Adolescent Alcohol and Drug Use Practical Approaches for Pediatricians
Total Page：16
File Type：pdf, Size：1020Kb
Adolescent Alcohol and Drug Use Practical Approaches OHSUfor Pediatricians Ana Hilde MD MPH Adjunct Assistant Professor Child &. Adolescent Psychiatry Oregon Health & Science University March 8, 2019 Disclosures I have no financial disclosures OHSU Objectives Recognize screening tools commonly used to assess substance use in teens. Become familiar with diagnostic criteria for substance use disorders and complexities in diagnosing teens. Increase comfort level related to assessment and brief intervention for youth with substance use disorders. OHSU Increase awareness of vaping and understand level of nicotine exposure with adolescent use. OHSU What’s the big deal Adolescent vulnerability Intervening can have tremendous long term impact 75 % of adults receiving treatment of substance use OHSUdisorders started using substances before the age of 17. Oregon Specific SAMHSA NSDUH (US civilians ages 12 and older) 12% 10% 8% 6% 4% OHSU2% 0% Marijuana Alcohol Tobacco Prescription pain med Past Month Use Ages 12-15 Need for treatment 1.3 million adolescents (5.1 percent of this age group) classified as needing treatment in the past year OHSU 1 in 20 adolescents and 1 in 6 young adults Figure 1. Need for substance use treatment in the past year among people aged 12 or older, by age group: 2015 Receiving treatment Of adolescents needing treatment only 6.3 % received treatment at a specialty facility Adolescent are the least likely to receive treatment at a specialty facility 93.7 of adolescent who met criteria for specialty treatment did not OHSUreceive it in the past year Clinical Case 15 yo male lives with mother, step father and 4 yo half brother in 10th grade who comes to clinic for annual exam. He denies any problems or concerns. Mom shares that his grades have fallen and he has OHSUbeen more irritable with verbal aggression toward her. Screening 2 brief screening tools for ages 12-17 solely focusing on frequency of use Brief Screener for Alcohol tobacco and other Drugs (BSTAD) Frequency of use in past year Screening to Brief intervention (S2BI) OHSU Frequency of using eight types of drugs in the past year High sensitivity and specificity for identifying use and disorders BSTAD In the past year, on how many days … Have you had more than a few sips of beer, wine or any drink containing alcohol? Have you smoked cigarettes or used other tobacco products? Did you use marijuana? Results OHSU Alcohol: report 2 or more days concern for AUD Tobacco: report 6 or more days concern for NUD Cannabis: report 2 or more days concern for CUD S2BI* In the PAST YEAR, how many times have you used: Tobacco: Never / Once or Twice / Monthly / Weekly Alcohol: Marijuana: Prescription drugs that were not prescribed for you (such as pain medication or Adderall): Illegal drugs (such as cocaine or ecstasy): Inhalants (such as nitrous oxide): Herbs or synthetic drugs (such as salvia, K2, or bath salts): Results OHSU Never: Positive reinforcement Once or twice: No SUD, brief advice Monthly: Possible mild to moderate SUD, brief intervention Weekly: Possible moderate to severe SUD, referral for assessment Screening Broader scope screening tools Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) Adolescent validated analog to adult screener CAGE Alcohol, Smoking and Substance Use Involvement Screening Test (ASSIST) Adolescent validated analog to CAGE Global Appraisal of Individual Needs (GAIN) OHSU Assesses both substance use and mental health disorders 4 subscales (substance use, internalizing disorders, externalizing disorders and crime/violence) 11 yo and older CRAFFT C: Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A: Do you ever use alcohol/drugs while you are by yourself, ALONE? F: Do you ever FORGET things you did while using alcohol or drugs? F: Do your family or FRIENDS ever tell you that you should cut down OHSUon your drinking or drug use? T: Have you gotten into TROUBLE while you were using alcohol or drugs? ASSIST Lifetime: Yes or No Cannabis Cocaine Prescription stimulants Methamphetamine Inhalants Sedative or sleeping pills Hallucinogens Street opioids Prescription opioids Other If Yes to any then in past three months: How often used: never, once or twice, monthly, weekly, daily OHSU Urge to use: never, once or twice, monthly, weekly, daily Use led to problems: never, one or twice, monthly, weekly, daily Failed to do what was expected: never, once or twice, monthly, weekly, daily Friend or relative expressed concern: no, never; yes, but not past 3 months; yes in past 3 months Tried and failed to control: no, never; yes, but not past 3 months; yes in past 3 months Case Continued S2BI In the PAST YEAR, how many times have you used: Tobacco: Weekly (vaping, couple times a week, low nicotine content) Alcohol: Monthly (with friends at parties) Marijuana: Weekly (using daily) Prescription drugs that were not prescribed for you: Once or twice OHSUIllegal drugs: Never Inhalants: Never Herbs or synthetic drugs: Never Case Continued CRAFFT C: Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs? No R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? Yes A: Do you ever use alcohol/drugs while you are by yourself, ALONE? Yes F: Do you ever FORGET things you did while using alcohol or drugs? No OHSU F: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? No T: Have you gotten into TROUBLE while you were using alcohol or drugs? No Assessment What else do we want to know? Risk factors Genetics Environment Personality and cognition Theoretical framework OHSU Biopsychosocial Drug Set Setting Theory George Engel MD – Biopsychosocial model OHSU Theory Norman Zinberg MD: Drug, Set, Setting OHSU Assessment Family history Trauma history Developmental history Peer relationships Consider other mental health concerns: OHSU Depression – PHQ A Anxiety - SCARED Substance use history Case Continued Biological father with substance use disorder. Witnessed violence perpetrated by father toward mother during childhood. Mother left biological father when patient was 4 years old and patient has had limited contact with bio dad. Step dad has been in his life since he was around 9. He does not have a close relationship with his step father. His mom works full time. He has a few friends and did not go to the same high school as his prior close friends and has lost contact with most of them. Has generally been a good student until this past year. Enjoys playing video games and used to like to play basketball. Started using marijuana occasionally in 8th grade but over the past year has OHSUbeen using almost daily. Meets criteria for major depression Assessment Motivational Interviewing Does the patient think there is a problem? Does he want to change? Critical piece: why is he using? How does it help? What does it help with? Are there any concerns related to that use? OHSU Compassion / Connection Case Continued He does not think his vaping, weed or alcohol use are problematic. He is worried about his grades and feels that this is causing problems with his mom which he does not like. OHSU He shares about feeling sad all the time and lonely. Diagnosis DSM V Diagnostic Criteria (next slide) Time frame – 12 months Severity Mild 2-3 symptoms Moderate 4-5 symptoms Severe 6 or higher Specifications OHSU In early remission – period 3 months to 12 months, no sxs except craving In sustained remission – period 12 months In a controlled environment Diagnostic Criteria Taken in larger amount or over Give up or decrease engaging longer period in important activities Desire to stop and inability to Recurrent use in dangerous control use situations Great deal of time spent Continued use despite obtaining and using knowledge that use is problematic Craving Tolerance Recurrent use that impacts OHSUfunctioning at work, school or Withdrawal home Continued use despite persistent problems Diagnostic Difficulties Inconsistent use More often binge type use Less physical symptoms related to craving, tolerance and withdrawal Limited insight and do not see as a problem but actually as a solution to underlying concerns such as OHSUanxiety and insomnia Case Diagnosis Mild cannabis use disorder Major depression Concerning risk factors – genetic, h/o trauma, social isolation Level of insight - Does not think his substance use is a OHSUproblem but does admit to feeling depressed and is unhappy about tension with mother. Intervention Referral Motivational interviewing Recovery support services OHSU Medication Referral More extensive mental health evaluation Child & Adolescent Psychiatry Dual diagnosis program Counseling OHSU Mutual self help groups Confidentiality Oregon Law A minor who is 14 years or older may access outpatient mental health, drug or alcohol treatment (excluding methadone) without parental consent. These services may include: Seeking help from a psychiatrist or psychologist; Seeking mental health therapy from a doctor or social worker; and Seeking help for drug or alcohol use. For mental health and chemical dependency services, the provider may disclose health information to a minor’s parent or OHSUguardian per ORS 109.680 if: It is clinically appropriate and in the minor’s best interests; The minor must be admitted to a detoxification program; or The minor is at risk of committing suicide and requires hospital admission. Confidentiality Summary Although minors age 14 and older can access outpatient mental health and chemical dependency services independently, parents are expected to be involved in their treatment at some point. Involvement does not mean that adults always have access to a minor’s mental health or chemical dependency records.