Substance Abuse: Current Perspectives, Trends & Treatments Kay Colbert, LCSW
February 7, 2013
MHA Adolescent Symposium
Working with the Substance Abuse Population Agenda  
overview of addiction
 
drugs of abuse, current trends with adolescents
 
prevalence & characteristics
 
symptoms in adolescents
 
treatment & best practice protocols for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
Agenda   overview of addiction
 
drugs of abuse, current trends with adolescents
 
prevalence & characteristics
 
symptoms in adolescents
 
treatment & best practice protocols for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
DSM-IV-TR Criteria Substance Use
Abuse
Dependence
Withdrawal
Substance-Induced Disorders
Kay Colbert, LCSW, 2013
DSM-IV-TR Criteria Substance Abuse
A “maladaptive pattern of substance use
leading to clinically significant impairment or
distress.”
1)
recurrent substance use resulting in failure to fulfill major role
obligations at work, school or home
2)
recurrent substance use in situations in which it is physically
hazardous
3)
recurrent substance-related legal problems
4)
continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of the
substance
(American Psychiatric Association, 2000, p. 199)
Kay Colbert, LCSW, 2013
DSM-IV-TR Criteria Substance Dependence
A “cluster of cognitive, behavioral and physiological
symptoms indicating that the individual continues use of
the substance despite significant . . . problems.”
1)  tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve
intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount
2)  withdrawal, as manifested by either of the following
(a) the characteristic withdrawal syndrome for the substance
(b) the same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms
3)
substance is often taken in larger amounts or over a longer period of time than
was intended
4)
persistent desire or unsuccessful efforts to cut down or control
(American Psychiatric Association, 2000, p. 192 - 197)
Kay Colbert, LCSW, 2013
DSM-IV-TR Criteria Substance Dependence
5)  great deal of time spent in activities necessary to obtain the substance, use the
substance or recover from its effects
6)  important social, occupational, or recreational activities are given up or reduced
7)  substance 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 the substance
(American Psychiatric Association, 2000, p. 197)
Kay Colbert, LCSW, 2013
DSM-IV-TR Criteria Substance Abuse versus Dependence?
 
Abuse can be episodic or continual, but
“normal” life continues despite some
negative consequences.
 
Dependency is a lifestyle. The need for
drugs replaces the need for people. Having
drugs available becomes a preoccupation.
Kay Colbert, LCSW, 2013
Agenda  
overview of addiction
  drugs of abuse, current trends with
adolescents
 
prevalence & characteristics
 
symptoms in adolescents
 
treatment & best practice protocols for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
Common Drugs of Abuse Central Nervous System Stimulants
Amphetamines
 
 
Ephedrine / Pseudoephedrine
 
Cocaine (powder)
Methamphetamine “meth, crank, Yaba”
 
Crack Cocaine
Crystal Methamphetamine “ice”
Synthetic stimulants:
Methylphenidate
 
 
Other Stimulant-related drugs
Phenylethylamine
 
 
 
Ritalin
Also mephedrone & pyrovalerone
 
Concerta
 
Adderal
MDPV- methylenedioxypyrovalerone
“bath salts”
 
BZP (A2, Legal E or Legal X)
 
Dexedrine
 
Vyvanse
 
Phentermine (appetite suppressant)
Kay Colbert, LCSW, 2013
Common Drugs of Abuse Cannabinoids
 
Marijuana
 
Marinol (dronabinol)
 
Rimonibant (diet pill, CB1 Cannabinoid Receptor Antagonist)
 
Synthetic Cannabis: Mimics the primary psychoactive ingredient
tetrahydrocannabinol (THC) in cannabis. Developed by researchers
to investigate the part of the brain responsible for hunger, memory,
and temperature control.
Sources: Maxwell, June 2012; Join Together Newsletter, July 10, 2012,
Partnership at Drugfree.org
Kay Colbert, LCSW, 2013
Common Drugs of Abuse Cannabinoids
 
Adolescents view as less harmful.
 
Early cannabis use is a risk factor for
the development of psychotic symptoms and
schizophrenia in young adults (50% - 200% increase).
 
Marijuana – increasing levels of THC, esp with “medical”
marijuana (1%-2% v. 20%).
 
Anecdotal evidence from treatment centers on increasing
cases of marijuana-induced psychosis.
 
Link between daily marijuana use and psychosis, even in
people with no family history.
Sources: Psychiatric Times. Vol. No. January 12, 2012; Archives Gen Psych/Vol 67 (NO. 5), MARCH 1, 2010 Kay Colbert, LCSW, 2013
Common Drugs of Abuse Trend: Synthetic Cannabis
K2, Spice, Yucatan Fire, Skunk, Moon Rocks, herbal incense
1 in 9 high school seniors have used
Synthetic cannabis associated with more negative effects, hangover effects
and greater paranoia. - Study at Kings College in London with15,000 subjects
Sources: NORML Newsletter, Thursday, 10 January 2013; Maxwell, June 2012
Kay Colbert, LCSW, 2013
“Why Legalizing Marijuana on Election Day Might Not
Be a Good Idea”
by Tony Dokoupil
The Daily Beast
October 29, 2012
www.thedailybeast.com
Common Drugs of Abuse Opiates/Opioids (narcotics)
 
Morphine
 
Codeine (Tylenol #2, #3, #4)
 
Heroin (Diacetyl morphine)
 
Cheese Heroin (Mexican black tar + Tylenol PM)
 
Hydrocodone (Vicodin, Norco, Lortab)
 
Oxycodone (Percocet, Percodan, Oxycontine)
 
Propoxyphene (Darvon, Darvocet)
 
Meperdine (Demerol)
 
Hydromorphine (Dilaudid)
 
Fentanyl (Duragisic Patches, Actic Lozenges) (mixed IV with heroin or cocaine)
 
Methadone
 
Bupenorphine (Suboxone)
 
Nalbuphine (Nubain)
Trend: TX heroin use continues
to increase among youth, esp
Mexican black tar & powdered
brown, Cheese
Source: Maxwell, June 2012.
Kay Colbert, LCSW, 2013
Heroin Abuse Among Teens TX Secondary: 1.4 %
TX high school: 3.3%
report having ever used heroin
•  Cheese heroin – black tar heroin
+Tylenol PM®
•  snorted
•  remains a problem in Dallas &
heroin inhaling increasing across
Texas
Source: Maxwell, June 2012.
trend
Pain Pill Abuse Among Teens   Every day, an average of more than 2,500 adolescents, aged 12 to
17, misuse a pain reliever for the first time. Almost 900 try a stimulant
for the first time on an average day. Decreased slightly in 2010 to
2011.
  Many adolescents view prescription drugs as safer than illicit drugs
because a doctor prescribed them for “someone.”
 Hydrocodone, oxycontin, methadone – in TX, hydrocodone 10 x oxy
Source: SAMHSA Blog, 1 September 2011
Kay Colbert, LCSW, 2013
trend
Pain Pill Abuse 1 in 20 people in the US 12+ (12 million) reported using
prescription painkillers for nonmedical reasons in the past
year.
15,000 annual death from overdoses - greater than those of
deaths from heroin and cocaine combined.
Enough prescription painkillers were prescribed in 2010 to
medicate every American adult around-the-clock for a
month.
Source: Centers for Disease Control Vital Signs 2011.
Kay Colbert, LCSW, 2013
trend
Pain Pill Abuse Visits to emergency rooms increased 111% from 2004 to 2008.
FDA: “extended-release and long-acting opioids are extensively
misprescribed, misused, and abused, leading to overdoses, addiction,
and even deaths.”
400 percent increase from 1998 to 2008 among SA admissions
Sources: SAMHSA News, July/August 2010, Volume 18, Number 4; May/June 2010,
Volume 18, Number 3; FDA September 9, 2011
Kay Colbert, LCSW, 2013
news
Pain Pill Abuse Physicians for Responsible
Opioid Prescribing
July 25, 2012
37 doctors, public health officials and researchers asked the FDA to
prohibit use of opioids for moderate pain.
Called on the FDA to add a maximum daily dose, and only permit
patients to take opioids for up to 90 days, unless they are being
treated for cancer-related pain.
Source: Physicians for Responsible Opioid Prescribing, July 25, 2010
Kay Colbert, LCSW, 2013
Source of Pain Pills for Nonmedical Use
2010-2011, 12 years +
Source: 2011 National Survey on Drug Use & Health, SAMHSA Publication No. (SMA) 12-4713
Common Drugs of Abuse  
Central Nervous System Depressants
Sedatives/Hypnotics
Alcohol
 
 
Barbituates
Phenobarbital (Luminal)
Amobarbital (Amytal)
Secobarbital (Seconal)
Pentobarbital (Nembutal)
Benzodiazepines
Chlordiazepoxide (Librium)
Diazepam (Valium)
Alprazolam (Xanax) Clonazepam (Klonopin)
Triazolam (Halcion)
Temazepam (Restoril) Lorazepam (Ativan) Flunitrazepam (Rohypnol) “roofies”
 
GHB (Gamma-hydroxybutyrate)
 
Zolpidem (Ambien)
Kay Colbert, LCSW, 2013
Alcohol Youth & Adolescents
  legal / most common drug abused in TX, the world & with adolescents
  slight decrease in use in last year
  binge drinking concern: 12% secondary students
  62% of Texas secondary school students (grades 7–12) use alcohol
  73% of Texas high school students (grades 9–12) had ever drunk alcohol
  29% consumed alcohol in last month
  22% of grades 4–6 have ever drunk alcohol, 14% had drunk alcohol in the past school year
  40 percent had drunk alcohol in the past month; and 24 percent had drunk five or more
drinks in a row in the last month
  7% Texans 12+ alcohol dependent or abusers in the past year, compared with 7.4 percent
of the U.S. population
Source: Maxwell, Substance Abuse Trends in Texas June 2012
Kay Colbert, LCSW, 2013
Alcohol Kay Colbert, LCSW, 2013
Alcohol Alcohol is the most commonly abused. It is legal, prevalent, high potential for abuse.
131.3 million Americans (51.8%) 12 years + use alcohol
58.6 million (23.1%) of 12 years + participated in binge drinking in past 30 days
16.9 million (6.9%) of 12+ participated in heavy drinking in past 30 days
5 drinks in a row
4 for females
= heavy episodic
drinking (binge)
or BAC .08%+
+2/day for males
+1/day for females
= heavy drinking
Sources: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658; CDC, 2012.
Kay Colbert, LCSW, 2013
Common Drugs of Abuse Hallucinogens and Dissociative Drugs
 
LSD (d-lysergic acid diethylamide)
Trend: TX dextromethorphan
still a problem with teens
Source: Maxwell, June 2012.
 
PCP (phencyclidine)
 
Ketamine “special K” (few cases 2011)
 
Dextromethorphan “DXM, CCC, Triple C, Skittles, Robo, Poor Man’s PCP”
 
Peyote (made from cactus)
 
Psilocybin (4-phosphoryloxy-N,N-dimethyltryptamine) “mushrooms”
Synthetics:
 
MDMA (3,4-methylenedioxymethamphetamine) “ecstasy,” MDA
 
TFMMP – (1-Benzylpiperazine) and (1-(3-trifluoromethylphenyl)piperazine) ;
“Molly” ; Schedule I ; often used with BZP
 
2C or 2C-I – 4lodo-2,5-Dimethoxyphenethylamine, “Smiles”
Kay Colbert, LCSW, 2013
 
Dextromethorphan: cough suppressant, active ingredient in
cold & cough meds (Robitussin, NyQuil, Dimetapp, Vicks,
Coricidin, Theraflu, Zicam, generics)
 
a dissociative hallucinogin, impaired motor function,
numbness, nausea and vomiting, increased heart rate & blood
pressure, hypoxic brain damage
 
robo-tripping, skittling
 
also acetaminophen
Source: National Inst. of Health, MedlinePlus, 2011; NIDA, 2013.
Common Drugs of Abuse Nicotine / Tobacco  
Cigarettes
 
Cigars
 
Chewing tobacco, dissolvables
 
Nicotine gum
 
Nicotine patches
 
Highly addictive
 
Serious health risks
 
Legal
“Through the use of tobacco, nicotine is one of the most heavily used
addictive drugs and the leading preventable cause of disease, disability,
and death in the U.S. Cigarette smoking accounts for 90% of lung cancer
cases in the U.S., and almost 50,000 deaths per year can be attributed to
secondhand smoke.”
- NIDA, 2012
Kay Colbert, LCSW, 2013
Nicotine & Adolescents Smoking in US is at lower levels,
4.9% 8th graders
10.8% 10th graders
17.1%12th graders
Smokeless tobacco on rise,
2.8% 8th graders
6.4%10th graders
7.9% percent of 12th graders.
Source: National Inst. of Drug Abuse, NIDA for Teens, 2013.
Common Drugs of Abuse Inhalants
These various products contain a wide range of chemicals such as:
Trend: TX air
fresheners &
dusting
sprays
Source: Maxwell,
June 2012.
  toluene (spray paints, rubber cement, gasoline)
  chlorinated hydrocarbons (dry-cleaning chemicals, correction fluids)
  hydrofluorocarbons - tetrafluoroethane or difluoroethane (air
dusters, air fresheners)
  hexane (glues, gasoline)
  benzene (gasoline)
  methylene chloride (varnish removers, paint thinners)
  butane (cigarette lighter refills, air fresheners)
  nitrous oxide (whipped cream dispensers, gas cylinders)
2010 Texas elementary school survey found that 11 percent of students in grades 4–6 had
ever used inhalants, 17 percent of students in grades 7–12.
Source: Maxwell, Substance Abuse Trends in Texas June 2012
Kay Colbert, LCSW, 2013
Newer Street Drugs Synthetic Drugs
 
Made in lab, often chemically related to amphetamines, marijuana or LSD.
 
Over 30 states have banned the chemicals put in synthetic drugs, new ones are
constantly being made.
 
On July 9, 2012 President Obama signed legislation that bans synthetic drugs.
 
National Association of Convenience Stores advised its more than 148,000 member
stores to remove the drugs from their shelves.
 
Operation Log Jam July 25, 2012: local and federal law enforcement officials raided
businesses in 31 states, in the first nationwide crackdown on synthetic drugs. Seized:
4.9 million packets of synthetic marijuana & supplies for 13.6 million more. 167,000
packets of MDPV & supplies for 392,000 more. $36 million in cash, 91 arrested.
 
Worldwide, efforts to reduce plant-based drugs offset by significant increases in
synthetic drug production.
Sources: Join Together Newsletter, July 10 & July 26, 2012, Partnership at Drugfree.org;
2012 United Nations World Drug Report; NY Times, July 27, 2012.
Kay Colbert, LCSW, 2013
Newer Street Drugs Synthetic Drugs:
MDPV
(methylenedioxypyrovalerone)
sold as Bath Salts, Plant Food, Insect Repellent, Bubbles, M-Cat, Meow Meow
Synthetic CathinonesCathinone: monoamine alkaloid found naturally in Catha edulis,
called khat in the Middle East, hagigat in Israel, native to east Africa and southern Arabia.
Schedule I drug in US. Psychoactive components of the plant, cathine and cathinone are
similar to a less potent form of amphetamine. Recent study at U of NC Med School shows
similar effect as cocaine on brain’s reward circuitry.
A final order to temporarily schedule these drugs under the federal Controlled Substances
Act went into effect on October 21, 2011, and it became Penalty Group 2 in Texas on
September 1, 2011.
Sources: NIDA Drug Facts, Jan 2011; Maxwell, Substance Abuse Trends in Texas June 2012
Kay Colbert, LCSW, 2013
Newer Street Drugs Synthetic Drugs:
BZP (1-Benzylpiperazine)
TFMPP (1-(3- trifluoromethylphenyl)piperazine)
BZP has pharmacological effects that are qualitatively similar to those of amphetamine. It is a
Schedule I drug that is often taken in combination with TFMPP, a noncontrolled substance, in
order to enhance its effects as a substitute for MDMA. It is generally taken orally but can be
smoked or inhaled.
Piperazines are a broad class of chemicals which include several stimulants (such as BZP and
TFMPP) as well as antivertigo agents (cyclizine, meclizine) and other drugs (sildenafil/Viagra).
Sources: NIDA Drug Facts, Jan 2011; Maxwell, Substance Abuse Trends in Texas June 2012
Kay Colbert, LCSW, 2013
Newer Street Drugs Synthetic Drugs:
2C-I, i, 2C, Smiles
2C drugs are a family of synthetic drugs with the chemical name 2,5-dimethoxy-4idodophenethylamine. Imported from Europe & Asia, internet retailers.
Can be taken dissolved on paper, in tablets or as a powder, often mixed with cocoa powder.
Sometimes sold as MDMA or LSD.
Hallucinogen, alters brain’s balance of dopamine & serotonin.
Highs can last up to 8 hours, but effects can take 40 min – 2 hours, so there is risk of overdose.
DEA: user population is high school & college students, young adults in dance & nightlife
settings
Sources: Brian Alexander, NBC News, January 15, 2013; DEA, February 2011
Kay Colbert, LCSW, 2013
Newer Street Drugs Synthetic Drugs:
Pump-It
  synthetic stimulant, made in lab
  users may test positive for methamphetamine
  made from methylhexanamine, which is found naturally in the geranium plant, according to
Medtox, a Minnesota-based toxicology firm that operates a drug testing laboratory
Sources: Starnews Online, April 9, 2012; Partnership for a Drugfree America, July 24, 2012.
Kay Colbert, LCSW, 2013
Newer Street Drugs Soma, Soprodal, Vanadom (Carisoprodol)
 
Muscle relaxant.
 
Very popular in DFW.
 
Often taken in combination with hydrocodone and Xanax (alprazolam) to make a
“Houston Cocktail” or “Holy Trinity” for a reported heroin-like high.
 
FDA recommends using carisoprodol no longer than 2 to 3 weeks to avoid the risk
for dependence, withdrawal, and abuse.
 
January 11, 2012, carisoprodol became a Schedule IV drug nationally.
Sources: SAMHSA DAWN Report October 27, 2011; Maxwell, Substance Abuse Trends in Texas June 2012
Kay Colbert, LCSW, 2013
Newer Drugs Retail Medical Marijuana
Legalization v. decriminalization – 18 states + DC; Colorado, Washington; soon will be a retail
model
Dixie Elixers
sodas with 120 milligrams THC, (v. 5 mg)
truffles with 300 mg & 50 mg THC, Crispy Rice
Treats with 75 mg THC
Appeals to youth, delivery mechanisms seem normal.
Sources: http://dixieelixirs.com/ ; Tony Dokoupil, Interview with Terry Gross, Fresh Air, Nov. 13, 2012.
Kay Colbert, LCSW, 2013
Coming soon to a store near you . . .
Finely milled tobacco + food grade binders
Kay Colbert, LCSW, 2013
Mint & cinnamon flavors, look like candy.
Estimated Lethal Dose
Camel Orbs (1 mg nicotine per pellet) 10 – 15 pellets
Camel Sticks (3.1 mg nicotine per stick) 3 - 5 sticks
Camel Strips (0.6 mg nicotine per strip) 17 – 24 strips
Source: Harvard School of Public Health, July 2011.
Kay Colbert, LCSW, 2013
ARGYLE SWEATER © 2013 Scott Hilburn. Dist. By UNIVERSAL UCLICK. Reprinted with permission. All rights reserved.
Kay Colbert, LCSW, 2013
Energy drinks: Can be high in caffeine (70 – 500 mg or 10x soda) &
related substances, high in sugar, other untested supplements such as
guarine, taurine, creatine. 5 deaths reported to FDA.
Appeal to youth, stimulant abusers. 30%-50% youth have used.
Am Academy of Pediatrics discourages.
Also come with ETOH or mixed with. FDA: “serious concern.”
Sources: FDA Nov 12, 2012; Mayo Clinic, October 11, 2011; DAWN Report, Jan 10, 2013.
Kay Colbert, LCSW, 2013
•  58% energy drinks alone
•  42% involved other drugs
 
FDA investigating 13 deaths, 92 adverse reports from 5-hour
Energy.
 
207 milligrams of caffeine in one 5-hour ENERGY. Red Bull
contains approx 80 mg of caffeine in 8.4-oz can, 16-oz grande
Starbucks Pike Place brewed coffee approx 330 milligrams of
caffeine.
 
Lethal dose is 170 mg/kg, or 12,500-14,600 mg for an average
adult male.
Sources: FDA Nov. 12, 2012; William Hudson, CNN Health, Nov. 16, 2013; Dr. Robert Drotman, Sept. 23, 2012.
Highly caffeinated products for “energy”
Kay Colbert, LCSW, 2013
Adjective
jacked (comparative more jacked, superlative most jacked)
(slang) high on drugs or stimulants
to be high on Ecstasy (MDMA) or other stimulant drugs
Sources: Wiktionary / Online Slang Dictionary
Kay Colbert, LCSW, 2013
“This special formulation was developed by a registered
pharmacist that knows what the streets demand.”
-  Text from SlowMotionPotion.com web site Feb 4, 2013.
Relaxation Drinks
Soft drinks that imitate Triple C or codeine cough syrup pattern called
“purple drank”. Lean and Drank marketed to youth to “slow your roll.”
Valerian root, melatonin – unknown effects, esp on developing brains.
Sources: slowmotionpotion.com; drankbeverage.com
Kay Colbert, LCSW, 2013
Agenda  
overview of addiction
 
drugs of abuse, current trends with adolescents
  prevalence & characteristics
 
symptoms in adolescents
 
treatment & best practice protocols for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
Prevalence & Characteristics
22.6 million Americans 12 years + used illicit drugs in past 30 days (8.9%)
Age:
highest use 18-25 years
use declines with age, from 26 years +
Source: 2011 National Survey on Drug Use & Health, SAMHSA Publication No. (SMA) 12-4713
Kay Colbert, LCSW, 2013
Prevalence & Characteristics 23.1 million people 12 years + need treatment for drug or
alcohol use problems
Source: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658
Kay Colbert, LCSW, 2013
Prevalence & Characteristics Substance Dependence or Abuse in past year 12 years +
Source: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658
Kay Colbert, LCSW, 2013
Prevalence & Characteristics Specific Illicit Drug Dependence or Abuse in Past Year 12 years +
Source: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658
Kay Colbert, LCSW, 2013
Prevalence & Characteristics First Drug Use 2011, 12+
Source: 2011 National Survey on Drug Use & Health, SAMHSA Publication No. (SMA) 12-4713
Prevalence & Characteristics Healthy People 2010
Substance abuse is a significant preventable public health threat - #4
$276 billion cost to US society annually
Costs in health care, legal issues, economic loss, family relationships, social functioning,
psychological problems, emotional problems, occupational consequences & educational
attainment.
Addiction to AOD is a brain disease. Constant substance abuse chemically alters the brain,
causing damage to the brain, also liver, heart, kidneys & resulting in many severe health
problems.
Deaths: 112,000 annually in America (100,000 alcohol)
Internationally: 263,000 drugs & 2.5 million alcohol
UN: Undermines economic & social development, increases crime, instability, insecurity,
spread of HIV, hep B & C, violence, kidnapping, corruption & human trafficking related to
transnational organized crime & drug trafficking.
Sources: U.S. Dept. of Health & Human Services, Healthy People 2010;
2012 United Nations World Drug Report; WHO, Alcohol, 2012.
Kay Colbert, LCSW, 2013
What Causes SA? Historical Perspective Through history, substance abuse viewed as: •  moral weakness, people are sinful
•  behavioral disorder
•  learned behavior
•  environmental
•  personality disorder
•  addictive personality
“allergy”
•  biological problem
• 
brain dysfunction
• 
biochemical “allergy”
•  genetic issue
• 
inherited trait
•  sociocultural
• 
society condones alcohol, tobacco use,
• 
why not other things?
•  a disease
Most early research based on alcoholism, white males.
Kay Colbert, LCSW, 2013
What Causes SA? Multiple Causes:
 
 
 
 
 
Genetics
Mental health disorder
Trauma (TBA, PTSD)
Brain disease
Epigenetics
Kay Colbert, LCSW, 2013
What Causes SA? Addiction & the Brain:
lower levels of dopamine
Repeated drug exposure changes brain function.
Positron emission tomography (PET) images are
illustrated. The striatum (which contains the reward
and motor circuitry) shows up as bright red and
yellow in the controls (in the top box), indicates
numerous dopamine D2 receptors. Conversely, the
brain of the addicted individual show a less intense
signal, indicating lower levels of dopamine D2
receptors.
Source: National Institutes of Health, The Science of Addiction, 2007.
Kay Colbert, LCSW, 2013
Current Theories Process Addictions / Non-substance addictions
A person becomes dependent on any repetitive, irresistible, harmful behavior or activity;
very similar to addiction:
• 
• 
• 
• 
• 
• 
Eating disorders (restriction, purging, binging)
Self-mutilation (cutting)
Compulsive Gambling
Compulsive Shopping
Internet / computer addiction:
porn (mainly men)
gaming- MMORPG (Massively multiplayer online role-playing game) - WOW,
Diablo 3, Guild Wars, Star Wars, Elderscrolls: Skyrim (RPG), Everquest, 2nd Life)
•  Co-dependency / unhealthy relationships
•  Love
•  Sex
These behaviors not only “resemble each other clinically, but share neurobiological
underpinnings with drug and alcohol dependence . . . .”
(Shaffer, 2007, p. 1).
Sources: Martin & Petry, 2005; Shaffer, 2007
Kay Colbert, LCSW, 2013
Current Theories Process Addictions / Non-substance addictions
These can be seen to be related to addiction using the 3 C’s Model:
The behavior is motivated by emotions ranging along the Craving to Compulsion
spectrum.
There is Continued use in spite of adverse consequences.
There is loss of Control.
Why do we care? Cross-addiction may occur. Addictive behaviors
may switch. Engaging in these behaviors in recovery may lead to
relapse in primary addiction.
Kay Colbert, LCSW, 2013
Agenda  
overview of addiction, drugs of abuse
 
drugs of abuse, current trends with adolescents
 
prevalence & characteristics
  symptoms in adolescents
 
treatment & best practice protocols for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
Symptoms Changes in
 
Mood: irritable, unfocused, angry outbursts, paranoia,
depressed, srying, possible threats of bodily harm or suicide
 
Energy levels
 
Eating habits or weight loss, gain
 
Sleep habits
 
Friends: new ones you don’t know
 
School: poor grades, skipping, sudden lack of interest
 
Activities: can’t account for time, isolating, lack of interest
 
Appearance: lack of bathing, grooming
Symptoms  
Money: unexplained needs for money or purchases
 
Stealing, unexplained items missing from home
 
Lying
 
Secret, sneaky phone calls & texts
 
Smoking: covers up marijuana
 
Finding drug paraphernalia
 
Health problems: coughing, red eyes, slurred speech, low
energy, dilated or pin-point pupils, breakouts or skin picking
Symptoms  
Uncommunicative
 
Begins to skip family routines
 
Threaten to quit school, run away, destroy family
property
NOTE: Many of these things are also symptoms of being
an adolescent . . .
Agenda  
overview of addiction, drugs of abuse
 
drugs of abuse, current trends with adolescents
 
prevalence & characteristics
 
symptoms in adolescents
  treatment & best practice protocols
for adolescents
 
populations at risk
Kay Colbert, LCSW, 2013
Treatment Intensive Outpatient,
Residential
Abstinence Model v. Harm Reduction
CBT
12-Step
Motivational Interviewing
Contingency Management
Medications to reduce cravings, reduce highs
Kay Colbert, LCSW, 2013
Treatment  
Exercise
 
Relaxation skills: meditation,
yoga, mindfulness, grounding
tai chi, qigong
 
Mindfulness Based Relapse Prevention
 
Total wellness: massage, acupuncture,
healthy diet, healthy sleep
 
Positive replacement activities
Treatment  
Longer time in treatment
 
Supportive follow up care
 
12 month follow ups: 12 Step, sponsors
 
Skill building
 
Family education
 
Novelty enrichment activities - neuroplasticity
Kay Colbert, LCSW, 2013
Engage the Group
Engage the Brain:
100 Experiential Activities
for Addiction Treatment
Kay Colbert, LCSW and Roxanna Erickson-Klein, RN, PhD
To be published 2013
by the Erickson Foundation Press
Treatment & Interventions for Youth   First screen for medical, mental health,
developmental, LD issues
– complete psychoeducational testing.
  More than 2/3 of young substance abusers have mental health
issues: anxiety, depression, ADHD, and eating disorders. Treat
concurrently.
  Screen for abuse, neglect, trauma
  Early remediation of any learning differences important – before
loss of self esteem.
  ADD / ADHD, LD – early intervention, coping skills; no treatment
increases risk.
Source: SAMHSA News, Winter 2013.
Kay Colbert, LCSW, 2013
Treatment for Youth  
No use contracts
 
Home contracts
 
Random drug tests
 
Counseling
 
Family counseling for parents, siblings
 
Drug diversion courts
Source: SAMHSA News, Winter 2013.
Kay Colbert, LCSW, 2013
Treatment & Interventions for Youth  
Mental health & some medical conditions can look like
drug use.
 
Some medical conditions can look like mental health
symptoms.
 
Note that trauma / PTSD symptoms can also look like
mental health symptoms.
 
Early intervention important.
Kay Colbert, LCSW, 2013
Interventions for Adolescents  
How are they spending their
time?
 
Engaged constructively in their schools &communities?
exercise
community service
arts, sports
church activities
tutoring
employment assistance
Kay Colbert, LCSW, 2013
Treatment & Interventions for Youth Brief Interventions with MI + CBT
Univ of Minn study: two 1-hour sessions “markedly reduced” SA in
315 middle & high school students
Session 1: pros & cons, willingness to change, identify goals for
behavioral change
Session 2: review progress, identify high-risk situations, triggers,
strategies for peer pressure, long-term goals.
Session 3: optional, for parents; how to improve communication with
teen & support teen’s goals.
Source: Winters, K.C., et al, 2012.
Treatment & Interventions for Youth Brief Interventions with MI + CBT
90 day, 6 month follow up: 50% reported abstinence from AOD
compared to 37% marj & 26% ETOH for untreated group. 60% for
marj with 3rd session.
Dr. Winters: “ . . . motivational interviewing is friendly to the
developing adolescent brain . . . Rather than telling teens they must
stop using drugs, therapists discuss the adolescents’ current
problems and realistic goals for their immediate future.”
Source: Winters, K.C., et al, 2012.
Interventions for Adolescents  
Who do they go to when they have a bad
day? Parental involvement? Outside support
channels?
 
What coping skills do they have?
 
Are they thinking about & planning for their
future?
 
Educate on risks: Those who perceived
greater risk less likely to use / abuse.
Source: 2011 National Survey on Drug Use & Health, SAMHSA Publication No. (SMA) 12-4713
Treatment & Interventions for Adolescents Older teens (college students)
  Lengthy educational sessions that explain the perils of drinking or drugging are not very
effective. Brief sessions that provide motivational feedback reduced AOD consumption
among college students
  Show actual drinking & using rates of peers – not everyone is doing it
  Personalize the information to the needs and attitudes or beliefs of the individual
calories they consume when they drink
better school performance
staying in better shape
preventing hangovers
avoiding disciplinary and legal problems
  College students tend to think that alcohol will enhance their social and sexual
encounters, and countering this perception can be helpful.
Sources: LaBrie, et al., 2006, Walters & Baer, 2006.
Kay Colbert, LCSW, 2013
Agenda  
overview of addiction, drugs of abuse
 
drugs of abuse, current trends with adolescents
 
prevalence & characteristics
 
symptoms in adolescents
 
treatment & best practice protocols for adolescents
  populations at risk
Kay Colbert, LCSW, 2013
Risk Factors for Adolesents  
 
 
 
 
 
 
 
 
 
 
 
 
 
history of early childhood negative, aggressive behavior
history of physical, sexual abuse
being male, Caucasian, an older adolescent
emotional, social, academic difficulties
poor impulse control
unstable emotions
thrill-seeking behavior
very low perception of the dangers inherent in drug use
low socioeconomic status
level of education
living in a high crime & drug-use neighborhood
ease of drug availability
peer-group pressure
history of mental illness
Source: Shahid, et al, 2011.
At Risk Populations: Young People  
Increased sensitivity to the effects of AOD due to specific changes in
physiological development.
 
Approx 7% of 12 – 17 year olds were dependent or abusing AOD in past
year.
 
Drugs and alcohol are becoming more socially acceptable and kids want
to be adults sooner these days.
 
Children’s brains are still developing, unclear what developmental delays
or learning disabilities may occur.
Source: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658
Kay Colbert, LCSW, 2013
At Risk Populations: Young People  
Developmental: teens feel invincible.
 
Judgment poor: adolescents’ brains (esp prefrontal cortex) are
not fully mature.
 
Sensation-seeking.
 
Pressures of emerging adulthood, emotions & hormones.
 
Isolation, peer pressure.
 
Lack of strong coping skills, support systems.
Source: 2010 National Survey on Drug Use & Health, SAMHSA Pub. No. 11-4658
Kay Colbert, LCSW, 2013
At Risk Populations: Socioeconomic  
Poverty: greatest stressor for families, lack of health insurance, & lack of
health care, lack of services
 
SAMHSA: “substantial unmet need for substance use treatment among
individuals living in poverty, particularly among young adults and
adolescents.”
 
12.2 percent of persons aged 12 or older (30 million) live in poverty.
 
SA not a problem of poor people – across all demographics
Source: SAMHSA National Survey on Drug Use, 2010.
Kay Colbert, LCSW, 2013
At Risk Populations: Mental Health Psychiatric Disorder
Increased Risk For Substance Abuse
Antisocial personality disorder
15.5%
Manic episode
14.5
Schizophrenia
10.1
Panic disorder
4.3
Major depressive episode
4.1
Obsessive-compulsive disorder
3.4
Phobias 2.4
  What came first?
  Need to diagnose early, treat both concurrently.
Source: Mental Health America, Dual Diagnosis, 2012.
Kay Colbert, LCSW, 2013
At Risk Populations: Disabilities  
Individuals with disabilities at increased risk for SA compared with general population.
 
Persons with any type of disability experience substance abuse at rates 2 to 4 times
that of the general population.
 
Deafness, arthritis & multiple sclerosis have shown SA rates of 2X general population.
Spinal cord injuries, orthopedic disabilities, vision impairment & amputations approx
40-50% can be classified as heavy drinkers.
 
Persons with MR tend to have lower rates of substance abuse disorders than the
general population.
Source: Dept of Health & Human Services, Office on Disability, SA & Disability, 2012.
Kay Colbert, LCSW, 2013
At Risk: Trauma Victims According to National Child Traumatic Stress
Network:
complex trauma
domestic violence
early childhood trauma
medical trauma
natural disasters
physical abuse
refugee & war zone trauma
school violence & crises
sexual abuse
terrorism
traumatic grief
Sources: National Child Traumatic Stress Network, 2012.
Kay Colbert, LCSW, 2013
At Risk: Trauma Victims  
Rates: Of clients in SA treatment,
12% - 34% PTSD;
more will have experienced trauma
 
Up to 2/3 of all people in drug treatment report childhood
physical, sexual or emotional abuse
 
Women in SA treatment, 33% - 59% (or higher)
 
Higher prevalence for females: 30 – 59% of women in
drug treatment meet criteria for PTSD
Sources: Lisa M. Najavits, PhD, 2012 & Seeking Safety, 2002. Kay Colbert, LCSW, 2013
At Risk: Trauma Victims  
 
When trauma is untreated, substance
abusers drop out
of treatment at high rate
Women with PTSD abuse the most severe substances
and are vulnerable to relapse for both conditions and
repeated trauma
Sources: Molony, K.P.,van den BerghB.J., Moller, L.F., Public Health, 2009.
Kay Colbert, LCSW, 2013
At Risk: Trauma Victims  
Rate of PTSD 2-3 times higher
for women in drug
treatment compared to men
in drug treatment
 
Women who are victims of both sexual and physical
abuse are twice as likely to abuse drugs
 
Gender: women typically sexual or physical
childhood trauma, men combat or crime
 
Self-medicating, numbing out. In 2/3 of cases, PTSD
first, then SA
Sources: Lisa M. Najavits, PhD, 2012 & Seeking Safety, 2002. Kay Colbert, LCSW, 2013
Trauma & Substance Abuse  
Treatment Strategies
practice (only 66%)
treatment of both conditions best
 
recognize symptoms may overlap – causality?
 
consider referring victims of childhood abuse and
domestic violence out for concurrent treatment
 
address issues in single-sex treatment groups
Source: National Survey of Substance Abuse Treatment Services, 2009.
Kay Colbert, LCSW, 2013
At Risk: Children of Addicts   Addiction is a Family Disease.
  Does not exist in isolation.   Move into recovery as a family.
  Children can feel alone & isolated.
  Children often think they caused the addiction, that they
can control it.
  Whole family recovery: education, awareness,
counseling, Al Anon, Ala-Teen.
  Be aware of physiological symptoms of stress in children.
Kay Colbert, LCSW, 2013
At Risk: Children of Users Exposure to AOD in Utero
  neurological differences
  developmental delays
  behavioral issues
Influenced by:
  amount & type of prenatal exposure
  when in the pregnancy the child was exposed
  the child's own biological vulnerability
  various other environmental factors
Negative outcomes not a given: Postnatal factors bear
on the ability of the newborn prenatally exposed to
drugs to recover; recovery of functioning is facilitated by
a favorable care taking environment.
Source: The Evan B. Donaldson Adoption Institute
Kay Colbert, LCSW, 2013
At Risk: Children of Addicts likely to become
  Children of addicts are 3-5 more
alcoholics or addicts. This may be due to genetic &
environmental (learned behavior) factors.
  Biological children of alcohol dependent parents who have
been adopted continue to have an increased risk
(2-9 fold) of developing alcoholism.
Source: National Assoc. for Children of Alcoholics
Kay Colbert, LCSW, 2013
At Risk: Children of Addicts   Stress of growing up in a household
with addictions
can also contribute to dysfunctional
behaviors, poor
school performance, acting out, unhealthy and/or
codependent relationships.
  Increases risk for trauma exposure and associated
emotional & developmental issues.
Source: National Child Trauma Stress Network, 2012.
Kay Colbert, LCSW, 2013
Children of Addicts I didn't CAUSE it,
I can't CURE it,
I can't CONTROL it,
but I can take CARE of myself
by COMMUNICATING feelings,
making healthy CHOICES,
and CELEBRATING myself.
Resource: Betty Ford 5 Star Kids Program
The Betty Ford Children’s Program is for seven- through 12-year-olds who come from families hurt by
alcoholism and other drug addiction. With locations in Southern California, the Dallas/Fort Worth
Metroplex, and Denver, Colorado, no child is ever turned away due to an inability to pay.
Kay Colbert, LCSW, 2013
Stigma of Addiction “Drug-dependent people should not be treated with
discrimination; they should be treated by medical experts and
counselors. Drug addiction is a disease, not a crime.”
- Ban Ki-moon, UN Secretary General, June 23, 2011
Kay Colbert, LCSW, 2013
Stigma of Addiction   Understand addiction is a disease
& the answer
is treatment not punishment.   Stigma, especially for mothers, prevents addicts seeking
treatment. Unresolved parenting issues, especially guilt &
shame, can lead to relapse.
  Incarceration is not treatment.
Kay Colbert, LCSW, 2013
Appropriate Services Needed in the Community To Address Substance Abuse More research on treatment & what works (lack of good
research in outcome evaluations).
More treatment, less jail time.
More drug courts.
More aftercare programs, sober housing - short term treatment not as effective for the long
term.
More treatment facilities for women.
More treatment for pregnant women.
More interventions for the children of SA’s - CPS removal not the answer.
More treatment facilities that treat dual diagnosis - mental illness & SA & trauma.
Better community mental health care.
More research on drugs to help with cravings.
More programs in schools to increase self esteem & get youth involved in positive community
Kay Colbert, LCSW, 2013
activities.
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Kay Colbert, LCSW, 2013
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Kay Colbert, LCSW, 2013
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Kay Colbert, LCSW, 2013
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Kay Colbert, LCSW, 2013
Go to my web site for a copy of this presenta3on www.kaycolbert.com