Download Substance Related Disorders

Substance Use Disorders in
Young People
Christopher Gerhart, MAC,
LADAC, CADC, SAP, MTTS, etc.
Objectives. At the end of this
talk you will be able to:
•Identify diagnostic criteria for
substance use disorders
•Describe the epidemiology of
substance-related disorders among
young people.
•Apply this information to clinical cases
•Apply skills to make your practice more
alive, dynamic and fun.
Normal (Usually) Adult Brain
REWARD SYSTEM
•Drugs of abuse activate the reward
system in the limbic area of the
brain—producing powerful feelings of
pleasure
•Fool brain into thinking that they are
necessary for survival
REWARD SYSTEM (cont.)
•Desire to repeat drug using behavior is
strong
•Drugs of abuse can/do exert powerful
control over behavior because they act
directly on the more primitive, survival
limbic structures— over-ride the
frontal cortex in controlling our
behavior
ADOLESCENCE
PUBERTY
Romantic motivation
Sexual interest
Emotional intensity
Sleep cycle changes
Appetite
Risk for affective disorders
(girls)
Increase in risk taking,
sensation seeking, and
novelty seeking
AGE/EXPERIENCE
Planning
Logic, reasoning
Inhibitory control
Problem solving
Understanding consequences
Affect regulation
Goal setting and pursuit
Judgment and abstract
thinking
A Definition of Addiction
American Society of Addiction Medicine
A primary, chronic, neuro-biologic disease
with genetic, psychosocial, and
environmental factors influencing its
development and manifestations. Addiction
is characterized by behaviors that include
one or more of the following: impaired
control over drug use, compulsive use,
continued use despite harm, and craving.
Graham, A.W.; Schultz, T.K.; Mayo-Smith, M.F.; Ries, R.K.; and
Wilford, B.B. eds. Principles of Addiction Medicine, Third Edition.
Chevy Chase, MD: American Society of Addiction Medicine, Inc.,
2003.
1-
Use of the DSM-5
•The primary purpose of the DSM-5
(Diagnostic and Statistical Manual of
Mental Disorders) is to assist trained
clinicians in the diagnosis of their
patients’ mental disorders as part of a
case formulation assessment that leads
to a fully informed treatment plan for
each individual.
Substances Frequently Used by
Young People
•Alcohol
•Cannabis
•Hallucinogens
•Inhalants
•Tobacco
•Opioids
•Sedatives, hypnotics,
and anxiolytics
•Stimulants
•Other
2015 Monitoring the Future Study
Prevalence of Past Year Drug Use Among 12th graders
Drug
Prev.
Drug
Prev.
Alcohol
58.2
Vicodin*
4.4
Marijuana/Hashish
34.9
Hallucinogens
4.2
Hookah
19.8
OxyContin*
3.7
Small cigars
15.9
Sedatives*
3.6
Amphetamines*
7.7
MDMA (Ecstasy)
3.6
Adderall*
7.5
LSD
2.9
Snus
5.8
Hall other than LSD
2.9
Narcotics o/t Heroin*
5.4
Cocaine (any form)
2.5
Synthetic Cannabinoids
5.2
Ritalin*
2.0
Tranquilizers*
4.7
Inhalants
1.9
Cough Medicine*
4.6
Salvia
1.9
* Nonmedical use
Categories not mutually exclusive
Substance-Related Disorders
•Substance Use Disorders
•Previously split into abuse or
dependence
•Involves: impaired control, social
impairment, risky use, and
pharmacological criteria
•Substance-Induced Disorders
Substance Use Disorder
•
•
•
•
•
•
Using larger amounts or for longer time than
intended
Persistent desire or unsuccessful attempts to cut
down or control use
Great deal of time obtaining, using, or recovering
Craving
Fail to fulfill major roles (work, school, home)
Persistent social or interpersonal problems
caused by substance use
Substance Use Disorder
• Important social, occupational, recreational activities
given up or reduced
• Use in physically hazardous situations
• Physical or psychological problems caused by use
• Tolerance
• Withdrawal
Tolerance
•Need to use an increased amount of
a substance in order to achieve the
desired effect
OR
•Markedly diminished effect with
continued use of the same amount
of the substance
Severity
•Depends on # of symptoms
•Mild: 2-3 symptoms
•Moderate: 4-5 symptoms
•Severe: 6 or more symptoms
Specifiers
•In early remission: no criteria for > 3 months
but < 12 months (except craving)
•In sustained remission: no criteria for > 12
months (except craving)
•In a controlled environment: access to
substance restricted (ex. Jail, placement)
Substance-Induced Disorders
•Intoxication
•Withdrawal
•Psychotic Disorder
•Bipolar Disorder
•Depressive
Disorder
•Anxiety Disorder
•Sleep Disorder
•Delirium
•Neurocognitive
•Sexual Dysfunction
Changes in the Brain
Neuroadaptation
Underlying CNS changes that occur following
repeated use such that person develops
tolerance and/or withdrawal
•Pharmacokinetic – adaptation of
metabolizing system
•Pharmacodynamic – ability of CNS to
function despite high blood levels
Epidemiology: Prevalence
•Start at earlier age (<15yo), more
likely to become addicted – ex.
alcohol: 18% vs. 4% (if start at 18yo
or older)
•Rates of abuse vary by age: 1%
(12yo) - 25% (21yo) - 1% (65yo)
Epidemiology (cont.)
•13 million people require treatment
for alcohol
•5.5 million people require treatment
for drug use
•2.5% population reported using Rx
meds non-medically within past
month
Epidemiology (cont.)
•40% of hospital admissions are
related to alcohol or drug use
•25% of all hospital deaths
Epidemiology (cont.)
•100,000 deaths/year
•Intoxication is associated with 50%
of all motor vehicle accidents, 50%
of all domestic violence cases and
50% of all murders
Region 6 Profile
State
Capital
Population1
Pop.
Density2
Joint
SA
Prevalence3
SMI
Prevalence4
Suicide
Rate5
Arkansas
Little Rock
2,915,918
56
Yes
8.34
6.92
15.6
Louisiana
Baton Rouge
4,533,372
104.9
Yes
9.05
4.76
12.1
New Mexico
Santa Fe
2,059,179
17
Yes
10.34
4.39
21.2
Oklahoma
Oklahoma City
3,751,351
54.7
Yes
9.45
5.09
15.8
Texas
Austin
25,145,561
96.3
Yes
8.63
4.29
10.8
United States
Washington,
DC
309,349,689
87.4
N/A
9.1
4.6
11.3
1U.S.
Census 2010
Census 2010
3SAMHSA, NSDUH 2008-2009, Table 19. Dependence on or Abuse of Illicit Drugs or Alcohol in Past Year among Persons Aged 18 or Older.
4SAMHSA, NSDUH 2008-2009, Table 22. Serious Mental Illness in Past Year among Persons Aged 18 or Older, by State.
5CDC, National Vital Statistics System-Mortality (NVSS-M) 2008, per 100,000
2U.S.
Source of Marijuana* among 12th Graders in
2012-2015, by State Policy
100
80
60
40
**
20
**
**
**
0
Medical Marijuana States
*Categories not mutually exclusive
** Statistically significant difference
SOURCE: University of Michigan, 2015 Monitoring the Future Study
Etiology
•Multiple interacting factors influence using
behavior and loss of decisional flexibility
•Not all who become dependent experience it
same way or are motivated by same factors
•Different factors may be more or less
important at different stages (drug
availability, social acceptance, peer pressure,
personality and biology)
Etiology
•“Brain Disease” – changes in structure and
neurochemistry transform voluntary drugusing compulsive
•Changes proven but necessary/sufficient?
(drug-dependent person changes
behavior in response to positive
reinforcers)
•Psychodynamic: disturbed ego function
(inability to deal with reality)
Etiology
•Self-medication
•Alcohol - panic; opioids -anger; amphetamine
- depression
•Genetic (well-established with alcohol)
•Conditioning: behavior maintained by its
consequences
•Terminate aversive state (pain, anxiety, w/d)
•Special status
•Euphoria
•Secondary reinforcers (ex. Paraphernalia)
Etiology
• Receptors
Too little endogenous opioid activity (ie low
endorphins) or too much endogenous opioid
antagonist activity = increased risk of dependence.
Normal endogenous receptor but long-term use
modulates, so need exogenous substance to maintain
homeostasis.
• Neurotransmitters
oOpioid
oCatecholamines
oGABA
oSerotonin
Learning and Physiological Basis
for Dependence
•
•
After using drugs or when stop – leads to a
depleted state resulting in dysphoria
and/or cravings to use, reinforcing the use
of more drug.
Response of brain cells is to downregulate
receptors and/or decrease production of
neurotransmitters that are in excess of
normal levels.
Comorbidity
•Up to 50% of persons that have a
substance use disorder also have a
comorbid psychiatric disorder
•Antisocial PD
•Depression
•Suicide
Insufficient Responses to Behavioral Health Issues
Or, Things That Do Not Work Well For Long
33
Increased
Security &
Police
Protection
Tightened
Background
Checks &
Access to
Weapons
Legal
Control of
Perpetrators
& Their
Treatment
More Jail
Cells,
Shelters,
Juvenile
Just ice
Facilities
Institutional
System
Provider
Oversight
Treatment
• Behavioral Interventions
Motivation to change (MI)
Group Therapy
Individual Therapy
Contingency Management
Self-Help Recovery Groups (AA)
Therapeutic Communities
Aversion Therapies
Family Involvement/Therapy
Twelve-Step Facilitation
Relapse Prevention
Treatment
•Pharmacologic Intervention
•Treat Co-Occurring Psychiatric Disorders
•50% will have another psychiatric disorder
•Treat Associated Medical Conditions
cardiovascular, cancer, endocrine, hepatic,
hematologic, infectious, neurologic,
nutritional, GI, pulmonary, renal,
musculoskeletal
The Original Jellinek Curve
Pareto’s 80/20 Rule
•Devoted himself to finding
laws in economics, trying to
make it into an exact science.
•Author of the three-volume
Trattato di Sociologia
Generale
•First noticed the 80/20 Rule
•Pareto’s Law of Principle
Vilfredo Pareto 1848 - 1923
Examples of the 80/20 Rule
•80% of Pareto’s peas came from 20% of
the peapods.
•80% of Italy’s land was owned by 20% of
the people
•80% of profit is produced by 20% of
employees.
•80% of crime is committed by 20% of
the criminals.
Prochaska and DiClemente’s Stages of
Change Model
 Precontemplation (Not yet acknowledging that there
is a problem behavior that needs to be changed)
 Contemplation (Acknowledging that there is a
problem but not yet ready or sure of wanting to make
a change)
 Preparation/Determination (Getting ready to change)
 Action (Changing behavior)
 Maintenance (Maintaining the behavior change) and
 Relapse (Returning to older behaviors and abandoning
the new changes)
Behavioral Health is Essential to Health
40
By 2020, mental & substance use disorders (M/SUDs) will
surpass all physical diseases as a major cause of disability
worldwide
One-half of U.S. adults will develop at least one mental illness
in their lifetime
 U.S. 2006: M/SUDs were 3rd most costly health condition behind
heart conditions and injury-related disorders
 Mental illness and heart diseases alone account for almost 70
percent of lost output/productivity
Websites
• SAMHSA – www.samhsa.gov
• Substance Abuse and Mental Health Services Administration
• NIDA – www.drugabuse.gov
• National Institute on Drug Abuse
• AAAP – www.aaap.org
• American Academy of Addiction Psychiatry
• ASAM – www.asam.org
• American Society of Addiction Medicine