1. Drugs and alcohol

2. Scale of the problem Per capita alcohol consumption doubles in last 50 years Reducing age of onset of regular drinking Associated with physical health problems Associated with neuro-cognitive deficits Age of onset associated with higher dependency, chaotic pattern of use & higher lifetime consumption SM is the single most important factor increasing the risk of suicide in young people with depression or psychosis

3. Drugs and alcohol Key Points Drinking increases with age - 14% of 12–13s, 33% of 14– 15s and 62% of 16–17s have drunk alcohol in the last wk 54% of pupils aged between 11 and 15 have smoked a cigarette, drunk alcohol or taken drugs on at least one occasion more pupils had drunk alcohol (45%) than had smoked cigarettes (27%) or taken drugs (18%).

4. Drugs and alcohol girls have caught up & possibly overtaken boys in binge drinking Beer and lager are the most popular drinks among under-18s. Spirits, wine and alcopops are also popular Ethnic minority teenagers are less likely to drink alcohol. One in 20 non-white 12-17year-olds are frequent drinkers compared with one in four whites.

5. Drugs and alcohol In 2010, the key survey estimates for 11 to 15 year olds in England included the following: 5% of pupils were regular smokers, equivalent to around 150,000 young people (CI=130,000-170,000) 13% had drunk alcohol in the last week, equivalent to around 400,000 young people (CI=370,000-430,000) 12% had taken drugs (including volatile substances) in the last year, equivalent to around 380,000 young people (CI=350,000-410,000) 7% had taken drugs in the last month, equivalent to around 200,000 young people (CI=180,000-230,000)

6. Drugs and alcohol Risk Factors Gateway Hypothesis Significant association between early onset cannabis use and subsequent illicit drug use ( Bowen & Horwood, 2006)

7. Drugs and alcohol Risk Factors (JAACAP 1997) Genetic SUD high in children of parents with Alcohol misuse. This could be direct inheritance or an association with ASPD in parents leading to conduct disorder, aggression and SUD in children Strong genetic link in alcohol (Kendler et al 1999)

8. Risk Factors Individual Extrovert personality Impulsive, risk taking teenager Depression, ADHD

9. Risk Factors Family + Environmental Parental drug & alcohol use Child maltreatment & abuse Parental separation & marital conflict Domestic – poor housing, disharmonious family Peer influences Media effect

10. Drugs and alcohol Risk Factors (JAACAP 1997) Peer relationships Less significant than previously thought in predicting drug use or misuse. Association may be because substance misusers select similar friendship groups

11. Drugs and alcohol Groups particularly at risk : Young Offenders Looked After Children Young Homeless Children whose parents misuse drugs Those who truant or are excluded from school Young people involved in prostitution Teenage mothers Young People with Mental Health Problems Care Leavers Abused children Family disintegration (Health Advisory Service 1996)

12. Drugs and alcohol Resilience Factors (JAACAP 1997) Intelligence Problem solving ability Social facility Positive self esteem Supportive family relationships Positive role models Affect regulation

13. Substance Misuse Disorder

14. ADHD 20- 30%

15. Substance Misuse Disorder ADHD 20- 30% Major depression and dysthymia 25-50%

16. Substance Misuse Disorder ADHD 20- 30% Major depression and dysthymia 25-50% Anxiety inc PTSD and phobias 20- 30%

17. Substance Misuse Disorder ADHD 20- 30% Major depression and dysthymia 25-50% Anxiety inc PTSD and phobias 20- 30% Conduct Disorder > 50%

18. Substance Misuse Disorder ADHD 20- 30% Major depression and dysthymia 25-50% Anxiety inc PTSD and phobias 20- 30% Conduct Disorder > 50% Bulimia 10-20%

19. Substance Misuse Disorder Comorbidity is the rule rather than the exception

20. Drugs and alcohol ADHD and SM ADHD - significant risk factor for SMADHD - significant risk factor for SM Risk higher if co-morbid Conduct DisorderRisk higher if co-morbid Conduct Disorder Risk very high for cocaine and nicotineRisk very high for cocaine and nicotine Stimulant Rx does not increase SM, it may protect from itStimulant Rx does not increase SM, it may protect from it

21. Drugs and alcohol ADHD and SM Stimulants can be usedStimulants can be used Long acting stimulants bestLong acting stimulants best Atomoxetine little abuse potentialAtomoxetine little abuse potential Tricyclics and clonidine high risks and low evidenceTricyclics and clonidine high risks and low evidence

22. Depression and SM Major depression common Adult studies - SSRI’s help in reducing depression and alcohol misuse 2 open studies of FLX in young people showed reduction in craving and frequency and severity of alcohol misuse Drugs and alcohol

23. SM and PTSD Very often missed - self medication common BDZ dependence is common Transfer to long acting BDZ Consider trial of SSRI or Mirtazapine Alcohol abuse not uncommon Specific PTSD treatment often required after management of SM Drugs and alcohol

24. SM and Psychosis Lithium in Bipolar and co-morbid alcohol and cannabis use : significant reduction in SM (Geller et al 1998) Open study - Clozapine reduces SM in schizophrenia and co-morbid SM ( Brunette et al - Schizophr Bull 2006) and co-morbid SM ( Brunette et al - Schizophr Bull 2006) ( Tsaung et al – AJP 1999 ) ( Tsaung et al – AJP 1999 ) Specific treatments for SM like Motivational Enhancement effective in Schizophrenia Drugs and alcohol

25. Urine testing Amphetamine : 2-4 days Barbiturates: 2-4 days Benzos: Up to 30 days Cocaine: 1-3 days Heroin: 1-3 days Cannabis: 1-3 days (Infrequent use) : 30 days (Chronic use) PCP: 2-7 days ( Acute use) : 30 days (Chronic Use) Drugs and alcohol

26. 15 year old girl. Referred by her drugs worker. Young person requests a psychiatric view of her difficulties Alcohol use is heavy and harmful bottle vodka per day. Cannabis use daily for 4 years Intermittent E’s, Amphet and Cocaine Separate up and think about assessment. What are you looking for Drugs and alcohol

27. Post traumatic symptoms numbing, vigilance, arousal, flashbacks, insomnia Depressive symptoms School failure What do you do next ? Drugs and alcohol

28. Family separation when 7. Lived with mother and sister. Mother’s new partner avoided. No relationship built. 2 suicide attempts aged 7 and 9. One by stuffing tissues into her mouth and one by throwing self into swimming pool What else do you want to know Drugs and alcohol

29. As a child was physically abused by father Watched mother being physically and sexually abused by father Father terrifying man Although lives abroad still uses young person to manipulate her mother How are you going to treat her ? Drugs and alcohol

30. Does alright. Good work with drug and alcohol worker Engages with individual therapist Then sudden deterioration. Why ? What kind of thing would you look for Drugs and alcohol

31. Trip out to party with friend Frightening experience where 4 adult men try to have sex with her a friend She fights her way out but friend is raped in front of her You want to give her an antidepressant Which one and why What are your concerns Drugs and alcohol