Tackling Teen Alcohol Use- The Six G’s

1. Tackling Teen Alcohol Use- The Six G’s Cathy McDonald, MD, MPH Alameda County ATOD Provider Network Thunder Road 510-653-5040

2. Teen Alcohol Use • Scope of the problem • Alcohol Effect on Teen Brain • Genetics & environment • Addiction Stage/ Dependence • Pediatrician’s Role • Screening & Intervention

3. Grade Any Use Been Drunk ever 8th 39% 18% 10th 62% 41% 12th 72% 55% The ProblemData: National • MONITORING THE FUTURE 2007

4. The ProblemData: State • California Student Survey 2005-2006 • Past 30 days

5. The ProblemData: State California Student Survey 2005-2006

6. The scope of the problem • Adult Alcohol dependence 5% M 2% F • 7000 teens <16 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 < .01% <21 ZERO TOLERANCE

7. 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 > drinks (women 4 or >) in a row once in past month • Monitoring the Future-5 or > 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

8. 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

9. Alcohol’s 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

10. An Immature Brain = Less Brakes on the “Go” System

11. Construction Ahead • Growth of the brain’s 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.

12. 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

13. Emerging Science: Teen Brains Are Still“Under 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

14. Judgment Gets Betterwith Age • By age 18, the adolescent’s 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

15. 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

16. Fewer Problems in Those Who Start Later % Age Started Drinking

17. . Percentages of Past Year Alcohol Use Disorder (Abuse or Dependence) Among Adults Aged 21 or Older, by Age of First Use (SAMHSA, 2004)

18. 2. Survey Data Suggest that Adolescents Are Less Sensitive to Alcohol’s Effects Monitoring the Future, 2001 Less sensitive

19. Adolescents continue to be less sensitive in 2007

20. 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.

21. 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.

22. Human Data: Alcohol’s 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.

23. 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

24. 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

25. 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

26. Impact of Environment • Family and Community • Reward • After work • Celebrate • sports

27. 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

28. 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

29. CRAFFT Car Relax Alone Family / Friends Forget Trouble Screening tools for ATOD once use recognized Two or more yes -there is a problem- needs further evaluation

30. Pediatrician’s Role: Prevention • Prenatal visit √FH 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)

31. Pediatrician’s 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

32. Pediatricians Role:Start 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

33. Pediatrician’s Role:How 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, I’m wondering about your drinking” • Ask about riding with people who have had a drink, drinking and driving, biking, safe sex

34. How are Peds Doing Millstein data 2003 Surveyed 1842 Peds & FP’s-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 GOAL:Increased 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

35. How are Peds Doing Millstein data 2003 Professional guides AAP, Gaps recommend alcohol screening all teens <25% 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 <1/3 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

36. 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 don’t drink • Practicing refusal skills

37. Using the 6 G’s 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

38. Using the 6 G’s 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 D&D? • Ever offered D&D ? 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 D&D? • Are you curious how D&D affect your body? • What do you think about underage D & D

39. Using the 6 G’s with teens • GREAT-get great physical & mental danger • What do you know about D&D effect on Young brain vs older? • What know about how D&D affect judgment /thinking? • Know anyone who’s life has been harmed by D& D -alcohol poisoning, attacked, injured in moving vehicle, cirrhosis, blackout etc. • GUIDANCE- grasp parent and societal • What’s your idea why grownups don’t want young people to use alcohol? • What’s your sense of where your parents stand? • What know about consequences -parents- school-legal if choose to D&D? ALSO CAN USE WITH PARENTS-handouts in article

40. 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.

41. 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- it’s late- teen afraid to drive home - not sure if he should call parents.

42. 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 don’t believe client check drug screen asking for benzo’s • 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

43. 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 don’t know. • Friends parents supplied the liquor at the party • Aware of effect on judgement if kept drinking

44. 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

45. References & Resources References: Levy S. et al. Office-based intervention for adolescent substance abuse. Ped Clinics North AM 2002;49:329. Millstein,S. et al. Screening and Counseling for Adolescent Alcohol Use… Pediatrics 2003;111:114-122. Heyman R. Combating Underage Drinking with the 6 g’s. Contemporary Pediatrics 2007;24 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