SUBSTANCE-RELATED AND ADDICTIVE DISORDERS
DSM-5 (American Psychiatric Association 2013) no longer includes separate diagnoses for substance abuse and dependence. A single list of criteria is provided for substance use disorder (SUD) (Box 15–1), with the type of substance specified. DSM-5 deleted the criterion of recurrent legal problems and added craving or strong desire to use. The threshold for making the diagnosis of substance use disorder is two criteria met, along with impairment or distress. DSM-5 also includes for each substance, where applicable, criteria for the diagnoses of intoxication and withdrawal. The continuum of adolescent substance use ranges from nonuse (abstinence), through experimental and casual use, to abuse and dependence. The line between use and abuse is crossed more easily by young persons than by adults, and some experts recommend that any use of alcohol or illicit drugs by a person under the legal drinking age be called abuse. Physical dependence is rare in adolescents. Gambling disorder is a new diagnosis in this chapter of DSM-5.
Box 15–1 DSM-5 symptom criteria for substance use disorder
- Often taken in larger amounts or over a longer period than was intended
- Persistent desire or unsuccessful efforts to cut down or control use
- A great deal of time spent in activities necessary to obtain the substance
- Craving, or a strong desire or urge to use the substance
- Recurrent use resulting in failure to fulfill major role obligations
- Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
- Important activities given up or reduced because of the substance use
- Recurrent use in situations in which it is physically hazardous
- Use 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
- Tolerance, as defined by either:
- Need for markedly increased amounts to achieve intoxication or desired effect
- Markedly diminished effect with continued use of the same amount
- Withdrawal, as manifested by either:
- Characteristic withdrawal symptoms
- Taking of a substance to relieve or avoid withdrawal symptoms
- Craving, or a strong desire or urge to use the substance
Three national surveys provide regularly updated data on substance use in youth. The National Institute on Drug Abuse (NIDA)–sponsored Monitoring the Future (MTF) project is an annual in-school survey of nationally representative samples of approximately 50,000 8th-, 10th-, and 12th-grade students (monitoringthefuture.org). The reported rates are likely underestimates, because many of the heaviest drug users drop out of school or are likely to be absent when surveys are taken. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), uses an interactive, computer-based questionnaire to provide annual reports and detailed tables on the prevalence, patterns, and consequences of drug and alcohol use and abuse in the general U.S. civilian noninstitutionalized population ages 12 years and older (www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2015-NSDUH). Every 2 years the Centers for Disease Control and Prevention (CDC) conduct school-based surveys (www.cdc.gov/healthyyouth/data/yrbs/index.htm). This Youth Risk Behavior Surveillance System (YRBSS) monitors health-risk behaviors in 9th- through 12th-grade students that contribute to the leading causes of death and disability among youth and adults, including behaviors that contribute to unintentional injuries and violence; sexual behaviors related to unintended pregnancy and sexually transmitted diseases, including HIV infection; alcohol and other drug use; and tobacco use.
The 2015 MTF found that teen smoking (7% past-month use) and alcohol (22.1% past-month use) decreased from the prior year, but use of marijuana (3.4% past-month use) and of e-cigarettes remained constant. Of concern is that among 12th graders, daily marijuana use (6%) exceeded daily tobacco use. The perception by 12th graders that marijuana use is risky continues to decline. Newer concerns are hookah water pipes, small cigars, and e-cigarettes, which are raising concern that they may increase rates of nicotine dependence, introducing “vaping” to teens, who then progress to tobacco use. MTF found more than twice as many 8th and 10th graders using e-cigarettes as were using conventional cigarettes. However, more than half reported vaping with only “flavoring,” not nicotine (Miech et al. 2016).
YRBSS 2015 data show a continuing decrease (since 1991) in rates of “ever tried” cigarette smoking (32.3%), currently smoking cigarettes (10.8%), and daily smoking cigarettes (2.3%). Current use of smokeless tobacco remains relatively steady at 7.3%. An electronic vapor product was reported to have been used at least once by 45% of surveyed high school youth. Rates of alcohol use have decreased since 1991, but 2015 rates are essentially unchanged from 2013. At least one drink of alcohol on at least one day in the past 30 days was reported by 32.8% of respondents. Use of a nonprescribed prescription drug (including opiates, stimulants, and benzodiazepines) was reported by 17%. Rates of cocaine and hallucinogen use have decreased since 2001 but have been stable since 2013. Use of inhalants and ecstasy continues to slowly decline. The rate of heroin use (“ever used” 2.1%) has remained between 2% and 3% since 2005 but is lower than in 2003 (3.3%).
There are no studies of prevalence of SUDs as defined by DSM-5. New or unconventional compounds for drug use appear frequently, including various herbs as well as synthetic drugs (e.g., bath salts, cannabinoids, fentanyl). Often these compounds are not detected by standard drug screening tests. All substances obtained illegally may have possible dangerous contaminants. A particularly deadly example is fentanyl sold as heroin.
Adolescents often present with multiple SUD diagnoses. Virtually all adolescents referred for treatment of substance use have additional disorders, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), depression, anxiety disorders, posttraumatic stress disorder (PTSD), psychosis, and specific learning disorders. Virtually any psychiatric disorder may occur in association with substance use as a cause, an effect, or a correlate. Psychiatric disorders may predate substance abuse or be secondary to pharmacological or situational effects of drug use. In a longitudinal school-based study of adolescents, major depression and heavy smoking each increased the prospective risk for the other. This association does not appear to be due to shared risk factors (Windle and Windle 2001). The presence of ADHD, especially when accompanied by ODD or CD, is associated with early onset of substance abuse.
Children of persons with substance use disorders appear to be particularly vulnerable to adolescent drug use, likely resulting from a combination of genetic and family dynamic factors with learned attitudes toward substance use (Table 15–1). Genetic contributions to alcoholism are strongest in males. Peer influence mediates avoidance of drugs, as well as both initiation and maintenance of substance use. Substances may be used to produce positive feelings and avoid unpleasant ones, relieve tension and stress, reduce disturbing emotions, alleviate depression or anxiety, and gain peer acceptance. Among youth, determinants of use are often specific to each drug, related to some extent to the perceived risks and benefits of the substance.
Early childhood trauma, including history of physical or sexual abuse
Elementary school underachievement
Failure to value education
Absence of strong religious convictions
Experimentation with drugs before age 15 years
Relationships with peers who have behavior problems and use drugs
Alienation from parents
Family lacking in clear discipline, praise, and positive relationships
Family history of substance abuse
COURSE AND PROGNOSIS
Adolescence is the critical period for initiation of drug abuse. Onset is rare in adulthood, except for the abuse of prescription drugs. Substance abuse typically progresses in predictable stages (Kandel 1975). Each stage serves as a “gateway” to the next—from abstinence to cigarettes, then beer or wine, to hard liquor, to marijuana, and then to other illicit drugs. The increasing availability of marijuana with medical and even recreational legalization for adults has increased the likelihood that cannabis will function as a gateway substance and that some adolescents will begin with cannabis and bypass tobacco and alcohol. At each stage, many youth do not progress further, but when progression occurs, stages are rarely skipped. Almost all adolescents who have tried cocaine and heroin first used alcohol, tobacco, and cannabis. The earlier cannabis use is begun and the more often cannabis is used, the more likely is the progression to other illicit drugs. Of concern is that the marijuana available now is far more potent than the marijuana available in the past. In general, drugs from each stage are continued into the next, leading to a pattern of abuse of multiple drugs. Abuse of inhalants is an exception. Children may begin to use these easily available volatile substances but then desist as they gain access to other drugs. Although many young people experiment with alcohol and drugs, a smaller number proceed to regular use, and only a fraction of those become dependent. Unfortunately, it is difficult to predict which young people will only experiment with substances or continue social use of alcohol, in contrast to those who will progress to a more severe SUD. Early onset and rapid progression appear to increase the risk for subsequent serious problems.
In children and adolescents, substance use interferes with developing cognitive, social, and physical abilities. Critical developmental experiences that are missed may be difficult or impossible to replace, leading to high risk for impairment of future functioning in every sphere. Potential morbidity and mortality from substance use are substantial. Rates of suicidal ideation and behavior are increased. The risk of death from intentional or accidental overdose, dangerous behavior while intoxicated (especially automobile accidents), or homicide related to drug dealing is significant. Chronic use of marijuana may result in apathy and resulting arrest of academic and social development. There is increasing concern regarding potential risks of cognitive impairment, decreased motivation, or psychotic disorder subsequent to early, frequent, and heavy adolescent cannabis exposure (Volkow et al. 2016). Injection drug use is the current major vehicle for the spread of HIV among adolescents. Hepatitis is also a risk. Indiscriminate sexual activity (related to direct drug effect on impulse control and judgment or induced by prostitution to buy drugs) places the adolescent at high risk for exposure to HIV and other sexually transmitted diseases. Adolescent female drug users may become pregnant and place the developing fetus at risk for drug-induced damage or HIV infection. Inhalant abuse may result in brain damage, cardiac arrest, liver and kidney damage, or lead poisoning.
EVALUATION AND DIFFERENTIAL DIAGNOSIS
A high index of suspicion for substance use is essential in all clinical settings. Virtually any change in emotional state, behavior, social activities, or academic performance can signal a problem with substance use. The clinician should question in a nonjudgmental manner all patients older than 9 years about substance use. If there is evidence of substance use, the patient should be asked about every category of substance, including details of amount, method of use, frequency, impairment, and social and emotional context. Verification by parents, teachers, other professionals, or peers may be crucial. Specific areas of inquiry should include intoxication at school, missing classes because of substance use, evidence of tolerance, and preferences among drugs that indicate experience. Sequelae of substance use, such as decline in school attendance or grades, increase in family conflict, cessation of previously important activities, association with a marginal peer group, and involvement in risky behavior (especially driving while intoxicated and reckless sexual behavior), should be specifically queried, as well as motivation and any attempts to decrease or stop use.
Self-report questionnaires are available for use with adolescents, including the revised Drug Use Screening Inventory (DUSI-R; Tarter 1990), the Drug and Alcohol Problem (DAP) Quick Screen (Schwartz and Wirtz 1990), and the CAGE (Dias 2002).
Because most young substance users have “dual diagnoses” (i.e., psychiatric disorders in addition to substance use disorders), the clinician should attempt to establish the chronology of substance use with respect to the emotional and behavioral symptoms. A detailed family history regarding psychiatric disorders and substance use is essential. The risk of substance abuse in parents and siblings is high.
Physical or neurological examination may disclose effects of substance use. Physical signs and symptoms of inhalant abuse may include spots or sores around the mouth, red or runny eyes or nose, dazed or dizzy appearance, and nausea or loss of appetite. Laboratory screening for drug use can provide valuable information, although false-positive and false-negative results occur, and verification and integration with the rest of the assessment are essential. Medical evaluation for HIV, hepatitis, and other sequelae is indicated.
The primary goal is achieving and maintaining abstinence. Medical detoxification is rarely necessary in adolescents. Common features of treatment programs for substance abuse include developmentally appropriate approaches to abstinence, group therapy with other substance abusers, participation in self-help “12-Step” programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and the concept of “recovery” rather than cure. The effects of denial, lack of motivation, and the peer drug culture make conventional individual psychotherapy unlikely to succeed. Pharmacological treatments for SUDs are rarely used in adolescents. Better response to treatment may be associated with motivation and cooperation in the patient and family, the patient’s willingness to undergo urine testing, earlier stages of drug use, and remaining in treatment longer. Legal interventions and sanctions may be needed. Suggested therapeutic interventions include using motivational interviewing techniques; teaching social skills and strategies for problem solving, coping, and relapse prevention; and encouraging structured and supervised recreational activities with drug-free peers. Comorbid psychiatric disorders and specific learning disorders must be addressed and treated, although they are difficult to validly assess without a period of abstinence. Academic deficits need to be remedied, and vocational testing and training may be useful for older adolescents for whom return to school is unlikely.
Family therapy approaches have been shown to be effective, particularly those that use structural and behavioral techniques to address parent–youth relationships and interaction patterns, as well as behavior management skills training for parents. Other effective models add interventions with peers, teachers, and other parts of the youth’s social environment, as well as job and school skills training for youth (Henggeler et al. 2002).
Short-term hospitalization is now used only for acute medical indications, medical treatment of overdose or intoxication, or comorbidity with other psychiatric conditions that increase the acute risk of harm to self or others. Both the patient and the family should be actively involved in group treatment and education regarding drugs. Psychotropic medications may alleviate concomitant disorders, reduce withdrawal symptoms, or facilitate abstinence. Residential treatment for 1–12 months is used only for the most severe, complex, or recalcitrant cases or when a parent is an active drug user.
Long-term continuation of treatment is important as an outpatient or in a day treatment program or halfway house. Intensive participation in AA or NA is often required. Adolescents generally do best in groups with other adolescents rather than mixed with adults. Family therapy is an integral part of treatment. Goals include educating parents about substance abuse and its consequences, thus decreasing denial and facilitating their support of treatment and of abstinence; improving parental skills of firm and consistent, but supportive, limit setting and supervision; and enhancing communication between family members. Parents may require referral for treatment of their own substance use or other psychiatric disorders. Effective treatment results in decreased substance abuse as well as improved school performance and fewer behavioral and psychological symptoms.
Relapses are common and should be viewed as predictable complications rather than as catastrophes or reasons for terminating treatment. Relapse prevention (i.e., specific attention to situations in which drug use is likely, with training in coping strategies) may reduce the number and severity of relapses. Periodic urine testing can facilitate abstinence.
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