Prescription Drugs and New Drugs of Abuse: Continuing Issues for Adolescents Patricia Kokotailo, MD, MPH Professor of Pediatrics Director of Adolescent Medicine Associate Dean for Faculty University of Wisconsin School of Medicine and Public Health

Objectives

Disclosure In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA.

Death rates for leading causes of death among persons 15-24 years of age: United States 1997-2007

• Discuss risks of prescriptions drugs used in an illicit way by adolescents • Identify newer drugs of abuse and how use patterns change over time and vary by area and populations • Use a screening and brief intervention strategy to identify problematic drug use CDC, 2010

Monitoring the Future • Annual cross-sectional national high school surveys • 12th grade since 1975 • 8th and 10th grade since 1991 • Multistage random sampling • 44,000 students in 400 public and private high schools • Up to 350 students per school • Findings consistent with National Survey on Drug Use and Health (formerly called the National Household Survey on Drug Abuse) and CDC Youth Risk Behavior Survey

Trends in Annual Prevalence of Illicit Drug Use: 1975 - 2010

Alcohol

Alcohol: Binge Drinking

Percent who used in the last 30 days

Percent who had 5+ drinks in last 2 weeks

Flavored Alcoholic Beverages Percent who used in the last 30 days

Current Alcohol Issues • “Wide awake drunk” with caffeine and alcohol mixing • Use of other alcohol products – Alcoholic whipped cream – “Shot paks” – Alcoholic slushies • Advertising and marketing issues – Targeting entry level drinkers – “Chick beer” –targeting women – Movies, social media, iPhone apps

Caffeinated Alcoholic Energy Drinks

Marijuana: Annual Use

Marijuana use • Environmental factors determine who will initiate marijuana use • Genetic predisposition determines who will develop dependence • Of adolescents who try marijuana more than 5 times, 20% become daily users and an additional 10%-20% near daily users • Approximately one third of adolescents with daily or near daily marijuana use will develop dependence

Marijuana risks • Increased potency => addiction and dependence • Impaired memory, attention, learning • Increased risk of anxiety disorders, depression, schizophrenia

Source: Gruber AJ, Pope HG. Pediatr Clin N Am 2002;49:397

Synthetic Cannabinoids

Synthetic Cannabinoids • “Fake pot” – “Spice”, “K 2”, “Blaze” – marketed as incense • US Drug Enforcement Agency (DEA) used emergency scheduling to ban 5 chemicals used • Poison Control and hospital reports of seizures, hallucinations, dependence • Issues with contaminants/additives in other drugs

“Bath Salts” • Amphetamine-like chemicals, such as methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone • Administered orally, IV, inhalation • “Ivory Wave”,“Red Dove”,“Blue Silk”, “Zoom”,“Cloud Nine”,“Lunar Wave”, “White Lightning” and “Hurricane Charlie” • Reported chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions

Abuse of prescription drugs • Opioids OxyContin® (oxycodone), Vicodin® (acetaminophen/hydrocodone) • CNS depressants Xanax® (alprazolam), Klonopin® (clonezepam) • Stimulants Ritalin® (methylphenidate), Adderall® (amphetamine/dextroamphetamine)

Abuse of prescription drugs

Vicodin Percent who used in the last 12 months

• Oxycodone -euphoric effect similar to heroin – rapid development of tolerance, dependence, withdrawal • Alprazolam – CNS depressant effect – tolerance, dependence, withdrawal – interaction with alcohol • Methylphenidate tablets – CNS stimulant effect – used orally, snorted or injected – can also be mixed with cocaine and/or heroin

Narcotics other than Heroin Percent who used in the last 12 months

Heroin: Annual Use

Tranquilizers: Annual Use Beginning in 2001 a revised set of questions on tranquilizer use was introduced, in which “Xanax” replaced “Miltown” in the list of examples. Source: The Monitoring the Future Study, the University of Michigan

Prescription Drug Abuse Issues • Increased medical exposure • Sharing prescription drugs • Mixing of drugs • Perception of safety issues • Use for self-treatment

Next Steps SBIRT: Screening, Brief Intervention, and Referral to Treatment

Informative Questioning for Substance Use • Give general information - social norms

Screening During the past 12 months did you:

• Assure conditional confidentiality

1. Drink any alcohol (more than a few sips)?

• Solicit information about community and peer behavior before individual behavior

2. Smoke any marijuana or hashish? 3. Use anything else to get high?

• Avoid yes/no response • Explore individual function at home, in school, at work and with peers

CRAFFT: A Brief Screen for Adolescent Substance Abuse • Have you ever ridden in a CAR driven by someone, including yourself, who was “high” or had been using AOD? • Do you ever use AOD to RELAX, RELAX feel better about yourself, or fit in? • Do you ever use AOD while you are by yourself, ALONE? ALONE • Do you ever FORGET things you did while using AOD? • Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? • Have you ever gotten into TROUBLE while using AOD?

(“Anything else” includes illegal drugs, overthe-counter and prescription drugs, and things that you sniff or “huff”.)

Screening • If the adolescent answers “no” to all 3 opening questions, ask the first CRAFFT question (Car question) • If all 3 negative, offer praise and encouragement; if car positive, counsel • If the adolescent answers “yes” to any of the 3 opening questions, ask all 6 CRAFFT questions

Ref: Knight, J et al. Arch Pediatr Adolesc Med 1999;153:591-596

Brief Advice/Intervention

Brief Advice/Intervention

• If no use and the score is 0, provide praise and encouragement

• With a positive CRAFFT (score is ≥ 2), do further assessment to explore pattern and stage of use and determine appropriate management

• If any use and the score is 0-1, provide brief advice regarding adverse health effects of AOD

• Use of Motivational Interviewing (MI) in brief intervention work

• Each “yes” response to the CRAFFT questions is scored 1 point

• If the score is ≥ 2, provide further assessment

Stages of Change • • • • •

Precontemplation Contemplation Determination Action Maintenance

• Relapse • Termination

 Not

considering change about change  Firmly committed to change  Engaged in change  Change is well learned but a risk for relapse remains  Resumption of undesired behavior  Firmly entrenched in new lifestyle  Ambivalent

Referral and Follow Up • Know your area resources • Be aware of co-occurring problems and possible need of dual treatment • Establish working relationships with treatment professionals • Encourage active family participation in treatment

Changes to Make in Practice • Be knowledgeable about prevalence and patterns of substance use

Thanks to:

• Screen all adolescent patients for AOD use at all health supervision and appropriate acute visits

John Kulig, MD

• Give brief advice to those at low risk and briefly assess those at high risk • Know referral resources • Be involved with prevention and advocacy programs

UW Adolescent Alcohol and other Drug Assessment and Intervention Program