and long-term use of alcohol can cause cognitive changes, which can be especially damaging to the adolescent who is continuing to undergo neurological development. Cognitive changes may include memory problems, difficulties with concentration, and problems with learning. These effects may be permanent in some people, even after they quit drinking. Alcohol is also dangerous for teens because it is commonly associated with other forms of drug use and with smoking. People who use alcohol and drink to the point of intoxication can become aggressive and violent, which places them at risk of accidents, injuries, and suicide. Drinking alcohol in college is an extremely widespread phenomenon, with approximately 4 out of 5 college students drinking alcohol and half of these participating in binge drinking, which is the consumption of more than 4 drinks for women or 5 drinks for men in a span of less than 2 hours. 43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9
Many teens enter college and start drinking alcohol during their experience there, even if they were not prior alcohol users. Unfortunately, drinking alcohol is often seen as part of the college experience, with alcohol being available to students at parties, social groups, and within college dorm rooms. The negative consequences of such rampant alcohol consumption affect thousands of students and their families each year, with college students experiencing injuries, academic problems, destruction of property, sexual assaults, and suicide attempts, as well as some deaths related to alcohol consumption, at college campuses throughout the United States. The younger a person is when he or she starts drinking, the higher the risk is that he or she will develop an alcohol use disorder. Teens who are not yet college age and who drink alcohol are more likely to develop an alcohol use disorder, even into adulthood. By comparison, those who wait until they are 21 years old, or who wait until they are in college to participate in binge drinking or routinely consume alcohol may not necessarily develop an alcohol use disorder as they grow into adulthood. Alcohol use among underage youth is widespread, and according to the National Institute on Alcohol Abuse and Alcoholism, over half of adolescents have tried alcohol by the time they turned 15, with over 70 percent having tried alcohol by the time they have reached age 18. 44 Random use of alcohol or experimentation is not the same as an alcohol use disorder and addiction but the negative results associated with chronic alcohol use can be staggering and affect thousands of people every year, many of whom started drinking during adolescence. While many healthcare providers may assume that an occasional drink or attempt at trying alcohol for teens is harmless, they must remember that every person who has become an nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10
alcoholic, whether during adolescence or in adulthood, started with that first drink. Illegal Drugs Drugs used by adolescents that are commonly abused are often classified as illegal or street drugs. These drugs are considered those that are not classified as prescription drugs or household substances. The most commonly abused illegal drug is marijuana, although there are many different types of illegal drugs that lead to a substance use disorder and addiction. Marijuana Marijuana is one of the most commonly used illegal drugs by adolescents in the United States. According to the Monitoring the Future Study, a research study conducted by the National Institute on Drug Abuse, over 44 percent of 12 th graders have tried marijuana, and 21 percent have used it within the last month. 46 Because of the uses of medical marijuana, the legalization of some types of marijuana use within some states, and the fact that marijuana comes from a plant leads many teens to believe that it is a harmless drug or that it does not result in addiction. Marijuana can be harmful, however, when its use impacts a teen s daily activities and when it leads to other forms of substance use. Marijuana comes from the hemp plant; it consists of dried and cut pieces of the plant, including its stems, flowers, and leaves. It is most often used when its pieces are rolled in paper or are put into a pipe and it is smoked. Marijuana may also be added to certain foods and eaten, brewed as tea, used as lollipops, or inhaled as vapor. The person who uses marijuana nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11
experiences psychotropic effects of pleasurable feelings, as well as a lack of coordination, increased appetite, and dizziness. 47 The effects are caused by a component of the drug called delta-9-tetrahydrocannabinol, also referred to as THC. While there are some states that have changed their laws and allowed the use of marijuana for medical purposes, or in some states, even for recreational purposes, it is still illegal for a teen to buy, possess, and use marijuana. The THC in marijuana affects several specific areas of the brain that can lead to cognitive changes that could potentially be permanent, even if the teen stops using marijuana later. THC affects coordination and memory, which may make it difficult for a person to make good decisions after using marijuana; additionally, THC impacts the area of the brain responsible for learning and memory, which can impair a teen s abilities to perform in school and to remember information. Studies have also shown that people who consistently smoke marijuana starting in their teens have a drop in IQ points that is not regained, even if they quit using it later. 47 Cannabis-related disorders is defined in the DSM-5 as a problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period, and the criteria are listed as: 77 Cannabis is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis or recover from its effects. Craving, or strong desire or urge to use cannabis. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12
Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis. Important social, occupational, or recreational activates are given up or reduced because of cannabis use. Recurrent cannabis use in situations in which it is physically hazardous. Cannabis use is continued despite knowledge or having a persistent recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis. Tolerance, as defined by either of the following: A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of cannabis. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal) Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Adolescents can become addicted to marijuana; over time, the person may start to crave the high that comes from using this drug. People have also experienced symptoms of withdrawal when stopping use of marijuana, including symptoms of dizziness, irritability, and sleep problems. Most teens that try marijuana do not go on to use other drugs or to become addicted. However, teens who use marijuana, alcohol, and tobacco are at higher risk nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13
of developing a substance use disorder later. 47 Marijuana use can lead to multiple physical and social problems, including changes in heart rate, breathing problems, mental health issues, and increased risk of injuries from accidents or use while driving. Although many people consider marijuana to be relatively safe when compared to other drugs that teens could get involved with, there are too many dangers associated with this drug to have it be considered safe. Opioids Opioids are drugs that are often considered to be prescription drugs, and they are typically administered as prescription drugs for pain control. However, opioids may also be classified as illegal drugs that have the potential for abuse when they are not used for medical purposes. Heroin is the most common form of opioid drug that is not prescribed for medical use but is abused as an illegal drug. Because of its high potential for causing a substance use disorder and addiction, heroin is classified as a Schedule I controlled substance. Opioid-related disorders is defined in the DSM-5 as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period, and the criteria are listed as: 77 Opioids are often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control opioid use. A great deal of tie is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. Craving, or a strong desire or urge to use opioids. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. Important social, occupational, or recreational activities are given up or reduce because of opioid use. Recurrent opioid use in situations in which it is physically hazardous. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been used or exacerbated by the substance. Tolerance, as defined by either of the following. A need for markedly increased amounts of opioids to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of an opioid. Withdrawal as manifested by either of the following: The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal) Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms. A person can use heroin in a number of ways to derive its effects. One of the most common methods is through injection, but it can also be smoked or sniffed. Because it is an opioid, heroin binds to opiate receptors in the brain when it enters the body, which gives the sensation of intense euphoria, leading to a very pleasant and relaxed state. When the drug binds to opioid receptors, they block the sensation of pain by blocking receptors in the central nervous system. Heroin also puts a person into a state of stupor, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15
which causes a slowed response, drowsiness, and mood changes. Lilley, Collins, and Snyder, authors of the book Pharmacology and the Nursing Process, defines this state of stupor as narcosis, which is why a drug such as heroin is referred to as a narcotic. 3 Stimulants Stimulants are drugs that are stimulating to the central nervous system. There are different classes of stimulants, some of which are classified as illegal drugs, while others are given as prescription medications. A teen may use prescription stimulants inappropriately in order to get the feelings of pleasure and euphoria that these drugs can cause. Many prescription stimulants, such as those administered for the treatment of ADHD, are meant as timed-release medications, in which they slowly release the medication into the body after the person takes them. However, these drugs could instead be crushed and then mixed with another solution of water to be injected, which causes a person to get high when the effects of the drug are released all at once. Amphetamines are stimulants that may be abused among adolescents and young adults; amphetamines, depending on their form, may be available as illegal drugs or as prescription drugs. Methamphetamine produces much more significant effects on the body when compared to some other types of stimulants. Crystallized methamphetamine, also referred to as crystal meth, is a smokeable form of the drug that is highly powerful. It is a man-made substance that is created from common products, including pseudoephedrine, which is found in some over-the-counter cold and sinus preparations. When a person smokes crystal meth, he or she experiences a rapid and very intense high from the release of excess dopamine. However, the feeling is short lived and when the intense feelings diminish, the person nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16
is left with lower levels of dopamine than before, which causes feelings of depression. 5 The person using the drug then often feels compelled to repeat the cycle of use to ward off the effects of depression and to experience the high feelings again. Meth addiction is very dangerous because it can cause permanent damage to the brain by affecting how the body adjusts neurotransmitter levels. Because crystal meth is created in homemade laboratories using some overthe-counter medications, the sale and distribution of products that contain pseudoephedrine has changed since 2005. 3 Pseudoephedrine is normally used in cold and sinus medications to shrink the size of the blood vessels in the nose, which decreases nasal congestion. Because people who create methamphetamine may use larger amounts of pseudoephedrine for the drug preparation, the sale of cold medications that contain pseudoephedrine has been regulated so that purchasers must buy these drugs directly from the pharmacy counter, rather than buying it off the shelf. Cocaine is an illegal drug that is a type of stimulant that impacts the central nervous system by causing an elevated state of being alert. Rather than producing a state of stupor, as with some opioid drugs, cocaine tends to have an opposite effect of euphoria, mental alertness, and increased energy. Among teens, cocaine use has actually been shown to be declining in the past decade, however, its availability, relatively inexpensive price, and multiple methods of use have made cocaine a dangerous drug that can lead to addiction among adolescents. Similar to other types of stimulants, cocaine produces its effects by increasing levels of dopamine, which leads to feelings of pleasure and satisfaction. Unfortunately, the effects of cocaine on the brain enable people nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17
to quickly become addicted, and teens may have a more difficult time overcoming cocaine addiction or may be predisposed to abusing cocaine or other stimulant drugs later in life. The changes that occur in the brain as a result of cocaine use, coupled with the neurodevelopmental changes occurring during adolescence, place a teen addicted to cocaine at high risk of permanent changes in neurotransmitter levels in the brain and ultimately greater risk of future drug abuse. 6 Stimulant-related disorders is defined in the DSM-5 as a pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period, and the criteria are listed as: 77 The stimulant is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use. A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant or recover from its effects. Craving, or a strong desire or urge to use the stimulant. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home. Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant. Important social, occupational, or recreational activities are given up or reduced because of stimulant use. Recurrent stimulant use in situations in which it is physically hazardous. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18
Stimulant use is continued despite knowledge of have a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant. Tolerance, as defined by either of the following: A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of the stimulant. Withdrawal as manifested by either of the following: The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal) The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. Stimulants can be dangerous because their changes in dopamine levels cause an elevation in heart rate and blood pressure. The person who abuses stimulants is at higher risk of eventual heart failure when the heart must work harder as a result of beating faster when using the drugs. The blood vessels are constricted with stimulant use and the person who regularly uses these drugs may suffer the effects of repeated blood vessel constriction followed by relaxation. Further negative effects can occur based on the method of using these drugs; for instance, a teen who regularly snorts cocaine can develop skin breakdown in the nose; those who inject stimulants are at higher risk of contracting infectious diseases spread by shared needles. Another illegal drug that is part stimulant and part hallucinogen is methylenedioxymethamphetamine (MDMA), which is also called Ecstasy and is on the rise in use among adolescents. Ecstasy, also called Molly, produces nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19
the effects of stimulants in that the person taking it feels more energy and experiences a sense of euphoria, acceptance of others, and feelings of pleasure. Additionally, Ecstasy also causes psychedelic effects, which makes it very attractive for users. It is typically taken as an oral tablet, but it may also be injected or snorted. Ecstasy produces a high because it affects the neurotransmitters dopamine, serotonin, and norepinephrine in the brain. People who use it may feel sexually aroused and emotionally close to those around them, which can be dangerous for teens who may find themselves in situations where there is considerable peer pressure to use the drug and then engage in unsafe sexual practices. People who use Ecstasy can develop drug tolerance in which they require more of the drug to experience the same effects. Some teens have died from abusing Ecstasy because the drug causes an increase in body temperature that can result in dangerous hyperthermia. 8 Because adolescence is such an important time of building skills, learning, and growing developmentally, illegal drug use can significantly inhibit teens abilities to grow and mature into healthy and responsible adults. The accessibility of illegal drugs may vary for some teens, with some kids having greater access to illegal drugs and others not having the connections needed to buy or use street drugs. Still, many adolescents can find and use illegal drugs when they want to, which can potentially lead to greater problems and can prevent the healthy normal teen development. Prescription Drugs Although most people use prescription drugs appropriately and take them as they are ordered, prescription drugs can cause health issues and can lead to addiction for anyone who uses them inappropriately, including adolescents. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20
Teens are at high risk of the negative effects of drug use when they take prescription drugs inappropriately, whether the drugs are prescribed for them by a healthcare provider or whether they are accessing someone else s prescription to use. The National Institute on Drug Abuse (NIDA), when performing the Monitoring the Future Survey in 2014 found that 1 in 12 high school seniors reported inappropriate use of prescription Vicodin within the last year. Misuse of prescription drugs is the fourth most common type of drug abuse among teens after alcohol, tobacco, and marijuana. 9 The availability of certain drugs makes inappropriate use of prescription drugs more common, particularly among teens; however, the effects of a prescription drug use disorder are just as damaging to adolescents and can include severe health problems, overdose, and death. Opioids The most commonly abused prescription drugs among adolescents include opioids, stimulants, and depressants. Opioids are administered to relieve and control pain. Because they cause pleasant effects, they are also more commonly misused and abused. Opioids interrupt the pain signal between the nervous system and the brain so that the person experiencing pain does not feel the effects of it as much while taking these types of drugs. Opioids can also cause negative side effects of drowsiness, constipation, and confusion; further negative effects can also develop when a person takes the drugs in a method in which it was not originally intended. For example, some opioid preparations are designed to be extended-release tablets, but some people instead take them by crushing the pills and snorting or injecting them, which provides a rapid response. Unfortunately, taking the drug in nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21
this manner can also significantly increase the risk of overdose and respiratory depression. Examples of opioids are codeine, oxycodone (OxyContin ), morphine, meperidine (Demerol ), and hydrocodone (Vicodin ). Depending on the patient s condition, these drugs may be prescribed for various reasons. Some opioids are administered for mild pain or to control coughs associated with illness; an example of this type of drug is codeine. Alternatively, some drugs are prescribed after medical procedures that can cause significant pain, such as with morphine or hydrocodone. Misuse of these medications cannot only lead to addiction but can also cause significant side effects. Opioid medications cause a histamine release in the body, which results in vasodilation, low blood pressure, and flushed skin. The person may also experience intense itching, hives, sweating, urinary retention, and constipation. 3 More significantly, respiratory depression can occur with overuse of opioids, leading to apnea and death if the situation is not corrected. Opioids, when taken appropriately according to a prescription, can be used safely for long-term use, even among adolescents. An opioid use disorder can lead to serious consequences when the patient seeks to get more of the drug than is allowed by prescription. Because opioids can cause respiratory depression, overdose of these types of drugs can be fatal even the first time that they are misused. Stimulants Prescription stimulants may be misused and abused among adolescent patients even if they are given to the adolescent under a prescription. Prescription stimulants may be ordered for some adolescent patients who nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22
need medications for treatment of conditions that require management of fatigue or mood. Methylphenidate (Ritalin ) is a common medication prescribed for the treatment of ADHD and has the potential to be abused. If a teen patient with ADHD has been given a prescription for a stimulant such as methylphenidate, there is potential for abuse of the drug and resulting addiction when it is used inappropriately for a long enough period of time. Methylphenidate stimulates the central nervous system and helps a person to focus and concentrate on activities around him or her; it can help the person taking it to feel more awake and alert. 4 Teens who abuse this drug may be more likely to do so because of the results it provides; for instance, an adolescent patient may use methylphenidate inappropriately because it helps him or her to stay awake longer to study and get better grades. Stimulants have also been prescribed for other reasons as well, such as weight loss, to stimulate the respiratory center of the brain and prevent central apnea, and for treatment of sleep disorders such as narcolepsy. Some teens have found the effects of stimulants to be beneficial to appearance because they help with weight loss and promote activity and wakefulness. Unfortunately, adolescents are often plagued by messages of the importance of appearance and being thin. Some teens are able to secure prescription stimulants that cause weight loss and they take them inappropriately to attempt to lose weight and try to keep up with images seen on television and online. Whether or not they are prescribed for this purpose, prescription stimulants tend to suppress appetite, so they can be useful for weight loss among some people because taking stimulants will most likely cause them to eat less. Stimulants have also been shown to enhance performance, so some teens may be more likely to take them in order to keep up with the demands of schoolwork and extracurricular activities. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23
Unfortunately, prescription stimulants also increase dopamine levels, which normally lead to feelings of pleasure and an increased ability to concentrate, but these drugs can also cause high blood pressure and an increase in heart rate and body temperature. 4 They also disrupt sleep and lead to insomnia, which can negatively impact an adolescent s performance at school or abilities to maintain friendships and relationships. Central Nervous System Depressants Central nervous system (CNS) depressants are another form of drug that may be prescribed and abused by some teens. Depressant medications include such drugs as benzodiazepines and barbiturates and are used as sedatives to control anxiety or to induce sleep. Benzodiazepines are typically prescribed for management of anxiety or for sleep disturbances; because they can cause dependence and are at increased risk of being abused, benzodiazepines are often only prescribed for short-term use. 9 Examples of benzodiazepine medications include alprazolam (Xanax ) and diazepam (Valium ). Non-benzodiazepines are medications that have depressant effects and act in a manner similar to benzodiazepines, but they are chemically different. They are considered to be less risky when it comes to dependence and they typically produce fewer side effects. Examples of these types of drugs include zolpidem (Ambien ) and zalepon (Sonata ). Barbiturates are depressants that are also prescribed for anxiety; because of their risk of abuse and overdose, they are not as commonly prescribed. Examples of barbiturates include mephobarbital (Mebaral ) and pentobarbital (Nembutal ). Barbiturate use was more prominent in the 1960s and 1970s in U.S. history, resulting in a number of prominent deaths from overdose. Many of today s adolescents are unaware or do not remember some of the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24
celebrity deaths associated with barbiturate use and they may not be aware of how dangerous these drugs can be. Central nervous system depressants work by affecting gamma-aminobutyric acid (GABA) to produce a sense of drowsiness and a feeling of calm or relaxation. Depressant medications more commonly cause tolerance, in which a person who uses them requires more of the drug; among many benzodiazepines and barbiturates, tolerance can develop within a few days use. 9 If an adolescent becomes addicted to benzodiazepines, he or she may suffer withdrawal symptoms that can lead to seizures, increased anxiety or panic attacks, insomnia, and psychosis. Alternatively, barbiturate addiction can cause life-threatening effects during withdrawal, such as seizures and hyperthermia, and the person undergoing detoxification from these drugs must be monitored closely. Prescription drug abuse among adolescents is a serious problem; teens that abuse these types of drugs have been shown to start even before reaching the 8 th grade. Adolescents who admit to misusing prescription drugs have stated that they most often use drugs that they take or buy from someone else who has the prescription, making these drugs relatively easy to access for many teens. Further, teens who abuse prescription drugs are more likely to misuse other types of drugs as well, including alcohol, tobacco, or marijuana. When combining prescription drugs with other types of drugs, the effects of more than one substance together can result in effects that are multiplied, which is often dangerous. For example, a teen who misuses prescription benzodiazepines and who drinks alcohol can suffer the consequences of both types of CNS depressants used together, which can lead to significant nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25
drowsiness, changes in mental status, and respiratory depression. Healthcare providers play important roles in recognizing the signs of a prescription drug use problem among adolescent patients and assisting them to obtain the help they need to overcome an issue of addiction. Household Items Drugs can be found within the home, which makes abusing household items very dangerous for teens. Adolescents have easy access to these items. When an adolescent can find these items at home he or she often does not need to buy anything or find someone to sell the drugs or alcohol. These items are also dangerous because they are completely unregulated; and, it is just as easy to overdose on inhalants and toxic substances used as drugs from household items as it is for a person to overdose on prescription or illegal drugs. Inhalants Inhalants are common, everyday products found in the environment that people inhale to get high. A teen may use inhalants by sniffing the fumes from a container or spraying items directly into the mouth or nose. Huffing is the process of soaking a rag or cloth with an inhalant, putting it in the mouth, and then breathing in the fumes. Inhalants can be found in all sorts of substances, chemicals, and products found in the home, in the yard, or in the garage. Examples of inhalants may include: Aerosols: spray bottles of hairspray, deodorant, compressed air for cleaning keyboards, whipped cream dispensers, and spray paint. Solvents: paint thinner, gasoline, glue, correction fluid, nail polish remover, and cleaning solutions. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26
Nitrates: amyl nitrate, butyl nitrate; found in products labeled as leather cleaner, or room odorizer 10 Gases: Propane tanks, butane lighters, refrigerant solutions, chloroform, nitrous oxide. After inhaling the gas or spray, the person feels a rush or high right away that is short lived. Inhalants often produce feelings of euphoria, dizziness, lightheadedness, and the person using them may experience hallucinations. He or she must continue to use the inhalants in order to get the same feeling because it is often so short. In larger amounts, inhalants can produce anesthesia, but too much can cause the person to lose consciousness. Because the inhalant is breathed in, the gas or fumes take the place of oxygen in the lungs. This puts the user at risk for respiratory problems and decreased oxygen levels in the bloodstream, which then leads to decreased oxygen reaching the brain. The heart also beats faster and must work much harder, which can lead to heart failure. Inhalant-related disorders is defined in the DSM-5 as a problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period, and the criteria are listed as: 77 The inhalant substance is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control use of the inhalant substance. A great deal of time is spent in activities necessary to obtain the inhalant substance, use it, or recover from its effects. Craving, or a strong desire or urge to use the inhalant substance. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27
Recurrent use of the inhalant substance resulting in a failure to fulfill major role obligations at work, school, or home. Continued use of the inhalant substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use. Important social, occupational, or recreational activities are given up or reduced because of use of the inhalant substance. Recurrent use of the inhalant substance in situations in which it is physically hazardous. Use of the inhalant substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Tolerance, as defined by either of the following: A need for markedly increased amounts of the inhalant substance to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of the inhalant substance. Clinicians are guided in the DSM-5 to specify the particular inhalant and, when possible, the particular substance involved should be named. The chemicals inhaled during the process are also damaging to the body; the chemicals enter the bloodstream and can lead to toxic levels that eventually affect tissue perfusion and proper organ function. Typically, high levels of chemicals in the bloodstream cause toxicity that leads to poor concentration, slowed response times, and mental status changes. For a teen who is still going through neurological development, this is particularly damaging to the brain and central nervous system. Growing teens also suffer the physical effects of brain hypoxia after using inhalants, affecting their abilities to study nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28
or participate in sports or games. Inhalants are also dangerous because it is difficult to control how much a person takes in each time; the person using the inhalant can easily overdose and take in too much, causing them to lose consciousness or even die after one use. Long-term use of inhalants can lead to nerve damage after breakdown of the myelin sheath covering some of the nerves. Brain hypoxia also occurs from chronic inhalant use, which leads to memory problems and delays in thinking and processing, which can make it difficult to hold a conversation or make quick decisions. This may cause problems with movement, such as maintaining a normal gait or performing daily activities. Further health problems include chronic muscle weakness, liver failure, and aplastic anemia. 10 Inhalants are one of the earliest forms of drug use among teens that start abusing drugs. According to the National Institute on Drug Abuse, younger teens are more likely to use inhalants when compared to older teens, and a greater percentage of 8 th graders admit to using inhalants in the past month when compared to 10 th or 12 th graders. 10 Inhalant use is often not something that occurs once or twice; often, the teen who experiments with inhalants to get high tends to repeat its use, which may lead to chronic, long-term abuse of inhalants. Poisoning or Ingestion In addition to inhaling toxic substances, some teens may get high by ingesting other products that are commonly found around the house. Spices, kitchen items, mouthwash, and perfume are just some of the items that adolescents have used for their effects when taken in large amounts. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29