3/31/2016
Antoine Douaihy, MD
Professor of Psychiatry & Medicine
University of Pittsburgh School of Medicine
Medical Director of Addiction Medicine Services
Western Psychiatric Institute and Clinic
Co-Director of Tobacco Treatment Service of UPMC
[email protected]
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NIDA
NIMH
NIAAA
Orexo
Alkermes
Royalties for 2 academic books published by OUP:
Substance Use Disorders, UPP and Motivational
Interviewing: A Guide for Medical Trainees and
another book published by PESI Media & Publishing
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1- Describe recent trends in illicit substance use among adolescents and
young adults
2- Differentiate between illicit substance use that is experimental in nature
versus use that may be indicative of a substance use disorder
3- Identify negative outcomes (including associations with other psychiatric
disorders) that can result from use of illicit substances at younger ages
4- Explain how treatment approaches for younger patients, including the
use of pharmacological agents, may need to differ from those used with
older patients in order to better engage this patient population
5- Discuss current and emerging treatment strategies that can be used with
adolescents and young adults with substance use disorders
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Monitoring the Future (MTF)
National Survey on Drug Use and Health
(NSDUH)
Youth Risk Behavior Surveillance Survey (YRBSS)
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This is a slide.
 This is a bullet
 This is a bullet
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First point
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Showed progress in reducing some forms of substance use
– especially among adolescents. Substance use levels in
many areas, however, have remained relatively constant.
With regard to substance use, the report found some areas
of progress, particularly among adolescents.
National Survey on Drug Use and Health. https://nsduhweb.rti.org/respweb/homepage.cfm
Accessed on 3/24/16.
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Past Month Usage
by 12 to 17-YearOlds in Medical
Marijuana States
(red)vs. Nonmedical MJ States
(blue)2012
National Survey on Drug Use and Health. https://nsduhweb.rti.org/respweb/homepage.cfm. Accessed
on 3/24/16.
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Marijuana continues to be the most commonly used illicit drug.
Nonmedical pain reliever use continues to be the second most
common type of illicit drug use; the percentage of people aged 12 or
older in 2014 who were current nonmedical users of pain relievers (1.6
percent) was lower than in most years since 2002, and about the same
as in 2013.
Current heroin use increased from 0.1 percent of the population age
12 and older in 2013 to 0.2 in 2014.
Overall, the use of illicit drugs – including marijuana – among
Americans aged 12 and older increased from 9.4 percent in 2013 to
10.2 percent in 2014. This was driven particularly by the increase in
adult marijuana use.
National Survey on Drug Use and Health. https://nsduhweb.rti.org/respweb/homepage.cfm. Accessed on
3/24/16.
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Purpose
 YRBSS monitors six categories of priority risk behaviors among youth
and young adults: tobacco use, alcohol and other drug use, sexual
behaviors that contribute to unintended pregnancy and sexually
transmitted diseases, unhealthy dietary behavior, and physical
inactivity
Relevance to Drug Abuse
 Includes questions of alcohol and other drug use, in addition to other
risk factors
 Only captures those students in school at time of survey
National Youth Risk Behavior Surveys. http://www.cdc.gov/healthyyouth/data/yrbs/data.htm
Accessed on 3/24/16
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Percentage of High School Students Who
Currently Used Marijuana,* 1991-2013†
*One or more times during the 30 days before the survey.
†
Increased 1991-2013, increased 1991-1995, decreased 1995-2013 [Based on linear and quadratic trend analyses using
logistic regression models controlling for sex, race/ethnicity, and grade (p < 0.05). Significant linear trends (if present) across all
available years are described first followed by linear changes in each segment of significant quadratic trends (if present).]
National Youth Risk Behavior Surveys, 1991-2013. http://www.cdc.gov/healthyyouth/data/yrbs/data.htm
Accessed on 3/24/16
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Marijuana
Synthetic marijuana
Synthetic Cathinones: “Bath Salts”
DXM (cough medicine)
Rx drug abuse
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Still legal in some states, “bath salts” are the latest designer
drug to be sweeping the nation. Never intended to be put in
bathwater, this powdery substance is packaged as “bath
salt” to circumvent drug laws.
Bath salts are a hallucinogen that can cause:
- Intense paranoid delusions
- Days of anxiety and paranoia
Easily found at gas stations and convenience stores, it is
important to learn the many names of this drug to protect
against its dangerous effects.
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Alternative names: Bloom, White Dove, and Ocean Snow
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Used orally, inhaled, or injected
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One in 10 American teenagers has abused products
with DXM to get high, making it more popular in that
age group than cocaine, ecstasy, LSD, and meth
DXM can cause hallucinatory and dissociative effects
similar to those of PCP or ketamine (Special K)
DXM is easy to get
DXM is cheap
DXM seems safer
DXM is popular
Hard for parents to detect DXM abuse
Toxic effects of DXM/overdose
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 It normalizes the misuse of these drugs
 Legitimate reasons – with or without a
prescription – to stay awake, remain alert,
to go to sleep, get high or try something
new
 “Pharming” and “bowling” parties
 Are often unaware that these activities can
lead to disastrous results
 Warning physical and behavioral signs as
well as school performance
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Spend a lot of time alone
Lose interest in their favorite things
Get messy—for instance, not bathe, change clothes, or
brush their teeth
Be really tired and sad
Be very energetic, talk fast, or say things that don't
make sense
Be nervous or cranky (in a bad mood)
Quickly change between feeling bad and feeling good
Sleep at strange hours
Miss important appointments
Have problems at school
Eat a lot more or a lot less than usual
National Institute on Drug Abuse 2013. https://www.drugabuse.gov/ Accessed on 3/24/16.
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Rx Access Points—
Friends & Family Source of Concern
SAMHSA. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings
(Office of Applied Studies, NSDUH Series: H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.
Available at: www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf
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Addict
Addicted to _
Addiction OR
Alcoholic
Clean
Dirty
Drug habit
Drug Seeker
-Pt with a SUD
- Has a ___ use disorder
- Substance use disorder
-Pt with an alcohol use disorder
-Neg: Free of illicit substances
- Pos: Active use
-Substance use disorder
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Relief seeking
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Drug Abuser
Former
Maintenance
Pain Seeker
Recreational
Reformed
Replacement
Substance Abuser
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̵
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̵
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Pt with SUD
In sustained remission
Medication Asstd
Treatment
Relief / Treatment Seeking
Non-medical use
In remission
MAT
Pt with SUD
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Adolescent Brain Development
•“what teens do during their adolescent years – whether Environment and activities during teenage years guide
it's playing sports or playing video games – can affect
how their brains develop”
--J Giedd
BJ Casey,
JAACAP 2010
selective synapse elimination (“pruning”) during critical
period of adolescent development
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Alcohol and drugs affect the brains of
adolescents and young adults differently than
they do adult brains
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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
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There are multiple genetic and environmental
risk factors that make adolescents vulnerable to
the initiation of substance use
Unfortunately, earlier use of tobacco, alcohol,
and drugs is more likely to result in substance
use disorders in adulthood
The substance use in the teenage years which
begins as minimal or experimental use with
minimal consequences can progress in a subset
of individuals to more serious substance use
disorders
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Addiction Is a Developmental Disease
Starts in Childhood and Adolescence
1.8
1.6
1.4
TOBACCO
THC
ALCOHOL
1.2
1.0
0.8
0.6
0.4
0.2
0.0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Age
Age for tobacco, alcohol and cannabis dependence, as per DSM IV
National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
http://www.niaaa.nih.gov/Publications/. Accessed on 3/24/16.
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Abuse: Hazardous use; Social/interpersonal
problems; neglected major roles to use; legal
problems (≥1criterion)
Dependence: withdrawal; tolerance; used larger
amounts/longer; repeated attempts to
quit/control use; much time spent using;
psychological/physical problems related to
use; activities given up to use (≥3 criteria)
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Washington, DC. American Psychiatric Association, 1994.
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Dropped legal problems related to use as a
criterion
Added “craving or strong desire or urge to use
the substance” as a new criterion
All other 10 criteria remain the same
≥ 2 criteria
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Washington, DC. American Psychiatric Association, 2013.
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Substance Use Disorders
 A maladaptive pattern of substance use leading to
clinically significant impairment or distress,
as manifested by 2 (or more) of the following
occurring within a 12-month period:
 Severity specifiers based on 11 criteria
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Merging DSM-IV ‘abuse’ & ‘dependence’ criteria minus
legal
 Mild: 2-3 criteria
 Moderate: 4-5 criteria
 Severe: 6 or more criteria
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One size fits all doesn’t work anymore!!!
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. Washington, DC. American Psychiatric Association, 2013.
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3- Identify negative outcomes (including
associations with other psychiatric disorders)
that can result from use of illicit substances at
younger ages
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Childhood-onset psychiatric disorders increase risk for SUD &
SUD increases risk for psychiatric disorders
1.8
% in Each Age Group to Develop
First-time Dependence
1.6
TOBACCO
THC
1.4
ALCOHOL
1.2
1.0
0.8
0.6
0.4
0.2
0.0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Age
½ psychiatric disorders ¾ psychiatric
onset before age 15
disorders
onset before age 24
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The Developmental Relationship
Between Psychiatric Disorders and SUD
Family
Genetics
Gene Environment Interactions
Genetics
Fetal Exposure
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School
Peers
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Brain Development
Difficult temperament
ODD
ADHD (30-50%)
Conduct Disorder
(60-80%)
Antisocial PD
Depression (15-30%)
Individual
Substance Use Disorders
85% experiment before graduating HS;
10% develop problem use, abuse,
dependence
Bipolar Disorder (10-13%)
Anxiety Disorders (20-40%)
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4- Explain how treatment approaches for
younger patients, including the use of
pharmacological agents, may need to differ
from those used with older patients in order
to better engage this patient population
5- Discuss current and emerging treatment
strategies that can be used with adolescents
and young adults with SUDs
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Need for services
Difference in treatment needs between
adolescents and adults
Significant clinical differences: Polysubstance
use; less withdrawal; serious problems without
meeting SUD criteria
Less likely than adults to seek treatment on
their own
Psychopathology occurs commonly in that
population
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1- The majority of youth referred for substance
abuse treatment have at least one co-occurring
psychiatric disorder (COD), a DSM-IV-TR
mental health disorder and a substance use
disorder (SUD)
2- Adolescents with SUD are at a six times risk of
having a co-occurring psychiatric disorder
(Dennis, 2004)
3- COD are associated with poorer treatment
outcomes, both physical and psychological
when either disorder is not treated (Riggs, 2003)
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SOC sites (N= 18, 290) 44% reported COD
Turner WC et al. J Psychoactive Drugs. 200436(4):455-62.
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Co-Occurring Disorders at Intake: SOC
38.4%
ADHD
13.3%
27.1%
25.2%
Oppositional Defiant Disorders
32.9%
28.4%
Mood Disorders and Depression
13.2%
Adjustment Disorders
8.1%
9.9%
Conduct Disorders
34.0%
8.9%
6.8%
PTSD and Acute Stress
4.6%
3.5%
Impulse Control
5.5%
7.5%
Disruptive Behavior Disorders
4.5%
2.3%
Anxiety
Autistic Disorders
Mental Health Problems Only (n = 10,541)
2.4%
1.8%
Psychosis
Comorbid with Susbtance Use (n = 782)
2.1%
0.1%
5.1%
4.3%
Learning and Related Disorders
Mental Retardation
3.8%
2.4%
Personality Disorder
1.5%
3.8%
5.6%
3.3%
V Code
7.6%
Other
2.8%
0%
20%
40%
60%
80%
100%
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Is Addiction Treatment Effective?
What Does Research Tell Us?
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Psychiatric Disorders
Conduct Disorder (60-80%)
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Family-Based
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CBT
Substance Use Disorders
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Family-based (MDFT, FFT, MST,
BSFT, ACRA-with MET/CBT)
Depression, Anxiety(30-40%)
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CBT
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Pharmacotherapy
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Behavioral--CM/ motivational
incentives
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Cognitive Behavioral Therapy
(CBT)+ MET
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Pharmacotherapy
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Courtesy Paula Riggs, MD
ADHD (30-50%)
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CBT

Pharmacotherapy
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Treatment is better than no treatment
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Treatment is effective for reducing alcohol/drug use in adolescents
and young adults
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Individual cognitive/behavioral treatment showed higher effect sizes
and better long-term effects compared to family-based interventions
Tripodi et al. Arch Pediatr Adolesc Med. 2010; 164(1):85-91
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Alcohol Use Disorder
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ACAMPROSATE
NALTREXONE
TOPIRAMATE
GABAPENTIN
Opiate Use Disorder
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METHADONE
BUPRENORPHINE
NALTREXONE
NAC
Cannabis
Nicotine
BUPROPION
VARENICLINE
Gambling
NALTREXONE
NAC
Cocaine/Methamphetamine Use
Disorder
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BUPROPION
NALTREXONE
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N-Acetyl-cysteine (NAC)
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What Does Research Tell Us About
Integrated Mental Health and Substance
Treatment?
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Improving Treatment Outcomes
Combined Pharmacotherapy and Behavioral Treatment
Psychiatric Disorders
Substance Use Disorders
Common
• CD
Neurobiological
• ADHD
• Depression Targets
• Anxiety
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Randomized controlled trial fluoxetine vs placebo +
16 weeks CBT in adolescents with MDD, CD, SUD
(Riggs et al., 2007)
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Randomized controlled trial of fluoxetine in
adolescents with MDD and AUD (Cornelius et al., 2009)
Evaluation of CBT/MET in a treatment trial of comorbid MDD/AUD adolescents (Cornelius et al., 2011)
Treatment trial and long-term follow up evaluation
among co-morbid youth with MDD and cannabis
use disorder (Cornelius et al., 2012)
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Feasibility and efficacy of using mobile
technology approaches in chronic illnesses
Texting promoting the intervention features of
“monitoring-feedback; reminders; education;
and support”
Increase mobile phone utilization and
acceptance among youth populations
Youth as “perpetual texting generation” (Fox S,
2012)
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Few studies for substance use prevention
among young people
One pilot study showed efficacy and utility of a
12-week mobile texting aftercare intervention
vs. aftercare-as-usual produced positive results
Follow-up extension of this pilot study focused
on 6-month and 9-month follow up effects of
this intervention
What do the results mean?
Gonzales R et al. Am J Addict. 2016;25(1):62-8.
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First: Is marijuana addictive?
ADDICTION:
A developmental brain disease expressed as compulsive behavior
through continued use of a drug despite negative consequences.
What is the impact of legalization?
Substance treatment admissions for CUD in young adults
Public health impact
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