Substance Use Disorders

Vape Rates for Nicotine and Weed Going Up

-8th: 17.6% -9th: 32.3% -10th: 37.3%

DSM-5 Table for Substance Use Disorder

(A) A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: (1). Substance is often taken in larger amounts or over a longer period than was intended. (2). There is a persistent desire or unsuccessful effort to cut down or control substance use (3). A great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects. (4). There is a craving or a strong desire or urge to use substance (5). Recurrent substance use results in failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household). (6). Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. (7) Important social, occupational, or recreational activities are given up or reduced because of substance use. (8) There is recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use). (9) 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. (10) Tolerance, as defined by either or both of the following: a. A need for markedly increased amounts of substance to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of the substance. (11) Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for a substance. b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. Specify if: In early remission: None of the criteria have been met for at least 3 months but for less than 12 months (with the exception of "craving") In sustained remission: None of the criteria have been met at any time during a period of 12 months or longer (with the exception of "craving") Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to substance is restricted. Specify current severity: Mild: Presence of two to three symptoms Moderate: Presence of four to five symptoms Severe: Presence of six or more symptoms

risky use

- Continues use despite hazards - Continues use despite worsening physical or psychological problems

Nicotine withdrawal symptoms

- Dysphoria or depressed mood - Insomnia, irritability, frustration, or anger - Anxiety, restlessness and difficulty concentrating - Decreased heart rate and increased appetite or weight gain

Impaired Control

- Uses more substance, or for longer, than intended - Tries unsuccessfully to regulate substance use - Spends much time gaining, using, or recovering from substance use - Craves the substance

Rates of Substance Use Disorders in Adolescents

-6% -boys more than girls

Alcohol Use

-70% of people use alcohol at some point -use increases in adolescne, and dicreases in adulthood

Age of Onset

-A certain amount of substance use during adolescence is normative behavior; therefore, researchers have looked at several factors that may differentiate trajectories of use that are relatively benign from those that have lasting significance. -Age at first use is one of the most widely supported risk factors for the onset of substance-use problems and subsequent disorders -The Canadian National Longitu-dinal Survey of Youth (NLSY), for example, found that the odds of developing alcohol dependence decreased by 9% for each year that the onset of drinking was delayed (Grant, Stinson, & Harford, 2001). In gen-eral, researchers find that alcohol use before age 14 is a strong predictor of subsequent alcohol abuse or dependence, especially when early drinking is followed by rapid escalation in the quantity of alcohol consump-tion

social impairment

-A failure to fulfill major role obligations at work, home, or school. -cont. use despite social/interpersonal problems -important activities given up/reduced

Cause: Family Background

-Adolescents with a positive family history for alco-holism may inherit certain brain structures and func-tional abilities from one or both parents. In particular, they show greater activation in the frontolimbic areas of the brain, as compared with teens without such family histories (Silveri et al., 2011). Such activation is associated with poor inhibition, suggesting they may have a neurobiological vulnerability that reduces their ability to inhibit risk-taking behaviors such as substance use -Part of the picture for youths with histories of parental alcohol abuse lies not only in neurobiological factors but also in child rearing and family functioning more generally. Based on a systematic review of 131 studies, three parenting risk factors affecting teens' initiation and problematic alcohol and drug use have been identified: parents' providing alcohol to their kids, favorable parental attitudes toward alcohol, and parental drinking. Conversely, four protective factors have been identified that decrease teens' risk: parental monitoring, parent-child relationship quality, parental support, and parental involvement -It demonstrates that even at a time when youths are turning to their peers for cues about accept-able behavior, parent attitudes and parental drinking patterns still play an important role -Similarly, low parental monitoring—or the extent to which parents do not know "where their adolescents are and who they are with"—has consistently emerged as a predictor of adolescent substance use (DiClemente et al., 2001; Shorey et al., 2013). Interestingly, it seems to be the teens' perception of parental monitoring that is important. (Presumably, there is a correlation between adolescent perceptions of parental monitoring and actual parental practices.) Related family char-acteristics that have been linked to adolescent sub-stance use include poor parent-teen communication, poor family values, family conflict, and past trauma

Overview

-Although most adolescents experiment with substances ranging from cigarettes to street drugs without experiencing adverse effects, the risks include increased mortality and morbidity related to impaired driving, unsafe sexual practices, aggression, and similar concerns -Frequent and prolonged consumption not only increases their risk of developing a substance-use disorder, but it also interferes with the development of important psychosocial skills in young adulthood -The use and abuse of substances (e.g., nicotine, alcohol, marijuana, and other drugs) is an increasing area of concern, particularly in adolescents. Substance abuse has physical implications for the developing child or adolescent, and it may produce symptoms that mimic other psychopathological behaviors. Substance abuse is also related to a wide variety of psychological disorders.

Sex and Ethnicity

-Although past surveys have found that girls typically use fewer types of drugs and use them less often than boys, sex differences in the lifetime prevalence rates of substance use are converging, due mostly to increased substance use among girls. By 2005, girls caught up to boys by the tenth grade and the rates have remained equivalent ever since. Similarly, rates of diagnoses for SUDs no longer differ significantly between boys and girls -Ethnic differences in rates of substance use and abuse in the 30 days leading up to a survey are shown in ● Figure 13.3. For many years, black or African American youths had substantially lower rates of use of any illicit drug than did whites, but the differences have narrowed in recent years, mostly due to increasing marijuana use among African American students. Hispanics' rates of use for many drugs tend to fall near or below rates for whites and African Americans. However, His-panic seniors have the highest rate of lifetime usage for powder cocaine, crack cocaine, heroin with and without a needle, methamphetamine, and crystal methamphetamine

Associated Characteristics

-Among adolescents who fit criteria for substance-use disorder, many related symptoms and behaviors have been noted. These youths tend to use more than one drug simultaneously, with marijuana and alcohol the most common combination, followed by alcohol and hallucinogens (Conway et al., 2013). They also have problems related to poor academic achievement, higher rates of academic failure, higher rates of delinquency, and more parental conflict -Emerging research also suggests that heavy drinking may be physically more dangerous at 15 years of age than a few years later at age 20, because it may disrupt or dis-turb ongoing neurodevelopmental processes of myelina-tion and synaptic pruning (Luciana et al., 2013; Welch, Carson, & Lawrie, 2013). As compared with teens with lower substance-use levels, teens with histories of heavy drinking performed poorly on tests of memory and atten-tion, in addition to exhibiting other signs of abnormal neurological development (Sullivan et al., 2016; Welch et al., 2013). The adolescent hippocampus may be par-ticularly susceptible to alcohol, potentially because of an interaction between adolescent brain development and alcohol exposure

Importance of Transitions and Prevention

-Because adolescence is a time of rapid, major transitions and changes in physical, emotional, and social domains, universal and targeted prevention efforts related to substance use increasingly are being introduced at the elementary and secondary school levels. -Facilitating successful transitions—for example, in the areas of romantic and peer relationships, sexual behavior, and healthy lifestyle choices—has the added major benefit of reducing multiple problematic out-comes in later life -Critical health-damaging behaviors that are preventable include substance use and abuse, unsafe sexual practices, and abusive behavior, which all have a common context of peer and dating relationships -These prevention efforts are being recognized as having important payoffs in terms of reductions in future health problems and enhance-ment of personal goals

Cigarette Use in Adolescents

-Cigarette smoking continued its down-ward trend: in the month leading up to the survey, 11% of high school seniors had smoked cigarettes, a huge decline since its peak of 37% in 1977.

weed and cigarette use among 12th graders

-Cigs: 24.6% (1997) / 4.2%(2017) -Weed: 1.9% (1992)/ 5.9% (2017) -more likely to smoke weed

Cause: Peers and Culture

-Given the importance that peer culture generally plays in adolescents' lives, it is not surprising that peer influ-ences play a large role in determining substance use. The role of peers seems to operate in more than one way. For example, associating with deviant and sub-stance-using peers likely causes youths to adopt beliefs supporting drug use (we tend to have beliefs similar to those of our friends). At the same time, affiliation with these peers also increases access to substances. In addi-tion, the idea of a false consensus (i.e., the belief that everyone is doing it) exerts pressure on youths to engage in substance use. The extent to which individual teens think that their peer group is using substances is related to the individual's decision to use or not use substances (Branstetter et al., 2011). Peer culture also glamorizes substance use, encouraging teens to use alcohol and drugs as a way of "fitting in." About one-third of hit songs, including three-quarters of rap songs, have some form of explicit reference to drug, alcohol, or tobacco use

Cause: Personality and Developmental Factors

-Some studies have shown a link between developmental changes in sleep and circadian rhythms during adolescence, dis-cussed previously, and the risk of alcohol-use disorders -The significant adjustments in the sleep-wake cycle that occur during adolescence can lead to a misalignment between teens' sleep-wake schedules and their internal circadian timing. This mis-alignment, in turn, alters the adolescent's reward-related brain functions. Specifically, critical neurocognitive abilities, such as executive functioning and inhibitory control, are impaired by sleep problems, which lead to an imbalance within the reward circuit. -This circadian imbalance and its related effects on brain development may explain the increased risk-taking and sensation-seeking during adolescence, which accelerates the transition from alcohol and drug experi-mentation to alcohol-use disorders among teens (Oshri et al., 2013; Stautz & Cooper, 2013). Sensation seeking has been described as a preference for novel, complex, and ambiguous stimuli, and it has been linked to a range of high-risk behaviors, including adolescent sub-stance use (Heinrich et al., 2016; Tapper et al., 2015). A longitudinal study looking at two samples of ado-lescents between grades 8 and 10 found that sensation seeking had a strong predictive value for both current and future marijuana and alcohol use (Crawford et al., 2003). The relationship between sensation seeking and substance use was strongest for predicting marijuana use, followed by alcohol use, and to a lesser extent, cig-arette use. Furthermore, there were both sex and eth-nicity differences in levels of sensation seeking—males tended to score higher than females, and white ado-lescents tended to score higher than adolescents with other ethnic backgrounds. However, sensation seeking was not stable over time, suggesting that a window of opportunity may exist to intervene and prevent sensa-tion seeking. -There are also many attitudes that predict sub-stance use; some relate directly to substance use and others are more general attitudes. Having positive attitudes about substance use (i.e., high perceived ben-efit and acceptability, low perceived risk) and having friends who hold similar views are attitudes and beliefs associated with substance use (Bountress, Chassin, & Lemery-Chalfant, 2017; Brooks-Russell et al., 2013). Perceiving oneself to be physically older than same-age peers and striving for adult social roles are also risky attitudes. Finally, how highly positive adolescents feel about school—in particular, how connected they feel to their school community—is associated with a lower risk for use of substances (Holmbeck et al., 2006). This concept of school connectedness is a nonspecific risk factor; that is, adolescents who feel engaged with and supported by their school tend to exhibit lower levels of risk behavior in a variety of domains (e.g., substance use, violence, sexual behavior, suicidality). In contrast, youths who are more alienated and not involved in school tend to report higher levels of these behaviors.

Differences between Adults and Adolescents

-Substance-abusing adolescents experience withdrawal symptoms, but their physiological dependence and symptoms are less common than the withdrawal symptoms experienced by adults. -Adolescents are more likely to show cognitive and affective features associated with substance abuse and/or withdrawal, such as disorientation or mood swings -SUDs among youths also differ from those of adults in terms of their pattern of use, which is likely a func-tion of the restrictions on availability. For example, adolescents tend to drink less often, but drink larger amounts at any one time than adults drink (i.e., binge drinking), which is associated with acute health and social risks -Adolescents' sub-stance use also is strongly influenced by peers, their desire for autonomy and experimentation with adult "privileges," and the level of parental supervision they receive (Branstetter, Low, & Furman, 2011; Lippold, Greenberg, & Collins, 2013). These influences affect the expression and features of the SUDs in ways that differ from those of adults.

DSM-5 Substance Use Disorder

-The central diagnostic feature is straightforward: a problematic pattern of substance use leading to significant impairment or distress. -To meet this criterion, an adolescent (or adult) must show two or more significant clinical signs of dis-tress for at least 12 months. The 11 possible signs of distress shown in Table 13.6 reflect four groupings of symptoms that capture the core features of this diagnosis (APA, 2013): impaired control; social impairment; risky use; and pharmacological criteria

Treatment Outcomes

-Treatment outcomes for adolescents with SUDs have been mixed. Approximately half of adolescents receiving treatment for SUDs relapse within the first 3 months after treatment, and only 20% to 30% remain abstinent at 1 year -Despite limitations, among the more promising treatments for adolescent substance abuse are those that involve the larger systems affecting the adolescent's behavior, such as peers, family, and school climate -Other effective methods focus on personality factors linked to alcohol abuse, such as hopelessness, anxiety sensitivity, impulsivity, and sensation seeking

Course

-Typically, rates of substance use peak around late adolescence and then begin to decline during young adulthood, in conjunction with adult roles of work, marriage, and parenthood -However, for some youths, a pronounced pat-tern of early-onset risk taking may signal a more troublesome course that can threaten their well-being in both the short term and long term. As we note in Chapter 9 on conduct disorders, concern is particularly warranted when high-risk behaviors begin well before adolescence, are ongoing rather than occasional, and occur among a group of peers who engage in the same activities -Indeed, most adolescent risk and problem behaviors co-occur, so an indication of one problem is often a signal that others may be happening or on their way -Although experimentation with substances is com-monplace among teenagers, it is not harmless; sub-stance use lowers inhibitions, reduces judgment, and increases the risk of physical harm and sexual assault (Oshri et al., 2013; Thompson et al., 2008). A survey of Canadian high school students found that alcohol use influenced the practice of, or involvement in, many other high-risk behaviors (Feldman et al, 1999), most notably unsafe sexual activity, smoking, and drinking and driving. Moreover, girls who report dating aggres-sion are 5 times more likely to use alcohol than girls in nonviolent relationships, whereas boys are 2.5 times more likely to be in such relationships (Pepler et al., 2002). Teens who use alcohol and drugs are more likely to have sexual intercourse at an earlier age, have more sexual partners, and are at greater risk for sexually transmitted diseases (Connolly, Furman, & Konarski, 2000). Substance use is also a risk factor for unhealthy weight control and obesity (such as taking diet pills or laxatives), suicidality, and mood and anxiety disorders

Alcohol Use in Adolescents

-alcohol remains the most prevalent substance used, and abused, by adolescents. -55% of high school seniors, 38% of tenth-graders, and 18% of those in eighth grade report that they have used alcohol over the past year, based on 2016 survey data from over 45,000 students -drug and alcohol use among youth appears to be on the decline, most likely due to active prevention and education programming. Across the broad spectrum of drugs surveyed in 2016, almost all showed a decrease in prevalence.

Weed Use in Adolescence

-annual prevalence of marijuana use showed a small but sig-nificant decline in the younger grades (and held steady in grade 12), even while attitudes continued to move toward acceptance

Rates of Illicit Drug Use (holding steady)

-any illicit drug; 38% -any illicit drug that is NOT weed: 11.5% (actually going down)

Opioid withdrawal symptoms

-appear within 12 hr, peak at 24-48 hr -Excessive sweating, restlessness, and dilated pupils Agitation, goose bumps, tremor, and violent yawning Increased heart rate and blood pressure Nausea/vomiting and abdominal cramps and pain Muscle spasms and weight loss

Alcohol withdrawal symptoms

-appear within 4-12 (8) hrs, peak at 24-72 hr -abd cramping -vomiting -tremors -restlessness -inability to sleep -TACHYCARDIA -HTN -transient hallucinations or illusions -anxiety -increased RR, temp -tonic clonic seizures -diaphoresis -CAN RESULT IN DEATH, as well as SEDATIVES

Rates of Opioid Use in Adolescence

-dropped to lowest rates -Vicodin = 2% in 2017

Substance-use Disorders

-during adolescence involve self-administration of any of these substances that alters mood, perception, or brain functioning, resulting in substance abuse or substance dependence

Stimulant withdrawal symptoms

-dysphoric mood -fatigue -vivid unpleasant dreams -increased appetite -insomnia -psychomotor agitation or slowing

Peak Onset for Substance Use Disorders

-late adolescence and early adulthood

Legalization of Marijuana

-legalized recreationally or for medical use -associated with increase in adult use, slight decreases in adolescent use -maybe due to increased difficulty in adolescent access and adult use makes it less cool/rebellious

Binge Drinking Rates

-steadily declining for 8th, 10th, 12th graders -8th: 13.3% (1996)/ 3.7% (2017) -10th: 24.1% (2000)/ 9.8% (2017) -12th: 31.5% (1998)/ 16.6% (2017)

National Survey on Drug Use and Health (NSDUH)

A national survey of illicit drug use among people 12 years of age and older that is conducted annually by the Substance Abuse and Mental Health Services Administration.

Substance-related and Addictive Disorders

DSM-5 encompasses 10 separate classes of drugs, including alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other (or unknown) substances. Gambling has been added in DSM-5 as an addictive disorder.

Treatment: Family-Based Approach

Derived from interventions for conduct disorder, family-based approaches seek to modify negative interactions between family members, improve communication between members, and develop effective problem-solving skills to address areas of conflict

Prevention Programs/ Life Skills Training

Effective approaches to adolescent substance-abuse prevention have addressed multiple influences on the individual from peers, family, school, and community. Life Skills Training, a detailed and well-evaluated program, emphasizes building drug-resistance skills, personal and social competence, and altering cognitive expectancies around substance use (Botvin & Griffin, 2015). Because adolescents must receive consistent messages and reinforcement regarding pressures to use alcohol and drugs, as well as develop effective refusal skills, societal messages about responsible use are emphasized to influence students' behavior. Prevention programs also target the social environment through community and school norms and their efficacy to enact change, and they often include some level of parent involvement and education to improve parent-child communication about sub-stance use

Overview of Substance Use in Adolescence

Given the relatively high level of experimentation with substance use among adolescents, it is not surprising that a small but significant portion meet criteria for a diagnosis of substance abuse or substance dependence. Community-based samples of youths estimate that about 6% of American adolescents (ages 12 to 17) met criteria for substance abuse or dependence (Center for Behavioral Health Statistics and Quality, 2016). Not surprisingly, much higher rates of these disorders (about one in three) are reported among youths with histories of other mental health problems, or with involvement in the child welfare or juvenile justice systems

psychological dependence

refers to the subjective feeling of needing the substance to adequately function.

Treatment: Motivational Interviewing

The effectiveness of motivational interviewing (MI) with this population has also been supported (Jensen et al., 2011). Motivational interviewing uses a patient-centered and directive approach that addresses the ambivalence and discrepancies between a person's cur-rent values and behaviors and their future goals. In general, the type of treatment indicated depends on levels of use and the individual's home environment. Adolescents with low to moderate levels of substance abuse and a more stable home environment are reasonable candidates for outpatient treatment, whereas those with more severe levels of substance abuse, an unstable living situation, or comorbid psychopathology may require an inpatient or residential setting

MDMA Use in Adolescence

The number of adolescents who have used MDMA (i.e., ecstasy), opiates, cocaine, and crack had also been decreasing or stabilizing, as is the number of adolescents using hallucinogens and inhalants

Monitoring the Future Study

a University of Michigan study that surveys around 50,000 youth about their drug use patterns in middle and high schools in Grades 8, 10, and 12 across the United States, and then one more time the year after they graduate

Treatment: Multisystemic Therapy

involves intensive intervention that targets family, peer, school, and community systems; it has been especially effective in the treatment of SUDs among delinquent adolescents (Henggeler et al., 2008). Parents or other care providers are provided with step-by-step guide-lines for implementing contingency management to control adolescent substance abuse. These steps include familiar cognitive-behavioral interventions such as behavioral contacts and contingencies to reinforce abstinence, as well as ways to overcome common road-blocks to treatment

physical dependence

occurs when the body adapts to the substance's constant presence, and tolerance refers to requiring more of the substance to experience an effect once obtained at a lower dose. Another aspect of physical dependence is the experience of withdrawal, an adverse physiological symptom that occurs when consumption of an abused substance is ended abruptly and is thus removed from the body.

pharmacological symptoms

tolerance and withdrawal