Integrated Substance Abuse Programs
Department of Psychiatry & Biobehavioral Sciences
David Geffen School of Medicine at UCLA
Pacific Southwest Addiction Technology Transfer Center
www.uclaisap.org
www.psattc.org
1
Monitoring the Future 2013
Elicit and Prescription
Powdered Cocaine
2.6
2.6
Salvia
2.6
3.4
3.4
MDMA/Ecstasy
3.4
44
K2/Spice
4
7.9 7.9
7.9
Marijuana
36.4
36.4
Any Alcohol
49.4
Ritalin
2.3
2.3
OxyContin
2.3
3.6
3.6
Tranquilizers
3.6
4.64.6
Cold Medicines
4.6
5 5
Vicodin
5
5.35.3
Adderall
5.3
7.4 7.4
0
5 10 2 10
7.4
20154
20
30
62540
30 8 5035
10
40
60
Co-Occurring MH and SUD
 Adolescents with SED are five times more likely
to have an alcohol problem than those without
 43% of youth receiving mental health (MH)
treatment services have a COD
 Among young adults ages 18-25 with a serious
mental illness, 48% report past-year illicit
substance use, and 36% meet criteria for a SUD
COD
 36% of all adults with COD
are ages 18-25 years
3
Normal Dopamine Transmission
Natural Rewards Elevate
Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
SEX
200
150
100
15
10
5
0
0
0
60
120
Time (min)
180
ScrScr
BasFemale 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
DA Concentration (% Baseline)
FOOD
Methamphetamine
and Dopamine
Dopamine D2 Receptors are Lower in Addiction
DA
DA
Cocaine
DA
DA DA
DADA
Meth
DA
DA
DA DA
DA
Reward Circuits
Non-Drug Abuser
DA
DA
Alcohol
DA
DA
DA
DA
Heroin
control
addicted
Reward Circuits
Drug Abuser
Control
> MA
4
3
2
1
0
MA >
Control
5
4
3
2
1
0
Continuing Brain Development
Early in development, synapses are rapidly created and then
pruned back. Children’s brains have twice as many synapses as
the brains of adults.
SOURCE: Shore, 1997.
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Brain Development
Ages 5-20 years
 MRI scans of healthy children and teens compressing
15 years of brain development (ages 5–20).
 Red indicates more gray matter, blue less gray matter.
 Neural connections are pruned back-to-front.
 The prefrontal cortex ("executive" functions), is last to mature.
Information taken from NIDA’s Science of Addiction
http://www.drugabuse.gov/ScienceofAddiction/
SOURCE: Gagtay, et al., 2004.
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The Interaction between the
Developing Nervous System and
Substances of Abuse Leads to:
• Difficulty in decision making
• Difficulty understanding the
consequences of behavior
• Increased vulnerability to
memory and attention problems
This can lead to:
• Increased experimentation
• Alcohol and drug addiction
SOURCE: Fiellin, 2008.
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Young Brains are Different
from Older Brains
• Alcohol and drugs affect the brains of adolescents and
young adults differently than they do adult brains
 Adolescent rats are more sensitive to the memory
and learning problems than adults
 Conversely, they are less susceptible to intoxication
(motor impairment and sedation) from alcohol
• These factors may lead to higher rates of dependence in
these groups
SOURCE: Hiller-Sturmhöfel & Swartzwelder, 2004/2005.
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Marijuana
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Monitoring the Future 2013
MARIJUANA: AS PERCEIVED HARM DROPS,
USE GOES UP
Using
Perceived Harm
35.6%
26.0%
1993
34.9%
26.6%
2003
36.4%
19.5%
2013
Neurologic Impact of Marijuana
 When cannabis users were asked to rate the
effects of their own cannabis use as positive,
neutral, or negative, they gave overwhelmingly
negative ratings of the effects that cannabis had
had on their
social life (70%):
physical health (81%) :
mental health (60%) :
cognition (91%) :
memory (91%) :
career (79%) :
Gruber AJ, et al., (2003). Psychol Med. 33(8):1415-22.
Neurologic Impact of Marijuana
in Adults
 Administered neuropsychological tests to 63 current
heavy cannabis users who had smoked cannabis at
least 5,000 times in their lives and to 72 control
subjects who had smoked no more than 50 times in
their lives.
 Differences between the groups after 7 days of
supervised abstinence were reported. However, no
deficits were found after 28 days abstinence, after
adjusting for various potentially confounding variables.
 Suggests that cognitive deficits associated with longterm cannabis use are reversible and related to recent
cannabis exposure.
Pope HG, et al. (2001). Arch Gen Psychiatry. 2001 Oct; 58(10):909-15.
Marijuana and the Adolescent Brain
 Human studies suggest early onset (prior to 16-
18 yo) associated with more severe cognitive
consequences.
 Poorer attention
(Ehrenriech et al., 1999)
 Executive functioning
(sustained attention,
cognitive inhibition,
abstract reasoning)
(Fontes et al., 2011)
(Lisdahl and Price., 2011)
Marijuana and the Adolescent Brain
 Longitudinal research demonstrates that early onset
marijuana use associated with lower IQ
 Drop from childhood “average” to adult low “average”
 Never achieved predicted adult IQ trajectory even with
sustained abstinence in adulthood (Meier et at., 2012)
• Overall studies suggest that regular adolescent MJ use
may cause brain structural changes associated with
 poor neuronal efficiency
 poorer cognitive functioning (psychomotor speed, executive
functioning, emotional control, and learning and memory)
(Lisdahl et al., 2013)
• This may indelicate a large proportion of youth are
experiencing cognitive difficulties that may negatively
impact their performance, leading to increased school
difficulty and reduced grades (Medina et al., 2007)
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• Brief interventions trigger change
• A little counseling can lead to significant
change, e.g., 5 min. has same impact as 20 min
• Research is less extensive for illicit drugs, but
promising
• Cocaine/heroin users seen in primary care: 50%
higher odds of abstinence at follow-up after
receiving BI than those who didn’t get BI
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Brief interventions are most successful
when clinicians relate patients’
risky substance use
to
improvement in their overall
health and well-being
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2.5M people (1%) receiving treatment*
21M people (8%) have problems
needing treatment, but not receiving it*
≈ 60-80M people (≈19-25%)
using at risky levels
US Population:
316,148,990
US Census Bureau, Population Division
July 2013 estimate
*NSUDH, 2012 results
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In treatment (4 Million)
• Diagnosable problem with substance use
• Referred to treatment by:*
Self/Family 37%
Criminal Justice 25%
Other SUD Program 8%
County Assessment Center 19%
Healthcare 3%
Other 8%
*Los Angeles County Data
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In need of treatment (23 Million)
• Reported problems associated with use
• Not in treatment currently
• 1.7% Made an effort to get treatment
• 3.7% Felt they needed treatment, but
made no effort to get it.
• 94.6% Did not feel that they needed
treatment
Conclusion: The vast majority of people
with a diagnosable illicit drug or alcohol
disorder are unaware of the problem or
do not feel they need help.
SOURCE: SAMHSA, NSDUH, 2012 results.
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These people
may need
services,
but will
never enter
the treatment
system
Using at risky levels (60-80 Million)
• Do not meet diagnostic criteria
• Level of use indicates risk of developing
a problem.
• Some examples…
Drinks 3-4 glasses of wine a few
times per week
Pregnant woman occasionally has
a shot of vodka to relieve stress
Adolescent smokes marijuana
with his friends on weekends
Occasionally takes one or two
extra Vicodin to help with pain
27
Severe
Specialized
Treatment
Substantial
Moderate
Brief
Intervention
Mild
Prevention
None
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Screening
to Identify Patients At Risk for
Substance Use Problems
29
Drinking Guidelines
 Men: No more than 4 drinks on any day and 14 drinks
per week
 Women: No more than 3 drinks on any day and 7
drinks per week
 Men and Women >65: No more than 3 drinks
on any day and 7 drinks per week
NIAAA, 2011
Beer
12 oz
Wine
5 oz
Fortified Wine
3.5 oz
Liquor
1.5 oz
It’s Not About the Nail
32
SUD
MH
Pain
Family
Medical
Issues
SUD
33
Feedback
Setting the stage and getting buy in
Tell screening results
Explore pros & cons
Listen & understand
Explain importance
Assess readiness to change
Discuss change options
Options explored
Follow up
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Why SBIRT for Adolescence?
 Substance use starts in adolescents.
 Mental health issues increase vulnerability
to SUD
 Substance use increases vulnerability to MHD
 Catching use early we can change the life
trajectory and outcomes for these people
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Thomas E. Freese, PhD
[email protected]
For additional information on SBIRT or other
training topics, visit:
www.attcnetwork.org
www.worldofsbirt.wordpress.com
http://www.attcelearn.org/
(“Foundations of SBIRT”)
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