Approaching Substance
Abuse in Adolescents
{
Celia Neavel, MD FSAHM
Director, Center for Adolescent Health
People’s Community Clinic
Kirsten Gibbs Nieto, MD
Internal Medicine & Pediatric Hospitalist
Dell Children’s & University Medical Center Brackenridge
Case Presentation
 National & Local Statistics
 Screening (Procedure applied to populations & intended
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to identify those w/ disease, condition, or symptom. Does not yield
diagnosis, but guides further decision-making)
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Intervening (Screening outcome-responsive
conversation that focuses on encouraging making healthy choices &
personal behavior changes regarding risky activity)
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Resources
OUTLINE
17 year old male in your office for WCC
 Sister is seeing your partner and in therapy
 Mother is upset and wants to speak with
you alone

JULIO
Smoking marijuana daily
 Does not think this is a problem
 Attending school, has a counselor he
likes, wants to be a chef
 Has a girlfriend who stays sober
 Family chaos

JULIO
Monitoring the Future (MTF)
Survey 2013
 11.4% in 2011
(K2/Spice)
 10.5% in 2005
 6.9% in 2006
15%
Bath Salts
0.9%
Alcohol use among
teens remains at
historically low
levels
{
NIDA Monitoring the Future Survey
2013
{
Now Fewer Teens Smoke Cigarettes than Marijuana
2008
2013
8th
5.8%
7%
10th
13.8% 18%
12th
19.4% 22.7%
AISD Student Substance
Abuse & Safety Survey 2013
You can find data on the
specific schools in your area…
AISD Survey 2013
AISD High School Students
Self Reporting Marijuana Use
2012-13
AISD Middle School Students
Self Reporting Marijuana Use
2012-13
“I’ve Never Heard of that Drug!”
NIDA  EMERGING TRENDS
Update Local Drugs of
Abuse
{ Contributed by John Abraham DO,
Child and Adolescent Psychiatrist
Collaboracare and Phoenix Academy
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Packaged under a variety of names
Not easily detected under basic drug screens
Not one single compound but an ever changing array of
synthetic cannabis
Intoxication is similar to cannabis
However, more profound effects are seen
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Paranoia
Alterations in sense of time
Migraines
In one instance, I had a patient develop “Alice in Wonderland
Syndrome” extending weeks after last use
New Synthetics “K2” “spice”
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A cheap, easy way to get high
At high levels can cause hallucination, dissociation,
rapid heart rate
If used in a form with acetomeniphen can cause
liver damage
Often used in combination with other drugs
DXM can increase the effective concentration of
other serotoninergic drugs (fluoxetine and others)
and increase the risk of serotonin syndrome
Dextromethorphan “DXM”
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Effects are increase alertness, irritability, or euphoria
ADHD meds
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Dextroamphetamine and more short acting formulations seem to be
more easily abused (but all of them can be!)
Keep in mind that both clonidine and guanfacine are also used in
ADHD treatment. A patient abusing a peers “ADHD meds” may not
know the difference
Usually taken orally when abused
Stimulants
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Does not appear to be a major local contributor
However, they are packaged and distributed in the same way that
K2/spice is so a person may not know what they have
Just like synthetics the compound is ever changing
Seems to be most closely associated with Mephadrone which is
similar to effects of MDMA, cocaine, amphetamines
Bath Salts
Starting to make a comeback
 Often starts with Rx opiate abuse that becomes too
expensive
 Hydrocodone pills cost $5 to $15 on the street
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Heroin
Hydrocodone/opiate derivatives
 Often in forms with Acetaminophen (liver damage)
 Can be a number of different drugs from tramadol to
antihypertensive meds
 Inquire about a child or teenagers access to drugs at
relatives and friends homes
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Prescription Abuse
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“Duster” air can computer duster = easy and cheap
way to get high
Inhalants
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Assess What
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How
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Substance Abuse Severity +
Home Life
Psychiatric Status
School Status
Short Questionnaire
Brief Interview
Whom
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Youth
Accompanying Adult
http://store.samhsa.gov/shin/content//SMA12-3597/SMA123597.pdf
SCREENING
CRAFFT
“I’m going to ask you a few questions that I ask all my patients.
Please be honest. I will keep your answers confidential.”
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Part A: During the PAST 12 MONTHS, did you:
1. Drink any alcohol (more than a few sips)?
(Do not count sips of alcohol taken during family or religious events.
2. Smoke any marijuana or hashish?
3. Use anything else* to get high?
*includes illegal drugs, over-the-counter,
prescription drugs, and things that you sniff
http://www.ceasar-boston.org/clinicians/crafft.php
1. Have you ever ridden in a CAR
driven by someone (including yourself) who was
“high” or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. Do you ever FORGET things you did while using alcohol or drugs?
5. Do your FAMILY or FRIENDS ever tell you that you should cut down on
your drinking or drug use?
6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CRAFFT-Part B
Each “yes” response in Part B scores 1 point.
 ≥2 is (+), need for additional assessment
 Probability of substance abuse/dependence
diagnosis correlates with # of (+) answers
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CRAFFT Scoring
Abuse = 1 or more:
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Use causes failure to fulfill
obligations work, home, school
 Recurrent Use in Hazardous Settings
 Recurrent Legal Problems
 Continued Use Despite Recurrent
Problems
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ABUSE vs DEPENDENCE
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Dependence = 3 or more:
Tolerance
 Withdrawal
 Use larger amounts or over longer time than planned
 Unsuccessful efforts to cut down or quit
 Great deal of time spent obtaining or recovering from
 Important activities given up because of
 Continued use despite harmful consequences
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ABUSE vs DEPENDENCE
DRUG
DURATION OF DETECTABILITY
Alcohol
Very Short
Amphetamine
2-4 Days
Methamphetamine
2-4 Days
Barbiturates (most types)
2-4 Days
Phenobarbital
Up to 30 Days
Benzodiazepines
Up to 30 Days
Cocaine
12-72 Hours
Methadone
2-4 Days
Opioids (heroin, codeine)
2-4 Days
Marijuana casual
2-7 Days
Marijuana chronic
Up to 30 Days
Phencylidene casual
2-7 Days
PCP chronic
Up to 30 Days
DRUG SCREENING?
http://store.samhsa.gov/shin/content//SMA12-3597/SMA12-3597.pdf
Home Life
 Delinquency History
 Physical/Sexual Abuse
History
 Medical Status
 Learning Status
 In-Depth Psychiatric Status
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Environmental Risks
 Environmental
Assets/Strengths
 Sexual Behavior
 Developmental
Status
 Leisure &
Recreational
Preferences
 Family Dynamics
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COMPREHENSIVE ASSESSMENT
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Screening, Brief Intervention, and Referral to
Treatment
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Endorsed by SAHMSA and AAP
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Use Motivational Interviewing Skills
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http://pediatrics.aappublications.org/content/e
arly/2011/10/26/peds.2011-1754.full.pdf+html
SBIRT
Stage
Description
Office Intervention
Goals
Abstinence (CRAFFT -,
Low Risk)
Time before ever used
drugs or alcohol
(more than a few sips)
Prevent/delay initiation
through positive
reinforcement &
patient/parent education
Experimentation (CRAFFT The first 1–2 x use &
Promote strengths;
0-1, Mod Risk)
wants to know how using encourage abstinence &
feels
cessation through brief,
clear medical advice &
educational counseling
Limited Use (CRAFFT 0-1, W/friends in relatively
Mod Risk)
low-risk situations
& without problems;
typically occurs
predictable times,
weekends
Promote strengths;
encourage cessation
through brief, clear
medical advice &
educational counseling
Substance Use Spectrum and Goals for Office
Intervention
Stage
Description
Office Intervention Goals
Problematic Use (CRAFFT 2+,
High Risk)
Use in high-risk situation, i.e.
driving/babysitting; use associated
w/problem like fight, arrest, school
suspension; use for emotional
regulation to relieve stress or
depression
Above + initiate office visits or
referral for brief intervention to
enhance motivation to make
behavioral changes; provide
close follow-up; consider
breaking confidentiality
Abuse (CRAFFT +, High Risk)
Associated w/ recurrent problems
or interferes w/ functioning as
defined in the DSM-IV
Above + enhance motivation to
make behavioral changes,
explore ambivalence & triggering
preparation for action; monitor
closely for progression to
addiction; refer for
comprehensive assessment &
treatment; consider breaking
confidentiality
Addiction/Dependence
(CRAFFT +, High Risk)
Loss of control or compulsive drug
use, as defined in the DSM-IV-TR
as “dependence”
Above, + enhance motivation to
accept referral to subspecialty
treatment if necessary; consider
breaking confidentiality;
encourage parental involvement
whenever possible
Summarize Assessment
 Repeat for Emphasis Problems
Experienced
 Ask if would Like to Change
 Consider Signed Contract
 Risk/Harm Reduction
 Follow-up
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BRIEF NEGOTIATING INTERVIEW
I _________________ agree to not drink alcohol, use
drugs, or take anyone else’s medication for the next _____
days. I also will not provide drugs, alcohol, or prescription
medications for anyone else during this time. In addition, I
agree to not drive a motor vehicle while under the
influence of drugs or alcohol, nor will I ride with a driver
who has been drinking or using drugs. I will come to my
follow-up appointment with ______________on
___________.
Signed, ________________________
Date: ____________________
SIGNED CONTRACT
http://www.youtube.com/w
atch?v=fX90j4jD9Sc
http://withcarson.org/
http://awareawakealive.org
https://awareawakealive.org/
educate/911-lifelinelegislation

CARSON
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Local Examples
Austin Travis County Integral Care (ATCIC)
 Free evening groups 512-804-3101,
CFSInfro@atcic.org,
http://atcic.org/content/adolescent-substanceuse
-Phoenix Academy www.phoenixhouse.org
 Inpatient
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Shoal Creek http://www.seton.net/locations/shoal_creek/
Austin Oaks http://austinoakshospital.com/
Children’s Optimal Health www.childrensoptimalhealth.org
Private therapists, psychiatrists
Others
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http://www.cleaninvestmentsinc.com
http://parc.memorialhermann.org/locations/austin-outpatient-rehab/
http://starlite.crchealth.com/
http://www.summersky.us/
RESOURCES
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Online
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http://familymed.uthscsa.edu/sstart/resourcesOPEN.asp
Substance Use Screening, Brief Intervention, and Referral to Treatment
for Pediatricians COMMITTEE ON SUBSTANCE ABUSED Pediatrics
originally published online October 31, 2011; DOI: 10.1542/peds.20111754
Quick Guide for Physicians
http://store.samhsa.gov/shin/content//SMA12-3597/SMA12-3597.pdf
Substance Abuse and Mental Health
Services Administration http://www.samhsa.gov/
RESOURCES
17 YO in your office for WCC
 Sister seeing your partner and in therapy
 Mom upset, wanting to speak with you alone
 Smoking MJ daily
 Doesn’t think is problem
 Attending school, has counselor likes, wants to be
a chef
 Has girlfriend who stays sober
 Family chaos

JULIO