Drugs and alcohol

1
Drugs and alcohol
2
Drugs and alcohol

• Scale of the problem
• Per capita alcohol consumption doubles in last 50
  years
• Reducing age of onset of regular drinking
• Associated with physical health problems
• Associated with neuro-cognitive deficits
• Age of onset associated with higher dependency,
  chaotic pattern of use higher lifetime
  consumption
• SM is the single most important factor increasing
  the risk of suicide in young people with
  depression or psychosis

3
Drugs and alcohol

• Key Points
• Drinking increases with age - 14 of 1213s, 33
  of 1415s and 62 of 1617s have drunk alcohol in
  the last wk
• 54 of pupils aged between 11 and 15 have smoked
  a cigarette, drunk alcohol or taken drugs on at
  least one occasion
• more pupils had drunk alcohol (45) than had
  smoked cigarettes (27) or taken drugs (18).

4
Drugs and alcohol

• girls have caught up possibly overtaken boys in
  binge drinking
• Beer and lager are the most popular drinks among
  under-18s. Spirits, wine and alcopops are also
  popular
• Ethnic minority teenagers are less likely to
  drink alcohol. One in 20 non-white 12-17year-olds
  are frequent drinkers compared with one in four
  whites.

5
Drugs and alcohol

• In 2010, the key survey estimates for 11 to 15
  year olds in England included the following
• 5 of pupils were regular smokers, equivalent to
  around 150,000 young people (CI130,000-170,000)
• 13 had drunk alcohol in the last week,
  equivalent to around 400,000 young people
  (CI370,000-430,000)
• 12 had taken drugs (including volatile
  substances) in the last year, equivalent to
  around 380,000 young people (CI350,000-410,000)
• 7 had taken drugs in the last month, equivalent
  to around 200,000 young people (CI180,000-230,000
  )

6
Drugs and alcohol

• Risk Factors
• Gateway Hypothesis
• Significant association between early onset
  cannabis use and subsequent illicit drug use
  (Bowen Horwood, 2006)

7
Drugs and alcohol

• Risk Factors (JAACAP 1997)
• Genetic
• SUD high in children of parents with Alcohol
  misuse. This could be direct inheritance or an
  association with ASPD in parents leading to
  conduct disorder, aggression and SUD in children
• Strong genetic link in alcohol (Kendler et al
  1999)

8
Risk Factors

• Individual
• Extrovert personality
• Impulsive, risk taking teenager
• Depression, ADHD

9
Risk Factors

• Family Environmental
• Parental drug alcohol use
• Child maltreatment abuse
• Parental separation marital conflict
• Domestic poor housing, disharmonious family
• Peer influences
• Media effect

10
Drugs and alcohol

• Risk Factors (JAACAP 1997)
• Peer relationships
• Less significant than previously thought in
  predicting drug use or misuse. Association may be
  because substance misusers select similar
  friendship groups

11
Drugs and alcohol

• Groups particularly at risk
• Young Offenders
• Looked After Children
• Young Homeless
• Children whose parents misuse drugs
• Those who truant or are excluded from school
• Young people involved in prostitution
• Teenage mothers
• Young People with Mental Health Problems
• Care Leavers
• Abused children
• Family disintegration
• (Health Advisory Service 1996)

12
Drugs and alcohol

• Resilience Factors (JAACAP 1997)
• Intelligence
• Problem solving ability
• Social facility
• Positive self esteem
• Supportive family relationships
• Positive role models
• Affect regulation

13
Substance Misuse Disorder
14
Substance Misuse Disorder
ADHD 20-30
15
Substance Misuse Disorder
Major depression and dysthymia 25-50
ADHD 20-30
16
Substance Misuse Disorder
Major depression and dysthymia 25-50
Anxiety inc PTSD and phobias 20-30
ADHD 20-30
17
Substance Misuse Disorder
Major depression and dysthymia 25-50
Anxiety inc PTSD and phobias 20-30
ADHD 20-30
Conduct Disorder gt 50
18
Substance Misuse Disorder
Major depression and dysthymia 25-50
Anxiety inc PTSD and phobias 20-30
ADHD 20-30
Conduct Disorder gt 50
Bulimia 10-20
19
Substance Misuse Disorder
Comorbidity is the rule rather than
the exception
20
Drugs and alcohol

• ADHD and SM
• ADHD - significant risk factor for SM
• Risk higher if co-morbid Conduct Disorder
• Risk very high for cocaine and nicotine
• Stimulant Rx does not increase SM, it may protect
  from it

21
Drugs and alcohol

• ADHD and SM
• Stimulants can be used
• Long acting stimulants best
• Atomoxetine little abuse potential
• Tricyclics and clonidine high risks and low
  evidence

22
Drugs and alcohol

• Depression and SM
• Major depression common
• Adult studies - SSRIs help in reducing
  depression and alcohol misuse
• 2 open studies of FLX in young people showed
  reduction in craving and frequency and severity
  of alcohol misuse

23
Drugs and alcohol

• SM and PTSD
• Very often missed - self medication common
• BDZ dependence is common
• Transfer to long acting BDZ
• Consider trial of SSRI or Mirtazapine
• Alcohol abuse not uncommon
• Specific PTSD treatment often required after
  management of SM

24
Drugs and alcohol

• SM and Psychosis
• Lithium in Bipolar and co-morbid alcohol and
  cannabis use significant reduction in SM
  (Geller et al 1998)
• Open study - Clozapine reduces SM in
  schizophrenia
• and co-morbid SM (Brunette et al -
  Schizophr Bull 2006)
• (Tsaung et al AJP 1999)
• Specific treatments for SM like Motivational
  Enhancement effective in Schizophrenia

25
Drugs and alcohol

• Urine testing
• Amphetamine 2-4 days
• Barbiturates 2-4 days
• Benzos Up to 30 days
• Cocaine 1-3 days
• Heroin 1-3 days
• Cannabis 1-3 days (Infrequent use)
• 30 days (Chronic use)
• PCP 2-7 days ( Acute use)
• 30 days (Chronic Use)

26
Drugs and alcohol

• 15 year old girl. Referred by her drugs worker.
  Young person requests a psychiatric view of her
  difficulties
• Alcohol use is heavy and harmful bottle vodka per
  day.
• Cannabis use daily for 4 years
• Intermittent Es, Amphet and Cocaine
• Separate up and think about assessment. What are
  you looking for

27
Drugs and alcohol

• Post traumatic symptoms numbing, vigilance,
  arousal, flashbacks, insomnia
• Depressive symptoms
• School failure
• What do you do next ?

28
Drugs and alcohol

• Family separation when 7. Lived with mother and
  sister. Mothers new partner avoided. No
  relationship built.
• 2 suicide attempts aged 7 and 9. One by stuffing
  tissues into her mouth and one by throwing self
  into swimming pool
• What else do you want to know

29
Drugs and alcohol

• As a child was physically abused by father
• Watched mother being physically and sexually
  abused by father
• Father terrifying man
• Although lives abroad still uses young person to
  manipulate her mother
• How are you going to treat her ?

30
Drugs and alcohol

• Does alright. Good work with drug and alcohol
  worker
• Engages with individual therapist
• Then sudden deterioration. Why ?
• What kind of thing would you look for

31
Drugs and alcohol

• Trip out to party with friend
• Frightening experience where 4 adult men try to
  have sex with her a friend
• She fights her way out but friend is raped in
  front of her
• You want to give her an antidepressant
• Which one and why
• What are your concerns