Adolescent Substance Abuse

1
Adolescent Substance Abuse

• Rachel Gonzales, Ph.D.

2
(No Transcript)
3
What is Prescription and Over the Counter Drug
Misuse?

• Any Rx and OTC drug can be misused
• Misuse Non-medical use or any use that is
  outside of a medically prescribed regimen
• Examples can include
• Taking for psychoactive high effects
• Taking in extreme doses
• Mixing pills
• Using with alcohol or other illicit substances
• Obtaining from non-medical sources

4
Adolescents Young Adults
5
Nationally, theres Good News
Alcohol
Cigarettes
-35
Illicit Drugs
-57
-47
MTF Study Past Month Use for 12th Graders
6
Every Generation of Teens Looks for New Ways to
Get High
Nationally, theres also Bad News
7
Generation Pharming Culture
Cough medicine
Inhalants
8

• Epidemiology of Rx and OTC Drug Misuse Among Youth

9
What do we know about the problem?

• Nationally
• National Survey on Drug Use and Health (NSDUH)
• Monitoring the Future Study (MTF)
• State/County
• Biannual California Student Survey
• Publicly-funded treatment admission data from
  county data systems

10
Landscape of Drug Abuse among Teens
Marijuana
8.6 million
4.5 million
Prescription Medicine
2.4 million
Cough Medicine
Crack/Cocaine
2.4 million
Ecstasy
1.9 million
Meth
1.9 million
1.3 million
LSD
Heroin
1.1 million
Ketamine
1 million
1 million
GHB
NSDUH, 2006
Excludes ETOH
11
Pharming Culture

• Today's teens are more likely to have abused Rx
  and OTC drugs than most illicit drugs
• Every day 2,500 teens 12-17 try a painkiller for
  the 1st time

MTF, 2006
12
Commonly Misused Rx Drugs

• Opiates pain-killers
• Ex) Vicodin, Oxycontin
• Sedatives/Tranquilizers (Depressants) treat
  anxiety and sleep disorders
• Ex) Xanax, Valium
• Stimulants treat ADHD
• Ex) Aderall, Ritalin, Concerta

13
OTC Medicine Misuse

• Dextromethorphan DXM (narcotic codeine) the
  active ingredient in over 100 cold/cough
  remedies.
• Found in tablets, capsules, gel caps, lozenges
  syrups
• Teens discovered using mass quantities of
  DXM-containing products get them high.

14
Examples of Popular OTC Products

• Coricidin HBP Cough Cold
• Robitussin Cough products
• Sudafed Cough medicines
• Dimetapp DM
• Tylenol Cold products
• Vicks NyQuil and Dayquil
• Alka-Seltzer Plus Cold  Cough
• Triaminic Cough syrups

15
Top 5 Drugs Used by 12th Graders
3.8 Ritalin
SOURCE MTF, 2006
16
OTC Medications Misused by Teens
SOURCE MTF, 2006
17
Concerning Trends

• Adolescents 12-13
• Teen Females
• Young Adults 18-24

18
Extent of Rx OTC Drug Misuse among Youth in
California
19
12th Biennial California Student Survey Drug,
Alcohol Tobacco Use

• Secondary students (7th, 9th, 11th graders)
• Representative State sample random schools
  classrooms
• 13,930 students
• 48 middle and 68 high schools (including 10
  continuation)

20

• Misuse of opiate painkillers (no prescription) to
  get high 2006
• 15 of 11th graders
• 9 of 9th graders
• 4 of 7th graders

California Student Survey 2006
21
Changes to Survey

• 2007 Expanded substances and made separate
  question on recreational use of pharmaceuticals
  (high school only)
• Added cold/cough medicines, diet pills, and
  Ritalin/Adderal

22
Lifetime Prevalence
to get high not for medicinal reasons
23

• The Pharming Subculture Generation Rx
• Youth Young Adult Risk Factors

24
Top Reasons for Rx OTC Drug Misuse

• Social with friends
• Legal - Widely Available
• Easily Accessible
• Affordable Low Cost/Free
• Safe - Prescribed
• Non-addictive Medicine

Partnership Attitude Tracking Survey (PAT)
Released in April 2006 by The Partnership for a
Drug-Free America
25

• Recent Research Why Teens Use?

• Teens admit to misusing Rx drugs for reasons
  other than getting high, including to relieve
  pain or anxiety, to sleep better, just to
  experiment, to help with concentration or to
  increase alertness. (Boyd, McCabe, Cranford
  young, 2006).
• More than 1/3 of teens say they feel pressure to
  abuse Rx drugs and say using these drugs is an
  important part of fitting in with their friends.
  (Seventeen, 2006).
• When teens abuse Rx drugs, they often
  characterize their use as responsible or
  controlled (Friedman, 2006).

26
Access Availability
27

• Family Friends Homes
• Retail Pharmacies

28
Modern Culture

• Increasing trend to use Psychiatric Drugs to
  Treat Youth Behavioral Problems

Problem Massive Media Marketing from Pharma
29
Direct-to-Consumer Advertising of Rx Drugs

• Amazon.com pushing ADHD drugs with front-page,
  celebrity-endorsed
• Free Trials

30
The Reality

• Big Pharma
• Ex) Several reports suggest that Purdue Pharma,
  the maker of OxyContin, helped fuel widespread
  abuse of the drug by aggressively promoting it to
  general practitioners not skilled in pain
  treatment or in recognizing drug abuse
• Sales grew from 48 million in 1996 to 1.1
  billion in 2000
• Became leading drug of abuse in 2004

• Oxycontin alone had 21 million prescriptions
  written for them in 2007 to 3.7 million patients
  (many of which were minors and young adults)

Van Zee, 2009
31
of new non-medical users
Pharm Sales Grew

• Oxycontin alone had 21 million prescriptions
  written for them in 2007 to 3.7 million patients
  (many of which were minors and young adults)

32
Endorsements from MDs
Development of Medicine Subculture
33
The Internet Technology
34
Social Networking Web SitesVenues for
penetrating the Medicine Abuse Subculture

• YouTube
• MySpace
• LiveJournal
• Facebook

• Footage of teens high
• User Guides Rx OTC abuse instructions
  (recipes)
• Blogs videos of experiences

35
Social Rx OTC Slang

• Xbrs or xanabars anti-anxiety Xanax
• Vic Vicodin
• Skittles, Dex, Robo, Tussin, (any OTC cold pill
  containing DXM)
• Triple Cs or CCC Coricidin Cough Cold med
• SIZzurp cough syrup ETOH
• Trail Mix Pharm Party

Keeping Parents Clueless
36
Treatment for Rx Drug Misuse

• Little known about specific treatments for
  addressing Rx drug abuse among youth.

• Abusing Rx drugs before the age of 16 leads to a
  greater risk of dependence later in life.
• The of teens going into treatment for Rx drug
  abuse has increased by more than 300 during the
  last 10 years.
• Between 2004-05, the proportion of youth seeking
  treatment for Rx drugs increased by 9.

TEDS, 2006
37
Rx Drug Misuse Treatment Settings

• Youth coming to treatment for self-medicating
  with Rx drugs to treat underlying psychiatric
  condition.
• Rx drug misuse among youth in treatment for
  co-occurring disorders is problematic
• Cheeking or saving unswallowed Rx meds for
  obtaining a later high

38

• Consequences/Effects

39
The High

• Slurred speech
• Flushed skin, sweating
• Loss of appetite
• Mild distortions of color/sound
• Confusion, forgetfulness
• Clumsiness/loss of motor control
• Mood swings, irritability
• Excessive energy or sleepiness

40
The Lows

• Delusions
• Panic attacks
• Memory problems
• Blurred vision
• Stomach pain, nausea, vomiting
• High blood pressure Rapid heart beat

• Numbness of fingers/toes
• Drowsiness Dizziness
• Fever headaches
• Rashes/itchy skin
• Loss of consciousness

41
Side Effects can be Lethal if

• Combining Rx OTC medications.
• Taking Rx and OTC meds with alcohol.
• Using Rx and OTC with other illicit drugs.
• Interactions Rx OTC meds with other physical
  medications (i.e., HIV or Hepatitis)

42
Poison Control System Prescription Narcotics LA
2005-2008
SOURCE California Poison Control System
43
Rx OTC Drug Over Doses

• Last 2 months Rapper Pimp C (Chad Butler) cough
  syrup Hennessey sizerp
• This Year Heath Ledger lethal cocktail of Rx
  drugs - pain, sleeping, anti-anxiety
• Last Year Anna Nicole Smith Son (Daniel) both
  died due to Rx drugs
• Last 2 Years Rapper ODB fatal mixture of Rx
  drugs cocaine

44
Teens Dont Understand the Risks Effects of
Abusing Rx and OTC Medicines

• Over 50 believe that abusing these medicines
  to get high is NOT risky

Join Together, 2006
45
An Invisible Epidemic

• Unrecognized
• Under-screened
• Under-treated

46
Parents Dont Recognize Problem

• Only 8 of parents are aware of Rx OTC abuse.
• 75 dont talk to their kids about the problem.
• Unaware that the drug supply can come from their
  own home.

47
Under-Screened

• 57.7 of physicians say they don't discuss Rx
  abuse with their patients because there is a lack
  of knowledge on what to screen for and how to
  treatment it...
• 35.1 of physicians cite time constraints lack
  of reimbursements for screening and treating a
  Rx-abusing patient.

CASA Released Survey of Primary Care Physicians
Patients, 2000
48
Other Key Stakeholders

• Lack of screening and awareness about Rx and OTC
  problem among
• Substance abuse treatment practitioners
• Social workers, juvenile delinquent counselors,
  probation officers
• School teachers, nurses, counselors

McCabe, S.E., Teter, C.J., Boyd, C.J. (2004)
49

• Efforts to Address Rx OTC Misuse

50
Youth Prevention Activities

• ONDCP
• 12 week national public awareness campaign
• Began with 2 Ads aired during Super Bowl
• 1st paid TV advertising targeting parents in 2
  years.
• DARE
• New School Curriculum Addresses Rx and OTC Drug
  Abuse
• Five Moms Campaign
• Stopping Cough Medicine Abuse keeping parents
  informed and educated of the issue

51
New Rx Drug Regulations

• Action has taken place throughout U.S. federal
  and state levels.
• Federal address issues with poor Rx practices
  among MDs
• F.D.A. will be placing new limits on
  prescriptions of 24 popular narcotics (like
  OxyContin) for increasing MD responsibility
• State establishing prescription monitoring
  programs, continuing medical education and
  practice guidelines

NY Times, 2009 McLellan, 2009
52
Efforts in California

• Establishment of Statewide Rx Drug Task force
  charged with
• Monitoring trends and strategies statewide.
• Developing prevention strategies for teens.
• Developing intervention strategies for teens
  entering treatment settings.

53
Self-Medicated Culture Be aware of the potential
for misuse and abuse
54
Need for Evidenced-Based Practices

• Evidence-based practiceresearched-based
  interventionsscience-based servicesscience-verif
  ied practicesempirically-supported
  practicesessentially mean the same thing.
• Programs or practices that are proven to be
  successful through empirical research study and
  result in consistently positive results.

SOURCE NIDA Institute of Medicine.
55
9 Key Elements Effective Adolescent Treatment
Program

• Assessment and treatment matching comprehensive
  assessments that cover psychiatric,
  psychological, and medical problems, learning
  disabilities, family functioning, and other
  aspects of the adolescents life.
• Comprehensive, integrated treatment approach
  Adolescents problems should be addressed
  comprehensively rather than concentrating solely
  on curtailing substance abuse.
• Family involvement in treatment Engaging both
  adolescent and parents and maintaining close
  links with the adolescents family, home, school.
  
• Developmentally appropriate program Important
  that programs be specifically designed for
  adolescents rather than merely modified adult
  programs.
• Engage and retain teens in treatment Programs
  should build a climate of trust between the
  adolescent and the therapist.

SOURCE Brannigan et al., 2004.
56
9 Key Elements Effective Adolescent Treatment
Program

• Qualified staff Staff should be trained in
  adolescent development, co-occurring mental
  disorders, substance abuse, and addiction.
• Gender and cultural competence Programs should
  address the distinct needs of adolescent boys and
  girls as well as cultural differences among
  minorities.
• Continuing care Programs should include relapse
  prevention training, aftercare plans, referrals
  to community resources, and follow-up.
• Treatment outcomes Rigorous evaluation is
  required to measure success, target resources,
  and improve treatment services.

SOURCE Brannigan et al., 2004.
57
What has Traditionally Been Done?

• Historically, adolescents were integrated into
  adult programs, which ignore the unique needs of
  youths
• CSAT now advocates the separation of adolescent
  and adult services into Adolescent-only care
  that implements unique evidence-based treatment.

58
Evidence-Based Youth Treatments

• Family-Based Therapies
• Multi-systemic therapy (MST Henggeler, et al.,
  1996)
• Multi-dimensional Family Therapy
• Functional family therapy (FFT Waldron et al.,
  2001)
• Community Reinforcement Approach
• Motivational Enhancement Therapy (Wagner et al.,
  1999)
• 12-step approach/Minnesota Model (Winters et al.,
  2000)
• Studies could not clearly identify a superior
  treatment approach, optimal dosage, and length of
  required involvement that maximized short-and
  long-term treatment outcomes

59
Evidence-Based Youth Treatments

• Cognitive-Behavioral Therapy (Kaminer et al.,
  1998)
• Contingency Management/Reinforcement (Corby et
  al., 2000)
• Integrative treatment models employing CBT
  combined with MI and/or with a family
  intervention (Dennis et al., 2000)
• Studies could not clearly identify a superior
  treatment approach, optimal dosage, and length of
  required involvement that maximized short-and
  long-term treatment outcomes

60
Effective Strategies During Treatment Engagement

• Medications
• Motivational Interviewing
• Voucher-based Techniques
• Counseling to Promote Transfer to Long Term Care
• NIATx Strategies

61
Effective Strategies in Rehabilitation Phase

• Interventions/Services
• Clinical Case Management
• CRAFT
• 12-Step Facilitation
• Voucher Reinforcement
• Matrix Model Treatment
• Medications
• Alcohol (Naltrexone, Disulfiram, Citalopram)
• Opiates (Naltrexone, Methadone, Buprenorphine)

62
Types of Continuing Care

• Self/mutual help programs
• Medications
• Traditional counseling visits
• Home visits
• Recovery check-ups
• Specialty care-based
• Primary care-based
• Telephone-based protocols
• Monitoring
• Monitoring and counseling
• Other stuff

63
Evidence-Based Practices for Adolescent
Treatment Resources/Tools
64
Treatment Protocols for Youth

• Manualized treatment protocols for youth show
  promising results in clinical trials

• Community Reinforcement Approach

• Motivational Enhancement Therapy

• Cognitive Behavioral Therapy

• Multi-Dimensional Family Therapy

• Family Support Network

65
NIDA and SAMHSA Resources
NIDA Red Book
NIDA Blue Book
TIP 31 Screening Assessing Adolescents for
Substance Use Disorders TIP 32 Treatment of
Adolescents With Substance Use Disorders
66
California Treatment Resources

• The Need to Invest in Adolescent Treatment
  Policy Recommendations for Adolescent Treatment
  in California (2004).
• California Department of Alcohol and Drug
  Programs (ADP) Youth Treatment Guidelines

67
Contact Information

• Rachel rachelmg_at_ucla.edu
• [phone]