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ADOLESCENT

SUBSTANCE ABUSE
Anne Cristine D. Guevarra, MD
Child Psychiatry Rotator

Adolescent substance abuse


DSM-5 does not separate the diagnoses of substance

abuse from substance dependence


combined substance use criteria including both abuse and
withdrawal phenomena may strengthen the validity of the
disorder in adolescents

Psychosocial risk factors


Parent modeling of substance use
Family conflict
Lack of parental supervision
Peer relationships
Individual stressful life events

Protective risk factors


Stable family life
Strong parentchild bond
Consistent parental supervision
Investment in academic achievement
Peer group that models prosocial family and school

behaviors

Epidemiology
Approximately one of five adolescents have used

marijuana or hashish
Approximately one third of adolescents have used
cigarettes by age 17 years
By 13 years of age, 1/3 of boys and almost of girls
have tried alcohol
By 18 years of age, 92% of males and 73% of females
reported trying alcohol, and 4% reported using alcohol
daily
Of high school seniors, 41% reported using marijuana;
2% reported using the drug daily

Filipinos using illegal drugs has decreased


to 6.7 million from around 10 million in 2001
based on the 2004 survey results of the
Dangerous Drugs Board (DDB)
Philippine Drug Enforcement Agency (PDEA)
Office of the Senate: Press Release, May 8, 2006

National Institute on Drug Abuse, 2012

National Institute on Drug Abuse, 2012

National Institute on Drug Abuse, 2012

Nicotine
Nicotine is one of the most addictive substances known; it

involves cholinergic receptors, and enhancing


acetylcholine, serotonin, and -endorphin release.
Young teens who smoke cigarettes are also exposed to

other drugs more frequently than nonsmoking peers.

Nicotine
Psychoactive agent of tobacco
Agonist at the nicotinic subtype of Ach receptors in the

CNS
25% of inhaled nicotine reaches the bloodstream
Half-life: 2 hours

Positive and addictive by


reinforcing the dopaminergic pathway projecting from the ventral
tegmental area to the cerebral cortex and the limbic system
causes an increase in the concentrations of circulating NE and E
causes an increase in the release of vasopressin, endorphin,
ACTH and cortisol (contribute to the basic stimulatory effects of
nicotine)

Nicotine: Adverse Effects


Highly toxic alkaloid
0.5mg: 1 stick of cigarette
60mg: fatal secondary to respiratory paralysis

Nicotine Toxicity
Low dose: nausea,

vomiting, salivation,
pallor, weakness,
abdominal pain,
diarrhea, dizziness,
headache, increased
blood pressure,
tachycardia, tremor,
and cold sweats

High dose: inability to

concentrate,
confusion, and sensory
disturbances,
decreased REM
Pregnancy: increased
incidence of LBW and
Persistent pulmonary
hypertension

Griesler, P.C., et al. Comorbid psychiatric disorders and nicotine dependence in adolescence.
Addiction 106(5):10101020, 2011
Nicotine Dependence Linked to Higher Rates of Mental Disorders Among Teens, March 2012, NIDA.

Drinking
Follows adult demographic drinking patterns
Whites >> other groups
Roman Catholics least likely nondrinkers
More than 1/3 of adolescents are treated in pediatric

trauma center for alcohol or drug use


Four most common cause of death 10-24 years of age
37% motor vehicle accidents
14% homicide
12% suicide
12% other injuries or accidents

Alcohol
72.5% of high school students had tried at least one alcoholic drink
24.2% reported an episode of heavy drinking in the month preceding
the survey
39% of adolescents have used alcohol before 8th grade
70% at 8th grade
A significant problem for 10 20% of adolescents
Ages 13 -17 years, 3 million problem drinkers
300,000 with alcohol dependence
Gap between male and female alcohol consumers is

narrowing

Mechanism of Action
no single molecular target
Enhanced: ion channel activities associated with the

nicotinic acetylcholineserotonin 5-hydroxytryptamine3 (5HT3,) and GABA type A (GABAA) receptors


Inhibited: ion channel activities associated with glutamate

receptors and voltage-gated calcium channels

Short-term: intercalating itself into membranes and, thus,

increasing fluidity of the membranes


long-term: membranes become rigid or stiff
The fluidity of the membranes is critical to normal
functioning of receptors, ion channels, and other
membrane-bound functional proteins.

Alcohol
May diminish hippocampal brain volume
Compromised cognitive function, especially attention

CIWA-Ar
The Clinical Institute Withdrawal
Assessment for Alcohol measures 10
categories of symptoms, with a range
of scores in each. The maximal score
is 67.
Minimal-to-mild withdrawal symptoms
result in a total score below 8;
moderate withdrawal symptoms
(marked autonomic arousal), in a total
score of 8 to 15; and severe withdrawal
symptoms, in a total score of more
than 15.
High scores are predictive of seizures
and delirium.

N Engl J Med 2003;348:1786-95

Adolescents with alcoholism show rates of 50% or higher

for additional psychiatric disorders, especially mood


disorders.
A recent survey of adolescents who used alcohol found
that more than 80% met criteria for another disorder.
depressive disorders
disruptive behavior disorders
drug use disorders

Marijuana
most widely used drugs by young people in developed

countries, and recently it has become highly used globally.


used by 3.9% of people worldwide (15 - 64 years)
most commonly used illicit drug among high school
students in the United States
10% become daily users
20 30% become weekly users
gateway drug, because the strongest predictor of future
cocaine use is frequent marijuana use during adolescence
10% in 8th grade, 23% in 10th grade, 36% in 12th grade
students

Marijuana
Short-term effects:
impairment in memory and learning
distorted perception
diminished problem-solving ability
loss of coordination
increased heart rate
anxietyand panic attacks

Withdrawal symptoms:
Insomnia
Irritability
Restlessness
drug craving
depressed mood
nervousness followed by anxiety, tremors, nausea, muscle twitches
Increased sweating, myalgia, and general malaise

Marijuana
Short-term effects: of the active ingredient in marijuana,

tetrahydrocannabinol (THC), include impairment in


memory and learning, distorted perception, diminished
problem-solving ability, loss of coordination, increased
heart rate, anxiety, and panic attacks

Marijuana
Withdrawal syndrome begins 24 hours after the last use,

peaks at 2 to 4 days, and diminishes after 2 weeks


associated with increased risk of psychiatric disorders
Acute & Chronic use changes in cerebral blood flow to
certain brain regions
Chronic use poor cognitive functioning (verbal learning,
memory, attention)
Those who had used marijuana by 18 years of age were
2.4 times more likely to develop schizophrenia

Marijuana
Risks:
Motor vehicle accidents
Impaired respiratory function
Increased risk of cardiovascular disease
Increased risk for psychotic symptoms and disorders

Cocaine
The annual cocaine use reported by high school seniors

decreased more than 30% between 1990 and 2000.


0.5% of 8th grade, 1% of 10th grade, and 2% of 12th
grade students
Prevalence rates for crack cocaine use, however, is
increasing and is most common among those between
the ages of 18 and 25.

Cocaine
Sniffed, snorted, injected, smoked
Crack is the term given to cocaine after it has been

changed to a free base for smoking


Effects:
constriction of peripheral blood vessels
dilated pupils
hyperthermia
increased heart rate
hypertension

High doses or prolonged use of cocaine can induce

paranoid thinking.
There is immediate risk of death secondary to cardiac
arrest or from seizures followed by respiratory arrest.

Cocaine
In contrast to stimulants used to treat ADHD, such as

methylphenidate, cocaine quickly crosses the bloodbrain


barrier and moves off the dopamine transporter within 20
minutes; methylphenidate remains bound to dopamine for
long periods.

CRACK USERS SHOW HIGH RATES OF


ANTISOCIAL PERSONALITY DISORDER,
ENGAGEMENT IN ILLEGAL ACTIVITIES AND
OTHER PSYCHOSOCIAL PROBLEMS
Paim Kessler FH, Barbosa Terra M, Faller S,
Ravy Stolf A, Carolina Peuker A, Benzano D,
Pechansky F

Objectives
To compare three groups of Brazilian psychoactive

substance (PAS) abuse patients in terms of psychiatric


comorbidities and severity of psychosocial problems

738 Current PAS abusers

Sixth version of the Addiction Severity Index (ASI-6):

293
Crack cocaine

126
Powder cocaine

319
Non-cocaine PAS

Findings
Crack and powder cocaine users were significantly

younger than non-cocaine PAS users


Crack users presented a higher rate of antisocial
personality disorder (25%) than powder cocaine (9%) and
non-cocaine PAS users (9%),

Crack users vs. Non-cocaine PAS users


ASI-6 summary scores
significantly higher rate of occupational, family, and legal problems
and reported more illegal and violent activities such as burglary
and theft (23%) and threatening or assaulting (32%) than noncocaine PAS users.

Opiods
A survey of 7,374 high school seniors found that 12.9%

reported nonmedical use of opioids. Of users, more than


37% reported intranasal administration of prescription
opioids.

Opioids: Adverse Effects


Death from an overdose: respiratory arrest from the

respiratory depressant effect


symptoms of overdose: marked unresponsiveness, coma,
slow respiration, hypothermia, hypotension, and
bradycardia

Opioids: Adverse Effects


clinical triad of coma, pinpoint pupils, and respiratory

depression
opioid overdose as a primary diagnosis
inspect the patient's body for needle tracks in the arms, legs,

ankles, groin, and even the dorsal vein of the penis

Heroin
Heroin, a derivative of morphine, is produced from a poppy

plant.
Usually appears as a white or brown powder that can be
snorted, but more commonly, it is used intravenously.
Withdrawal symptoms:
Restlessness
muscle and bone pain
Insomnia
Diarrhea
Vomiting
Cold flashes with goose bumps
Kicking movements

Withdrawal occurs within a few hours after use; symptoms peak

between 48 and 72 hours later and remit within about a week.

Smyth, B. et al. Years of potential life lost among heroin addicts 33 years after treatment.
Preventive Medicine 44(4):369-374, 2007
Reduced Longevity Among Male Heroin Abusers, 1962-1997, June 2008, NIDA.

Crystal Methamphetamine
Crystal methamphetamine, or ice, was at a relative low

level of use in adolescence about one decade ago of 0.5


percent, and has steadily increased to a recent rate of 1.5
percent among 12th graders.

Lysergic Acid Diethylamide (LSD)


Lysergic acid diethylamide is reportedly used by 2.7% of

8th grade students, 5.6% of 10th grade students, and


8.8% of 12th grade students.
Of 12th grade students, 0.1% report daily use.
The current LSD rates are lower than rates of LSD use

during the past two decades.

Lysergic Acid Diethylamide (LSD)


LSD is odorless, colorless, and has a slightly bitter taste. Higher

doses of LSD can produce visual hallucinations and delusions and,


in some cases, panic.
The sensations experienced after ingestion of LSD usually diminish

after 12 hours. Flashbacks can occur up to 1 year after use.


LSD can produce tolerance.
Substance use is related to a variety of high-risk behaviors,

including early sexual experimentation, risky driving, destruction of


property, stealing, heavy metal or alternative music, and,
occasionally, preoccupation with cults or Satanism.

Adolescents with inadequate social skills may use a

substance as a modality to join a peer group. In some


cases, adolescents begin their substance use at home
with their parents, who also use substances to enhance
their social interactions.
Although no evidence indicates what determines a typical

adolescent user of alcohol or drugs, many substance


users seem to have underlying social skills deficits,
academic difficulties, and less than optimal peer
relationships.

Club Drugs
MDMA, GHB, Rohypnol, and ketamine.
GHB, Rohypnol (a benzodiazepine), and ketamine (an

anesthetic) are primarily depressants and can be added


to drinks without detection because they are often
colorless, tasteless, and odorless. DATE RAPE
MDMA is a derivative of methamphetamine, a synthetic

with both stimulant and hallucinogenic properties


can inhibit serotonin and dopamine reuptake
can result in dry mouth, increased heart rate, fatigue, muscle

spasm, and hyperthermia.

3,4-Methylenedioxymethamphetamine
(MDMA)
The popularity of MDMA has increased over the last

decade, and current rates of use in the United States are


in the range of about 5% for 10th graders and 8% of 12th
graders
Despite that, the perceived harmfulness of this drug has

increased over the last decade to almost 50% among


12th graders.
Accidental adolescent deaths have been associated with

the use of MDMA.

3,4-Methylenedioxymethamphetamine (MDMA)
MDMA is a derivative of methamphetamine, a synthetic

with both stimulant and hallucinogenic properties.


MDMA can inhibit serotonin and dopamine reuptake.
MDMA can result in dry mouth, increased heart rate,
fatigue, muscle spasm, and hyperthermia.

Gamma-Hydroxybutyrate (GHB)
Gamma-hydroxybutyrate, a club drug, has been found in

surveys to have an annual prevalence rate of 1.1% for 8th


graders, 1.0% rate for 10th graders, and a 1.6% rate of
use for 12th graders.

Ketamine (Ketalar)
Ketamine, another club drug, was found recently to have

a rate of 1.3% annual prevalence for 8th graders, 2.1% for


10th graders, and 2.5% rate for 12th graders.

Flunitrazepam (Rohypnol)
Flunitrazepam (Rohypnol), a third club drug, has been

found to have an annual prevalence rate of about 1% for


all high school grades combined.

Club Drugs
Primarily depressants and can be added to drinks without

detection because they are often colorless, tasteless, and


odorless.
The Drug-Induced Rape Prevention and Punishment Act

was passed after these drugs were found to be


associated with date rape.

Anabolic Steroids
Despite reported knowledge of the risks of anabolic

steroids among high school students, surveys over the


last 5 years found rates of anabolic steroid use to be 1.6%
among 8th graders and 2.1 among 10th graders. Up to
45% of 10th and 12th graders reported knowledge of the
risks of anabolic steroids; however, over the last decade it
appears that high school seniors reported less
disapproval of their use.

Anabolic steroids (testosterone containing)


testosterone-like hormones
exhibit various degrees of anabolic (muscle

building) and androgenic (masculinizing) effects


treatment of hypogonadal men, the wasting
syndrome associated with human
immunodeficiency virus (HIV) infection, and a few
specific diseases such as hereditary angioedema
and Fanconi's anemia.

Mode of Action
from cholesterol
eugonadal male: physiological dosages of

testosterone has no net gain in testosterone


concentrations because exogenously
administered AAS shut down endogenous
testosterone production via feedback inhibition of
the hypothalamic-pituitary-gonadal axis.
illicit users: supraphysiological effects(10 to 100
times the therapeutic dosages)
Oral and injected

Inhalants
The use of inhalants in the form of glue, aerosols, and

gasoline is relatively more common among younger than


older adolescents. Among 8th grade, 10th grade, and
12th grade students, 17.6, 15.7, and 17.6%, respectively,
report using inhalants; 0.2% of 8th grade students, 0.1%
of 10th grade students, and 0.2% of 12th grade students
report daily use of inhalants.

REVIEW ARTICLE by Edward Press, Alan K. Done


SOLVENT SNIFFING: Physiologic Effects and Community Control
Measures for Intoxication from the Intentional Inhalation of
Organic Solvents II
The vapors of a wide variety of organic solvents contained in such products as glues,

paint thinner, fingernail polish removers, and cleaning and lighter fluids are being used
by juveniles for the deliberate induction of intoxication
Sniffing provides a chemical escape from reality which is more adaptable, and

therefore more readily accepted, by young children than are such other intoxicating
practices as alcohol ingestion or the use of narcotic drugs.
Among sniffers as among all juveniles apprehended by the police, there is a great

preponderance of boys over girls, and the majority are in their early "teens,. Although
some are as young as 7 to 8 years of age. Although sniffers usually had prior histories
of scholastic under achievement, intelligence per se bore little positive relation to
the adoption of the habit.
In some studies, but not in others, sniffers of toluene have been found to have an

abnormal incidence of vague neurological signs, hepatomegaly, eosinophilia, and,


rarely, acute intracranical hypertension.

Multiple Substance Use


Among adolescents enrolled in substance abuse

treatment programs, 96% are polydrug users; 97% of


adolescents who abuse drugs also use alcohol.

Genetic Factors
The concordance for alcoholism is reportedly higher

among monozygotic than dizygotic twins.


One twin study of drug users showed that the drug abuse
concordance for male monozygotic twins was twice that
for dizygotic twins.
Studies of children of alcoholics reared away from their
biological homes have shown that these children have
about a 25 percent chance of becoming alcoholics.

Psychosocial Factors
Among adolescents, substance use, particularly marijuana use, is

strongly influenced by peers, and especially for those


adolescents who report using marijuana for relaxation
Escape from stress and a social activity
There are data to suggest, however, that marijuana use is also
associated with both social anxiety disorder and depressive
symptoms.
Among young adolescents who start using alcohol, tobacco, and
marijuana at an early age, data suggest that they often come from
families with low parental supervision.
The risk of early initiation of substances is greatest for children
below 11 years of age

Increased parental supervision during middle childhood years may


diminish drug and alcohol sampling and ultimately diminish the risk of
using marijuana, cocaine, or inhalants in the future.

Comorbidity
higher in relatives of youth with depression and anxiety

disorders
mood disorders are common among those with
alcoholism
strong link between early antisocial behavior, conduct
disorder, and substance abuse
Early intervention with children who show early signs of social deviance
and antisocial behavior may conceivably impede the processes that
contribute to later substance abuse.

Diagnosis & Clinical Features


According to the DSM-5, substance-related disorders include the
following three categories:

Substance use refers to a maladaptive pattern of

substance use leading to clinically significant impairment


or distress, manifest by one or more of the following
symptoms within a 12-month period:
recurrent substance use in situations that causes physical danger

to the user
recurrent substance use in the face of obvious impairment in
school or work situations
recurrent substance use despite resulting legal problems
recurrent substance use despite social or interpersonal problems.

Diagnosis & Clinical Features


According to the DSM-5, substance-related disorders include the
following three categories:

Substance intoxication refers to the development of a

reversible, substance-specific syndrome caused by use of


a substance. Clinically significant maladaptive behavioral
or psychological changes must be present.
Substance withdrawal refers to a substance-specific
syndrome caused by the cessation of, or reduction in,
prolonged substance use. The substance-specific
syndrome causes clinically significant distress or impairs
social or occupational functioning.

Treatment
Effective screening and identification
Brief intervention motivational interviewing, with the

goal of helping the student to gain motivation for


behavioral change; referred for more intensive treatment if
needed
Child and Adolescent Levels of Care Utilization Services
(CALOCUS)

Child and Adolescent Levels of Care Utilization


Services (CALOCUS)
Level 0: Basic services (prevention)
Level 1: Recovery maintenance (relapse prevention)
Level 2: Outpatient (once per week visits)
Level 3: Intensive outpatient (2 or more visits per week)
Level 4: Intensive integrated services (day treatment,

partial hospitalization, wraparound services)


Level 5: Nonsecure, 24-hour medically monitored service
(group home, residential treatment facility)
Level 6: Secure 24-hour medical management (inpatient
psychiatric or highly programmed residential facility)

Cognitive-behavioral approaches to psychotherapy for

adolescents with substance use generally require that


adolescents be motivated to participate in treatment and
refrain from further substance use. The therapy focuses
on relapse prevention and maintaining abstinence.
Psychopharmacological interventions for adolescent
alcohol and drug users are still in their early stages.
Because comorbidity influences treatment outcome, it is
important to pay attention to other disorders, such as
mood disorders, anxiety disorders, conduct disorder, or
ADHD during the treatment of substance use disorders.

Legislation: The legal drinking age


and the minimum age of purchase of
tobacco is 18 in the Philippines.

Alcohol use: According to 2003 figures,


among 1824 year olds, 7.3% were
heavy episodic drinkers (13.6% males
and 0.9% females). Youth who were out
of school accounted for a greater
number of drinkers.

20032004 GSHS
18.9% of surveyed students were
13 years old or younger when they
had their first drink of alcohol;
23.6% drank alcohol in the past
30 days; and 24.3% had
engaged in heavy drinking.