Tackling Teen Alcohol Use- The Six G

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Tackling Teen Alcohol Use- The Six Gs

• Cathy McDonald, MD, MPH
• Alameda County ATOD Provider Network
• Thunder Road
• 510-653-5040

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Teen Alcohol Use

• Scope of the problem
• Alcohol Effect on Teen Brain
• Genetics environment
• Addiction Stage/ Dependence
• Pediatricians Role
• Screening Intervention

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The ProblemData National

• MONITORING THE FUTURE 2007

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The ProblemData State

• California Student Survey 2005-2006
• Past 30 days

Grade Any Binge 5 drinks
7th 12 5
9th 24 12
11th 36 21
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The ProblemData State

• California Student Survey 2005-2006

Grade 2 criteria dependence Drove or Driver Under Influence
7th
9th 5 20
11th 13 30
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The scope of the problem

• Adult Alcohol dependence 5 M 2 F
• 7000 teens lt16 take first drink every day (SAMSHA
  2004)
• 20 of US alcohol used by teens
• 31 traffic deaths in teens alcohol related
  (15-20) NHTSA 2006 ( 77 of these unrestrained)
• CA Blood Alcohol lt .01 lt21 ZERO TOLERANCE

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The scope of the problem

• 1995 survey 30 4th-6th graders peer pressure to
  drink beer
• 70 12-20 no alcohol past month
• 15 binge drink any month
• State-Men 5 or gt drinks (women 4 or gt) in a row
  once in past month
• Monitoring the Future-5 or gt drinks in a row in
  previous 2 weeks Male and female
• 2 14-20 buy alcohol on line
• 8 adults ever shoulder tap-19 21-30 yo men

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What is a drink

• 12oz can of beer
• 5 oz glass of wine
• 1.25 oz shot 80 proof hard liquor
• Alcohol poisoning depends on how much, how
  strong, how fast, how empty the stomach is
• 180 lb male 5 beers 4 shots in 3 hours.144
  BAC
• 180 lb male 1 beer .02 BAC out of zero tolerance
• 180 lb male 4 drinks .08 BAC
• BAC decreases by .01 every 40 minutes

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Alcohols effect on adolescent brain

• Slides from Ken Winters, Ph.D.
• Associate Professor
• Director of the Center for Adolescent Substance
  Abuse Research
• University of Minnesota

, PhD
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An Immature Brain Less Brakes on the Go
System
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Construction Ahead

• Growth of the brains nerve cells (neurons)
  occurs through late childhood
• 1,000,000,000,000,000 possible connections.
• Around 11 GIRLS 12½ - BOYS
• Some of these connections are pruned off.

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Construction Ahead

• When the pruning is complete, the brain is faster
  and more efficient.
• But during the pruning process, the brain is not
  functioning at full capacity

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Emerging Science Teen Brains Are StillUnder
Construction

• New insights about
• Why teenagers take risks and show poor judgment
• How teenagers may be highly vulnerable to
  substance abuse
• These findings can help parents,
• policy makers

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Judgment Gets Betterwith Age

• By age 18, the adolescents judgement for
  structured challenges is roughly equal to that of
  adults.
• But judgement that involves resisting impulses or
  delaying gratification is still under
  construction during late adolescence and early
  adulthood until 24yo

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Implications of Arrested Development for
Adolescent Behavior

• Sensory and physical activities benefit from
  earlier back of the brain development
• Complex, judgment-demanding thinking are
  compromised by later front of the brain
  development

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Fewer Problems in Those Who Start Later

Age Started Drinking
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. Percentages of Past Year Alcohol Use Disorder
(Abuse or Dependence) Among Adults Aged 21 or
Older, by Age of First Use (SAMHSA, 2004)
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2. Survey Data Suggest that Adolescents Are Less
Sensitive to Alcohols Effects
Monitoring the Future, 2001
Less sensitive
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Adolescents continue to be less sensitive in 2007
Grade 5 drinks in a row last 2 weeks Drunk in last month
8th 10 5
10th 22 18
12th 26 29
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Are adolescents more susceptible to alcohol than
adults?

• 1. Epidemiological data
• 2. Adolescent rats are less sensitive to the
  sedative and motor impairment effects of
  intoxication.
• 3. Adolescent rats are more sensitive to the
  social disinhibition effects of alcohol.

2 and 3 May contribute to binge drinking and
increased risk to alcohol dependence.
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Are adolescents more susceptible to alcohol than
adults?

• 1. Epidemiological evidence
• 2. Adolescent rats are less sensitive to the
  sedative and motor impairment effects of
  intoxication.
• 3. Adolescent rats are more sensitive to the
  social disinhibition effects of alcohol.
• 4. Alcohol produces greater cognitive
  disruptions in adolescent rats.

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Human Data Alcohols Effects(Brown, 2002
Wuethrich, 2001)

• Adolescents with a history of extensive use.
• Hippocampus volume (10)
• brain activity during memory tasks

converts information to memory
Not known if restoration or recovery will occur.
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Evidence in support that youth are highly
vulnerable to the effects of alcohol
SUMMARY

• Greater rates of alcohol use disorders at earlier
  ages
• Reduced sensitivity to intoxication
• Increased social disinhibition
• Increased cognitive disruption

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Impact of genetics and environment

• Genetics
• sons of alcoholics 25 risk
• daughters increased risk
• Environment
• alcohol responsible for 50 marital violence
• 35-70 child abuse
• Youth at High Risk
• FH alcoholism
• Delinquent
• learning disabilities including ADHD
• psychosomatic complaints
• Family antisocial behavior
• poor parenting

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Impact of environment

• Family Attitude and availability
• Home is primary place for early use
• Some at meals -no big deal
• Often available
• Media Messages societal norms-Conveys adult
  status
• Advertised widely-seen in tv and movies
• Ads linked to sociability, elegance, good looks,
  success, relaxation, romance, advertising
• 56 of 5th -12th graders say ads encourage to
  drink
• Hundreds of websites promote drinking
• Conveys maturity, bravado, masculinity

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Impact of Environment

• Family and Community
• Reward
• After work
• Celebrate
• sports

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Stages of Use / Abuse

• Potential-impulsive, available,peer driven
• Stage I Experimentation
• Stage II Active seeking
• Stage III Preoccupation
• Stage IV Addiction- withdrawal, shame, remorse,
  depression, powerlessness, unmanageablity
• Potential for big consequences early

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DSMIV criteria for alcohol dependence

• Three of the following present in 12 months
• Using more/same but less effective-tolerance
• Withdrawal symptoms shaky or uncomfortable
• Using more than care to
• Want to cut down but not able
• Lots of time spent getting, using and recovering
• Important activities given up due to use
• Continue inspite of physical / mental consequence

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Screening tools for ATOD once use recognized

• Family / Friends
• Forget
• Trouble

• CRAFFT
• Car
• Relax
• Alone

Two or more yes -there is a problem- needs
further evaluation
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Pediatricians Role Prevention

• Prenatal visit vFH alcoholism-urge 12 step
  support AA/Alanon- Be alert for COA or fetal
  alcohol syndrome
• Adolescence
• store alcohol meds away from kids
• Set firm rules about expectations
• Urge family to discuss risks-judgement problems
• Child of alcoholic discuss with family, discuss
  genetic risks, alateen (problem list prenatal)

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Pediatricians RoleWhen to consider

• Parent concerned
• FU ER visit or hospitalization for injury
• Occasionally ulcer
• High suspicion with other drug thc, nicotine
• Teen who is sex active (? rate)
• History of rape
• Alcohol poisoning in ER
• Major change in behavior-grades drop
• Teen in recovery who relapses

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Pediatricians RoleStart Counseling Early

• 8-12 years old
• Incorporate into HEEADSSS-Home, education,eating,
  activities,Drugs alcohol tobacco, suicidality
  sex,safety
• Incorporate into SSHADESS-Strengths, school,
  home,activities, drugs, emotions, sex, safety
• Start early if FH alcohol And/or High risk youth

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Pediatricians RoleHow to ask

• Family use
• Friend use
• Own use not -how much do you use?- rather I see
  that some of your family members and/or friends
  drink, Im wondering about your drinking
• Ask about riding with people who have had a
  drink, drinking and driving, biking, safe sex

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How are Peds Doing Millstein data 2003

• Surveyed 1842 Peds FPs-docs ask, Do you use
  Alc
• Pediatricians 23-43 counseling
• Family Practice 14-27 counseling
• Intervention increased when perceived resources/
  skills
• Problems time and lack of resources
• GOALIncreased screening and counseling
• If all of you do it today in your office at least
  one person would be likely to be protected from
  an alcohol related adverse event

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How are Peds Doing Millstein data 2003

• Professional guides AAP, Gaps recommend alcohol
  screening all teens
• lt25 sample screened all adolescents
• Screening for alcohol use in family and peers
  recommended typical physician does this in only a
  minority of patients
• Screening for alcohol use in Motor Vehicles is
  done even less often
• lt1/3 adhered to recommendation all teens be
  educated even though teens see docs as credible
  source of info
• Younger teens less likely than older conflict
  with use data
• 1/3 8th graders in school had had a drink
• 1/7 8th graders have been drunk
• Solutions- time and training- knowledge of
  resources

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Millstein Counseling levels identified

• Low level counseling-general risks, risk of
  abuse, risk of injury (warning drink drive,
  boat, swim, physical or sex abuse by
  acquaintance, unsafe sex)
• Medium level counseling
• Advising drinkers to stop and encouraging
  non-drinkers to maintain abstinence
• Aim for High level counseling
• Information about common teen alcohol situations
• Normative info on teens who dont drink
• Practicing refusal skills

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Using the 6 Gs with teens

• GENETIC
• Family members drink more than they should?
• Feel scared when family drink?
• GROUP
• Where hang with friends?
• What do for fun with friends?
• When at friends - how often parent present
• Heyman, R. Contemporary Pediatrics June 2007

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Using the 6 Gs with teens

• GIVE- someone likely to try to give to teen
• Have you been at parties where people your age
  and or older drinking and drugging (D D)?
• Do your friends prefer drinking to other
  activities?
• Ever feel weird cause the only one at party not
  DD?
• Ever offered DD ? How handled? Refusal skills
• GET-willing to get
• Are you the kind who like to live on the edge?
• Do you think people have more or less fun when
  DD?
• Are you curious how DD affect your body?
• What do you think about underage D D

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Using the 6 Gs with teens

• GREAT-get great physical mental danger
• What do you know about DD effect on Young
  brain vs older?
• What know about how DD affect judgment
  /thinking?
• Know anyone whos life has been harmed by D D
  -alcohol poisoning, attacked, injured in moving
  vehicle, cirrhosis, blackout etc.
• GUIDANCE- grasp parent and societal
• Whats your idea why grownups dont want young
  people to use alcohol?
• Whats your sense of where your parents stand?
• What know about consequences -parents-
  school-legal if choose to DD?
• ALSO CAN USE WITH PARENTS-handouts in article

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Use existing resources young teens

• Adolescent Health Working Group Behavioral
  Health an Adolescent Provider Toolkit. Contains
  the Crafft. Also contains multiple tools to use
  with teens related to stress management and
  coping. Stress is often at the core of substance
  use in teens.

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Use existing resources and opportunities-older
teensCA DMV PARENT TEEN TRAINING GUIDE 2006

• Advises parents discuss 4 questions with kids
• 1. Being driven home from a party by friend who
  is now under influence
• 2. Date intoxicated at party and insists on
  driving.
• 3. Riding in car with older teens-one using
  alcohol and offers to you.
• 4. Told teen no alcohol-went to party and wine
  served and feeling strange from the wine- its
  late- teen afraid to drive home - not sure if he
  should call parents.

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Teen in hospital who is regular drinker-rarely
needs withdrawal meds

• Assess magnitude of drinking
• Assess what happens if stops for a day or
  two-does s/he get shaky?
• Is s/he doing prescription drugs- benzodiazepans
  can be a problem if withdrawing from both. - If
  dont believe client check drug screen asking for
  benzos
• Shaking and jitteriness are late symptoms after
  _1-2days
• If concerned monitor with alcohol withdrawal
  checklist (Web Source Royal Brisbane Hospital)
• Very rarely are meds necessary

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Cases

• 16 yo female glass of wine at party with friends.
  Drank 2 times in last year-Max 1 drink. Parents
  rule no drinking. They dont know.
• Friends parents supplied the liquor at the party
• Aware of effect on judgement if kept drinking

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Cases

• 15 year old female 6 beers a day for the last
  year. FH of alcoholism in dad still drinking.
  Multiple black outs almost every day.
• Source-stealing and shoulder tapping

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References Resources

• References Levy S. et al. Office-based
  intervention for adolescent substance abuse. Ped
  Clinics North AM 200249329.
• Millstein,S. et al. Screening and Counseling for
  Adolescent Alcohol Use Pediatrics
  2003111114-122.
• Heyman R. Combating Underage Drinking with the 6
  gs. Contemporary Pediatrics 200724 63-99.
• www.contemporarypediatrics.com
• Resources Hopelinks.net
• www.ahwg.net download Adolescent Provider Toolkit
• www.drugabuse.gov
• www.safeyouth.org/scripts/teens/alcohol.asp