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.  Federal regulation 42 CFR 2.14 states that if a minor is OHSUable to self-consent for drug or alcohol treatment, the minor's treatment records cannot be disclosed without the minor's written consent (including to the parent or guardian). Motivational Interviewing

 Fundamentals  Build motivation over time  Explore and resolve ambivalence  Power of empathy – unconditional positive regard

 4 Processes  Engaging – partnership and collaboration  Focusing - goal  Evoking – change, motivation  Planning

 Micro skills: OARS OHSU Open ended questions  Affirmation – acknowledge efforts and strengths  Reflections  Summarize – note ambivalence and emphasize change talk Recovery Support Services

 Mutual Help Groups  12 step programs – young peoples meetings  SMART Recovery  Peer Recovery Support Services  Recovery community centers  Portland has 4th Dimension OHSU Recovery High Schools  Plan to open recovery high school in Portland in 2019 Case Conclusion

 Referral for assessment with dual diagnosis emphasis  Engage in MI  Consider initiation of SSRI to target depression  Provide information on mutual help groups with focus on young people OHSU What about the vaping? Should we be concerned? Vaping

 Vaping: inhalation of nicotine, cannabis and flavor OHSU OHSU How vaping works  Delivers nicotine without other chemicals produced by burning tobacco  Activates brain rewards circuits and increases dopamine same as cigarettes  Design  Puff on mouthpiece to activate battery powered vaporizer  Vaporizer heats up liquid inside cartridge that contains nicotine, flavors and other chemicals OHSU Liquid turns to vapor and is inhaled  Not approved for cessation  Not recommended for those not already smoking cigarettes  Research suggest that may be less harmful then cigarettes for those currently smoking Nicotine Levels  Traditional Cigarettes  1 pack = 25 cigarettes (25-50 mg nicotine per pack)  1 cigarette contains 10 mg nicotine but actual intake around 1-2 mg  Smokeless tobacco  Nicotine per gram 4.4 mg to 25 mg.  Average size dip held for 30 min is roughly equivalent to smoking 3 cigarettes.  E cig  Nicotine cartridges range from 0-36 mg of nicotine OHSU Nicotine content can vary depending on temp, puff duration and volume  JUUL  3% and 5% nicotine pods equivalent to 23 mg per pod and 40 mg per pod  1 pod 200 puffs Vaping & Nicotine Levels OHSU Conclusion  Ask about vaping  flavor, nicotine, cannabis  nicotine level  pods per day  Screening tools are a vital resource  Ask about all drugs of abuse  Consider risk factors OHSU Engage in motivational interviewing  Open ended questions  Be curious  Refer when indicated Questions OHSU References

 Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E (2018). Monitoring the Future national survey results on drug use: 1975-2017: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.

 Substance Abuse and Mental Health Services Administration's (SAMHSA) NSDUH (formerly called the National Household Survey on Drug Abuse) Lipari, R. N., Park-Lee, E., and Van Horn, S. America’s need for and receipt of substance use treatment in 2015. The CBHSQ Report: September 29, 2016. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.

 Lipari, R. N., Park-Lee, E., and Van Horn, S. America’s need for and receipt of substance use treatment in 2015. The CBHSQ Report: September 29, 2016. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.

 NIDA. (2014, July 1). Drugs, Brains, and Behavior: The Science of Addiction. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science- addiction on 2018, May 11

 NIDA. (2016, August 9). Understanding Drug Use and Addiction. Retrieved from https://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction on 2018, May 11

 NIDA. (2014, January 14). Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide. Retrieved from https://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-research-based-guide on 2018, May 28

 California Society of Addiction Medicine (September 2009). Impact of Marijuana on Children and Adolescents. CSAM Website.

OHSU Gray, Kevin and Squeglia, Lindsey (2017). Research Review: What have we learned about adolescent substance use? The Journal of Child Psychology and Psychiatry.

 U.S. Department of Health, and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease, Prevention and Health Promotion, Office on Smoking and Health. E-Cigarette Use Among Youth And Young Adults: A Report of the Surgeon General — Executive Summary.; 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_Summ_508.... Accessed February 21, 2017.