1 / 78

Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington

Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY. Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington Co-Director, Adolescent Substance Abuse Program Seattle Children’s Hospital

beau
Télécharger la présentation

Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington Co-Director, Adolescent Substance Abuse Program Seattle Children’s Hospital PAL Conference, Laramie, WY; 3/24/12

  2. Objectives • Participants will learn about the prevalence and patterns of substance use and substance use disorders (SUDs) in adolescents • Participants will become familiar with common screening and assessment tools of SUDs in adolescents • Participants will be able to describe and utilize common treatment options for SUDs in adolescents

  3. Disclosure • No conflict of interest to report • Off-label discussion of medications

  4. Overview • Definitions • Prevalence • Screening: the Adolescent Perspective and Risk and Protective Factors • Assessment • Treatment • Co-Occurring Disorders • Questions and Answers

  5. Substance-Related Disorders • Substances covered in DSM IV-TR: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine, Sedative/Hypnotic/Anxiolytic, Other/Unknown • Substance Use Disorders (SUDs) = Substance Abuse or Dependence • Substance-Induced Disorders = Substance Intoxication or Withdrawal • Nicotine & Polysubstance: No Abuse • Caffeine: No Abuse or Dependence

  6. Substance Abuse • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring at anytime within a 12-month period: • Recurrent use resulting in a failure to fulfill major role obligations at work, school or home • Recurrent substance use in situations in which it is physically hazardous • Recurrent substance-related legal problems • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance • Never met criteria for dependence

  7. Substance Dependence • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance: “a need for markedly increased amounts of the substance to achieve intoxication or desired effect” or “markedly diminished effect with continued use of the same amount of the substance” • Withdrawal: “the characteristic withdrawal syndrome for the substance” or “the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

  8. Substance Dependence • Substance is often taken in larger amounts or over a longer period than intended • Persistent desire or unsuccessful efforts to cut down or control substance use • Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover • Important social, occupational, or recreational activities are given up or reduced • Substance use is continued despite knowledge of persistent or recurrent physical or psychological problem caused or exacerbated by substance

  9. Dependence Specifiers • With Physiological Dependence • Without Physiological Dependence Course Specifiers • Early Full Remission • Early Partial Remission • Sustained Full Remission • Sustained Partial Remission • On Agonist Therapy • In a Controlled Environment

  10. Polysubstance Dependence • Repeatedly using at least 3 groups of substances (not including caffeine or nicotine) • Dependence criteria were met as a group but not for any specific substance • Most commonly in individuals where the substance use is highly prevalent but the drugs of choice frequently changed

  11. DSM 5: Substance Use Disorders • 11 criteria: replaced “legal problem” with “craving or a strong desire or urge to use a specific substance” • New Severity Specifiers • Moderate: 2-3 criteria positive • Severe: 4 or more criteria positive • Same Course Specifiers as DSM IV-TR • Potentially identify problematic use earlier and lead to proper intervention

  12. Frequently Asked Question # 1 • How common is substance use in adolescents? • Who is using? • What are they using?

  13. Quiz #1 • How common is substance use? In a class of 100 high school seniors, how many have tried the following during their lifetime: • Cigarettes? • Alcohol? • Illicit Drugs? • Illicit Drugs other than Cannabis?

  14. Prevalence of Substance Use • Monitoring The Future (MTF) Study • www.monitoringthefuture.org • NIDA funded national study • Middle/high school, college, young adults • 40,000+ adolescents from 300+ sites • Survey behaviors/attitudes on substance use • Annual follow-up survey to graduating class

  15. MTF Lifetime Prevalence: 2011

  16. MTF Lifetime Prevalence: 2011

  17. Summary of MTF Trend Findings • Male generally more drug use • College-bound adolescents use less • Regional variation is quite complex & changing • Population density is not a predictor of use • Socioeconomic class difference mostly small • Whites ≥ Hispanics > African Americans: Hispanics in 8th grade higher in most categories but may have higher drop-out rate and earlier initiation to account for lower numbers in 12th grade

  18. Quiz #2 • In adolescents ages 12-17: • How common is Substance Abuse? • How common is Substance Dependence?

  19. Prevalence of SUDs • National Household Survey on Drug Use and Health (NHSDUH) • http://oas.samhsa.gov/nsduh.htm • Formerly NHSDA(buse) • Youth 12-17 years old: survey use and abuse • 8% classified with SUDs in 2005 (3.1% Abuse, 4.9% Dependence): 8.3% for males, 7.8% for females • 7.3% classified with SUDs in 2010 (4.5% Alcohol, 4.7% Illicit drugs): 6.9% for males, 7.7% for females

  20. Prevalence of SUDs • National Comorbidity Survey-Adolescent Supplement ( NCS-A): Merikangas et al, JAACAP 2010 • Youth 13-18 years old: diagnostic survey • 11.4 classified with SUDs: (6.4% Alcohol, 8.9% Illicit drugs): 12.5% for males, 10.2% for females • SUDs rates by age group: • 13-14: 3.7% • 15-16: 12.2% • 17-18: 22.3%

  21. NHSDUH 2010: SUDs Pattern • Most Common Types of Substance Used: Alcohol > Marijuana > Pain Relievers > Cocaine > Others (methamphetamine, heroin, hallucinogen) • Polysubstance use is common • Reflected in most treatment studies and clinical trials (O’Brien et al 2005)

  22. Summary: Epidemiological Studies • Experimentation is normative but consequences can be severe and far-ranging • Abuse is the exception: look for early initiation and heavy use • “Gateway Theory”: Cigarettes Alcohol  Cannabis  Other illicit drugs

  23. Frequently Asked Question #2 • How do I know whether my patient is using too much or not? (i.e., Is he/she just a typical teenager or someone who needs an intervention or assessment)

  24. Tasks of Adolescence • Emancipation/surrender of childhood • Identity formation • Sexual • Intellectual • Moral • Spiritual • Ethnic • Functional role in society

  25. Risk Factors for SUDs Newcomb 1997 • Four generic domains • Cultural/Societal • Interpersonal: family and peers • Psychobehavioral • Biogenetic • Relevance modified by age, gender, and ethnicity

  26. Mediating Factors • Early experimentation • Substance-Dependent parents • Substance-Abusing siblings • Conduct disturbances • Deviant and substance-abusing peers • Sensation-seeking temperament • Impulse and self-control problems

  27. Mediating Factors • Poor parental supervision • Heavy drug-use neighborhoods • School problems • Social skills deficits • Parents with poor parenting skills • Victims of trauma, abuse and neglect

  28. Riggs’ Developmental Pathways to Adolescent Mental Health, Substance Problems IQ; academic performance; female hobby; empathic gatekeeper Resilience Substance Use Abuse Dependence IMPEDES DEVELOPMENT • Coping skills • Social /interpersonal skills • Communication skills • Identity, values consolidation • Affect identification/regulation • Self-Efficacy/external locus control • Cognitive development • Pro-social network PEERS Antisocial; drug-using School Truancy, failure, HS dropout Family SUD, abuse, neglect Genetics Attachment 0 10 5 15 20 Fetal Exposure Drugs/Alcohol ADHD ODD CD ASP Depression Individual

  29. Quiz #3 • What is the screening instrument recommended by the American Academy of Pediatrics for adolescents with substance use disorders?

  30. Screening/Testing • CRAFFT (Knight 2002): screening; 2 or more of the following indicate significant problem • Car • Relax • Alone • Family/friends • Forget • Trouble • Drug testing: urine or other modalities

  31. Frequently Asked Question #3 • What do I do if my patient is in need of an assessment or intervention? • What happens at a chemical dependency assessment? Who performs the assessment?

  32. Chemical Dependency Assessment • Usually performed by Substance Abuse Counselors/Chemical Dependency Professionals (CDPs) • Assessment usually consists of a clinical interview that addresses the 6 dimensions of American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC)

  33. Quiz # 4 • How many dimensions of the ASAM PPC can you name?

  34. ASAM PPC Dimensions • I: Acute intoxication and/or withdrawal potential • II: Biomedical conditions and complications • III: Emotional, behavioral, or cognitive conditions and complications • IV: Readiness to Change • V: Relapse, continued use, or continued problem potential • VI: Recovery environment

  35. Quiz # 5 • Can you name the 4 different levels of chemical dependency treatment identified in the ASAM PPC?

  36. ASAM PPC Levels • Level 0.5: Early Intervention • Level I: Outpatient Services: <9hours/week • Level II: Intensive outpatient (9-19 hours/week)/ Partial hospitalization (>20 hours/week) • Level III: residential/inpatient services (e.g., imminent risk in relapse, continued use or recovery environment) • Level IV: medically managed intensive inpatient services (e.g., imminent risk in D1, D2, or D3)

  37. Psychiatric Assessment • Multiple domains: Timeline approach • Psychiatric/behavioral • Family • School/Vocational • Recreational/Leisure • Medical • Collateral, collateral, collateral!!! • Toxicology

  38. Peers • Deviancy • Substance Use • Gang Riggs’ Lifetime Timeline Longitudinal Developmental History • Pre-natal; attachment School • LD; special education • Behavior problems • Academic performance • Family • Abuse, neglect, conflict, SUD • Family management • Parental monitoring Pre-natal Attachment Adolescent Adult School-age College-age Substance Use • Onset, experimentation • For all substances used >5x • Progression to regular use • Peak use • Current use (last month) • Last use Onset and Progression of Psychiatric Symptoms • ODD/CD • ADHD • Depression • Mania /hypomania • Anxiety (SAD, PTSD, GAD, OCD) • Psychosis

  39. Frequently Asked Question #4 • How do I get my patient into treatment? • What happens when my patient is in treatment in Washington State?

  40. Outpatient/Intensive Outpatient Services • Non-residential programs providing chemical dependency assessments, alcohol/drug free counseling services and education for youth age 10 to 20 • Designed to screen, assess, diagnose, and treat misuse, abuse, and addiction to alcohol and other drugs

  41. Detox/Stabilization Services • Services providing at-risk, runaway, homeless youth age 13-17 a safe, temporary, and protective environment • Criteria: experiencing crisis related to the harmful effects of intoxication and/or withdrawal from alcohol and other drugs, in conjunction with an emotional or behavioral crisis • Typical length of stay: 1-5 days

  42. Inpatient Treatment • Programs designed for “chemically dependent” youth age 13-17 • Services include intensive individual, group, and family counseling, education, school activities, recreation, recovery support groups, and connection to continuing treatment in the home community

  43. Levels of Inpatient Services Level 1 • Primary addiction problems requiring less clinical intervention and behavior management Level 2 • Co-occurring emotional and mental health problems, youth resistant to treatment, or high probability to run from treatment Recovery House • Continued residential stay after completing primary inpatient treatment

  44. NHSDUH 2010: Treatment Needs • Overall: 1.8 million youths aged 12-17 (7.5% of sample population) needed treatment -> 138,000 youths received treatment at a specialty facility (7.6% of youths who needed treatment) • Most treatment occurred in outpatient settings

  45. Barriers to Treatment • Five most often reported reasons for not receiving treatment (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) • Not ready to stop using (40.2%) • Cost or insurance barriers (32.9%) • Stigma (e.g., negative opinions from neighbors and community, negative effect on job) (22.8%) • Can handle the problem without treatment (9.9%) • Did not know where to go (9.3%)

  46. Barriers to Treatment • Five most often reported reasons for not receiving treatment despite seeking treatment: (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) • Cost or insurance barriers (45.2%) • Not ready to stop using (30.3%) • Treatment not needed (15.5%) • Stigma (15.0%) • No Transportation/Inconvenient (8.4%)

  47. Additional Complications in Adolescent SUD Treatment • Polysubstance use: typically alcohol and marijuana, occasional cocaine or opiates (Winters et al 2000; Kaminer et al 2002; Henggeler et al 1996) • High rates of comorbid psychiatric disorders (Armstrong et al 2002) • High rates of substance abuse in immediate families (Henggeler et al 1996; Winters et al 2000) • Developmental vulnerability • Involvement in multiple systems: legal, school, and medical problems may present first • High attrition rate: 50-80% (Henggeler et al 1996)

  48. Frequently Asked Questions #5 • Does treatment work? (e.g., “I’ve known people who have been through rehab many times but they are still addicted”)

  49. Why Treatment • Inconsistent outcomes after treatment prior to 1990’s(Catalano et al. 1992) • Treatment might escalate problems(Kaminer 2005; Dishion et al 1999) • Recent reviews show psychosocial treatment is better than no treatment(Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006) • Effective early intervention is critical and can be preventive in later years(Grant & Dawson 1997; Santisteban et al. 2003; NHSDUH series)

  50. Treatment Evaluation Studies: Older Studies • Older studies tend to be evaluations of four types of programs • “Minnesota Model”: comprehensive 4-6 week inpatient program using 12-Step • Outpatient drug-free programs: individual and group with some family counseling • “Therapeutic Community”: 6-12 months residential program using 12-Step • Outward Bound or life skills training programs: 3-4 weeks wilderness program focusing on challenges of survival and group interdependency

More Related