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Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY Ray C. Hsiao, MD Assistant Professor of.

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Presentation on theme: "Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY Ray C. Hsiao, MD Assistant Professor of."— Presentation transcript:

1 Assessment and Treatment of Adolescent Substance Use Disorders: Practical Tips for Primary Care Providers in WY Ray C. Hsiao, MD Assistant Professor of Psychiatry, University of Washington Co-Director, Adolescent Substance Abuse Program Seattle Children’s Hospital PAL Conference, Laramie, WY; 3/24/12

2 Objectives Participants will learn about the prevalence and patterns of substance use and substance use disorders (SUDs) in adolescents Participants will become familiar with common screening and assessment tools of SUDs in adolescents Participants will be able to describe and utilize common treatment options for SUDs in adolescents

3 Disclosure No conflict of interest to report Off-label discussion of medications

4 Overview DefinitionsPrevalence Screening: the Adolescent Perspective and Risk and Protective Factors AssessmentTreatment Co-Occurring Disorders Questions and Answers

5 Substance-Related Disorders Substances covered in DSM IV-TR: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine, Sedative/Hypnotic/Anxiolytic, Other/Unknown Substance Use Disorders (SUDs) = Substance Abuse or Dependence Substance-Induced Disorders = Substance Intoxication or Withdrawal Nicotine & Polysubstance: No Abuse Caffeine: No Abuse or Dependence

6 Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring at anytime within a 12-month period: Recurrent use resulting in a failure to fulfill major role obligations at work, school or home Recurrent substance use in situations in which it is physically hazardous Recurrent substance-related legal problems Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance Never met criteria for dependence

7 Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: Tolerance: “a need for markedly increased amounts of the substance to achieve intoxication or desired effect” or “markedly diminished effect with continued use of the same amount of the substance” Withdrawal: “the characteristic withdrawal syndrome for the substance” or “the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

8 Substance Dependence Substance is often taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful efforts to cut down or control substance use Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover Important social, occupational, or recreational activities are given up or reduced Substance use is continued despite knowledge of persistent or recurrent physical or psychological problem caused or exacerbated by substance

9 Dependence Specifiers With Physiological Dependence Without Physiological Dependence Course Specifiers Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled Environment

10 Polysubstance Dependence Repeatedly using at least 3 groups of substances (not including caffeine or nicotine) Dependence criteria were met as a group but not for any specific substance Most commonly in individuals where the substance use is highly prevalent but the drugs of choice frequently changed

11 DSM 5: Substance Use Disorders 11 criteria: replaced “legal problem” with “craving or a strong desire or urge to use a specific substance” New Severity Specifiers Moderate: 2-3 criteria positive Severe: 4 or more criteria positive Same Course Specifiers as DSM IV-TR Potentially identify problematic use earlier and lead to proper intervention

12 Frequently Asked Question # 1 How common is substance use in adolescents? Who is using? What are they using?

13 Quiz #1 How common is substance use? In a class of 100 high school seniors, how many have tried the following during their lifetime: Cigarettes?Alcohol? Illicit Drugs? Illicit Drugs other than Cannabis?

14 Prevalence of Substance Use Monitoring The Future (MTF) Study NIDA funded national study Middle/high school, college, young adults 40,000+ adolescents from 300+ sites Survey behaviors/attitudes on substance use Annual follow-up survey to graduating class

15 MTF Lifetime Prevalence: 2011 8th10th12th Any Cigarettes 18.4%30.4%40.0% Any Alcohol 33.1%56.0%70.0% Any Illicit Drug 20.1%37.7%49.9% Any Illicit Drug other than MJ 9.8%15.6%24.9%

16 MTF Lifetime Prevalence: 2011 8 th 10 th 12th Marijuana16.4%34.5%45.5% Inhalants13.1%10.1%8.1% Amphetamines5.2%9.0%12.2% Heroin1.2%1.2%1.4% Hallucinogen3.3%6.0%8.3% Cocaine2.2%3.3%5.2% Methamphetamine1.3%2.1%2.1% Ecstasy/MDMA2.6%6.6%8.6% Tranquilizers3.4%6.8%8.7% Other Narcotics N/AN/A13.0%

17 Summary of MTF Trend Findings Male generally more drug use College-bound adolescents use less Regional variation is quite complex & changing Population density is not a predictor of use Socioeconomic class difference mostly small Whites ≥ Hispanics > African Americans: Hispanics in 8 th grade higher in most categories but may have higher drop-out rate and earlier initiation to account for lower numbers in 12 th grade

18 Quiz #2 In adolescents ages 12-17: How common is Substance Abuse? How common is Substance Dependence?

19 Prevalence of SUDs National Household Survey on Drug Use and Health (NHSDUH) Formerly NHSDA(buse) Youth 12-17 years old: survey use and abuse 8% classified with SUDs in 2005 (3.1% Abuse, 4.9% Dependence): 8.3% for males, 7.8% for females 7.3% classified with SUDs in 2010 (4.5% Alcohol, 4.7% Illicit drugs): 6.9% for males, 7.7% for females

20 Prevalence of SUDs National Comorbidity Survey-Adolescent Supplement ( NCS-A): Merikangas et al, JAACAP 2010 Youth 13-18 years old: diagnostic survey 11.4 classified with SUDs: (6.4% Alcohol, 8.9% Illicit drugs): 12.5% for males, 10.2% for females SUDs rates by age group: 13-14: 3.7% 15-16: 12.2% 17-18: 22.3%

21 NHSDUH 2010: SUDs Pattern Most Common Types of Substance Used: Alcohol > Marijuana > Pain Relievers > Cocaine > Others (methamphetamine, heroin, hallucinogen) Polysubstance use is common Reflected in most treatment studies and clinical trials (O’Brien et al 2005)

22 Summary: Epidemiological Studies Experimentation is normative but consequences can be severe and far- ranging Abuse is the exception: look for early initiation and heavy use “Gateway Theory”: Cigarettes  Alcohol  Cannabis  Other illicit drugs

23 Frequently Asked Question #2 How do I know whether my patient is using too much or not? (i.e., Is he/she just a typical teenager or someone who needs an intervention or assessment)

24 Tasks of Adolescence Emancipation/surrender of childhood Identity formation SexualIntellectualMoralSpiritualEthnic Functional role in society

25 Risk Factors for SUDs Newcomb 1997 Four generic domains Cultural/Societal Interpersonal: family and peers PsychobehavioralBiogenetic Relevance modified by age, gender, and ethnicity Relevance modified by age, gender, and ethnicity

26 Mediating Factors Early experimentation Substance-Dependent parents Substance-Abusing siblings Conduct disturbances Deviant and substance-abusing peers Sensation-seeking temperament Impulse and self-control problems

27 Mediating Factors Poor parental supervision Heavy drug-use neighborhoods School problems Social skills deficits Parents with poor parenting skills Victims of trauma, abuse and neglect

28 ADHD Depression ODD CD ASP Substance Use Abuse Dependence Family 010 20 5 15 PEERS Resilience Resilience SUD, abuse, neglect School Truancy, failure, HS dropout School Truancy, failure, HS dropout Antisocial; drug-using Antisocial; drug-using Riggs’ Developmental Pathways to Adolescent Mental Health, Substance Problems Genetics Attachment Individual Fetal Exposure Drugs/Alcohol IMPEDES DEVELOPMENT Coping skills Social /interpersonal skills Communication skills Identity, values consolidation Affect identification/regulation Self-Efficacy/external locus control Cognitive development Pro-social network IQ; academic performance; female hobby; empathic gatekeeper

29 Quiz #3 What is the screening instrument recommended by the American Academy of Pediatrics for adolescents with substance use disorders?

30 Screening/Testing CRAFFT (Knight 2002): screening; 2 or more of the following indicate significant problem CarRelaxAloneFamily/friendsForgetTrouble Drug testing: urine or other modalities

31 Frequently Asked Question #3 What do I do if my patient is in need of an assessment or intervention? What happens at a chemical dependency assessment? Who performs the assessment?

32 Chemical Dependency Assessment Usually performed by Substance Abuse Counselors/Chemical Dependency Professionals (CDPs) Assessment usually consists of a clinical interview that addresses the 6 dimensions of American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC)

33 Quiz # 4 How many dimensions of the ASAM PPC can you name?

34 ASAM PPC Dimensions I: Acute intoxication and/or withdrawal potential II: Biomedical conditions and complications III: Emotional, behavioral, or cognitive conditions and complications IV: Readiness to Change V: Relapse, continued use, or continued problem potential VI: Recovery environment

35 Quiz # 5 Can you name the 4 different levels of chemical dependency treatment identified in the ASAM PPC?

36 ASAM PPC Levels Level 0.5: Early Intervention Level I: Outpatient Services: <9hours/week Level II: Intensive outpatient (9-19 hours/week)/ Partial hospitalization (>20 hours/week) Level III: residential/inpatient services (e.g., imminent risk in relapse, continued use or recovery environment) Level IV: medically managed intensive inpatient services (e.g., imminent risk in D1, D2, or D3)

37 Psychiatric Assessment Multiple domains: Timeline approach Psychiatric/behavioralFamilySchool/VocationalRecreational/LeisureMedical Collateral, collateral, collateral!!! Toxicology

38 Pre-natal Attachment School-age Adolescent College-age Adult Longitudinal Developmental History  Pre-natal; attachment Onset and Progression of Psychiatric Symptoms  ODD/CD  ADHD  Depression  Mania /hypomania  Anxiety (SAD, PTSD, GAD, OCD)  Psychosis Peers  Deviancy  Substance Use  Gang Substance Use  Onset, experimentation  For all substances used >5x  Progression to regular use  Peak use  Current use (last month)  Last use School  LD; special education  Behavior problems  Academic performance Riggs’ Lifetime Timeline Riggs’ Lifetime Timeline  Family  Abuse, neglect, conflict, SUD  Family management  Parental monitoring

39 Frequently Asked Question #4 How do I get my patient into treatment? What happens when my patient is in treatment in Washington State?

40 Outpatient/Intensive Outpatient Services Non-residential programs providing chemical dependency assessments, alcohol/drug free counseling services and education for youth age 10 to 20 Designed to screen, assess, diagnose, and treat misuse, abuse, and addiction to alcohol and other drugs

41 Detox/Stabilization Services Services providing at-risk, runaway, homeless youth age 13-17 a safe, temporary, and protective environment Criteria: experiencing crisis related to the harmful effects of intoxication and/or withdrawal from alcohol and other drugs, in conjunction with an emotional or behavioral crisis Typical length of stay: 1-5 days

42 Inpatient Treatment Programs designed for “chemically dependent” youth age 13-17 Services include intensive individual, group, and family counseling, education, school activities, recreation, recovery support groups, and connection to continuing treatment in the home community

43 Levels of Inpatient Services Level 1 Primary addiction problems requiring less clinical intervention and behavior management Level 2 Co-occurring emotional and mental health problems, youth resistant to treatment, or high probability to run from treatment Recovery House Continued residential stay after completing primary inpatient treatment

44 NHSDUH 2010: Treatment Needs Overall: 1.8 million youths aged 12-17 (7.5% of sample population) needed treatment -> 138,000 youths received treatment at a specialty facility (7.6% of youths who needed treatment) Most treatment occurred in outpatient settings

45 Barriers to Treatment Five most often reported reasons for not receiving treatment (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) Not ready to stop using (40.2%) Cost or insurance barriers (32.9%) Stigma (e.g., negative opinions from neighbors and community, negative effect on job) (22.8%) Can handle the problem without treatment (9.9%) Did not know where to go (9.3%)

46 Barriers to Treatment Five most often reported reasons for not receiving treatment despite seeking treatment: (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older) Cost or insurance barriers (45.2%) Not ready to stop using (30.3%) Treatment not needed (15.5%) Stigma (15.0%) No Transportation/Inconvenient (8.4%)

47 Additional Complications in Adolescent SUD Treatment Polysubstance use: typically alcohol and marijuana, occasional cocaine or opiates (Winters et al 2000; Kaminer et al 2002; Henggeler et al 1996) High rates of comorbid psychiatric disorders (Armstrong et al 2002) High rates of substance abuse in immediate families (Henggeler et al 1996; Winters et al 2000) Developmental vulnerability Involvement in multiple systems: legal, school, and medical problems may present first High attrition rate: 50-80% (Henggeler et al 1996)

48 Frequently Asked Questions #5 Does treatment work? (e.g., “I’ve known people who have been through rehab many times but they are still addicted”)

49 Why Treatment Inconsistent outcomes after treatment prior to 1990’s (Catalano et al. 1992) Treatment might escalate problems (Kaminer 2005; Dishion et al 1999) Recent reviews show psychosocial treatment is better than no treatment (Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006) Effective early intervention is critical and can be preventive in later years (Grant & Dawson 1997; Santisteban et al. 2003; NHSDUH series)

50 Treatment Evaluation Studies: Older Studies Older studies tend to be evaluations of four types of programs “Minnesota Model”: comprehensive 4-6 week inpatient program using 12-Step Outpatient drug-free programs: individual and group with some family counseling “Therapeutic Community”: 6-12 months residential program using 12-Step Outward Bound or life skills training programs: 3-4 weeks wilderness program focusing on challenges of survival and group interdependency

51 Treatment Evaluation Studies: Older Studies On average 50% reported they had reduced use measured in days and 38% followed had complete abstinence at 6 months (Williams et al 2000) Limited by methodological problems: tend to be evaluations of inpatient programs (Dennis & White 2003) Uncontrolled evaluation of single program Few control groups Varied primary outcome measures Reliance on self-report or clinical records Lack of standardized or validated measures Limited follow-up

52 Frequently Asked Question #6 What kind of treatment should my patient be getting?

53 Quiz # 6 How many “evidence-based” treatment can you name for adolescents with substance use disorders?

54 Emerging Evidence for Psychosocial Treatments Emerging evidence for interventions in individual or group settings and in combination Family-based approaches Behavioral Therapies Cognitive Behavioral Therapy (CBT) 12-Step Programs Harm Reduction Motivational approaches

55 Emerging Evidence for Psychosocial Treatments Studies often had limitations (O’Brien et al 2005) Differential attrition No validated independent outcome measures with objective evaluation of drug use Small sample sizes No specification and evaluation of treatment fidelity and quality Dilution of interventions Limited follow-up

56 Multisystemic Therapy Manualized approach addressing multiple determinants of substance use and antisocial behaviors Engage family members as collaborators Stressing the strength of youth and families Addressing barriers to treatment goals Therapists familiar with several therapies including CBT and structural family therapy Frequent home visits and on-call full time

57 Brief Strategic Family Therapy (BSFT) Less intensive than MST: fewer systems and less frequent (weekly office visits) Target patterns of interactions Engaging all family members in treatment Identify family strengths and roles and relationships linked to problem Develop new family interactions to protect the adolescent (e.g. parenting skills; conflict resolution)

58 Multidimensional Family Therapy (MDFT) Multicomponent, staged, family therapy Liddle et al 2001: 182 SUD adolescents MDFT vs Group (CBT) vs Multifamily education 6 months of weekly sessions: 70% completed MDFT superior at 6 and 12 months 42% vs 32% vs 26% Other promising family interventions include family system therapy (FST) and functional family therapy (FFT)

59 Behavioral Therapy Operant conditioning principles to address reinforcing properties of substances Azrin et al 1994: 26 substance-using youths Behavior therapy vs supportive counseling Modeling, rehearsal, self-monitoring, homework Behavior therapy had better school and family functioning and less substance use on urine toxicology screens and self-reports

60 Behavioral Therapy Contingency management: utilize reward systems Vouchers (Higgins et al 1994) or Fishbowl (Petry et al 2000) Cash incentives reduced smoking (Corby et al 2000) Vouchers improved treatment retention (Sinha et al 2003)

61 Cognitive Behavioral Therapy Based on social learning theory Functional analysis of substance use Skills training and self-regulation strategies Waldron et al 2001: 129 SUD adolescents FFT(12hrs) vs Individual CBT(10+2 MET) vs CBT+FFT(24) vs Psychoed/CBT group (12) 70-80% completion: follow-up at 4, 7, 19 months Significant reduction for all: FFT & CBT+FFT better and effects persisted at 7-month follow-up Waldron et al 2003: 31 SUD treatment refusers Ind. CBT reduced use but use was still heavy

62 Cognitive Behavioral Therapy Kaminer et al 2002: 88 SUD adolescents 8 weeks of Group CBT vs Psychoed group 86% completion; 65% available for 9-month follow-up CBT>Psychoed for males; same for females Same at follow-up with high relapse rate 52% high drop out rate with Conduct Disorders Emerging support in comparison studies ( Liddle 2002; Liddle et al 2001)

63 Twelve-Step Programs Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and many other substance specific programs Focus on building support network Spiritually based and abstinence only Most common but no RCT: TSF effective in adult studies (Project Match 1997; Carroll et al 1998) “Minnesota Model” study (Winters et al 2000) Better substance & psychosocial outcome

64 Harm Reduction Client centered approach applying readiness to change concept Precontemplation, contemplation, preparation, action, maintenance, relapse Focus on reducing consequences of use Develop strategies and skills Emerging adolescent data (Toumbourou et al 2007) Controversial but valuable as intermediate treatment goal (AACAP 2005)

65 Motivational approaches Motivational interviewing (MI) Client-centered approach focusing on ambivalence Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy Motivational Enhancement Therapy (MET) Assessment interview + personal feedback using MI techniques Commonly used in combination with others

66 Motivational approaches MI Techniques (Miller & Rollnick 2002) Open-ended questions Listen Reflectively AffirmSummarize Elicit self-motivational statements Monti et al 1999: MI vs TAU 94 adolescent in ER: alcohol related problem MI decreased problems at 6-months

67 Cannabis Youth Treatment (CYT) 600 adolescents from 4 sites MET/CBT5 vs MET/CBT12 vs Family Support Network vs MDFT vs Adolescent Community Reinforcement Approach (ARCA): 6-21 sessions over 5-12 weeks 95% follow-up rate up to 30-months All performed equally well: 50% reduction Effects maintained at follow-up

68 Pharmacological Treatment Limited research with few controlled studies and very small samples (Waxmonsky & Wilens 2005) Nicotine Bupropion (Wellbutrin) (Upadhyaya et al 2005) Nicotine Replacement Therapy Alcohol Disulfiram (Antabuse) Naltrexone (Deas et al 2005) AcamprosateOpiateMethadoneBuprenorphineNaltrexone

69 SUD Treatment factors Treatment > none & Longer better Pretreatment Non-white, high severity, criminality, lower educational status = poorer outcome Intreatment Time, family, skills, scope of services Posttreatment Peers, activities Positive factors Treatment completion, low pretreatment use, peer & parent social support

70 Summary Treatment is better than no treatment Well-defined structured approaches targeting broad dimensions work best Treatment completion-> better outcome Most support for family-based tx Growing support for CBT, Contingency Management, Motivational approaches Difference in effect may be time and person dependent

71 Co-Occurring Disorders SUDs + Mental Disorders: evolving COD is the rule, not the exception 60% (Armstrong & Costello, 2002) Disruptive Behavior Disorders (DBDs) Depression & other mood disorders Anxiety disorders Attention-Deficit Hyperactivity Disorder (ADHD) Learning disabilities & sensory problems Others: Bulimia, Psychosis, Personality Disorders

72 Co-Occurring Disorders Presence of psychiatric disorders leads to increased risk of SUDs Especially Conduct and Depressive Disorders COD vs. SUD alone: More alcohol or drug dependence More family, school, criminal problems More likely to engage in delinquent behaviors and use hallucinogens & cannabis in the 12 months after treatment Treatment needs to target both SUD and psychiatric problems (Pumariega et al 2004) Medications have increased role Tackle comorbid problem aggressively

73 ADHD Depression ODD CD ASP Substance Use Abuse Dependence Family 010 20 5 15 PEERS Resilience Resilience IQ; academic performance; female hobby; empathic gatekeeper SUD, abuse, neglect School Truancy, failure, HS dropout School Truancy, failure, HS dropout Antisocial; drug-using Antisocial; drug-using Evidence-Based Treatment of Adolescent SUD Genetics Attachment Individual Angold et al., 99; Capaldi et a 1992l., 199 Ingoldsby et al 2006; Fergusson et al., 1998; Lewinsohn,Rohde et al.,1995 Fetal Exposure Drugs/Alcohol Adolescent Brain Development Family-based interventions  Multidimensional; MST; BSFT;  Functional Family Therapy (FFT) Behavioral interventions  Operant Principles  Contingency Management  Motivational Incentives Motivational Enhancement Therapy Cognitive-behavioral therapy (CBT) Pharmacotherapy (adult trials)  Aversive (disulfram)  Antagonists (naltrexone)  Agonists (methadone, buprenorphine)  Detoxification protocols

74 Integrated Treatment Riggs et al., 2007: Landmark study 126 adolescents 13-19 16-week individual CBT+Fluoxetine vs. CBT+Placebo for SUD+MDD+CD MDD remission: Fluox > Placebo on CDRS-R SUD: reduce use in both groups Remitters > non-remit Conduct: reduced in both groups Remitters > non-remit Riggs et al., 2007: Follow-up CBT retained gains at one year follow-up

75 Overall Summary SUDs are complex disorders Uniqueness of adolescents: Problems with classification/nomenclature Epidemiological data to enhance understanding Prevention efforts Treatment development

76 Suggestions for Primary Care Providers Remember the “1 in 10” rule Use screening tools: when in doubt -> REFER! Gather collateral information (including drug testing) and educate parents on warning signs Know your local resources and assemble your own referral/treatment network Inquire about training, modality of treatment, treatment philosophy, scope of services Support groups for patients/families

77 Suggestions for Primary Care Providers Know your state law: age of consent for treatment, confidentiality Encourage adolescents to engage in pro-social activities and recovery support Treat Co-Occurring Disorders: consider medications for primary psychiatric disorders Consider training in Motivational Interviewing and Twelve Step Facilitation Consider training in Buprenorphine Judicious use of medications with addictive potentials when indicated

78 Additional Useful Resources NIDA for Teens Resources for Parents/Teachers Resources for Providers Facts for Families Practice Parameters Wikipedia: common slang terms for illicit substances and current trends but need to verify original source Free training opportunities: Hazelden

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