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Adolescents And Addiction

Introduction

Substance abuse and addiction, whether to alcohol, illicit drugs, or other substances, is harmful to those of any age, but is particularly damaging to adolescents. Teens across various socioeconomic and cultural backgrounds abuse drugs and alcohol. This leads to physical or psychological problems and can also affect a teen’s learning abilities, capacity to retain and remember information, and activities and relationships with family and peers. Also, teens who start to use alcohol or tobacco or to experiment with certain types of drugs are at higher risk of moving on to other drugs and further increasing their risks of addiction.

Unfortunately, adolescents often engage in potentially harmful behavior before considering the consequences. The growth and maturity that develops during adolescence does not necessarily stay in sync with the physical progress that occurs during this time. In other words, adolescents often experience increased physical growth, the effects of increased hormone secretion and puberty; and, teens are subject to social pressures that result in them potentially making choices that are not always the best for their health and well-being. Adolescents and young adults tend to more actively experiment with drugs and alcohol, but these groups are also more likely to develop substance use disorders.7

Poor habits or even addictions that develop during adolescence can continue to plague a person as an adult, long after the teen years have ended. That is to say, choices that a person makes during adolescence, such as whether to use drugs or alcohol or whether to start smoking, can lead to habits that are

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 1 not only difficult to break later, but that can cause dangerous complications if they continue into adulthood.

Types Of Substance Use Disorders

The reasons adolescents develop substance use disorders and addiction on drugs and alcohol are varied and complex, but unfortunately, substance use addiction is more common among teens than many would like to admit. According to the Substance Abuse and Mental Health Services Administration (SAHMSA), over 23 million people over the age of 12 years needed treatment for substance use in 2012.1 Adolescents are often under significant pressure and are influenced by their peers, family members, and others in the community, all of whom have an effect on whether many teens start to experiment with harmful substances. Whether a substance use disorder takes the form of alcohol, illegal drugs, tobacco, or prescription drugs, teens that use these substances are at risk of the damaging and long- term effects that can last into adulthood.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was developed to assist trained mental health clinicians to diagnose mental and substance use disorders. The DSM-5 chapter, Substance-Related and Addictive Disorders, includes diagnostic criteria and symptoms of a substance use disorder and summarize characteristic signs and symptoms suggestive of an underlying disorder. In the sections below, the DSM-5 changes to the substance use disorders groups and the criteria defining substance use conditions or addictions are discussed.

Alcohol

Alcohol is one of the most commonly used substances across all age groups. It is legally available for purchase by people over a certain age, which is 21 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 2 years old in the United States, and adolescents are not legally eligible to purchase or drink alcohol, regardless of its prominence among this age group. According to the Monitoring the Future study, approximately 80 percent of adolescents have consumed some amount of alcohol by the time they reach their senior year of high school, and half of these teens have taken their first drink by the time they have reached the eighth grade.2

An adolescent may develop an alcohol use disorder after repeated use. An alcohol use disorder and addiction develops when a person is unable to stop using alcohol despite making attempts to quit; when a person suffers negative symptoms and effects of withdrawal when stopping intake; or when a person is unable to stop drinking alcohol routinely, even though its use is negatively impacting work, school, and relationships. An alcohol use disorder develops when a person uses alcohol and drinks too much or too often; the person may engage in dangerous activities as a result of alcohol intoxication, such as driving while drunk or engaging in unsafe sexual practices. Alcohol addiction involves a craving for alcohol, an inability to stop drinking once starting, increased tolerance to alcohol, requiring more and more of it to achieve the same effects of intoxication, and withdrawal symptoms when not drinking alcohol.40

Alcohol is a central nervous system depressant, and the adolescent who consumes it may initially feel tired and sluggish, but may also experience euphoria and pleasant or happy feelings. The short-term use of alcohol increases the work of inhibitory neurotransmitters such as GABA and serotonin, which produces these initial effects. Over time, though, alcohol use then increases the work of excitatory transmitters, such as epinephrine and norepinephrine and decreases the effects of inhibitory neurotransmitters. The person then experiences tolerance and requires more

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 3 drinks to achieve the same effects as was initially felt early on.40 Increased consumption because of tolerance can eventually lead to a substance use disorder and addiction when the person craves the effects of alcohol and has a desire to drink and continues to consume alcohol despite negative consequences.

The DSM-5 section on Alcohol-Related Disorders defines alcohol use disorder as “a problematic pattern of alcohol use leading to clinical significant impairment or distress, as manifested by at least two of the following occurring within a twelve month period”, and the criteria are listed as:77  Alcohol is often taken in larger amounts or over a longer period than was intended;  There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.  A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.  Craving, or a strong desire or urge to use alcohol.  Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.  Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.  Important social, occupational, or recreational activities are given up or reduced because of alcohol use.  Recurrent alcohol use in situations in which it is physically hazardous.  Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbate by alcohol.  Tolerance, as defined by either of the following:

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 4 o A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. o A markedly diminished effect with continued use of the same amount of alcohol.  Withdrawal as manifested by either of the following: o The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal) o Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

An alcohol use disorder causes many significant effects to various body systems. Alcohol has been shown to contribute to liver disease, including cirrhosis and hepatitis; gastrointestinal dysfunction, such as esophageal varices and portal hypertension; heart disease, obesity, poor sleep habits, osteoporosis, pneumonia, and certain types of cancer.40 Both short- and long-term use of alcohol can cause cognitive changes, which can be especially damaging to the adolescent who is continuing to undergo neurological development. Cognitive changes may include memory problems, difficulties with concentration, and problems with learning. These effects may be permanent in some people, even after they quit drinking.

Alcohol is also dangerous for teens because it is commonly associated with other forms of drug use and with smoking. People who use alcohol and drink to the point of intoxication can become aggressive and violent, which places them at risk of accidents, injuries, and suicide. Drinking alcohol in college is an extremely widespread phenomenon, with approximately 4 out of 5 college students drinking alcohol and half of these participating in binge

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 5 drinking, which is the consumption of more than 4 drinks for women or 5 drinks for men in a span of less than 2 hours.43

Many teens enter college and start drinking alcohol during their experience there, even if they were not prior alcohol users. Unfortunately, drinking alcohol is often seen as part of the college experience, with alcohol being available to students at parties, social groups, and within college dorm rooms. The negative consequences of such rampant alcohol consumption affect thousands of students and their families each year, with college students experiencing injuries, academic problems, destruction of property, sexual assaults, and suicide attempts, as well as some deaths related to alcohol consumption, at college campuses throughout the United States.

The younger a person is when he or she starts drinking, the higher the risk is that he or she will develop an alcohol use disorder. Teens who are not yet college age and who drink alcohol are more likely to develop an alcohol use disorder, even into adulthood. By comparison, those who wait until they are 21 years old, or who wait until they are in college to participate in binge drinking or routinely consume alcohol may not necessarily develop an alcohol use disorder as they grow into adulthood.

Alcohol use among underage youth is widespread, and according to the National Institute on Alcohol Abuse and Alcoholism, over half of adolescents have tried alcohol by the time they turned 15, with over 70 percent having tried alcohol by the time they have reached age 18.44 Random use of alcohol or experimentation is not the same as an alcohol use disorder and addiction but the negative results associated with chronic alcohol use can be staggering and affect thousands of people every year, many of whom started drinking during adolescence. While many healthcare providers may

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 6 assume that an occasional drink or attempt at trying alcohol for teens is harmless, they must remember that every person who has become an alcoholic, whether during adolescence or in adulthood, started with that first drink.

Illegal Drugs

Drugs used by adolescents that are commonly abused are often classified as illegal or “street” drugs. These drugs are considered those that are not classified as prescription drugs or household substances. The most commonly abused illegal drug is marijuana, although there are many different types of illegal drugs that lead to a substance use disorder and addiction.

Marijuana

Marijuana is one of the most commonly used illegal drugs by adolescents in the United States. According to the Monitoring the Future Study, a research study conducted by the National Institute on Drug Abuse, over 44 percent of 12th graders have tried marijuana, and 21 percent have used it within the last month.46 Because of the uses of medical marijuana, the legalization of some types of marijuana use within some states, and the fact that marijuana comes from a plant leads many teens to believe that it is a harmless drug or that it does not result in addiction. Marijuana can be harmful, however, when its use impacts a teen’s daily activities and when it leads to other forms of substance use. Marijuana comes from the hemp plant; it consists of dried and cut pieces of the plant, including its stems, flowers, and leaves. It is most often used when its pieces are rolled in paper or are put into a pipe and it is smoked. Marijuana may also be added to certain foods and eaten, brewed as tea,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 7 used as lollipops, or inhaled as vapor. The person who uses marijuana experiences psychotropic effects of pleasurable feelings, as well as a lack of coordination, increased appetite, and dizziness.47 The effects are caused by a component of the drug called delta-9-tetrahydrocannabinol, also referred to as THC.

While there are some states that have changed their laws and allowed the use of marijuana for medical purposes, or in some states, even for recreational purposes, it is still illegal for a teen to buy, possess, and use marijuana. The THC in marijuana affects several specific areas of the brain that can lead to cognitive changes that could potentially be permanent, even if the teen stops using marijuana later. THC affects coordination and memory, which may make it difficult for a person to make good decisions after using marijuana; additionally, THC impacts the area of the brain responsible for learning and memory, which can impair a teen’s abilities to perform in school and to remember information. Studies have also shown that people who consistently smoke marijuana starting in their teens have a drop in IQ points that is not regained, even if they quit using it later.47 Cannabis-related disorders is defined in the DSM-5 as “a problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period”, and the criteria are listed as:77  Cannabis is often taken in larger amounts or over a longer period than was intended.  There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.  A great deal of time is spent in activities necessary to obtain cannabis, use cannabis or recover from its effects.  Craving, or strong desire or urge to use cannabis.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 8  Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.  Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.  Important social, occupational, or recreational activates are given up or reduced because of cannabis use.  Recurrent cannabis use in situations in which it is physically hazardous.  Cannabis use is continued despite knowledge or having a persistent recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.  Tolerance, as defined by either of the following: o A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. o Markedly diminished effect with continued use of the same amount of cannabis.  Withdrawal, as manifested by either of the following: o The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal) o Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Adolescents can become addicted to marijuana; over time, the person may start to crave the high that comes from using this drug. People have also experienced symptoms of withdrawal when stopping use of marijuana, including symptoms of dizziness, irritability, and sleep problems. Most teens that try marijuana do not go on to use other drugs or to become addicted. However, teens who use marijuana, alcohol, and tobacco are at higher risk

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 9 of developing a substance use disorder later.47 Marijuana use can lead to multiple physical and social problems, including changes in heart rate, breathing problems, mental health issues, and increased risk of injuries from accidents or use while driving. Although many people consider marijuana to be relatively safe when compared to other drugs that teens could get involved with, there are too many dangers associated with this drug to have it be considered safe.

Opioids

Opioids are drugs that are often considered to be prescription drugs, and they are typically administered as prescription drugs for pain control. However, opioids may also be classified as illegal drugs that have the potential for abuse when they are not used for medical purposes. Heroin is the most common form of opioid drug that is not prescribed for medical use but is abused as an illegal drug. Because of its high potential for causing a substance use disorder and addiction, heroin is classified as a Schedule I controlled substance.

Opioid-related disorders is defined in the DSM-5 as “a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period”, and the criteria are listed as:77  Opioids are often taken in larger amounts or over a longer period than was intended.  There is a persistent desire or unsuccessful efforts to cut down or control opioid use.  A great deal of tie is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.  Craving, or a strong desire or urge to use opioids. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 10  Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.  Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.  Important social, occupational, or recreational activities are given up or reduce because of opioid use.  Recurrent opioid use in situations in which it is physically hazardous.  Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been used or exacerbated by the substance.  Tolerance, as defined by either of the following. o A need for markedly increased amounts of opioids to achieve intoxication or desired effect. o A markedly diminished effect with continued use of the same amount of an opioid.  Withdrawal as manifested by either of the following: o The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal) o Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

A person can use heroin in a number of ways to derive its effects. One of the most common methods is through injection, but it can also be smoked or sniffed. Because it is an opioid, heroin binds to opiate receptors in the brain when it enters the body, which gives the sensation of intense euphoria, leading to a very pleasant and relaxed state. When the drug binds to opioid receptors, they block the sensation of pain by blocking receptors in the central nervous system. Heroin also puts a person into a state of stupor,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 11 which causes a slowed response, drowsiness, and mood changes. Lilley, Collins, and Snyder, authors of the book Pharmacology and the Nursing Process, defines this state of stupor as narcosis, which is why a drug such as heroin is referred to as a narcotic.3

Stimulants

Stimulants are drugs that are stimulating to the central nervous system. There are different classes of stimulants, some of which are classified as illegal drugs, while others are given as prescription medications. A teen may use prescription stimulants inappropriately in order to get the feelings of pleasure and euphoria that these drugs can cause. Many prescription stimulants, such as those administered for the treatment of ADHD, are meant as timed-release medications, in which they slowly release the medication into the body after the person takes them. However, these drugs could instead be crushed and then mixed with another solution of water to be injected, which causes a person to get high when the effects of the drug are released all at once. Amphetamines are stimulants that may be abused among adolescents and young adults; amphetamines, depending on their form, may be available as illegal drugs or as prescription drugs. Methamphetamine produces much more significant effects on the body when compared to some other types of stimulants. Crystallized methamphetamine, also referred to as crystal meth, is a smokeable form of the drug that is highly powerful. It is a man-made substance that is created from common products, including pseudoephedrine, which is found in some over-the-counter cold and sinus preparations. When a person smokes crystal meth, he or she experiences a rapid and very intense high from the release of excess dopamine. However, the feeling is short lived and when the intense feelings diminish, the person is left with lower levels of dopamine than before, which causes feelings of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 12 depression.5 The person using the drug then often feels compelled to repeat the cycle of use to ward off the effects of depression and to experience the high feelings again. Meth addiction is very dangerous because it can cause permanent damage to the brain by affecting how the body adjusts neurotransmitter levels.

Because crystal meth is created in homemade laboratories using some over- the-counter medications, the sale and distribution of products that contain pseudoephedrine has changed since 2005.3 Pseudoephedrine is normally used in cold and sinus medications to shrink the size of the blood vessels in the nose, which decreases nasal congestion. Because people who reate methamphetamine may use larger amounts of pseudoephedrine for the drug preparation, the sale of cold medications that contain pseudoephedrine has been regulated so that purchasers must buy these drugs directly from the pharmacy counter, rather than buying it off the shelf.

Cocaine is an illegal drug that is a type of stimulant that impacts the central nervous system by causing an elevated state of being alert. Rather than producing a state of stupor, as with some opioid drugs, cocaine tends to have an opposite effect of euphoria, mental alertness, and increased energy. Among teens, cocaine use has actually been shown to be declining in the past decade, however, its availability, relatively inexpensive price, and multiple methods of use have made cocaine a dangerous drug that can lead to addiction among adolescents.

Similar to other types of stimulants, cocaine produces its effects by increasing levels of dopamine, which leads to feelings of pleasure and satisfaction. Unfortunately, the effects of cocaine on the brain enable people to quickly become addicted, and teens may have a more difficult time

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 13 overcoming cocaine addiction or may be predisposed to abusing cocaine or other stimulant drugs later in life. The changes that occur in the brain as a result of cocaine use, coupled with the neurodevelopmental changes occurring during adolescence, place a teen addicted to cocaine at high risk of permanent changes in neurotransmitter levels in the brain and ultimately greater risk of future drug abuse.6

Stimulant-related disorders is defined in the DSM-5 as “a pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period”, and the criteria are listed as:77  The stimulant is often taken in larger amounts or over a loner period than was intended.  There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.  A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant or recover from its effects.  Craving, or a strong desire or urge to use the stimulant.  Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home.  Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant.  Important social, occupational, or recreational activities are given up or reduced because of stimulant use.  Recurrent stimulant use in situations in which it is physically hazardous.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 14  Stimulant use is continued despite knowledge of have a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant.  Tolerance, as defined by either of the following: o A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect. o A markedly diminished effect with continued use of the same amount of the stimulant.  Withdrawal as manifested by either of the following: o The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal) o The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Stimulants can be dangerous because their changes in dopamine levels cause an elevation in heart rate and blood pressure. The person who abuses stimulants is at higher risk of eventual heart failure when the heart must work harder as a result of beating faster when using the drugs. The blood vessels are constricted with stimulant use and the person who regularly uses these drugs may suffer the effects of repeated blood vessel constriction followed by relaxation. Further negative effects can occur based on the method of using these drugs; for instance, a teen who regularly snorts cocaine can develop skin breakdown in the nose; those who inject stimulants are at higher risk of contracting infectious diseases spread by shared needles.

Another illegal drug that is part stimulant and part hallucinogen is methylenedioxymethamphetamine (MDMA), which is also called Ecstasy and is on the rise in use among adolescents. Ecstasy, also called Molly, produces

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 15 the effects of stimulants in that the person taking it feels more energy and experiences a sense of euphoria, acceptance of others, and feelings of pleasure. Additionally, Ecstasy also causes psychedelic effects, which makes it very attractive for users. It is typically taken as an oral tablet, but it may also be injected or snorted.

Ecstasy produces a high because it affects the neurotransmitters dopamine, serotonin, and norepinephrine in the brain. People who use it may feel sexually aroused and emotionally close to those around them, which can be dangerous for teens who may find themselves in situations where there is considerable peer pressure to use the drug and then engage in unsafe sexual practices. People who use Ecstasy can develop drug tolerance in which they require more of the drug to experience the same effects. Some teens have died from abusing Ecstasy because the drug causes an increase in body temperature that can result in dangerous hyperthermia.8

Because adolescence is such an important time of building skills, learning, and growing developmentally, illegal drug use can significantly inhibit teens’ abilities to grow and mature into healthy and responsible adults. The accessibility of illegal drugs may vary for some teens, with some kids having greater access to illegal drugs and others not having the connections needed to buy or use street drugs. Still, many adolescents can find and use illegal drugs when they want to, which can potentially lead to greater problems and can prevent the healthy normal teen development.

Prescription Drugs

Although most people use prescription drugs appropriately and take them as they are ordered, prescription drugs can cause health issues and can lead to addiction for anyone who uses them inappropriately, including adolescents.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 16 Teens are at high risk of the negative effects of drug use when they take prescription drugs inappropriately, whether the drugs are prescribed for them by a healthcare provider or whether they are accessing someone else’s prescription to use.

The National Institute on Drug Abuse (NIDA), when performing the Monitoring the Future Survey in 2014 found that 1 in 12 high school seniors reported inappropriate use of prescription Vicodin within the last year. Misuse of prescription drugs is the fourth most common type of drug abuse among teens after alcohol, tobacco, and marijuana.9 The availability of certain drugs makes inappropriate use of prescription drugs more common, particularly among teens; however, the effects of a prescription drug use disorder are just as damaging to adolescents and can include severe health problems, overdose, and death.

Opioids

The most commonly abused prescription drugs among adolescents include opioids, stimulants, and depressants. Opioids are administered to relieve and control pain. Because they cause pleasant effects, they are also more commonly misused and abused. Opioids interrupt the pain signal between the nervous system and the brain so that the person experiencing pain does not feel the effects of it as much while taking these types of drugs. Opioids can also cause negative side effects of drowsiness, constipation, and confusion; further negative effects can also develop when a person takes the drugs in a method in which it was not originally intended. For example, some opioid preparations are designed to be extended-release tablets, but some people instead take them by crushing the pills and snorting or injecting them, which provides a rapid response. Unfortunately, taking the drug in

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 17 this manner can also significantly increase the risk of overdose and respiratory depression.

Examples of opioids are codeine, oxycodone (OxyContin®), morphine, meperidine (Demerol®), and hydrocodone (Vicodin®). Depending on the patient’s condition, these drugs may be prescribed for various reasons. Some opioids are administered for mild pain or to control coughs associated with illness; an example of this type of drug is codeine. Alternatively, some drugs are prescribed after medical procedures that can cause significant pain, such as with morphine or hydrocodone. Misuse of these medications cannot only lead to addiction but can also cause significant side effects. Opioid medications cause a histamine release in the body, which results in vasodilation, low blood pressure, and flushed skin. The person may also experience intense itching, hives, sweating, urinary retention, and constipation.3 More significantly, respiratory depression can occur with overuse of opioids, leading to apnea and death if the situation is not corrected.

Opioids, when taken appropriately according to a prescription, can be used safely for long-term use, even among adolescents. An opioid use disorder can lead to serious consequences when the patient seeks to get more of the drug than is allowed by prescription. Because opioids can cause respiratory depression, overdose of these types of drugs can be fatal even the first time that they are misused.

Stimulants

Prescription stimulants may be misused and abused among adolescent patients even if they are given to the adolescent under a prescription. Prescription stimulants may be ordered for some adolescent patients who

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 18 need medications for treatment of conditions that require management of fatigue or mood. Methylphenidate (Ritalin®) is a common medication prescribed for the treatment of ADHD and has the potential to be abused. If a teen patient with ADHD has been given a prescription for a stimulant such as methylphenidate, there is potential for abuse of the drug and resulting addiction when it is used inappropriately for a long enough period of time. Methylphenidate stimulates the central nervous system and helps a person to focus and concentrate on activities around him; it can help the person taking it to feel more awake and alert.4 Teens who abuse this drug may be more likely to do so because of the results it provides; for instance, an adolescent patient may use methylphenidate inappropriately because it helps him or her to stay awake longer to study and get better grades.

Stimulants have also been prescribed for other reasons as well, such as weight loss, to stimulate the respiratory center of the brain and prevent central apnea, and for treatment of sleep disorders such as narcolepsy. Some teens have found the effects of stimulants to be beneficial to appearance because they help with weight loss and promote activity and wakefulness. Unfortunately, adolescents are often plagued by messages of the importance of appearance and being thin. Some teens are able to secure prescription stimulants that cause weight loss and they take them inappropriately to attempt to lose weight and try to keep up with images seen on television and online. Whether or not they are prescribed for this purpose, prescription stimulants tend to suppress appetite, so they can be useful for weight loss among some people because taking stimulants will most likely cause them to eat less. Stimulants have also been shown to enhance performance, so some teens may be more likely to take them in order to keep up with the demands of schoolwork and extracurricular activities.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 19 Unfortunately, prescription stimulants also increase dopamine levels, which normally lead to feelings of pleasure and an increased ability to concentrate, but these drugs can also cause high blood pressure and an increase in heart rate and body temperature.4 They also disrupt sleep and lead to insomnia, which can negatively impact an adolescent’s performance at school or abilities to maintain friendships and relationships. Central Nervous System Depressants

Central nervous system (CNS) depressants are another form of drug that may be prescribed and abused by some teens. Depressant medications include such drugs as benzodiazepines and barbiturates and are used as sedatives to control anxiety or to induce sleep. Benzodiazepines are typically prescribed for management of anxiety or for sleep disturbances; because they can cause dependence and are at increased risk of being abused, benzodiazepines are often only prescribed for short-term use.9 Examples of benzodiazepine medications include alprazolam (Xanax®) and diazepam (Valium®).

Non-benzodiazepines are medications that have depressant effects and act in a manner similar to benzodiazepines, but they are chemically different. They are considered to be less risky when it comes to dependence and they typically produce fewer side effects. Examples of these types of drugs include zolpidem (Ambien®) and zalepon (Sonata®). Barbiturates are depressants that are also prescribed for anxiety; because of their risk of abuse and overdose, they are not as commonly prescribed. Examples of barbiturates include mephobarbital (Mebaral®) and pentobarbital (Nembutal®). Barbiturate use was more prominent in the 1960s and 1970s in U. S. history, resulting in a number of prominent deaths from overdose. Many of today’s adolescents are unaware or do not remember some of the

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 20 celebrity deaths associated with barbiturate use and they may not be aware of how dangerous these drugs can be.

Central nervous system depressants work by affecting gamma-aminobutyric acid (GABA) to produce a sense of drowsiness and a feeling of calm or relaxation. Depressant medications more commonly cause tolerance, in which a person who uses them requires more of the drug; among many benzodiazepines and barbiturates, tolerance can develop within a few days’ use.9 If an adolescent becomes addicted to benzodiazepines, he or she may suffer withdrawal symptoms that can lead to seizures, increased anxiety or panic attacks, insomnia, and psychosis. Alternatively, barbiturate addiction can cause life-threatening effects during withdrawal, such as seizures and hyperthermia, and the person undergoing detoxification from these drugs must be monitored closely.

Prescription drug abuse among adolescents is a serious problem; teens that abuse these types of drugs have been shown to start even before reaching the 8th grade. Adolescents who admit to misusing prescription drugs have stated that they most often use drugs that they take or buy from someone else who has the prescription, making these drugs relatively easy to access for many teens. Further, teens who abuse prescription drugs are more likely to misuse other types of drugs as well, including alcohol, tobacco, or marijuana.

When combining prescription drugs with other types of drugs, the effects of more than one substance together can result in effects that are multiplied, which is often dangerous. For example, a teen who misuses prescription benzodiazepines and who drinks alcohol can suffer the consequences of both types of CNS depressants used together, which can lead to significant

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 21 drowsiness, changes in mental status, and respiratory depression. Healthcare providers play important roles in recognizing the signs of a prescription drug use problem among adolescent patients and assisting them to obtain the help they need to overcome an issue of addiction.

Household Items

Drugs can be found within the home, which makes abusing household items very dangerous for teens. Adolescents have easy access to these items. When an adolescent can find these items at home he or she often does not need to buy anything or find someone to sell the drugs or alcohol. These items are also dangerous because they are completely unregulated; and, it is just as easy to overdose on inhalants and toxic substances used as drugs from household items as it is for a person to overdose on prescription or illegal drugs.

Inhalants

Inhalants are common, everyday products found in the environment that people inhale to get high. A teen may use inhalants by sniffing the fumes from a container or spraying items directly into the mouth or nose. Huffing is the process of soaking a rag or cloth with an inhalant, putting it in the mouth, and then breathing in the fumes. Inhalants can be found in all sorts of substances, chemicals, and products found in the home, in the yard, or in the garage. Examples of inhalants may include:  Aerosols: spray bottles of hairspray, deodorant, compressed air for cleaning keyboards, whipped cream dispensers, and spray paint.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 22  Solvents: paint thinner, gasoline, glue, correction fluid, nail polish remover, and cleaning solutions.  Nitrates: amyl nitrate, butyl nitrate; found in products labeled as leather cleaner, or room odorizer10  Gases: Propane tanks, butane lighters, refrigerant solutions, chloroform, nitrous oxide.

After inhaling the gas or spray, the person feels a rush or high right away that is short lived. Inhalants often produce feelings of euphoria, dizziness, lightheadedness, and the person using them may experience hallucinations. He or she must continue to use the inhalants in order to get the same feeling because it is often so short. In larger amounts, inhalants can produce anesthesia, but too much can cause the person to lose consciousness. Because the inhalant is breathed in, the gas or fumes take the place of oxygen in the lungs. This puts the user at risk for respiratory problems and decreased oxygen levels in the bloodstream, which then leads to decreased oxygen reaching the brain. The heart also beats faster and must work much harder, which can lead to heart failure.

Inhalant-related disorders is defined in the DSM-5 as “a problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period”, and the criteria are listed as:77  The inhalant substance is often taken in larger amounts or over a longer period than was intended.  There is a persistent desire or unsuccessful efforts to cut down or control use of the inhalant substance.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 23  A great deal of time is spent in activities necessary to obtain the inhalant substance, use it, or recover from its effects.  Craving, or a strong desire or urge to use the inhalant substance.  Recurrent use of the inhalant substance resulting in a failure to fulfill major role obligations at work, school, or home.  Continued use of the inhalant substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.  Important social, occupational, or recreational activities are given up or reduced because of use of the inhalant substance.  Recurrent use of the inhalant substance in situations in which it is physically hazardous.  Use of the inhalant substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.  Tolerance, as defined by either of the following: o A need for markedly increased amounts of the inhalant substance to achieve intoxication or desired effect. o A markedly diminished effect with continued use of the same amount of the inhalant substance.

Clinicians are guided in the DSM-5 to specify the particular inhalant and, when possible, the particular substance involved should be named.

The chemicals inhaled during the process are also damaging to the body; the chemicals enter the bloodstream and can lead to toxic levels that eventually affect tissue perfusion and proper organ function. Typically, high levels of chemicals in the bloodstream cause toxicity that leads to poor concentration, slowed response times, and mental status changes. For a teen who is still

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 24 going through neurological development, this is particularly damaging to the brain and central nervous system. Growing teens also suffer the physical effects of brain hypoxia after using inhalants, affecting their abilities to study or participate in sports or games. Inhalants are also dangerous because it is difficult to control how much a person takes in each time; the person using the inhalant can easily overdose and take in too much, causing them to lose consciousness or even die after one use.

Long-term use of inhalants can lead to nerve damage after breakdown of the myelin sheath covering some of the nerves. Brain hypoxia also occurs from chronic inhalant use, which leads to memory problems and delays in thinking and processing, which can make it difficult to hold a conversation or make quick decisions. This may cause problems with movement, such as maintaining a normal gait or performing daily activities. Further health problems include chronic muscle weakness, liver failure, and aplastic anemia.10

Inhalants are one of the earliest forms of drug use among teens that start abusing drugs. According to the National Institute on Drug Abuse, younger teens are more likely to use inhalants when compared to older teens, and a greater percentage of 8th graders admit to using inhalants in the past month when compared to 10th or 12th graders.10 Inhalant use is often not something that occurs once or twice; often, the teen who experiments with inhalants to get high tends to repeat its use, which may lead to chronic, long-term abuse of inhalants.

Poisoning or Ingestion

In addition to inhaling toxic substances, some teens may get high by ingesting other products that are commonly found around the house. Spices,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 25 kitchen items, mouthwash, and perfume are just some of the items that adolescents have used for their effects when taken in large amounts.

It may seem unlikely, but kids have been known to abuse everyday kitchen spices for their effects. Some teens have found that snorting large amounts of nutmeg produces sensations similar to smoking marijuana. It is believed that nutmeg contains a component known as myristicin, which is also found in Ecstasy and is responsible for some of its psychedelic properties. Ingesting large amounts of nutmeg impacts the central nervous system, neurotransmitters in the brain, and the cardiovascular system. Nutmeg causes hallucinations that can last for several hours and in some cases, can go on for several days.

Nutmeg is often snorted through the nose, but a person can get some of the same effects by eating large amounts of the spice. Even one tablespoon of nutmeg consumed all at once has been shown to produce symptoms similar to anticholinergic toxicity.12 Although it may appear that nutmeg is harmless because it is a commonly used spice, teens who ingest excess nutmeg to get high are in danger of its toxic effects, which can include hyperthermia, breathing difficulties, anxiety, aggression, rapid pulse, and delirium.

Another method that some teens use to get access to alcohol is by drinking extracts, which are flavorings used for baking and cooking. One of the most commonly used extracts in the kitchen is vanilla; pure vanilla extract contains up to 35 percent ethanol and can be a source of alcohol for some people who have no other access to getting it.13 Vanilla extract falls in the same category as other products found in the home that contain ethanol, such as mouthwash, hand sanitizer, or some types of perfumes.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 26 A case report found in The Internet Journal of Family Practice showed that teens and young adults may likely ingest extracts and other household products containing ethanol with the desire to get high, but these substances can cause harmful effects to the cardiovascular system. Ingestion of ethanol depresses the central nervous system and produces effects of intoxication similar to that of drinking too much beer or wine. The person may also experience an upset stomach and may vomit, the skin becomes flushed, and the person can develop hypotension and a low body temperature.13 Unlike drinking beer or wine, the amount of alcohol found in some household products is at a much higher concentration; the teen who gains access to alcohol by drinking vanilla extract is more likely to experience a much more rapid and dangerous period of ethanol intoxication that warrants medical attention, when compared to becoming intoxicated by drinking alcoholic beverages.

Many teens use household products as substances for the experience of a rush or getting high because they are often more accessible than illegal or prescription drugs or alcohol. Adolescents may believe that it is safer to use household items than it is to use drugs or alcohol because, after all, these items are safe to have in the home; the truth, however, is that abusing household substances, whether by using inhalants or by ingesting toxic items in the home, can cause significant physical effects, can lead to chronic use that is damaging to the body, and often serves as a gateway to other forms of substance use disorder, such as with illegal drugs or alcohol.

Tobacco

There was a time when tobacco use was common and even encouraged among adults and adolescents; society was unaware of the dangers of tobacco use and people smoked everywhere, including in public places and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 27 in their homes. This trend has changed with more information about the effects of tobacco use, including long-term negative health consequences. The effects of tobacco use have been taught in schools throughout the United States and many more people are now aware of the dangers of long- term tobacco use.

This has not necessarily stopped some adolescents from trying tobacco and eventually using it on a regular basis. The U. S. Department of Health and Human Services Office of Adolescent Health states that almost 4 million 14- to 17-year olds have smoked cigarettes and one in 15 high school seniors is a daily smoker. Smoking is also more common among white adolescents when compared to black or Hispanic teens; and adolescents who live in the South and Midwest regions of the country are also more likely to smoke.48

Tobacco comes from a plant that is grown in various parts of the world, including within the United States. Tobacco leaves are cut from the plant and dried, where it is then packaged into different forms depending on its use. Cigarettes contain shredded tobacco that is rolled in paper; shredded tobacco can also be loosely placed in pipes. Cured tobacco makes up smokeless tobacco, also called dip that some teens use by placing a pinch of it on the inside of the cheek next to the gums. Ground tobacco is made into snuff, which is used by snorting it into the nose.

Tobacco is addictive because it contains nicotine, which causes changes in the brain; after using tobacco, a person can become addicted and crave more of the nicotine, in which he will continue to use the tobacco. Among teens, the most common method of using tobacco is by smoking cigarettes.48 Tobacco causes a number of negative effects on various body systems, and cigarette smoking is responsible for approximately 480,000

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 28 deaths each year in the United States.68 Smoking contributes to such long- term illnesses as cardiovascular disease, lung cancer, and stroke, among many other potential complications that can cause sickness and can lead to death.

Teens who smoke and become addicted to tobacco are putting their bodies at risk of developing health problems associated with tobacco use. Cigarette smoke has been shown to contain more than 7,000 chemicals, many of which are toxic to the body and can cause cancer. Further, addiction to nicotine is controlling for the teen who tries to continue smoking cigarettes during school or work, finding someone to buy cigarettes for him or her if underage, and spending the money to buy packs of cigarettes.

Tobacco-related disorders is defined in the DSM-5 as “a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period”, and the criteria are listed as:77  Tobacco is often taken in larger amounts or over a longer period than was intended.  There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.  A great deal of time is spent in activities necessary to obtain or use tobacco.  Craving, or a strong desire or urge to use tobacco.  Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (i.e., interference with work).  Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (i.e., arguments with others about tobacco use).

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 29  Important social, occupational, or recreational activities are given up or reduced because of tobacco use.  Recurrent tobacco use in situations in which it is physically hazardous (i.e., smoking in bed).  Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.  Tolerance, as defined by either of the following: o A need for markedly increased amounts of tobacco to achieve the desired effect. o A markedly diminished effect with continued use of the same amount of tobacco.  Withdrawal as manifested by either of the following: o The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for tobacco withdrawal) o Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

Cigarette smoking contributes to poor lung function, and a teen who smokes may have a longer period of healing if he or she becomes ill with colds or the flu because of the lung damage incurred from smoking. Cigarette smoking can also reduce a person’s stamina and ability to perform daily activities, leading to potential problems completing work, maintaining responsibilities, or participating in sports.

Electronic cigarettes, also called e-cigarettes are forms of smoking in which tobacco is delivered through a vapor that the person inhales. The vapor is created through an electronic device that can also deliver other flavors of vapor for the person to inhale and use. E-cigarette use by teens increased

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 30 significantly between 2010 and 2014, with rates of use jumping from 4 percent to over 17 percent.48

It is illegal for many teens to buy tobacco products in the United States, with most states requiring that a person be at least 18 years old to purchase it; although there are a couple of states that require a person to be at least 19 years old before purchasing tobacco. Cigarettes, cigars, loose tobacco, and dip can all be purchased over the counter; many products are available at grocery stores, pharmacies, and specialty shops, although many teens would be required to show proof of age with identification to purchase. E-cigarettes may be purchased at specialty shops that sell many types of vapors for smoking; many of these shops require that a person be at least 18 years old to even enter the store.

Some people may consider tobacco abuse to be not as harmful as other types of drugs or alcohol, yet quitting smoking and overcoming nicotine addiction can be extremely difficult. There are many adults who started smoking while in their teens and have never been able to successfully quit permanently because the cravings for nicotine are so great. Smoking is often a social activity in addition to the physical changes it causes, which means that many teens who smoke may do so in groups; later, when trying to quit, it can be difficult to be around others who are smoking and to abstain. Smoking is associated with alcohol use, which also the case with teens that smoke. When it comes to using tobacco, there is no safe amount and teens should be encouraged to avoid any type of tobacco to protect their health in the future and to avoid becoming addicted to a substance that is extremely difficult to let go.

Contributing Factors To A Substance Use Disorder

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 31 In most cases, a drug and alcohol use disorder does not develop in isolation. There are a number of elements in the environment and within a person that contribute to the risk of a teen developing a substance use problem. Some factors can be controlled, or at least can be minimized; for instance, a teen may watch his parents consume alcohol to excess and may make a conscious choice never to become intoxicated himself. Alternatively, there are other factors, such as genetic background or mental health issues that cannot necessarily be controlled, and it is up to the adolescent to make positive choices to decrease his risk for developing a substance use disorder.

Family and Social Environment

The environment in which a teen is raised plays a significant role in the risks of developing drug or alcohol problems. The home and family environment sets a certain amount of values that impact whether a teen will choose to experiment or use drugs or alcohol or whether he or she will abstain. Teens grow up in diverse family environments, with various types of family structures, such as a nuclear family, single parent family or various other structures of family relationships.

As a child grows through adolescence, the importance of family relationships significantly impacts his growth and development. Relationships with parents and caregivers are important in predicting which teens will more likely struggle with substance abuse and which teens will choose to avoid alcohol or drugs. Teens who have supportive caregivers, who experience less conflict and arguments with their parents, and who are able to communicate openly with their parents are less likely to turn to drugs or alcohol because they may feel more support at home. Alternatively, teens may more likely struggle with substance use and mental health disorders when they feel

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 32 misunderstood, have frequent conflict with parents or caregivers, or have home lives that are chaotic or violent.18

The social environment and the community in which a teen grows up also impact whether he or she is more likely to get involved with drugs or alcohol. Many factors affect whether a teen chooses to experiment with substances and although family plays a significant role, the teen often must also be familiar with how to access drugs or alcohol, must have money to buy these items, and typically knows which of his or her friends are using drugs and which friends are not. When drugs and alcohol are easily available to teens within a community, there will be more instances of adolescents abusing these substances. Teens who know who to contact to access drugs or alcohol will more likely engage in using these substances compared to those who do not know how to get drugs.

A teen that has friends who talk about drugs and alcohol and who use them frequently is at higher risk of also engaging in these activities. A teen’s friends or acquaintances may talk about certain items at school, while playing games or sports, or just when hanging out together. The adolescent may view drug or alcohol use when visiting another teen’s home or when attending parties. Although parents may talk about avoiding drug and alcohol use and may not use these substances in front of their children, teens can be exposed to drug and alcohol use because of their social environments; another friend’s parents may not monitor their child as carefully and the teen may know that drugs or alcohol are used in other homes.

The complete lack of family or a supportive care environment also plays a negative role in increasing the risk of a substance use disorder. A study

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 33 found in the journal Contemporary Nurse demonstrated that homeless teens that have aged out of the foster care system are at higher risk of developing a substance use disorder and mental illness.17 Youth who have run away from home and who are living in shelters or are homeless may abuse drugs or alcohol because of several factors, including to avoid some of the pain in their lives from living alone and without support, to stay awake at night and avoid being assaulted, or to cope with the difficulties of living on the street.

The availability of family members to provide a source of support can also help a teen to cope with a substance use disorder and to overcome an addiction. Often, through treatment, a patient requires substantial help and support for when he leaves an inpatient environment and returns to working or going to school without using drugs or alcohol. During this time, the family dynamic plays a significant role in a teen’s ability to overcome addiction and to heal; alternatively, a family environment or community that is not supportive could cause the patient to relapse or make overcoming addiction much more difficult.

It is important for parents to continue to monitor the activities of their teen; while many parents fear being intrusive into the life of their teen, it is better to be aware of a teen’s activities, his or her friends, and how the teen spends time instead of inadvertently finding out that their teen has a substance use disorder. Although it is a parent’s job to raise a child to eventually become independent, frequent parental monitoring teaches a teen that someone cares and pays attention to whether or not he or she engages in risky behaviors. Setting limits, keeping an organized home, and maintaining supportive communication with teens is important for parents to reduce the chance that their teen will turn to drugs and alcohol for support instead of their family.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 34 Mental Health Disorders

Mental health issues are a common theme associated with substance use disorders. Approximately 70 percent of adolescents in treatment for a substance use disorders have co-occurring depression; approximately 33 percent also have some form of anxiety disorder.20 Many teens suffer from dual diagnosis, which occurs when a patient is diagnosed with both a substance use and a mental health disorder. Co-occurring mental health conditions may range from depression and anxiety to issues with anger, post-traumatic stress, or violence. Many adolescents seeking treatment for a substance use disorder have already undergone therapy for mental health problems or have served some time in the juvenile justice system because of their behavior; however, a significant number of teens who need treatment for a substance use disorder remain undiagnosed for having mental illness.

A substance use disorder has also been associated with other mental health issues, including diagnosis of ADHD and depression with suicidal ideation. A teen may abuse drugs or alcohol to avoid feeling some of the pain or confusion associated with a mental health diagnosis. Often, conditions such as depression, anxiety, or post-traumatic stress leave a teen feeling sad, isolated, and apprehensive. Using drugs or alcohol may provide some short- term relief for the teen who feels overwhelmed by these feelings. Mental health problems may also contribute to a substance use disorder when a teen feels angry or upset because of the relationship with his or her parents or friends; the teen may use substances as a method of coping with painful or difficult feelings, or as a form of self-medication that brings temporary relief by numbing pain and feelings.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 35 Theoretically, substance use disorders are a form of a mental health issue, as addiction causes changes in the structure of the brain that can lead to many symptoms that are found in mental health diagnoses, such as impulsivity, depression, poor concentration, and mood alterations. When mental health issues occur as comorbidity with a substance use disorder, the adolescent may develop both conditions at the same time, or one condition may precede the other. In many cases, a mental illness diagnosis occurs before a substance use disorder and it is the cause of the teen using drugs or alcohol. This is not the case in every situation, however, and careful assessment and intervention is essential for determining both the timeline of when each type of mental illness occurred and for how each condition contributed to the other.

The National Institute on Drug Abuse states that a teen that struggles with both a mental health diagnosis and substance abuse may have shared factors in which each condition contributes to the other.21 For instance, a teen may have a genetic predisposition to developing substance abuse and may also have a family history of mental illness. There may be factors in the environment that contribute to an increase in symptoms of mental illness, substance abuse, or both; such as, trauma triggers from PTSD causing anxiety, fear, and the teen turning to drug use to self medicate. A significant percentage of adults who become addicted to drugs or alcohol started using these substances as teenagers, during the time when the brain is still undergoing developmental changes as part of maturity. When a teen is exposed to drugs or alcohol at a young age, such as during adolescence, the effects of substance use on the brain can lead to changes that are similar to or that contribute to later mental illness.21

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 36 It is important for clinicians to recognize the frequent pairing of a substance use disorder and mental health diagnoses, and to consider potential signs or symptoms of each situation when caring for the adolescent patient. Behavioral therapies and medications exist to help affected adolescents control one or both of these conditions when they are accurately diagnosed and can receive proper treatment.

Genetics

Genetics, or the inherited characteristics a person receives from his or her family, plays an important role in whether a teen will develop a substance use disorder. Substance use disorders tend to run in families, with development of drug addiction or alcoholism occurring between members of the same family and noted patterns of use between parent and child, grandparent and grandchild, or other family associations. Not only is the potential for a substance use disorder genetically related but the amount of use, whether to the level of experimentation with substances or of a diagnosed addiction, as well as the type of substance use, all have genetic components as well.22 When discussing the genetic predisposition to a substance use disorder, it is important to note that a person who has a genetic tendency toward substance use and addiction is more likely to become addicted after using drugs, but is not necessarily set on becoming a user. The genetic component describes an adolescent’s vulnerability toward addiction, in that if he or she chooses to try drugs or alcohol, there may be a greater risk of becoming addicted.23 Alternatively, despite having a genetic predisposition for addiction, if a teen never tries drugs or alcohol then the addiction will not develop because the teen has not succumbed to the vulnerability present in his or her genetic state.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 37 Despite this fact, many teens can and do try alcohol and drugs and, when a genetic predisposition for addiction is present, it can cause harm and long- term substance use problems that may require treatment before an adolescent even reaches young adulthood. Twin studies are useful methods of measuring genetic influences on people who were born together but have grown up in different environments. Twin studies demonstrate how genetics affect people who have inherited many of the same characteristics but who do not have the same environmental stimuli to affect their behavior. Linda Spear, author of the book The Behavioral Neuroscience of Adolescence, states that according to several twin studies, the genetic contribution toward alcohol dependence is 50 to 60 percent, while the genetic contribution for the risk of drug addiction is up to 80 percent.23

Further studies have shown that genetics also play differing roles when comparing whether a teen will try a drug in the first place, versus becoming addicted to a drug after continued use.23 For example, a teen may have a genetic predisposition that increases his or her risk of trying certain drugs when faced with a situation where there is the ability to use them. Alternatively, another teen may have genetic background that increases the risk of becoming addicted, but only after he or she has used drugs or alcohol for a period of time.

The genetic contribution that increases risk of trying substances before even becoming addicted appears to affect more teens trying illegal drugs, not necessarily alcohol. Teens who excessively use alcohol do not necessarily have an increased risk of trying alcohol based on genetic influence. Instead, teens tend to try alcohol more because of environmental influence, such as when they see a parent using alcohol regularly. However, there still is a genetic link between alcohol addiction after continuous drinking.23 A teen

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 38 who starts to drink alcohol regularly may choose to begin drinking based on environmental influences, but may become addicted to alcohol based on genetic components.

The specific genes that cause alcohol or drug addiction have not necessarily been identified; in fact, many studies have had a difficult time narrowing down which specific genes are related to a drug and alcohol use disorder and addiction. In the area of alcohol, studies have shown that there are differences in the genes related to enzymes that metabolize alcohol when comparing people who are alcoholics and those who are not. Also, certain forms of genes have been shown to be associated with increased use of certain substances, including marijuana and tobacco, when present in some groups of teens, with less substance use and addiction in those of whom the altered gene is not found. Other gene variations have been found in the neurotransmitter GABA, glutamate, and mu opiate receptor genes that are related to an increased susceptibility of a drug and alcohol use disorder.23

Adolescence is a critical time of brain growth and neurodevelopment, yet it is also a time when many adolescents begin to experiment with drugs and alcohol. Although parents and healthcare providers cannot always know if a teen is genetically predisposed to developing a substance use problem, caregivers should continue to work to prevent substance abuse through counseling and education, as well as demonstrating appropriate behavior, so that a teen at risk will be more likely to make better choices about his or her health, regardless of whether the teen has a genetic risk or not.

Family History

Family history of a substance use disorder plays a strong role in the development of substance use problems in the adolescent, even if the teen ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 39 does not directly witness substance use by a family member, as genetic factors also play a significant role.15 However, when a teen witnesses a family member using drugs or alcohol, he or she may be more likely to develop substance use problems because of the example set by the parent or family member.

The relationship a teen has with his or her parents and the home environment are important factors in preventing a substance use disorder. When a teen has little supervision, lives in a disordered or chaotic environment, and witnesses his or her parents or family members using drugs or alcohol, the teen is more likely to use substances as compared to adolescents who do not live in these types of environments.15

Whether or not a teen decides to start using drugs or alcohol is often related to the messages the teen receives in the home, as well as his or her home and community environment. However, after using and abusing certain substances, the risk of the adolescent becoming addicted is related to family genetics. A teen may become addicted to drugs or alcohol if his or her body is genetically predisposed to addiction to these substances. That is not to say that a person who does not have drug addiction and alcoholism in his or her genetic background will not become addicted if using too many drugs or too much alcohol; instead, it means that drug addiction and alcoholism “runs in the family” for teens who have a family history of substance abuse. Such teens are at much greater risk of becoming addicted to substances.16

The decision of a teen to engage in harmful behaviors is a combination of nature and nurture: the teen does not have a choice as to whether his or her family history contains genetic factors that increase the risk for alcoholism or drug addiction, but the teen can make choices against abusing substances,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 40 regardless of the environment and associated triggers. While it is true that an adolescent who becomes an alcoholic has had a higher risk of becoming so, if the family history includes alcoholism or drug addiction the increased risk in alcohol use could also be related to the individual’s exposure to drugs or alcohol within the family.

Parents should remember that their actions send a much more powerful message to their children than their words. A parent may tell their teen that it is important to avoid alcohol and drugs and may talk about the dangers of substance use, but the teen will be much more affected and likely to misuse substances if he or she sees the parent doing it. Alternatively, a parent who models appropriate behavior is likely to be more successful in teaching their child about the importance of avoiding a substance use disorder when compared to simply talking about it.

Trauma

A traumatic event can be painful and frightening for the adolescent patient who may continue to suffer through memories of what happened. Trauma can be both physically and emotionally debilitating; although a person who experiences a traumatic event may come through the event alive, he or she may suffer long-term physical damage that requires rehabilitation and the emotional effects of the event can last for the rest of his or her life. Traumatic events impact many youth of today, with estimates of approximately 25 percent of teens experiencing some form of trauma by 16 years of age.14

Trauma is any event or series of events that are overwhelmingly frightening and harmful to a person. A traumatic event may be such circumstances as the loss of a loved one, an experience in which a teen is gravely injured or ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 41 assaulted, a situation in which a person endures an act of violence, or a natural disaster. After living through trauma, a person may then suffer from traumatic stress, which occurs as continued feelings of guilt, shame, anger, or fear about an event. For example, a teen may have lived through a natural disaster and survived the event, only to be plagued by traumatic stress for years afterward, in which he or she feels terror every time there is an adverse weather condition.

During a traumatic event, the body responds with a stress reaction, which is known as the fight-flight-freeze phenomenon, designed to help the body counter the threat. During this time, the person experiences such sensations as a rapid heart rate, difficulty swallowing, nausea, and sweating. The person may also feel detached from his or her surroundings or feel a sense of displacement in which the body does not seem to be part of the environment. These responses are the body’s method of protecting itself in the face of danger.

Traumatic memories may trigger outbursts or temporary changes in behavior that cause the teen to act out in harmful ways, which may include substance use. A teen that has suffered a traumatic event may experience triggers in the environment, which are stimuli that can release memories or thoughts about the event. The person may have profound memories of the feelings he or she experienced during the trauma and may not be able to control behavior. Triggers that cause traumatic memories to return may lead some adolescents to feel angry and hypervigilant in their surroundings, and they may want to avoid others.14 Trauma triggers can also lead a person to crave substance use, whether he or she has an addiction or has been using drugs or alcohol to numb some of the pain of the trauma.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 42 Post-traumatic stress disorder (PTSD) occurs when an individual continues to experience psychological problems related to a traumatic event; it is associated with increased substance use and addiction to drugs or alcohol. PTSD causes a person to experience feelings and physical symptoms similar to what occurred during the traumatic event, in a sense, he or she is “re- living” the event in this way. The person may also experience a state of hyperarousal, hypervigilance, and fear that the event or something like it will occur again.

A substance use disorder is a response as part of PTSD when a person tries to avoid the feelings connected to the trauma. The teen with PTSD may turn to alcohol or drugs in order to feel numb against the pain of remembering the traumatic event. The use of substances works temporarily as a method of self-medicating some of the feelings experienced. Using drugs or alcohol may help the affected person to control some of the intensity of emotions that may be happening. Over time, the person can become addicted to the substance when he or she turns to using it every time the effects of a trauma trigger are felt. The teen then needs treatment not only for managing the intense feelings associated with the trauma, but also for a substance use disorder, which has developed as a response.

Signs And Symptoms Of A Substance Use Disorder

Many teens are susceptible to the risks associated with drug and alcohol use because of pressure from friends and because they are often easily influenced by the behavior of adults. Because many adults who have become addicted to drugs or alcohol began by experimenting with substances when they were teens, it is extremely important for parents and caregivers of teens to recognize the signs and symptoms that may demonstrate that their youth are using drugs or alcohol.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 43 Before becoming addicted to a certain substance, an adolescent will most likely go through a time of regular use. During this time of substance use, parents may find that their child is behaving differently, has experienced a change in attitude, or is pursuing new or unhealthy relationships.24 If a parent, friend, or healthcare provider notices differences in a teen’s behavior or attitude and is concerned that he or she may be using drugs or alcohol, it is important to intervene, even if the suspicions are not correct. By gently approaching the teen and acting in a non-threatening manner, the caregiver can communicate concern for the individual and might be able to discuss the situation further with the affected teen. If the symptoms are associated with a substance use disorder, this opening conversation can be the beginning of getting help for the adolescent.

Changes in Appetite

Adolescents often demonstrate changes in appetite as a result of growing; changes associated with growth and puberty may cause a teen to eat more. Boys, in particular, may eat much more food as adolescents when compared to how much they ate during childhood. Teen boys are typically growing taller and developing more muscle mass that causes an increase in appetite and they often eat much more food. Alternatively, an adolescent affected by drug or alcohol use may demonstrate changes in appetite such that the changes may depend on the type of drug being used. For example, stimulants such as methamphetamines or cocaine cause the adolescent to lose weight over time and to eat less. Stimulants often work as an appetite suppressant, and chronic use may cause the person using them to feel less hungry and therefore eat less and lose weight.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 44 Ecstasy may cause symptoms of nausea and the person who uses this type of drug consistently may experience jaw clenching. Both of these symptoms can make it difficult for the person to eat and he or she may eat less because of the discomfort. Heroin use also may cause nausea, which can cause a change in appetite when the person feels uncomfortable and doesn’t want to eat. Heroin crosses the blood-brain barrier very quickly and enters a person’s system at a rapid pace. The drug slows down cognitive function because, as it enters the brain, it is converted into the chemical morphine and binds to opioid receptors.26 The person then experiences a rush, but with it also comes a heavy or dragging feeling, slowed thinking, dry mouth, and nausea.

Too much alcohol use can also lead to changes in appetite; the person who struggles with alcohol addiction may experience a decrease in appetite as a result of changes in cortisol production, which affects appetite. According to an article in ABC Science, two hormones, dehyrdoepiandrosterone sulfate (DHEAS) and cortisol, affect the appetite, as well as cognitive function and memory. The body needs to produce sufficient cortisol in order to feel hungry, but consuming too much alcohol can suppress the body’s ability to release cortisol.25 As a result, the person who drinks too much alcohol will have a decreased desire for food, even if he or she hasn’t been eating.

The release of hormones will depend on the type of alcohol consumed. The hormone DHEAS, which is also responsible for appetite control, has been shown to fluctuate in levels depending on the type of drink consumed. In the study noted, participants drank different types of alcoholic beverages and their levels of DHEAS and cortisol were measured afterward. The people who drank beer had low levels of DHEAS initially, but then their levels increased,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 45 which actually increased their appetites. Alternatively, participants who drank wine had lower levels of cortisol and DHEAS, which reduced their appetites.25 The type of alcohol a teen consistently drinks may then depend on whether he or she has an increased or a decreased appetite.

There are some drugs that increase a person’s appetite. A teen that uses some of these drugs may want to eat more and may experience weight gain from eating too much. Marijuana tends to cause a person to crave sweets, and the individual using marijuana may eat more desserts and sweet foods after smoking it. Using marijuana also increases appetite so that the person who smokes it eats more overall, particularly when feeling high. One known aspect of marijuana use is that it causes a person to be hungry, and teens that smoke marijuana may also then eat large amounts of food, go out for meals, or binge on snacks.

In many cases, a person who has been using drugs or alcohol or has developed an addiction will demonstrate changes in appetite, as well as weight loss, because the drug or the alcohol often replaces food intake. As a result, the teen who uses drugs or who drinks alcohol may not eat for long periods of time while feeling high and then again during the time afterward. The teen may not feel hungry if the body has replaced the effects of the drugs and alcohol with food. The affected person may then experience significant weight loss, muscle wasting, and malnutrition over time because he or she is not taking in enough food or nutrients. The person’s body then exhibits changes that may appear as symptoms that others may notice as weight loss or wasting. Changes in Sleep Patterns

A teen who abuses drugs or alcohol may experience changes in sleep patterns as a result of the substance use. Although the amount of sleep

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 46 required changes as a teen grows from childhood into adolescence, teens still need about 9 ½ hours of sleep at night. Delayed sleep phase syndrome, a condition in which a person has trouble falling asleep until very late at night and has difficulty with getting up in the morning, is much more commonly found among adolescents than among adults or children. Teens may be more likely to stay up late and may sleep late in the morning if they do not need to rise for school or work. Because of these patterns, it may be difficult to determine if a teen is exhibiting changes in sleep patterns as a result of drug use or if he or she is going through more common alterations in sleep schedules that are typically seen among adolescents.

People who suffer from substance abuse disorders are 5 to 10 times more likely to struggle with sleep difficulties.27 The most common sleep issues related to drug and alcohol use are insomnia and difficulties with staying asleep once a person has fallen asleep. Drugs that act as depressants, such as alcohol and benzodiazepines, can make a person feel sleepy initially, so that he or she may fall asleep rapidly at first. In fact, many benzodiazepines are prescribed for sleep difficulties to help an affected person to fall asleep more easily. The difficulties arise when the individual uses CNS depressants inappropriately; he or she will more likely suffer from sleep disruption by taking too many of these drugs. Alcohol, for example, will initially cause a person to feel sleepy, which is the depressant effect. However, after having several drinks, the person may fall asleep quickly or pass out, only to wake up much earlier than normal, during the second half of the sleep period. The person’s body reacts to the ingestion of alcohol by altering the cycles of REM sleep and deep sleep, which makes sleep unrefreshing, and the person awakens more often. Increased alcohol use can further perpetuate the cycle, in which the person experiences poor sleep after drinking too much alcohol but then spends longer periods being

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 47 awake, eventually becoming sleep deprived. Over a short period of time, the person develops tolerance to the sedative effects of alcohol and its use no longer induces sleepiness. Alcohol use has been shown to contribute to other types of sleep disorders in addition to insomnia, including worsening of symptoms of obstructive sleep apnea and causing further episodes of restless leg syndrome.27

Unfortunately, sleep problems may continue once they have developed, even if the person has undergone treatment and has overcome a substance use disorder. Studies have shown that a person who suffers from insomnia as a result of drug use may continue to have trouble sleeping, even when he or she no longer uses the drug.27 Parents and caregivers who suspect that their teen is struggling with substance use should be aware of changes in sleep patterns that may develop from the effects of substances on the brain.

Withdrawal from Activities

Many teens are notoriously busy with activities and school work; often, an adolescent may remain busy with school, hold down a part-time job, play sports, or stay involved in clubs and groups that keep him or her active almost all of the time. When a parent or provider notices that a teen is withdrawing from normal activities, it can be a sign of a problem. One of the warning signs that indicate a substance use disorder is when a teen demonstrates a loss of interest in normal activities. What the teen once considered enjoyable and kept him or her busy may become uninteresting, leading to avoidance of the groups that once held the teen’s attention. The affected teen may spend more time alone or may spend more time away from home, but not necessarily keeping up with hobbies or friends. The teen may spend time with new friends and hang out with groups of people that he

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 48 or she has not been with before. What was once normal and active behavior from a teen may be replaced with more secretive activities.

Parents of teens who use drugs or alcohol also have stated that their teen is caught lying more often and avoiding certain social interactions. Normal friendships may go by the wayside to be replaced with spending more time alone, demanding more privacy, sneaking out of the house, or keeping doors locked.69 Parents may also worry about their teen’s friends and wonder with whom the teen is spending time. When an adolescent is normally involved in regular activities, such as hobbies or sports, parents are often much more aware of who the teen is spending time with and they know that he or she is keeping busy. Withdrawal from normal activities is a red flag that something is wrong, as this indicates that the teen would rather spend time doing something else — which could be using drugs or alcohol — instead of staying engaged with activities that used to bring the teen joy.

Changes in Appearance

It is normal and common for teens to experiment with their appearance. Adolescence is a time when many teens evolve in what they wear and how they present themselves. Adolescence is also a time for increased self- expression, when a teen can communicate some individual beliefs or ideas through choosing a style of clothing and appearance. Once a teen has developed a style of appearance, sudden changes in how the teen presents in their appearance toward others are a warning sign that something may be wrong. A teen who normally bathes regularly and wears relatively clean clothes and who suddenly changes or stops taking care of his or her appearance may be struggling to keep up with self-care measures because of substance abuse.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 49 Teens often experiment with changing their appearance. It is not uncommon for an adolescent to decide to pierce a body part or change hair color or style. Parents may have a difficult time accepting what their teen decides to wear or present in his or her appearance. However, these methods do not necessarily reflect a lack of self-care; to the contrary, a teen may use various methods of changing personal style as a matter of self-expression. The cause for concern, rather, arises when the teen clearly does not seem to care about his or her appearance and no longer takes measures to care for their own body or health.

Further, a teen that has been using drugs or alcohol may demonstrate other physical changes beyond those in dress or grooming. Parents may notice that their teen is losing weight, often has bloodshot eyes, or has been injured without a good reason. These physical signs and changes in the teen’s health status are danger signals that a teen could be having a significant problem of a substance use disorder.70

Changes in Personality

Some people use drugs or alcohol because of the impact these substances have on their personalities. For example, someone who is normally shy may enjoy feeling less inhibited after drinking alcohol and may choose to drink more because it makes them feel popular and social. Alternatively, drug or alcohol use can bring out many negative behaviors among teens. A person who struggles with anger or violence may become even more aggressive after using drugs, while someone with a diagnosis of depression may have overwhelming symptoms that are difficult to overcome.

A teen often has fluctuating moods and it is not uncommon for a teen to experience the highs and lows of adolescence that cause mood fluctuations. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 50 A teen may feel happy and carefree one minute and then may experience anger, confusion, or frustration the next. Adolescence is a time when teens are solidifying the work of controlling their emotions so that when they become young adults they are better able to manage their behavior. However, a teen who seems to have a consistent personality and who exhibits sudden changes in temperament could be struggling with a substance use problem.

Personality changes that may be exhibited with drug or alcohol use include increased lethargy, moodiness, anger, and irritability.71 This may be the result of the effects of the drug or it may occur when the teen is experiencing feelings of withdrawal when trying to stop taking the drug. Drug and alcohol use that lead to changes in social activities may also lead the adolescent to experience personality changes. A teen who normally has a solid group of friends and who abandons them to spend more time using drugs with a new set of friends may be more irritable or depressed because he or she misses those who were once close. Unfortunately, certain types of drug use may change a person enough so that he or she no longer has the same personality or temperament, even after quitting the drug use. For example, chronic use of marijuana during adolescence has been shown to decrease IQ levels that are never recovered, even after the person later stops smoking marijuana.28 A teen that uses drugs or alcohol may develop personality changes that make him or her difficult to be around because of impaired social interactions or an inability to understand certain social cues; these traits may never resolve even if the teen stops using drugs, and the negative personality changes could potentially remain into adulthood.

Neglecting Responsibilities

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 51 When an adolescent has many activities to be involved with, he or she may become quite busy and active, leaving less time for family or time spent at home. Because adolescence is a time of growth by being involved in hobbies and activities, it is normal to see this time of recreation as a method of keeping a young person active and busy. When an adolescent fails to keep up with normal responsibilities and drastically changes his or her normal routine, parents have a cause to worry.

A teen that is struggling with a substance use disorder may be less able to keep up with normal responsibilities, especially if he or she reaches the point of craving drugs or alcohol enough that it consumes the teen’s time. The teen might be involved with drugs to the point that it is all that is thought about and the teen’s normal responsibilities, whether at home, work, or school, fall by the wayside. Parents may notice that their teen, once responsible enough to study regularly and maintain good grades, is failing classes and has been disciplined at school. Some parents notice that their teen becomes more reclusive at home and does not participate in family activities or take up their share of home responsibilities, such as taking part in house or yard work.

Neglecting normal responsibilities can be an ominous sign and is quite detrimental to the affected adolescent. A teen normally stays involved with activities to learn responsibility so that he or she can be a productive adult who contributes to society. When a teen starts to neglect responsibilities because of drug use, he or she is hurting their own ability to learn and to be dependable, which are skills needed in the future when working or managing their own family. The teen may also lose out on important contacts or tasks that could have worked out well. For instance, a teen may have a job that requires the teen to act responsibly and to show up to work on time, and

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 52 has also given the teen the chance to earn money, to meet others, and to have a reference for future employment.

When the teen starts neglecting responsibilities because of drug or alcohol use, he or she could potentially damage these connections and hamper future outcomes. Parents cannot always know when their teen is acting responsible or if they are upholding their duties to school, work, or friendships, but parents should be familiar with their child’s normal schedule of activities and monitor for changes that signify that something could be wrong.

Co-occurring Mental Illness And Addiction

Mental illness includes a wide range of potential health conditions that affect a person’s emotional or psychological state. Mental illness can range from severe and debilitating, in which the affected person is unable to function in society, to a struggle with signs or symptoms that can be managed through behavioral therapy or medications. Mental illness is more commonly seen among patients who have substance abuse disorders, and those diagnosed with a type of mental illness have been shown to be more likely to use drugs or alcohol when compared to those without mental illness.1

Depression

Depression is one of the most common forms of mental illness among adults and adolescents. According to Substance Abuse and Mental Health Services Administration (SAMHSA), 2.2 million teens age 12 to 17 had at least one major depressive episode in 2012.1 Depression describes a condition in which a person experiences feelings of sadness or despair, has difficulty completing tasks or performing everyday activities, and feels a loss of joy or hope in life. Depression may occur as one of several different types,

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 53 including major depression, persistent depressive disorder, seasonal affective disorder, psychotic depression, or bipolar disorder.72 Depression, while very common when associated with substance abuse, often remains underdiagnosed among teens. While the signs and symptoms may be present, parents and caregivers may not be familiar enough with what to look for or who to contact for help for their child.

Drugs and alcohol can lead to feelings of depression because of their effects. Some drugs cause a feeling of depression when the high goes away; for example, a person who uses certain stimulants that rapidly increase levels of dopamine in the brain to cause feelings of pleasure may suffer a rebound effect of depression after the drug wears off. People who become intoxicated or high while using drugs may become depressed after engaging in foolish or dangerous activities. And, a teen who struggles with a drug or alcohol use disorder and who has tried to quit may become depressed when he or she is unable to stop using.73

A teen that is already depressed before developing a substance use disorder may suffer from sad feelings, grief, anger, irritability, and may be unable to find pleasure in any activities. Alternatively, using drugs or alcohol may bring feelings of pleasure and euphoria that can make up for some of these negative feelings, even if it is only for a short period of time. The teen may eventually develop a substance use disorder because of continuing to crave the effects of using drugs, and may use drugs to self-medicate in order to deal with negative feelings. The teen may believe that using drugs brings short-lived positive feelings that can replace some of the sadness and negativity he or she experiences with depression. Parents and their teens can be immensely helped when informed that depression is treatable when a teen is properly assessed and diagnosed. Adolescents who suffer an episode

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 54 of a mental illness are more likely to have better outcomes if intervention is provided early, in particular, shortly after experiencing the first episode of mental illness. When a teen patient receives comprehensive and focused care either during an acute episode of mental illness or shortly following the first episode, he or she has a greater chance of a positive health outcome.1

Parents can monitor their children for signs or symptoms of depression, particularly when their teen experiences significant changes in his or her normal personality. Early intervention can mean a diagnosis of depression, but even if the teen is not actually diagnosed, it is helpful to seek out care and support for symptoms of depression because they can be quite debilitating to the affected teen. Once a diagnosis has been made, there are a number of options for treatment, including pharmacological therapies, behavioral interventions, and some types of brain stimulation therapies that can potentially bring relief of symptoms. Because of the close connection between a substance use disorder and depression, when a teen is suffering from symptoms of either condition, it is important for the provider to consider both conditions and to provide treatment to help the adolescent manage the pain of a mental health condition.

ADHD

Another mental health issue that is commonly associated with substance abuse is attention deficit hyperactivity disorder (ADHD). ADHD is the most common neurobehavioral disorder of childhood; it causes difficulties with attention and hyperactivity, as well as symptoms of impulsivity and lack of control. According to the Centers for Disease Control and Prevention (CDC), 11 percent of people ages 4 to 17 have been diagnosed with ADHD as of 2011.4

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 55 According to an article in The American Journal of Psychiatry, because of their neurodevelopment, teens already possess a drive to experiment with new situations, such as with drugs or alcohol; but, a teen with a mental health background that affects impulsivity, such as with a diagnosis of ADHD, is at even higher risk of engaging in risky and impulsive behaviors that can lead to addiction and substance use.7

ADHD is a chronic condition, and teens that use drugs or alcohol and who also have ADHD may be even more likely to struggle with impulsive and reckless behavior. This can increase the risk of injuries from poor judgment. Alternatively, a teen may use drugs or alcohol as a form of impulsive behavior because of having ADHD. Some teens with ADHD may be more likely to develop substance use disorders because they have a common genetic factor that is associated with both conditions; this theory is still being investigated for its accuracy.74

Under normal circumstances, ADHD is treated with stimulants, such as methylphenidate, which work by affecting the brain’s neurotransmitters and relieving some of the symptoms of disorganization and hyperactivity. Unfortunately, though, some of the stimulants used to treat ADHD can also increase a teen’s risk of substance use because they are commonly abused substances as well. Therefore, prescription stimulants should be used and monitored very carefully when administered to a teen with a substance use disorder who has concurrent ADHD. Alternatively, a clinical report in the journal Pediatrics showed that early treatment of ADHD with stimulants and psychological counseling, such as before adolescence or within the early years of adolescence, may reduce the risk of a teen later developing a substance use problem. The caveat is that the teens involved in the reported study received treatment for ADHD with stimulant medications at a young

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 56 age and not as older adolescents.74 The early recognition of ADHD symptoms and onset of interventions is much more likely to help teens who struggle with impulsivity and hyperactivity of ADHD before they move on to develop substance use disorders.

Bipolar Disorder

It is normal and common for teens to experience fluctuating levels of moods. Many adolescents transition between levels of happiness and despair on any given day. When a teen has difficulty performing usual tasks and is unable to carry out routine activities because of highs or lows in moods, parents may need to consider whether there is an underlying mental illness present, such as bipolar disorder.

Bipolar disorder is more commonly seen and diagnosed among children and adolescents. It is a type of mental illness that causes intense fluctuations in mood and emotions for the affected person. The moods a person experiences are different from his or her normal personality; high moods, referred to as mania, may include being overly silly, feeling extremely happy, talking fast, sleeping less, and engaging in risky behaviors. The person may also experience the opposite effects of depression, in which there may be feelings of prolonged sadness or guilt, and the person may eat more and sleep more often, may not show interest or pleasure in routine activities, and may be at risk of suicide.75

Teens with bipolar disorder are at higher risk of developing substance use disorders. Boys seem to be more susceptible to these co-occurring conditions happening together when compared to girls. Teens who have a history of suicide attempts because of bipolar disorder may also be more likely to develop substance use disorders.76 As with depression or other

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 57 forms of mental illness, teens may develop a substance use disorder after routinely using drugs or alcohol to self-medicate their conditions. The high produced from substance use often feels better for a short time instead of struggling with mania or depression. Over time, the teen with bipolar disorder may continue to turn to drugs or alcohol to feel better but may find that he or she has developed a craving for the substance and needs it. When this occurs, the teen then faces the difficulties of having co-occurring bipolar disorder and a substance use problem, both of which often require intensive management.

The good news is that treatment of bipolar disorder tends to decrease the risk of a substance use disorder as a comorbidity.76 Teens are more likely to manage their conditions and avoid developing substance use problems when they receive mental health treatment, particularly when the intervention is early in the disease. When screening an adolescent for signs or symptoms of mental illness, the provider should consider the possibility of substance use as well and perform an assessment. Parents and caregivers, as with other forms of mental illness, should be alert to the symptoms associated with bipolar disorder and seek to get help for their teen as soon as possible.

Other Brain Disorders

The crucial time of neurodevelopment during adolescence is an important factor in developing substance abuse disorders when a teen experiments with or uses drugs and alcohol. During adolescence, the brain still has a certain amount of neuroplasticity, in which the brain is able to change and adapt to circumstances. Some areas of the brain have matured more than others, so a teen may have some thoughts and feelings that are more established than others. For example, an individual may seek pleasurable activities and seek rewards through dangerous activities because the part of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 58 the brain that manages these emotions matures before other parts of the brain that control such activities as making decisions, controlling impulses, and assessing harmful situations.28

Because the brain of an adolescent remains immature until he or she has had more time to grow, even experimenting with drugs can lead some youth to quickly become addicted because of the brain’s response to the drugs. An adolescent may make a poor decision to try a certain drug at a party and the high from the drug causes a significant increase in the release of dopamine, in which the person feels intense pleasure associated with the release of the neurotransmitter.

The release of dopamine caused by the drug is much greater than what is produced during other activities that do not involve drugs. Because of this rush of dopamine, the teen finds that there is a desire to have the feeling and the experience again, so he or she seeks out a chance to try the drug another time. Each time the teen uses the drug, it reinforces the pleasurable feelings associated with the release of dopamine, but the teen’s brain may not be mature enough to recognize that this is abnormal.28 Eventually, the teen may engage in drug-seeking behavior and the desire for the drug has transcended other activities because his or her brain wants the continued rush that comes from excess dopamine release when taking the drug. When the adolescent becomes addicted to a drug, he or she is no longer able to turn away from the drug, even if there is the desire to do so, because the drug has affected the person’s levels of impulsivity and ability to make decisions.

As a result of drug use, many teens are at risk of mental health issues that develop as co-occurring conditions. These comorbidities may have been

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 59 present before the substance use began but were not diagnosed or they may develop as a result of substance use. Often, when a teen begins using drugs or alcohol, he or she may experience symptoms similar to mental illness, such as intense rage, impulsive behavior, or changes in cognition. Alternatively, a patient may have underlying symptoms of a mental illness that cause the teen to seek drugs or alcohol as a form of self-medication to help with managing the symptoms.

There are some conditions that may also have overlapping factors as to why they develop together. For instance, a person who is genetically predisposed to a certain type of mental illness may have the same genetic variants that increase his or her risk for substance use. Some types of mental illnesses that have been shown to be more likely to develop as comorbidities to substance use disorders include anxiety disorders, schizophrenia, and post- traumatic stress disorder.77

The DSM-5 addresses co-occurring substance use and mental disorders under various sections of the manual. For example, a depressive disorder that occurs during or as a result of intoxication is specified under the section Substance/Medication-Induced Depressive Disorder. Symptoms that may occur during intoxication or withdrawal are defined. The main classes of substance/medication induced depression that may be assigned to a diagnostic code are: alcohol, phencyclidine, other hallucinogen, inhalant, opioid, sedative, hypnotic, or anxiolytic, amphetamine (or other stimulant), cocaine, other (or unknown) substance. The other (or unknown) substance category is not specifically covered in this study but basically it involves a section in the DSM that allows the clinician to identify a substance use disorder not specified under the main categories raised above. Similarly, when reviewing the DSM-5 section on bipolar and related disorders as a co-

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 60 occurring condition with a substance use disorder, the diagnostic code remains dependent on whether or not there is a comorbid substance use disorder present for the same classes of substances. These main categories of substance use disorders occurring in the setting of comorbidity resonate throughout each section in the DSM-5 where a specific condition and symptoms of a mental illness are described.

As with other types of mental illness and co-occurring substance use, treatment of one condition often affects the other. A person who seeks treatment for a mental illness, such as a diagnosed anxiety disorder, may be at lower risk of developing another type of mental illness, including substance use disorder.77 There are many treatments available for adolescents who struggle with mental health issues. Often, diagnosis is the first hurdle to overcome when a person is seeking help for either a substance use disorder or a mental health issue.

Substance Use Disorder Treatment

When it comes to a substance use disorder, adolescents are not merely smaller adults, and they should not be treated as such. Instead, they need to be recognized as having distinctive needs associated with their age group, as they are still growing and maturing in their neurological, emotional, and physical developments. The transitions associated with adolescence pave the way for experimentation with different substances, the presence of peer pressure from fellow students and friends, and the continued progression toward maturity that make this timeframe not only difficult but also more prone to testing and experimenting with substances can lead to inappropriate use.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 61 As with other forms of chronic illness, the patient who struggles with a substance use disorder may take positive steps in treatment of his or her addiction but then may later have setbacks and periods in which there are relapses. When relapse occurs, the clinician and the affected teen should not consider the situation as a failure; rather, the clinician may need to work with the patient and the patient’s family to come up with another method of treatment that may be beneficial and more successful for the patient. Regular monitoring by parents or caregivers is important to prevent relapse. In many cases, the teen patient requires regular communication with a caregiver and close monitoring for changes in behavior or other symptoms that signify that a relapse has occurred. Further ongoing support, such as through 12-step groups that meet on a regular basis may provide help and encouragement that can prevent relapse after the teen has completed a treatment program.

Unfortunately, because they are younger and have fewer experiences during their shorter lives, teens may be less likely to seek treatment or to see the importance of treatment. Despite struggling with substance use and addiction, some adolescents may still not believe that substance use can be life threatening or may not be aware of the harmful effects of these problems. They may not want to get involved in a treatment program because they have not necessarily experienced some of the terrible effects that can occur as a result of chronic substance use. Because of their limited experiences with substance use when compared to adults, teens may not be as cooperative in seeking treatment or in maintaining the work needed to successfully complete a treatment program. Further, a number of teens undergo treatment for a substance use disorder because they are required to participate due to their behavior and legal action taken against them.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 62 A teen may only attend treatment sessions because they are required to participate, but they may not necessarily believe in the seriousness of the consequences associated with a substance use disorder. These situations require extensive patience on the part of the caregiver who must work with the teen to help him or her recover when the teen does not want to. The teen who does not believe that he or she needs substance use addiction treatment, or who is only undergoing treatment because of a mandatory requirement to attend sessions, can still overcome his or her addiction and may not necessarily revert back into abusing substances again after the sessions are complete. Most teens do not seek help for a substance use disorder on their own; they enter into treatment usually after being referred by a parent, healthcare provider, or through law enforcement. Even when the teen is unwilling to go to treatment early on, he or she can still have a successful treatment program and may still heal from their addiction.28

When determining the best course of treatment for the adolescent who struggles with a substance use disorder, the provider must consider several aspects of the patient’s situation to determine the best and most appropriate form of treatment. Factors to consider include the type of substance the patient has become addicted to, how long he or she has been using it, whether or not the patient has family support during the treatment process, and whether the patient has a co-occurring mental or physical illness that must also be managed.

A teen does not have to be classified as being addicted to a drug or to alcohol before undergoing treatment for substance use. Many teens benefit greatly from treatment programs in which interventions were made at relatively early points in the process of illness; in the case of an adolescent who is struggling with a mild substance use disorder, early treatment is

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 63 better than waiting for the teen to be showing signs of a severe disorder or complete addiction to a substance. The teen will have a much greater likelihood of succeeding through treatment when the problem is detected and managed early on.

Treatment programs are available in both inpatient and outpatient formats; many of them are specifically designed for the unique needs of teen patients. A teen who struggles with drug or alcohol substance use may need to be treated with inpatient intervention in which he or she stays in a treatment center for a designated period of time to go through periods of withdrawal and detoxification, receive education and counseling about addiction, and be treated for other health issues. Alternatively, outpatient treatment programs can deliver counseling and support through groups or individual therapy. The type of program the adolescent needs depends on his or her situation and the type of social support available. Unfortunately, although treatment is extremely important for the recovering teen substance user, only about 10 percent of teens with substance use disorders receive adequate treatment.29

The decision of whether to treat an adolescent as an inpatient or within an outpatient facility is determined by the amount of care needed, as well as other factors affecting the patient. The American Society of Addiction Medicine (ASAM) has developed a set of criteria that may be used to determine the length and intensity of treatment for the adolescent with a substance use disorder. The ASAM criteria are divided into six dimensions of assessment that help the provider to establish the most appropriate level of care to provide for the adolescent client. The six dimensions include:30  Dimension 1: Acute intoxication or the potential for significant withdrawal symptoms

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 64  Dimension 2: The presence of co-occurring medical conditions or complications  Dimension 3: Whether emotional, cognitive, or behavioral conditions or complications are present  Dimension 4: The patient’s readiness to change  Dimension 5: The potential for relapse or continued problems with abstinence  Dimension 6: The patient’s living environment and support available

By reviewing these six dimensions, the provider is better able to assess the patient’s background and determine his or her needs for support through treatment. The criteria were developed to prevent adolescents from receiving treatment that is inadequate in length or intensity, or that does not consider the complex needs of adolescents when being treated for a substance use disorder.

When determining the type of treatment needed during withdrawal from a substance disorder, the DSM-5 generally specifies the phase of remission (early or sustained), and the patient’s type of use and environment, i.e., whether the patient is on maintenance therapy or using in a controlled environment. In early remission, a substance use disorder has met full criteria to diagnose a problem but none of the criteria for a disorder have been met for at least 3 months but for less than 12 months or longer. In sustained remission, after full criteria for a substance use disorder were previously met, none of the criteria for the disorder have been met any time during a period of 12-months or longer. The severity of use is coded according to the ICD-10-CM codes, and most disorders are categorized as:  Mild – the presence of 2 - 3 symptoms  Moderate – the presence of 4 – 5 symptoms

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 65  Severe – the presence of 6 or more symptoms

Substance use disorders and addiction recovery programs are highly specialized area of mental health care. This course primarily focuses on the criteria to diagnose a substance use disorder according to the DSM-5; however, it is necessary for the clinician to be familiar with the general definitions of symptom severity within each category of a substance use disorder to be able to plan referrals and treatment programs for patient recovery. Determining the type of treatment indicated by the patient’s diagnosis and level of severity of a substance use disorder and withdrawal is beyond the scope of this study and a topic worthy of further focused review, which the interested learner is recommended to pursue. The following sections discuss types of inpatient and outpatient treatment programs and venues through which the patient can continue to follow a recovery treatment plan for a substance use disorder.

Inpatient Treatment Programs

Treatment for adolescents with substance use disorders differs from that of treating adults with the same problems. When caring for adolescents who are recovering from addiction, the healthcare provider must view the treatment from a neurodevelopmental perspective, as the teen is still going through stages of development, he or she has not yet reached adulthood, and is not necessarily established in individual thought and behavior patterns.29 Inpatient treatment for adolescents suffering from substance use disorders is considered for those who are in danger; and, for those who have co-existing psychiatric or medical complications, not otherwise responded to more conservative treatments, little to no social supports in place, and suffering from severe effects of acute withdrawal during the detoxification process. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 66 Detoxification is the process of getting rid of a certain substance from the body. Many patients who suffer from a substance use disorder and addiction will experience symptoms of withdrawal when the drug or alcohol is stopped; withdrawal can cause severe symptoms that are not only uncomfortable, but could also cause serious complications. Common symptoms of withdrawal include sweating, nausea, muscle aches, diarrhea, fever, and insomnia;3 withdrawal symptoms may also lead to life-threatening situations that also include seizure activity and changes in the patient’s level of consciousness. Because of this, the adolescent patient who is going through detoxification should be monitored carefully for signs and symptoms of withdrawal from the substance, and the clinician may need to provide medications for comfort and sedation until the severe symptoms have passed. It is therefore important that a teen undergoing detoxification be monitored through an inpatient treatment facility where he or she can receive continuous care if having severe symptoms of withdrawal, if suffering from an infectious illness or from symptoms of a co-occurring psychiatric illness, and if the teen does not have a support person who can help.

The process of detoxification for a teen is somewhat similar to detoxification in an adult patient. Inpatient rehabilitation centers may be located at stand- alone centers that have been developed for treatment of substance use disorders; they may also be found within hospitals or mental health centers. The adolescent patient is checked into the inpatient center where he or she will stay for several weeks. The amount of time required for a patient to stay as an inpatient depends on the program itself and the patient’s health status and needs for therapeutic treatment. The typical process of inpatient treatment involves an initial assessment where the teen undergoes psychiatric and physical health evaluations to determine the extent of care

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 67 needed during the teen’s stay. For instance, upon review of the patient’s history, the clinician may find out that in addition to a substance use disorder, the teen also has a co-occurring mental health diagnosis for which he or she will need routine medications while staying as an inpatient.

Following the initial evaluation, the teen may need to go through detoxification, in which the teen’s health will be managed, particularly if he or she is suffering from severe symptoms of withdrawal. After the detoxification process, the teen inpatient then has continued counseling and behavioral interventions, as well as medications administered to help control the addiction recovery process. Finally, the caregivers at the inpatient center focus on equipping the patient with resources and tools so that he or she can be integrated back into the community. This may mean setting up services for ongoing outpatient therapy with a trained counselor or helping the patient access information about local 12-step programs that can be attended.

One concept that has been used successfully in helping some teens overcome substance addiction is the implementation of therapeutic community living. A therapeutic community (TC) is a program located away from the typical area where the teen’s drug or alcohol use has occurred. The members of the TC live together in a group setting where they must uphold certain behavioral expectations and may need to contribute to the ongoing maintenance of the home. The members of the community also go through therapeutic interventions while living in the TC, in which they attend support groups, participate in community-based learning, and practice role-playing.

Throughout a person’s stay in a TC, it is expected that he or she will continue to grow in responsibility until becoming a role model for other

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 68 members. People move into and out of each TC; some have substance use problems but have had experience with holding jobs or maintaining other responsibilities, while others may have significant deficits in social functioning or may be suffering from severe symptoms of mental illness. The ultimate goal of living in a TC is to help the affected person learn coping skills for dealing with a substance use disorder, and to learn to manage feelings, live and cooperate with others, and live a respectful and responsible life away from substance addiction.45

Some teens may have contracted infectious diseases or other illnesses as a result of their drug and alcohol use. It is well known that using certain drugs increases the risk of some infectious diseases, such as human immunodeficiency virus (HIV) or hepatitis B, when the person engages in activities that promote the spread of these infections. Drug use also may increase unsafe sexual behavior on the part of the teen and he or she may have a sexually transmitted infection as a result. The clinician may need to provide treatment interventions for some of these conditions when a teen is receiving inpatient treatment for a drug or alcohol use disorder. This may involve administering medications, such as antibiotics for the treatment of some sexually transmitted infections, testing for infections, and administering antiviral medications to manage chronic illnesses, such as HIV infection.

Inpatient treatment programs are not as common as outpatient programs in the setting of teen substance use. However, they can be extremely beneficial in providing a solid base for which an addicted teen can recover from initial symptoms of withdrawal and then learn strategies for dealing with cravings and a substance use disorder. Inpatient programs are often successful at equipping patients to return to their normal environments; a teen cannot

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 69 live as an inpatient in a facility forever, but the tools the teen learns during his or her stay in one of these facilities may help the teen to engage in responsible activities and learn to live a normal life upon return home.

Outpatient Treatment Programs

Outpatient programs are the main form of treatment for most adolescents with substance use disorders. Studies have shown that outpatient treatments can be effective for adolescents with less severe addictions as well as those who suffer from severe symptoms of dependence and who have co-occurring mental health issues.28 Outpatient services can vary in intensity and length and can range from the patient meeting with a provider once or twice a week to intensive therapy that lasts several hours a day.

The most successful programs of outpatient treatment for a substance use disorder consider the needs of the teen patient as a whole person, including the teen’s medical background, the presence of any co-occurring mental health issues, the level of family support available, living arrangements, whether or not the teen has a job or is in school, and if the teen has transportation to get to outpatient treatment appointments. The healthcare provider must take a comprehensive approach when assessing the teen patient’s needs while he or she is undergoing treatment instead of focusing solely on the teen’s use of drug or alcohol.

Among adolescents, behavior interventions have been shown to be one of the most effective forms of treatment for substance use. Behavioral therapies may consist of such practices as cognitive-behavioral therapy, motivational interviewing, support groups, or family therapy, which provide education and direction for the teen as well as allow the teen to talk about issues and their use of substances. Behavioral intervention also helps the

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 70 teen to develop stronger interpersonal relationships so that he or she will be more likely to turn to friends or family for help instead of using drugs or alcohol during times of need. The teen patient may learn more about coping skills, in which solutions are readily available to turn to when the teen is struggling with mental health issues, relationships, or personal problems so that he or she will better understand how to manage feelings and behavior instead of using substances to self medicate.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy in which the adolescent patient meets with a counselor for treatment one or more times per week. Cognitive-behavioral therapy works when the therapist teaches the client to consider how his or her thoughts affect behavior. The patient then works on changing his or her thoughts and to replace thoughts with realistic thinking. For example, a teen may meet with a therapist to undergo CBT regarding use of marijuana. Throughout the discussion, the teen may recognize that negative encounters with the teen’s parents cause the teen to feel deficient or guilt, and the teen may feel that he or she has not been successful in achieving good grades or being active in school. Whenever the teen starts to feel this way, he or she smokes marijuana to help feel better and not think about the negative interactions had with the teen’s parents. The therapist can work with the teen to come up with alternative solutions for when he or she is feeling like a failure or when negative encounters occur with the teen’s parents, instead of smoking marijuana.

Cognitive behavioral therapy has been shown to be effective in reducing substance use among teens, improving coping skills and communication, and increasing self-monitoring activities. A study from the journal Addiction demonstrated that among the drug-using youth studied, participants showed

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 71 a significant decrease in frequency of cannabis use and a marginally significant decrease in alcohol use when they underwent CBT.31 The use of CBT can be extremely beneficial in helping adolescents with substance use disorders to cope with the difficulties of adolescence instead of turning to drugs or alcohol to self-medicate. The individual can continue to use the coping skills learned through CBT over a long period of time as new problems and issues develop, in order to reduce or eventually eliminate drug or alcohol use.

Motivational Interviewing

Motivational interviewing is another form of outpatient treatment that has been shown to be successful among some adolescent patients who struggle with substance use disorders. Motivational interviewing (MI) is a technique in which a caregiver or provider meets with a patient and works together with the patient to collaborate on how best to elicit change in the patient’s life.32 It does not involve the practitioner teaching the patient about what he or she should or shouldn’t do, and it is not used to treat all forms of substance use. Instead, it is designed as a method of respectfully working with a patient to consider what aspects of the patient’s life need to change and how he or she can go about making those changes.

Motivational interviewing may be successful when used with teens because it is often used in situations where a client does not necessarily want to change or does not see the need for change. Through the principles of motivational interviewing, the practitioner explores with the patient his or her feelings of ambivalence about making life changes. The clinician is not confrontational about the change; instead, the clinician uses the principles of empathy and support to help the client to see his or her own self-efficacy to make changes.33 This is done by talking through the situation with the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 72 patient, using “change talk,” which involves discussing the impetus for change and the patient’s ambivalence toward it, and helping the teen patient to understand that the provider is available to listen and to talk regardless of whether the patient decides to change.

There is some variation in how MI is delivered and how often the patient should undergo sessions of meeting with a therapist for the MI. In severe cases, the teen may need to meet with the practitioner on a frequent basis for many months to go through the process of change. Alternatively, MI has also been used in very brief episodes in the primary care provider’s office or the emergency department and has also shown benefits. Motivational interviewing has been demonstrated to be successful in helping both adults and teens to overcome tobacco use and to quit smoking.33 Motivational interviewing also plays a key role as another type of intervention that may be used as follow up to traditional therapy for a substance use disorder. In these situations, MI may provide the benefit of helping an adolescent to significantly reduce his or her use of alcohol or drugs, but not necessarily to promote complete abstinence. MI may also help an adolescent to make changes in the coping skills he or she has developed as part of treatment, even if the adolescent does not completely give up using drugs or alcohol. For example, a teen that has gone through substance use treatment and has learned to use certain coping skills in place of using drugs may use motivational interviewing to develop a plan for utilizing these coping skills when he or she wants to use drugs instead. Although the teen may not commit to abstaining from drugs completely during the process of MI, it can produce enough of an effective change that the teen will commit to using coping skills, which can drastically reduce his or her use of drugs.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 73 Outpatient Support Groups

Other outpatient groups are beneficial for teens when they are able to meet together with others for support and to discuss their circumstances. SMART Recovery® is an outpatient teaching program that educates teens about how to change their behavior when they make poor choices, such as engaging in drug use or smoking. SMART is an acronym that stands for Self Management And Recovery Training.34 The program provides a group where teens can meet with others who have similar issues for discussions and peer support. It is an alternative to other 12-step programs that are typically available as outpatient support groups.

SMART Recovery is based on a 4-point process: the group focuses on the motivation for change, developing coping skills for dealing with impulsive behavior that leads to drug or alcohol use, determining how to manage difficult feelings and how to control behavior, and learning how to live an organized and balanced life, such as by setting goals and finding new interests outside of drug or alcohol use.34 SMART Recovery is one option for outpatient treatment for a teen who can benefit from continuing treatment by meeting with others for small group support; it is considered a non- religious group that usually meets the requirements designated by the legal system when a teen has been ordered to attend meetings by the court. Meetings are also a place where teens can feel support from others in similar situations, make new friends, and have good discussions facilitated by a trained leader.

Twelve-step groups are another choice for some teens to attend ongoing support groups with others who have similar substance use problems. These programs are free and typically have meetings at a number of locations, making them relatively easy for teens to access. Some groups consist of

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 74 both adults and teens, while others may be centered specifically on the unique needs of adolescents. A 12-step program is based on 12 steps of change and recovery, in which the person with the problem admits that he or she has a problem and turns over control of the problem to a Higher Power. Other steps include admitting to others about the wrongs committed, making a list of people who have been hurt by the behavior and making peace with them, pursuing meditation and reflection about the changes that have been made in the teen’s life, and teaching others about the steps to recovery.35

There are various types of 12-step programs, and each is centered on the specific item or act that affected individuals are trying to overcome; as such, each type of group is so-named according to the topic needing change and then followed by the term “Anonymous” because the groups agree not to share personal information outside of the group and to respect the confidentiality of those in the group. Groups range from broad categories, such as Alcoholics Anonymous or Narcotics Anonymous, to specific types of substances or items needing to be changed, including Heroin Anonymous or Marijuana Anonymous.

Although teens can attend groups where there are also adults struggling with addiction and dependence, The Partnership for Drug-Free Kids states that 12-step programs are often more effective when they are tailored to the needs of adolescents.36 Some 12-step programs have been modified to meet the developmental needs of teens and they offer friendship with other teens who are in similar situations. Still, some people are uncomfortable with the spiritual component of 12-step programs and recognizing a Higher Power as part of the process. They may not want to continue in this type of treatment if they feel awkward about attending meetings. However, there are many

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 75 teens who succeed in abstaining from substance use by utilizing 12-step programs. They are paired with a sponsor, who is usually someone else who has overcome addiction, and who acts as a mentor to provide support during the process. Having someone at the meetings and discussing aspects of treatment is an important social outlet for many teens and helps them to make new friends in place of their former friends who may still continue to use drugs or alcohol. Family Therapy Groups

Family therapy is important for treatment of teen substance use; often, a teen still lives at home with family and if these family members can attend family therapy groups, the counselor can help everyone to work together. The family is a significant source of support for the teen both during the time that the teen is attending outpatient therapy and later when he or she goes forward into life as a recovering drug or alcohol addict. When family members attend group therapy with the teen, they learn to talk about issues present that may have contributed to the substance abuse, discuss their feelings regarding the patient’s problems with drugs or alcohol, and talk about their home life together. Family therapy is also a time to learn better forms of communication that will continue to serve the members of the family so that they can talk when issues arise in the future and work together to solve problems as a family.

Parents and other family members of the teen who has a substance use disorder also benefit from family therapy in that the group can provide ideas about coping methods to use when their teen is struggling. It can be difficult for family members to watch their child spiral out of control into drug or alcohol use; this often causes feelings of hurt, pain, confusion, and anger for others in the family. Family therapy can be a resource for those who must live with the teen patient to help them cope with difficult feelings associated

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 76 with drug and alcohol use and their teen’s behavior. When family members have coping skills and resources for dealing with a substance use disorder, they can better help their child who is struggling.

Many teens that have gone through inpatient treatment programs need continued care and monitoring after being discharged from inpatient care. These outpatient treatment programs are designed to follow up on the principles used during inpatient treatment so that the patient can continue to practice what he or she has learned. They are also designed to reduce the risk of relapse that may be more likely to occur among teens. Despite going through inpatient treatment programs, many adolescents later return to alcohol or drugs after a period of abstinence. This is often because the teen who receives intensive treatment for a drug or alcohol problem is learning about how to cope and recover from a situation that affects his or her life as a teen. The teen’s current lifestyle revolves around school, a job, peers, and activities that are related to adolescence, not necessarily adulthood. As the teen continues to grow and reaches adulthood, the teen’s life changes and he or she takes on different responsibilities and reaches a new stage of development.

Because a teen’s responsibilities become different as an adult, the person who received substance use addiction treatment as a teen may not necessarily be able to use the same coping measures once learned. The individual’s problems have changed and he or she may respond differently by returning to drugs or alcohol as methods of self-medicating for adult issues. Alternatively, just because a teen does not complete outpatient sessions after an inpatient treatment program does not mean that he or she is destined to have a lifelong addiction to drugs or alcohol. Because non- completion of a long-term outpatient program is more common among youth

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 77 than adults, an affected adolescent may also be more likely to re-enter a program for help with a substance use disorder. While this may need to occur a number of times during adolescence and into adulthood, it is still possible that the teen or young adult eventually gets the treatment needed to succeed.29

Medical Intervention

Although there are a number of medications to treat addiction, which are available for adults, there are few, if any, medications approved by the U.S. FDA for the treatment of adolescent substance users. In most cases, these drugs are not approved because of their potentially negative effects on the developing brain of an adolescent. Still, there are some providers who continue to prescribe some medications for drug or alcohol addiction in teens, in which the drugs are considered to be “off label” use. These medications are often indicated more for older teens who are closer to entering young adulthood, compared to very young teens with substance use addiction.

Methadone

Methadone is a drug that is sometimes used for the treatment of addiction to painkillers or heroin. Methadone itself is an opioid analgesic and provides pain relief as well as many similar symptoms associated with heroin or opioid use, but its onset of action is much slower when compared to other drugs. As part of treatment for addiction, a teen may receive methadone, which binds to the same receptors as heroin or other opioid drugs.37 Methadone may be administered in controlled settings known as methadone clinics, in which the provider determines the appropriate amount of the drug

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 78 needed and then administers it in a controlled environment where the patient can be monitored. The teen patient is given a dose of methadone and then the dose is slowly decreased over time to reduce the person’s dependence on opioids.

Methadone use is not without risks. Although it has been used as part of substance use treatment for thousands of people, a person who takes methadone as part of treatment may still become addicted to it. Methadone may also be given as a prescription to be taken on an outpatient basis as part of detoxification. This presents a potentially dangerous situation in which the teen is at greater risk of becoming addicted to the methadone if he or she takes it inappropriately. For instance, a person with a methadone prescription may not feel the effects of the drug right away because of its slower onset when compared to heroin. He or she may then take more methadone to try and achieve the same effects, which could result in an overdose.

Methadone is typically administered as an oral tablet, although in some methadone clinics, it may also be given as an oral liquid. The drug is given to block the effects of opiates and has been shown to reduce cravings for drugs such as heroin in addicted individuals.37 Among adolescents, methadone may be used for treatment of 16- to 18-year olds who have documented cases of other forms of failed drug treatments or opioid detoxification. The teen must also have consent signed by a parent or guardian to undergo methadone treatment.28

Buprenorphine

Buprenorphine is another type of narcotic analgesic that has been approved for use for people undergoing withdrawal from heroin or painkiller addiction.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 79 Buprenorphine is a partial opioid agonist, so it is less likely to cause dependence and symptoms of withdrawal when it is discontinued. This makes it different from methadone, as people who take buprenorphine are less likely to become addicted to it as part of the drug withdrawal process. It has been shown to reduce cravings for heroin and opioid analgesics because it blocks the effects of other opioids when administered correctly.28,29

A patient who takes buprenorphine may still experience some effects such as euphoria, but may not experience them to the full extent as with taking other types of opioids. Although it is available as an analgesic (Buprenex®), it is administered as Suboxone® for use as an opioid withdrawal treatment, which has been approved for the management of opioid addiction by the U.S. FDA, although not for adolescents.38 Suboxone is a combination of buprenorphine and naloxone, which is an opioid antagonist that has been added to protect against inappropriate administration of Suboxone; for instance, the person who injects Suboxone intravenously will experience negative side effects of a withdrawal reaction. Although it is technically not approved for pediatric use, some practitioners have been approved for in- office treatment with Suboxone for opioid or heroin addiction for teens; its use is typically regulated to older adolescents.28

Naltrexone

Naltrexone is an opioid antagonist medication that may be administered to some patients as part of treatment for drug and alcohol use. Naltrexone (Vivitrol®) works by blocking opioid receptors so that the person who takes an opioid medication does not experience the pleasant effects and euphoria.3 It may be administered as oral tablets or as a preparation given by injection. Extended-release naltrexone may be given as an injection, in which the drug is slowly released into the system over a longer period of time when

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 80 compared to oral tablets. A study in the Journal of Substance Abuse Treatment showed that patients who used extended-release naltrexone in injectable form in the physician’s office were more likely to continue their treatment of substance use over a longer period of time when compared to those who only used naltrexone as oral tablets. Naltrexone extended-release injections are more expensive than taking oral tablets, but patients who take the injections may more likely stay committed to treatment protocols and stay with their programs. The study determined that those who used the extended-release injections of naltrexone had shorter periods of detoxification and withdrawal and shorter stays in inpatient treatment facilities.39

Naltrexone is also used for the treatment of an alcohol use disorder and may be given to some teens that struggle with alcohol addiction. In this type of treatment, it is also given as an oral tablet or as an injectable medication. Other drugs are also specifically designed for the treatment of alcohol addiction; two of the most common forms used among adolescents are acamprosate and disulfiram. As with other forms of medications used for drug withdrawal, medications used for alcohol withdrawal among adolescents have not been extensively studied for this population and may not be entirely safe. However, they are still often prescribed, particularly in areas where adolescents do not respond to other forms of alcohol use treatment, such as through behavioral therapy.

Benzodiazepines

A teen that is undergoing acute symptoms of withdrawal, including delirium tremens, may be treated with benzodiazepines. Delirium tremens may occur during the acute stage of withdrawal as the affected person stops using alcohol; symptoms include sweating, high fever, seizures; and altered

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 81 mental status that can include hallucinations, delusions, and significant confusion.40 Benzodiazepines may be given as treatment for delirium tremens, but these drugs are used carefully because they may also increase the risk of dependence and addiction. Therefore, benzodiazepines are typically used on a short-term basis during an acute withdrawal period when they can be closely monitored.

Benzodiazepines act on the GABA receptors in the brain, so they reduce many of the hemodynamic and peripheral symptoms associated with alcohol withdrawal. They are most often effective when given as needed (PRN) for symptoms of delirium tremens, as opposed to scheduled, continued doses on a fixed basis.41 However, when benzodiazepines are given PRN for alcohol withdrawal symptoms, they require frequent and close monitoring by medical staff to ensure that affected patients receive the right amount when needed for symptoms and also to ensure that the benzodiazepines are working as they should. Diazepam and lorazepam are two types of benzodiazepines that may be administered intravenously for treatment in these cases.

Acamprosate

Acamprosate (Campral®) is another type of medication that may be administered for treatment of alcohol addiction. As stated, Campral has not been studied extensively among teen populations, but it has been used in this group of patients for significant alcoholism and among older teens.28 Acamprosate reduces cravings for alcohol among addicted persons; it works by inhibiting the neurotransmitter GABA in the brain. It often works more effectively for patients who use it in combination with behavioral counseling and therapy for their alcohol addiction. Campral has been shown to reduce

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 82 instances of alcohol consumption when taken appropriately, even among those who suffer from a severe alcohol substance use disorder.40

Disulfiram

Drugs known as aversion medications may also be used for the treatment of alcoholism. One of the most commonly known aversion medications is disulfiram (Antabuse®). Disulfiram works by blocking the enzyme aldehyde dehydrogenase, which disrupts how the body metabolizes alcohol. When a person drinks alcohol after taking disulfiram, the body is unable to process it and acetaldehyde builds up in the bloodstream.42 This causes the person to experience severe flushing, dizziness, nausea, and vomiting when a person drinks even a small amount of alcohol. As a result, the person is less likely to want to drink again, causing a psychological aversion to using alcohol because of the effects of the drug.

Disulfiram must be carefully controlled for its use by teens with an alcohol use disorder. The effects of the drug last up to 2 weeks, so a patient may take a dose and then continue to receive outpatient treatment for alcohol abuse at home. It is important for the healthcare provider to consistently remind the patient not to drink any alcohol after taking disulfiram and that the effects can occur 1 to 2 weeks after taking the dose. Overdose effects can cause a drastic drop in blood pressure, leading to hypotension, as well as chest pain and shortness of breath.40 Patients who take disulfiram seem to be more successful when they have continued monitoring through outpatient therapy, 12-step support groups, or frequent follow-up visits with a healthcare provider.

DSM-5 Criteria In The Diagnosis Of A Substance Use Disorder

The American Psychiatric Association (APA) Diagnostic and Statistical Manual ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 83 of Mental Disorders, Fifth Edition (DSM-5) provides the latest criteria for clinicians in the evaluation and diagnosis of mental illness and a substance use disorder. This is discussed in the DSM-5 chapter on “Substance-Related and Addictive Disorders” which categorizes a variety of substance use disorders (SUDs). While earlier DSM editions identified “substance abuse” and “substance dependence,” as separate categories, the DSM-5 eliminated those separate categories and identifies SUDs as one (1) category with changes to the diagnostic criteria that identify addictive behaviors along a continuum. Although professional studies and guidelines may continue to widely use terms interchangeably as relates to substance addiction, abuse and dependence, working committees and authors of the DSM-5 clearly identified how those terms had often been used inappropriately and tended to confuse the diagnosis of a substance related disorder or addiction.

The important distinction made in the DSM-5 for clinicians to understand as it relates to a SUD diagnosis and, importantly, in the education of patients with an addiction problem, is that prior criteria of “dependence” and “abuse” are no longer considered mutually exclusive disorders with one being a less serious disorder as compared to the other. There are levels of severity associated with SUDs in the DSM-5, and the criteria apply to the level of severity identified with a specific SUD diagnosis. The new DSM-5 criteria guiding the diagnosis of a SUD are outside the scope of this study, however, it is important for clinicians to have a basic familiarity with the new criteria and to adapt practice to incorporate DSM-5 criteria when considering a patient’s treatment plan for a substance use disorder. Additionally, in a therapeutic milieu, application of the DSM-5 criteria relative to SUDs will support clinicians and care teams to avoid some of the earlier pitfalls of confusing and stigmatizing language associated with the diagnosis of a substance use disorder.

ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 84 Summary

Adolescent substance use addiction is a dangerous situation that is often overlooked as being a real problem. Consequently, many teens that are struggling with a substance use disorder do not receive the treatment they need. Parents and caregivers of teens should be aware of the signs and symptoms of a substance use disorder and should learn to recognize when their teen is behaving differently, which can indicate a problem. When healthcare providers give time and attention to assessment of the needs of the adolescent who is struggling with substance use, the affected teen may be able to heal from this condition by receiving appropriate care.

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