Wednesday, December 16, 2009

Adolescents and Addiction

This is my paper on adolescents and addiction. The paper in format with bibliography is available here. I will try to get the next post about talking to kids about drugs up over the next few days. I will also be posting my communications paper on genderism and homophobia, probably tomorrow.

According to the 2008 National Survey of Drug Use and Health, a full 9.3% of youths between the ages of 12 and 17 were current illicit drug users (SAMSHA, 2009). According to the same report the rate of binge drinking in the same age group, was 8.8%, a rate that climbs to 17.2% of 16 and 17 year olds (SAMSHA, 2009). This rate of current illicit drug use indicates a very serious problem in youth today, especially when taken in the context that there is an increasing problem with drug use initiation starting as young as ten years old. Binge drinking is generally considered substance abuse, regular binge drinking is a sign that a given individual is very likely addicted to alcohol.

Substance use in this age group may be correlated with an orientation towards risk taking, arrests, less education, pregnancy and long term substance abuse problems. Even worse, substance use at this age increases the likelihood of psychopathology and stunted neurological development (Lopez, Schwartz, Campo & Pantin, 2008). Although not all adolescent substance use will qualify as addiction, it very often leads to addiction later in life. Regular adolescent substance use often does qualify as addiction.

Defining Addiction
Put very basically, addiction is the habitual use of a substance or engaging in a behavior that causes a certain level of harm and which the addict cannot control. That is not a very satisfactory definition however, because it is very vague and ultimately fails to address the understanding that not all addiction is the same (Denning, Little & Glickman, 2004; Dodes, 2003; Khantzian & Albanese, 2008). Although this paper is focusing on substance abuse and addiction, some addictions are not substance based. Some addictions result from unrelated neurological disorders, such as bipolar disorder, schizophrenia, depression and quite commonly attention deficit disorders. Other addictions are the result of a neurochemical propensity for addiction. Still others are simply the result of crisis. This is just a small number of reasons addictions happen. With all of these different causes, it is unreasonable to assume that there is one solution.

Dr. Dodes notes that “Addictions are in the mainstream of the human condition (Dodes, 2003, p. 185). Indeed Dr. Dodes asserts that the major difference between addictions and normal human compulsions is the harm and degree of harm caused by the compulsion. Dr. Khantzian and Dr. Albanese assert that the core of most addictions is a desire to self-medicate. They make a very strong case to support the notion that people use substances to compensate for unpleasant feelings, emotions or life situations (Khantzian & Albanese, 2008). Harm reduction pioneer, Dr. Denning with Little and Glickman asserts that there are many reasons people develop what they prefer to call “substance use problems.” They understand that not all substance use is the same and not all of it is abuse or addiction. Most importantly, they believe that the necessary approach is largely determined by the individual (Denning et al.,2004).

Adolescence involves many other factors that have a significant effect on addiction and substance abuse and treatment. With youth comes the developing brain and a lot more mental plasticity. This age range is also the time when many neurological disorders tend to surface. Finally, adolescence is also a time of hormonal changes
that often result in a great deal of emotional and physical distress. When the general life changes of being a teenager are factored in, adolescence significantly complicates an already complicated mental illness (Griswold, Aranoff, Kernan & Khan, 2008).

Adolescent Substance Abuse
Normative Use
According to the detailed tables of the 2008 National Survey on Drug Use and Health, 39% of adolescents will have used an illicit drug and 60% will have used alcohol (SAMHSA, 2008). It is clear that not all youth who try illicit drugs and alcohol become regular users or substance abusers. Most adolescents who use substances either use it once or rarely. While no substance use among children and adolescents is safe, it is important to recognize that most youth who try illicit drugs or alcohol will not become habitual substance

There are many dangers to non-regular drug use among children and adolescents. Intoxication often leads to impaired judgment and increased risk taking. The most common risks include attempting to drive under the influence and unsafe sexual behavior which in turn can lead to pregnancy and/or sexually transmitted infections (Wood, Drolet, Fertro, Synovitz & Wood, 2002). Another risk is that youth who use drugs infrequently will increase substance use either during adolescents or in adulthood (Lopez et al., 2008). There is also a significant risk that their substance use will escalate into increasingly risky substances. Finally, there is also the risk of death through overdose, allergic reaction or in the case of single
standard doses of MDMA, by mechanisms we simply don't understand at this time (Kaye, Darke & Duflou, 2009).

Dangerous Use and Abuse
By age 17, 4.6% of youths will have a substance use disorder involving illicit drugs, while 4.9% will have a substance abuse disorder involving alcohol. A full 60-75% of child and adolescent substance abusers will also be diagnosed with another mental disorder (Griswald et al., 2008; SAMHSA, 2008). It is also important to note
that while there is some crossover between illicit drug addiction and alcohol addiction, it is minimal. When the crossover is taken out of the equation 7.6% of youth, 17 and under have or have had substance use disorders (SAMHSA, 2008). To put this in context, in a group of 500 17 year old adolescents, it is very likely that 38 of those kids have experience with substance abuse disorders.

Although figures have gone down significantly since the late 1990s, they have gone down from a significant spike that started in the 1980s (SAMHSA, 2009). There is little indication that there will be a significant drop in substance abuse among youth any time soon. More importantly, the most recent fad in illicit drug use among
children and adolescents is the use of pharmaceuticals (Wood et al., 2002). The use of pharmaceuticals is particularly dangerous, because even youth who have expressed a refusal to use other illicit drugs are often willing to try pharmaceuticals in a recreational context (SAMHSA, 2009). Another serious problem is heroin use, which saw a spike in use from .5% in 1995, to steady out at 1.6% in 2001 (Hopfer, Kurhi, Crowley & Hooks, 2002) and changing little with a rate of 1.5% in 2007 and 2008(SAMHSA, 2008).

Both heroin and recreational pharmaceutical use are particularly dangerous. The potency of heroin is extremely unreliable, which creates an elevated risk of overdose leading hospitalization and death (Merscham, Leeuwen & McGuire, 2009; Hopfer et al., 2002). The danger of pharmaceutical use and abuse, is that pharmaceuticals are usually mixed with other pharmaceuticals and sometimes alcohol
(SAMHSA, 2009). This is particularly dangerous because even if it is a child's first time, the wrong combination can cause serious injury and death. Another significant problem with pharmaceuticals, is that their use is likely more prevalent among children who are not considered “at risk” than any other drug except for alcohol (Johnston, O'Malley, Bachman & Schulenberg, 2009).

Risk Factors
There are many factors that can determine whether a child is at an elevated
risk for substance use disorders. The primary factor is often described as peer pressure, but this is not an accurate description of the actual social pressures involved in initiating substance use. For most substances, the actual peer pressure is to stay away from drugs (Johnston et al., 2009; NIDA, 2003; Wood et al., 2002). Other factors that significantly elevate the risk of substance use and abuse among children and adolescents include socioeconomic status, parental involvement, parental substance use issues, parental abuse, early aggressive behavior and comorbidity (Callaghan, Tavares, Taylor & Veldhuizen, 2007; NIDA, 2003).

Social Pressure
Although general peer pressure seems to be moving in the direction of pressure not to use illicit drugs and even alcohol, it is important to explore the role that social pressures play in child and adolescent drug use. Because the general direction of peer pressure actively discourages illicit drug use, it may be causing some backlash among kids who feel they have been alienated from their general peer group (Griswald et al,, 2008; Dodes, 2003). Adolescents often feel a compulsion to rebel against not only their parents, but against people who ignore them, harass them or whom they perceive are against them in some way (Denning et al., 2004). This creates an inverse sort of peer pressure, directly countering the general
pressure not to use illicit drugs and/or alcohol. While this alone may not initiate substance use, there is more to the equation of social pressure.

Young people who feel like outcasts, tend to congregate with other kids who are like them. Many of the reasons that kids become outcast are factors that also put them at an elevated risk for substance use disorders (Denning et al., 2004; Khantzian & Albanese, 2008), creating a conjunction of elevated risk and inverse social pressure. Thus in an of itself, being a social outcast becomes a significant
risk factor. Kids who have no other elevated risk factors, who become social outcasts are at an elevated risk for that reason alone.

There are other social pressures that come into play. As kids get older, whether they have elevating risk factors or not, become increasingly likely to use alcohol. It is highly available and many children and adolescents witness their parents drinking alcohol, whether the parents drink a lot or are moderate drinkers. Thus while there may still be a general pressure to avoid illicit drugs, as children age the general peer pressure to avoid alcohol fades and often reverses into pressure to drink (Johnston et al,. 2009; SAMHSA, 2008; SAMHSA, 2009).

There is also often peer pressure involved in the abuse of pharmaceutical medications. This is complicated by many children not really perceiving recreational pharmaceutical drug use as being similar to other recreational drug use and abuse (Johnston et al,. 2009). Children and adolescents who sincerely believe that recreational drug use is bad, have no compunctions against the recreational use of pharmaceuticals. Worse, the younger a child is, the more likely it becomes that their initial drug use will be pharmaceuticals. In 2008, more than 5.4% of children ages 12-13 reported having engaged in the recreational use of pharmaceuticals.
Breaking the drug classes down, 5.4% reported using psychotheraputic drugs, 4.5% reported using pain relievers and almost 1% reported using stimulants (SAMHSA, 2008).

There is a great deal of evidence to support the assertion that people with attention deficit disorders are significantly more likely to become substance abusers, than the general population. The comorbidity of ADHD and substance abuse is estimated between 30% and 50% (Gordon, Trulak & Troncale, 2004). While there is no significant difference in the rates of alcohol abuse, persons with ADHD are at significantly higher risk for abusing other drugs and other drugs plus alcohol. The rates of lifetime substance use disorders among persons with ADHD is 52%, compared to persons without ADHD at 27% (Biederman et al, 1995).

The comorbidity of substance use disorders and mood disorders is also very common. About 70% of people diagnosed with bipolar, for example, are tobacco users (NIDA, 2008). An National Institute on Alcohol Abuse and Alcoholism sponsored study found a 40% comorbidity of mood disorders, among people who sought treatment for a substance use disorder (Grant et al., 2004). Though there are still a lot of
questions to be answered about the relationship between substance use disorders and mood disorders, there is no question that mood disorders significantly increase the risk of substance abuse and addiction.

In aggregate, it is estimated that there is somewhere between a 60% and 70% comorbidity between adolescent substance use disorders and other mental illness (Griswold, 2008). While there are some questions about potential misdiagnosis due to comorbidity, the statistics are too significant to be ignored. There is no doubt that there is an extremely significant correlation between substance abuse disorders and other mental disorders.

Parents and family play a very important role in determining whether a child or adolescent will develop a substance use disorder. Parents have a profound impact on their children. Many neurological disorders have a very strong familial connection, especially ADHD (Biederman et al., 2008), which is a major risk factor. The children
of parents with substance use disorders often develop substance use disorders themselves (SAMHSA, 2008). Children and adolescents from families that are economically disadvantaged have an elevated risk for substance use disorders (NIDA, 2003). Children and adolescents who do not have much interaction with their parents also have an elevated risk for substance use disorders (Denning et al., 2004;
Dodes, 2003; Johnston et al., 2009; Khantzian & Albanese, 2008; NIDA, 2003).

There are many ideas about preventing juvenile substance use disorders. Public service announcements, parental education, peer counseling, large scale local and national government programs in public schools, school assemblies, “scared straight” programs that introduce at risk youth to prisoners, and myriad after school programs. A significant problem with all of these measures, is that there is little evidence to support the efficacy of most of these preventative measures. The studies that have been done would suggest that certain changes to current approaches might be warranted.

Nixon, Mansfield and Thoms did a study of public service announcements that suggested that providing instructional materials for in class activities following the viewing of videos would likely increase the efficacy. While their study was limited in scope, it was more intensive than many studies into the efficacy of substance use prevention measures. They also suggested that targeting youth with specific risk factors and public service announcements that were culturally specific would likely increase the effectiveness of such materials (Nixon, Mansfield & Thoms, 2008).

There is evidence that would suggest that culture specific substance use prevention measures might reduce the incidence of substance use disorders. Developing and implementing prevention programs for the classroom that are specified for the cultures represented, would expose children and adolescents to a variety of programs, while also responding to culturally specific substance use trends (NIDA, 2003).

There is also evidence that peer counseling programs can be an effective preventative tool. Programs that include mentoring are likely to be even more effective, as they discourage adolescent mentors from engaging in behaviors that they are trying to discourage younger children from engaging in. Evidence would suggest that adolescents are significantly more likely to listen to information
about substance use and sexuality that comes from their peers, than when it comes from teachers (Whiston & Sexton, 1998).

Parents are an extremely important component to the treatment of juvenile substance use disorders. Children and adolescents with substance use problems are especially vulnerable and need a lot of support from their family and community. Family counseling is especially important, as is parental sobriety. The development of a
substance use free peer group is also very important (Griswold, 2008). It is also important to approach the situation realistically and understand that while sobriety is the ultimate goal, a harm reduction approach is not inappropriate. Complete sobriety may not happen overnight, especially if acute dependence is a factor.
Substance use disorders are often a chronic condition and in recognizing that, an implicit goal of reduction (Ie. Using only at specific times) and management may be the best short term goal (Bukstein et al., 2005; Denning et al., 2004).

Given the significant level of comorbidity, an intensive psychological assessment should be done as early in the intervention process as possible (Dodes, 2003; Griswold, 2008; Khantzian & Albanese, 2008). There is an elevated risk for suicide or other extreme responses to the intervention process (Denning et al., 2004). There is also the possibility that medication will be indicated and with certain disorders, such as bipolar type one. Abstinence from the substance of abuse may trigger an acute response without a pharmaceutical alternative (Khantzian & Albanese, 2008). In such cases there may be very little time in which to make an assessment and determine whether psychopharmacology may be appropriate (Griswald, 2008).

Unfortunately, there are many different types of addiction and substance abuse, each presenting its own unique challenges. Once the intervention has been initiated it is up to the juvenile's doctor, therapist and family to decide on the best course of action (Denning et al., 2004). It is up the the parent's, the child or adolescent
and the professionals to develop a set of goals that the child must stick to. Failure to meet specific goals must be explained by the child or adolescent and appropriate actions must be taken (Dodes, 2002; Khantzian & Albanese, 2008). If the juvenile is on medication, the medication must be closely monitored by parents (Griswald, 2008).

The most important consideration for dealing with an addict or substance abuser, is that they are still a human being. Compassion and empathy are a critical component to recovery. Disrespect and dehumanizing will not help recovery progress. Recovery does not happen because of concepts such as “tough love,”it sometimes happens in spite of those methods (Denning et al., 2004; Dodes, 2002; Khantzian & Albanese, 2008). It is important to remember that a child or adolescent with a substance use disorder is still a child.

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