Substance Abuse Recognition & Treatment

SUBSTANCE ABUSE: Recognition & Treatment in Adolescents Georgina M. Gozo-Oliver, MD, FCAPPI Child & Adolescent Psychiatrist

Substance Use in Adolescents 

Normal Trajectory 

Adolescents experiment with the use of cigarettes, alcohol, & other drugs.



Adolescents who use alcohol & other drugs experiment with a wide variety of substances for a while, & then abandon their use.



Few youth advance to more serious levels of substance use.



Relatively low percentages of young people develop a substance use disorder during adolescence.

Substance Use: Why do Adolescents use Substances? 

Reasons for Substance Use  Recreational

benefits (To have fun)  Social conformity *  Mood enhancement *  Coping with stress 

* Youth with a substance use dependence disorder assign more importance to these factors than less experienced adolescents

Substance Use: Stages  Stages

of Substance Use

(Kandel, et al, 1975)



No use of any drug



Use of beer or wine



Use of cigarettes or hard liquor



Use of illicit substances starting with marijuana

Substance Abuse: Stages  Stages

of Substance Use

 Use

of other illicit substances like methamphetamine & inhalants

 “Carry-over

 Multiple

effects”

drug use

Substance Abuse: Recognition 

Who are at risk?  Family  Peer

factors

factors

 Community  Individual

factors

factors

Substance Abuse: Recognition 

Who are at risk?

Family factors 

Substance abusing members



Excessive family conflict



Low parent-child attachment



Poor parenting skills



Low parental supervision



Child abuse or neglect

Substance Abuse: Recognition 

Who are at risk?  Peer

Factors



In mid-adolescence, peer influence peaks



Drug taking friends exert the strongest influence

Substance Abuse: Recognition 

Who are at risk?  Community

Factors



Poverty



Overpopulation



High crime rate

Substance Abuse: Recognition 

Who are at risk?  Individual

factors



Children of substance abusers



Victims of child abuse



Youth with mental health problems



Physically disabled



Children with poor academic achievement

Substance Abuse: Recognition  Early

Detection

 Most

commonly missed pediatric diagnosis

 Medical

findings depend on the type of substance used

Substance Abuse: Recognition 

Early Detection  COMMON

PHYSICAL SIGNS

Weight Loss  Chronic Fatigue  Chronic cough  Red eyes  Poor personal hygiene  General apathy  Malaise 

Substance Abuse: Recognition 

Early Detection  MENTAL

STATE

Impaired memory  Impaired attention/concentration  Disorientation  Illusions  Disordered thought  Low self esteem  Guilt  Suicidal Thoughts 

Substance Abuse: Recognition 

Early Detection  BEHAVIORAL

CHANGES

Irritability  Aggression  Sleep pattern changes  Mood swings  Change in social relationships  Failure in school  Social withdrawal  Substance-related legal difficulties 

Substance Abuse: Recognition 

Early Detection  

CRAFFT: Questions to Identify Adolescents with Substance Abuse (American Academy of Pediatrics, 2006)

C

Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R

Do you ever use alcohol or drugs to RELAX, feel better yourself, or fit in?

A

Do you ever use alcohol or drugs while you are by

about

yourself or ALONE?

Substance Abuse: Recognition 

Early Detection 

CRAFFT: Questions to Identify Adolescents with Substance Abuse

F Do you ever FORGET things you did while using

alcohol or drugs?

F Do your family or FRIENDS ever tell you that you

should cut down

T Have you ever gotten into TROUBLE while you were

using alcohol or

on your drinking or drug use?

drugs?

Referral for Treatment  Toxicology  Psychiatry

Substance Abuse: Treatment 

Goals of Treatment  Abstinence

substances

 Reduction

or reduction in the use & effects of

in the frequency & severity of relapse

 Improvement

in psychological & adaptive functioning.

Substance Abuse: Treatment 

Principles of Effective Treatment 

No single treatment is appropriate for all individuals.



Effective treatment attends to the multiple needs of the individual, not just his or her drug use.



The individual treatment plan must be assessed continually & modified as necessary to ensure that the plan meets the person’s changing needs.

Substance Abuse: Treatment 

Principles of Effective Treatment 

Remaining in treatment for an adequate period of time is critical for treatment effectiveness.



Counseling (individual or group) & other behavioral therapies are critical components of effective treatment for the addiction.



Medications are an important element of treatment for many patients. 50-90% of substance abusers have dual diagnosis.

Substance Abuse: Treatment  Principles

of Effective Treatment

 Medical

detoxification is only the first stage of addiction treatment & by itself does little to change long-term drug use.

 Possible

drug use during treatment must be monitored continuously.

Substance Abuse: Treatment  Stages  Detoxification

 Rehabilitation

 Relapse

Prevention

Substance Abuse: Treatment 

DETOXIFICATION 

Provides a setting in which a patient may enter recovery from addiction.



Serves to eliminate only the physical dependence on the drug.



Does nothing to eliminate the disease (Addiction).

Substance Abuse: Treatment 

DETOXIFICATION: Objectives 

Enhances the removal of the substance(s) from the body to minimize its damaging effects



Treat or minimize the physical or psychiatric symptoms associated with withdrawal



Identify & manage associated medical illnesses which may or may not be related to the substance use.



Provide an initial setting for patient’s recovery

Substance Abuse: Treatment  DETOXIFICATION:  Urine

Techniques

Acidification

 Forced

Diuresis

 Multiple

Dose Activated Charcoal

Substance Abuse: Treatment 

REHABILITATION  Therapeutic  Structured  Family

Community

Outpatient Group Therapy

Therapy

 Individual  Network

Therapies

Therapy

Substance Abuse: Treatment 

REHABILITATION: The Therapeutic Community 

Founded on a Social Learning model that fosters behavioral & attitudinal change as a result of membership in a community



Through intensive peer-based approach, the patient learns & addresses: 

Pro-social values



Self-Destructive & Anti-social behavioral patterns

Substance Abuse: Treatment 

REHABILITATION: The Therapeutic Community 

A concept designed to provide tools for growth on an emotional, spiritual, & intellectual plane



Offers individual & group counseling, family services, medical & mental health services, vocational & educational services



As patients progress in treatment, they earn more challenging & responsible assignments & a higher status level.

Substance Abuse: Treatment 

REHABILITATION: The Therapeutic Community 

ACTIVITIES 

Morning meetings

Static Groups



Encounter groups

Request Groups



Seminars Skills Development

Substance Abuse: Treatment 

REHABILITATION: The Therapeutic Community 

SPECIAL POPULATIONS 

Mothers in Recovery



Dual Diagnosis Clients



Adolescent Services

Substance Abuse: Treatment 

REHABILITATION: Structured Outpatient Group Therapy  Not a stand-alone modality  Part of a structured, comprehensive treatment program that provides Individual Counseling  Supervised Urine Testing  Family Counseling  Educational Sessions  Encouragement to participate in self-help recovery meetings 

Substance Abuse: Treatment REHABILITATION: Family Therapy  Stages 



Defining the problem & negotiating a contract



Establishing the context of a chemical-free life



Ceasing substance abuse



Managing the crisis & stablizing the family



Family reorganization & recovery



Termination

Substance Abuse: Treatment 

REHABILITATION: Individual Therapies  Traditional

weekly, insight-oriented psychotherapy sessions are not appropriate treatment for substance abusers who are actively using or recently detoxified from a substance

 Clinicians

can modify psychotherapeutic approaches or combine with other treatment elements

Substance Abuse: Treatment 

REHABILITATION: Network Therapy  Specific

family members & friends are enlisted to provide ongoing support & to promote attitude change

 Network

members are part of the therapist’s “working team”

 Goal:

the prompt achievement of abstinence with relapse prevention & the development of a drugfree adaptation

Substance Abuse: Treatment  RELAPSE  Case

PREVENTION

Management

 Educational

programs that painstakingly help patients find new ways to work, associate, & recreate

Substance Abuse: Treatment  RELAPSE  Empower

PREVENTION: Goals patients

 Gently

appraise them of their psychopathology

 Encourage

them to examine how drugs & psychopathology have affected their lives

Substance Abuse: Treatment 

RELAPSE PREVENTION: Goals  Discuss

treatment issues like rulebreaking, lack of sharing, etc.

 Promote

behavior

awareness of self-medicating

 Repetition

of concrete rules of behavior for severely disturbed

 THANK

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