1. Co-Occurring Disorders
Suicide and
Co-Occurring Disorders
Jean McCracken, CAC-AD
Safe & Drug Free Schools Project

2. Medical Definition of Addiction
DSM-IV – Answer yes to 3 or more questions
Tolerance. Has your use of drugs or alcohol increased over time?
Withdrawal. When you stop using, have you ever experienced physical or emotional withdrawal? Have you had any of the following symptoms: irritability, anxiety, shakes, sweats, nausea, or vomiting?
Difficulty controlling your use. Do you sometimes use more or for a longer time than you would like? Do you drink to get drunk? Do you stop after a few drinks or does one drink lead to another?
Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?
Putting off or neglecting activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
Spending significant time or emotional energy. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spend a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?
Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?
How many adolescents drink or use others drugs could fit this definition?

3. Definition of Addiction
Continued use despite
negative consequences
Addiction is a “bio-psycho-social-spiritual” disorder
Addiction is a brain disorder
Addiction is a brain disease which results when continued use changes the structure of the brain affecting how a person acts, thinks and feels.

4. Drug of Choice for Past Year Use of Illicit Drugs
Aged 12 or Older: 2008

5. FACT: Addiction starts in adolescence.
Alcohol Dependence or Abuse in the Past Year among Adults Aged 21 or Older, by Age at First Use of Alcohol: 2008
FACT: Addiction starts in adolescence.

6. Anne Arundel County Percent of Students By Grade Who Reported “Ever Used” these Substances
Substance th Grade th Grade 10th Grade th Grade
Cigarettes * * * *30.8
Any form of alcohol
5 or more servings of
alcohol at one time
Marijuana
Cocaine
Hallucinogens
(shrooms/not LSD)
Designer Drugs
Heroin
Narcotics (Percocet,
OxyContin, Vicodin)
Amphetamines (Ritalin,
Dexadrine, Caffeine)
Barbiturates (Valium,
Xanax)
Any drug other than
alcohol or tobacco
*Maryland State Results
2007 Maryland Adolescent Survey (

7. What does this mean for educators?
th graders are smoking cigarettes (which puts them at great risk for smoking marijuana)
1, th graders have smoked marijuana (wonder how many were 9th grade repeaters???)
2, th graders are binge drinking (how many will make it through their freshmen year of college?)
th graders are beginning to drink alcohol (which ones will become the 1 in 10 Americans who become addicted adults?)
th graders (going into high school) and 2, th graders (going into adult society) have or are using illicit drugs!!!
AND THAT DOESN’T COUNT THE STUDENTS WHO WERE ABSENT OR TRUANT THAT DAY. 6th – th – th –

8. Why Do Kids Use Alcohol and Other Drugs?
To satisfy curiosity
To feel good and relax
To escape problems
To fit in and belong
To take risks and rebel
To feel “grown up”
To not be “bored”
Why Do Kids Resist Drugs?
Feeling connected to family.
Being committed to school or a vocational goal
Strong Faith

9. Adolescent Stages of Use
Experimentation
Rarely use – behavior does not change
Curious
Friends use
Relax
Rebel
Escape problems
Problem: If you like the way it makes you feel, will you continue to use!?

10. 2. Use/Abuse Use on a regular basis with a change in attitude
May buy it – drugs are now something you value
Begin to lie to parents about what you are doing
Care less about school work
Break more rules like curfew, doing chores, etc.
May lose friends who don’t use
Begin to have negative consequences
Problem: Using drugs takes time away from healthy activities. The brain begins to change and develop a tolerance .

11. 3. Addiction/Chemical Dependency
A brain disease which takes away self-control and craves the use of drugs.
Use to feel normal
Drugs are the focal point in life
Unable to make good decisions
Affects the way you act, think and feel
Problem: Your brain has chemically and physically changed and you need to use to function.

12. Over the Counter (OTC) Most popular are DXM and Caffeine (energy pills, diet pills)
DXM: Dextromethorphan is a cough-suppressing ingredient found in a
variety of OTC cold medications. Robotussin/cough syrups, Coricidin Cough
and Cold (red pills – not blue with antihistamine)
Street names: Triple Cs, Skittles, Robo, Robotrippin, Tussin
What are short term effects of DXM and caffeine?
DXM users describe “plateaus” depending upon tolerance and amount
taken which range from hallucinations to “out of body” dissociative
sensations. Physical effects of both can include dizziness, confusion, slurred
speech, impaired coordination, abdominal pain, nausea /vomiting, rapid
heart beat and drowsiness.
What are long term effects?
DXM can damage liver and pancreas (used with alcohol, can be deadly).

13. Prescription Drug Abuse 3 out of 4 drugs used illegally are prescription medications
Narcotic/Opioid Painkillers – Percocet, Vicodin, OxyContin, Morphine, Codeine
Sedatives /Tranquilizers,- Xanax, Valium, Ativan
Stimulants – Ritalin, Adderall (ADHD medications)
Short Term Effects:
Narcotics: Constipation, Depression , Low blood pressure , Decreased respiration rate , Confusion
Sedatives: Drowsiness , Confusion , Unsteady gait , Impaired judgment , Involuntary and rapid movement of the eyeball
Stimulants: Weight loss, Agitation , Irritability , Insomnia , High blood pressure , Irregular heartbeat
OxyContin and prescription pain relievers cause euphoria or feelings of well being by affecting the brain regions that mediate pleasure. They are often crushed to diminish the time release factor.
Xanax slows down the central nervous system, triggering an alcohol-like high, creating a state of euphoria, lowering inhibitions and increasing sociability.

14. Withdrawal Symptoms Emotional Withdrawal Symptoms Anxiety Restlessness
Irritability
Insomnia
Headaches
Poor concentration
Depression
Social isolation
Physical Withdrawal Symptoms
Sweating
Racing heart
Palpitations
Muscle tension
Tightness in the chest
Difficulty breathing
Tremor
Nausea, vomiting, or diarrhea
Abusing any drug will result in emotion withdrawal symptoms. Physical symptoms primarily result with withdrawal from depressants (alcohol, tranquilizers, benzodiazepines) and opiates.

15. When is Detox Needed? When can you die from withdrawal?
When withdrawing from depressants:
alcohol
tranquilizers (Valium)
benzodiazepines (Xanax)
A medically supervised detox can minimize your withdrawal symptoms and life threatening complications such as:
Grand mal seizures
Heart attacks
Strokes
Hallucinations
Delirium tremens (DTs)
Withdrawal from opiates like heroin and OxyContin is extremely uncomfortable, but not usually dangerous. Heroin withdrawal is like having a severe case of the flu but does not produce seizures, heart attacks, strokes, or delirium tremens.

16. Early Stages of Recovery
Once an adolescent is not using alcohol or other drugs, it is often the expectation that their behavior and attitude will improve and they will be able to academically get back on track. However, the reality is that between two months to two years the following may be experienced:
Mood Swings
Anxiety
Irritability
Tiredness
Variable energy
Low enthusiasm
Variable concentration
Disturbed sleep
Post-acute withdrawal feels like a rollercoaster of symptoms. In the beginning, symptoms will change minute to minute and hour to hour. Later as you recover further they will disappear for a few weeks or months only to return again. As you continue to recover the good stretches will get longer and longer.

17. Did you know. . .
Suicide is the 8th ranked cause of death in the United States.
Suicide is the 3rd leading cause of death for those ages
Suicide is the 2nd leading cause for ages
For every completed suicide, there are 25 suicide attempts.
30% of those with bipolar disorder will attempt suicide at least once in their lives.
30% of those with clinical depression will attempt suicide, and 15% will succeed.
50 % of all suicide attempts involve alcohol and illegal drugs.
25 % of completed suicides occur among substance abusers.
Young adults who drink heavily have an increased rate of suicide in middle age.
More than 70 % of teens who commit suicide have a history of alcohol and drug use.
Nearly every troubled teenager has suicidal thoughts at some point.
Many teens who are considering suicide suffer from depression.
The suicide rate of people under age 30 is increasing, largely because of substance abuse among young adults.

18. Signs of Teen Substance Use
Decline in school or work performance, attendance, grades and behavior
Loss of interest in extracurricular activities that used to be important
Changes in attitude, mood, or temper
Less responsible and lack of motivation
Extreme mood swings
Isolating self from family or withdrawing from family activities
Change or deterioration of physical appearance and grooming
Unusual borrowing of money from friends and family
Signs of Teen Suicidal Behavior
Expresses thoughts of death and a desire to leave this life /gives possessions away
Loss of interest in schoolwork (may have declining or failing grades)
Loss of interest in extracurricular activities that were once important
Isolating self from family  (and possibly friends)
Substance use or abuse
Extreme mood swings (may become very happy after feeling very depressed)
Changes in normal habits, such as eating and sleeping
Dramatic weight fluctuations, in any direction

19. Brain Chemistry and Addiction
Dopamine is the chemical in our brain that makes us “feel good”. Neurotransmitters release these chemicals which make us feel good when something positive happens. Any unused dopamine goes back into the neurotransmitter to be stored for the next time it is to be released. This is a chemical balance.

20. Healthy Brain Drug Abuser (less dopamine and brain activity)

21. The brain chemistry relating to neurotransmitters becomes unbalanced
The brain chemistry relating to neurotransmitters becomes unbalanced. What pushes these chemicals off course? One possibility is the stress. Triggers may include a traumatic event; losing a loved one or a job; certain medications; substance abuse; hormonal changes ; or even the weather.
Illustrated here are neurons (nerve cells) in the brain communicating via neurotransmitters

24. The most effective way to prevent suicide is through the early identification and treatment of those at risk.
Yet, surveys report that an average of only 36% of youths at risk for suicide receive mental health treatment during this same time period.

25. Percentages of Youths Aged 12 to 17 at Risk for Suicide During the Past Year Reporting that They Received Mental Health Services During this Same Time Period (2000)

26. Past Year Mental Health Service Use among Youths Aged 12 to 17, by Gender: 2008

27. Past Year Mental Health Care and Treatment for Substance Use Problems among Adults Aged 18 or Older with Both Serious Mental Illness and a Substance Use Disorder: 2008
Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration
Hard copies may be obtained from

28. Substance Use among Youths Aged 12 to 17, by Major Depressive Episode in the Past Year: 2008
Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration
Hard copies may be obtained from

29. Substance Dependence or Abuse among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2008
Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration
Hard copies may be obtained from

30. Teen Suicide Prevention
One of the most important aspects of teen suicide prevention is support . Teens need to know that you are willing to help him or her find hope in life again.
The most effective, research based teen suicide prevention programs consist of identifying and treating the following problems: 
Mental and learning disorders 
Substance abuse problems 
Problems dealing with stress 
Behavior problems(such as controlling aggressive and impulsive behavior)
All of the above issues can be difficult for a teenager to cope with, leading to helplessness and discouragement, which in turn can turn to self-destructive thoughts in order to make an escape from the seemingly insurmountable pressures of life.
Getting help for underlying problems, which almost always include teen depression can lead to more effective teen suicide prevention. Your support as a teenager you know enters therapy can help him or her more effectively recover and know that there are people who want to help him or her deal with the issues of life.

31. Risk Factors for Suicide Attempts
The strongest risk factors for attempted suicide in adults:
depression
alcohol abuse
cocaine use
separation or divorce
loss of job
The strongest risk factors for attempted suicide in youth:
alcohol or other drug use (including binge drinking )
aggressive or disruptive behaviors
Suicide attempts among substance abusers are 5 times greater than among people who do not abuse alcohol or other drugs:
Major depression occurs among 50 % of alcoholics vs. non-alcoholics.
Self medication leads to greater anxiety, depression, and thoughts of suicide.
Many people recovering from heroin addiction make suicide attempts.
Drug abusers often have feel unwell or unhappy. These feelings may not last long enough to qualify as major depression, but they increase the risk of attempting suicide.
There is a direct relationship between injecting drugs and suicide attempts.

32. Evaluating Teens for Attempting Suicide
Any combination of these risk factors can be key in recognizing potential teen suicide:
Family history - This can include a family history of suicide, mental
disorders, and/or substance  abuse. 
Substance Abuse - The use of alcohol and other drugs, including
prescription and over the counter drugs can create feelings of dependency,
illness and depression. When this leads to feelings of being out of control
and powerless, there is a major risk of a suicidal attempt.
Abuse and Violence - Mental, emotional, physical or sexual abuse can increase the likelihood of attempted suicide. 
Mental, emotional or physical disorders. There are some disorders that teenagers find difficult to deal with. In these cases, it is important to realize that the stress caused by these disorders can actually trigger suicidal thoughts.

33. Emotional and Behavioral Changes Associated With Suicide
Teens and/or Adults
Emotionally, the suicidal person may be feeling:
overwhelming pain
hopelessness
powerlessness
worthlessness, shame, guilt or self-hatred
fear of losing control and harming themselves or others
Behaviorally, the person may:
appear sad, withdrawn, tired, apathetic, anxious, irritable, or angry
not be performing well in school, work, or other activities
become socially isolated or fall in with the wrong crowd
have declining interest in sex, friends, or activities previously enjoyed
neglect personal welfare or let their appearance go
experience a change in eating or sleeping habits

34. Depression + Substance Use + Major Interpersonal Event = Potential Suicide
Teen Risk Factors:
Stressful situations such as breakup with boy/girlfriend /friend drama /bullying
School failure or stress to perform and achieve
Exposure to violence (mental, physical, sexual or emotional) 
Loss of a loved one 
Divorce of parents 
Change in economic or social situation 
Changing schools 
Moving to another town
Adult Risk Factors:
Unemployment or loss of job
Separation/divorce or living alone
Lack of the support of family and friends at the time of this severe upset
Serious medical problems or diagnosis

35. Sex, Drug Use Increase Teen Suicide Risk
Abstainers Have Lowest Levels of Depression
From Health Behavior News Service, Updated September 12, 2004
Denise D. Hallfors, Ph.D., a Senior Research Scientist at the Pacific Institute for Research and Evaluation in Chapel Hill, NC, and colleagues analyzed various sex and drug behavior patterns via data from a survey of nearly 19,000 teens in grades 7 through 12 from 132 U.S. schools as part of the National Longitudinal Study of Adolescent Health. The results appear in the American Journal of Preventive Medicine. Funding for the study was from the National Institute of Drug Abuse.
Research found 28 % of U.S. high school students experienced severe depression. Suicide death rates among 15- to 19-year-olds doubled between 1960 and 2001.
Teens who engage in high-risk behaviors involving sex and drugs have significantly higher odds of depression, suicidal thoughts and suicide attempts.
"These results suggest that healthcare professionals who identify adolescent patients reporting sexual intercourse or drug use should screening for depression and risk of suicide." says Hallfors. "It is particularly important not to miss opportunities to diagnose depression because effective treatments are available, or to overlook suicide risk because suicide can be prevented.”

36. The researchers clustered the teens in 16 groups according to their behaviors.
Groups included:
abstainers of sex and drugs
sex dabblers
alcohol and sex dabblers
teens with multiple sexual partners
illegal drug users
Findings:
Abstainers had the lowest levels of depression, suicidal thoughts and suicide attempts
Heavy use of illegal drugs (including “just” marijuana) and sex had the highest levels
In between were the dabblers in sex, drugs, alcohol and tobacco
Girls were less likely than boys to pursue high-risk behaviors, but girls who did were more vulnerable than boys to depression, suicidal thoughts and suicide attempts.
Surprising Socioeconomic Findings:
Higher socioeconomic status reduced the likelihood of depression by about half; however, it increased the risk of suicidal thoughts.
Hallfors believes more research is needed to understand which comes first: sex and drugs or poor mental health
All teens should be screened for sexual behaviors and drug use
Teens who do more than dabble, should be screened for depression and suicide risk

37. What Can Educators Do?
Implement and participate in Student Assistance Programs for substance use and depression. Don’t assume that only “difficult” teens are at-risk for substance abuse or suicide. Rule out the possibility of substance use FIRST with an adolescent who is not successful. Be educated in the latest trends of substance use. Don’t be afraid to question or show your concern about depression, substance use or suicidal thoughts and behavior.

38. What Recovering Students Want You to Know!
If “someone” hadn’t intervened or told my parents, I would still be using today.
Recovery is a process, not an event. One referral might not be enough.
Teachers and administrators can be manipulated and charmed.
Teachers often don’t know what is going on with drugs – right under their noses – all the time.
Lecturing students about drugs doesn’t work. Talk to them like you know what is happening and you are concerned.
Kids will be angry when you confront them about drug use or an intervention is done.
Students in recovery may look healthy (and happier) but
the trip back is hard.
Want to help? Be truthful, set limits, be a good listener
and don’t let me get away with anything.

39. The Real Deal
We read in the papers, we hear on the air, Of stealing and killing, and crime everywhere. We sigh and we say as we notice the trend, “This young generation, where will it end?” But can we be sure it is their fault alone? Maybe most of it is really our own. Too much money to spend, too much idle time, Too many movies of passion and crime. Too many children encouraged to roam By too many parents who won’t stay at home. Kids don’t make the liquor, they don’t run the bars, They don’t make the laws, nor make high speed cars. They don’t make the drugs that rattle the brain, It’s all done by older folks just greedy for gain!

40. ONLINE RESOURCES
These web sites provide substance abuse information for parents, teens, and professionals.
NIH-NIDA
Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration