Trending Topics: Trends in Youth and Rx Drug Abuse

1. Trending Topics Track:
Trends in Youth and
Rx Drug Abuse
Presenters:
• Sean Clarkin, MBA, Director of Programs, Partnership for
Drug-Free Kids
• Roy Van Tassell, MS, LPC, Director, Trauma and Evidence-
based Interventions, Cenpatico
• William D. Holmes, MD, Senior Medical Director, Cenpatico
Behavioral Health, and Medical Director, Foster Care
Services, Cenpatico
Moderator: Nancy Hale, President and CEO, Operation UNITE

2. Disclosures
• Sean Clarkin, MBA; Roy Van Tassell, MS, LPC; and Nancy Hale
have disclosed no relevant, real, or apparent personal or
professional financial relationships with proprietary entities
that produce healthcare goods and services.
• William D. Holmes, MD – Employment: Cenpatio Behavioral
Health

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Chart the prevalence of Rx stimulant abuse
among young adults.
2. Identify young adults’ reasons and methods
for abusing Rx stimulants.
3. Outline strategies for reducing the risk for
substance use and mental health disorders
among youth in custodial care.

5. Trends in Youth and Rx Drug Abuse
Misuse and Abuse of Rx Stimulants
Among College Age Youth
April 8, 2015

6. 6
Sean Clarkin, Director of Programs
at Partnership for Drug-Free Kids,
has disclosed no relevant, real or
apparent personal or professional
financial relationships with
proprietary entities that produce
health care goods and services.

7. Contents
• Background
• Research Objectives
• Key Findings
• Implications for Prevention
7

8. Background
• Partnership for Drug-Free Kids
– Nonprofit dedicated to reducing substance use among adolescents by
supporting families and engaging with teens
• One of major programs is Medicine Abuse Project
– Reducing teen initiation of Rx drug abuse by 500,000
– Brings together private sector sponsors, key federal agencies and
strategic partner organizations
– Reaches key audiences
• Parents
• Healthcare providers
• Educators
• Community leaders
via media, partner activism, community toolkits and presentations,
sharing research
8

9. Background
• As young people’s past-year non-medical use of Rx pain relievers has
begun to decline, past-year non-medical use of Rx stimulants has
remained slightly, stubbornly, more stable
Substance / Ages 2011 2011 2012 2013
Rx pain relievers % % % %
16 or 17 9.4 9.5 8.2 7.2
18 to 20 11.5 10.2 10.8 8.9
21 to 25 10.8 9.5 9.7 8.7
Rx stimulants
16 or 17 2.3 1.9 2.4 2.0
18 to 20 3.9 3.4 3.9 3.5
21 to 25 3.5 2.9 3.9 3.9
Source: National Survey on Drug Use and Health 9

10. Research Objectives
• Partnership / MAP wished to understand better the
underlying dynamics of Rx stimulant abuse, particularly
among college students:
– Demographics
– Motivations
– Sourcing
– Perceived benefits and risks
– Environmental factors
• Ultimately, want to share this kind of learning with the field,
and inform the development / improvement of effective
prevention strategies
10

11. Research Objectives
• Methodology:
– Nationwide online survey conducted July 22 – August 3,
2014, by Whitman Insight Strategies, New York
– N=1,621 adults aged 18-25, representative of US
population
• 1,018 current students (enrolled full/part time in college)
• 603 non-students
11

12. Research Objectives
• Methodology, cont’d:
– N= 406 stimulant misusers / abusers (including 295 past year
misusers / abusers)
• 181 have a prescription and have taken Rx stimulants for reasons
other than their intended use, OR
• 225 do not have a prescription and have used Rx stimulants
– N= 1,215 non misusers / abusers
• Have an Rx prescription and have used it only as instructed by their
doctor OR have never used stimulants
– Weighting
• The overall sample has been weighted to match U.S. Census data
for age, college enrollment, gender, and race/ethnicity
• The Misuser oversample (25% of overall sample) was weighted to
within the incidence of total misuse in our primary research (17%)
12

13. Key Findings
17%
20%
15%
Total 18-25 Students Non-Students
Individuals without Rx stimulant prescriptions who have
ever used Rx stimulants AND those with a prescription
who have used for reasons other than intended use
13

14. Key Findings – Who Are Misusers?
49%
42%
67%
All Prescribed Stimulants First Prescribed
Age Under 18
First Prescribed
Age 18 Or Older
14

15. Key Findings – Who Are Misusers?
• More likely to be male
– 60% male / 40% female
– Prescribed misusers are even more likely to be male: 69%
• More likely to be a sophomore or higher than freshman
– 11% of freshman are misusers (vs. 20% of students overall)
15

16. Key Findings - Motivation
39%
44%
31% 29% 29%
16% 17%
12%
17%
6%
56%
38%
27%
21% 20%
15%
9% 10%
5% 2%
0%
20%
40%
60%
80%
100%
Prescribed Misusers Non-Prescribed Misusers
Improving academic & work performance, and staying
awake are top reasons for misusing Rx stimulants
16

17. Key Findings - Motivation
• Misuse is connected to managing a busier, more active,
more social lifestyle
– “I regularly attend and / or host parties for friends” 49% of misusers
vs. 29% of non-misusers
– “I have trouble balancing my work life and social life” 40% of misusers
vs. 27% of non-misusers
– “I enjoy being the center of attention” 43% of misusers vs. 28% of
non-misusers
• And misusers are more likely to have jobs and financial
pressures
– 27% of student misusers have full time jobs, vs. 12% of non-misusers
– 48% of misusers receive financial support from home, vs. 58% of non-
misusers
17

18. 18
15% 19% 13%
31%
12%
41%
42%
40%
44%
41%
56%
60%
53%
75%
53%
0%
20%
40%
60%
80%
100%
Total 18-25 Students Non Students Misusers Non Misusers
Key Findings - Sourcing
Very easy Somewhat easy
More than half overall, and 3 in 5 students say it would be
easy to obtain Rx stimulants without a prescription
How easy or difficult do you think it would be for you to obtain
prescription stimulants that are not prescribed to you?
(Asked if not prescribed stimulants)

19. Key Findings - Sourcing
57%
22%
10%
6%
3% 2%
0%
20%
40%
60%
80%
100%
From a friend My personal
prescription (used
it for nonmedical
purposes)
From a family
member
From a “dealer” I bought it online Other
Total 18-25 (Misusers)
Friends are the most likely source of supply for Rx stimulants
19

20. Key Findings - Sourcing
20
58% 61%
55%
96%
48%
0%
20%
40%
60%
80%
100%
Total 18-25 Students Non-Students Misusers Non Misusers
% Have close friends…

21. Key Findings - Sourcing
And have you ever given away or sold
prescription stimulants (e.g. Ritalin, Adderall,
Concerta) to another person?
(Asked Among Those Prescribed Stimulants)
52%
66%
0%
20%
40%
60%
80%
100%
Total 18-25
(Prescribed Stimulants)
Misusers
(Prescribed Stimulants)
28%
51%
0%
20%
40%
60%
80%
100%
Total 18-25
(Prescribed Stimulants)
Misusers
(Prescribed Stimulants)
1 in 2 with a prescription have been asked to share with friends. Half have complied
Have your friends or peers ever asked you to share or sell your
prescription stimulants (e.g. Ritalin, Adderall, Concerta)?
(Asked Among Those Prescribed Stimulants)

22. Key Findings - Sourcing
22
28%
48%
0%
20%
40%
60%
80%
100%
Total 18-25
(Prescribed Stimulants)
Misusers
(Prescribed Stimulants)
When talking to your doctor have you ever exaggerated
your symptoms to try to receive a larger dose of
prescription stimulants?
(Asked Among Those Prescribed Stimulants)
Nearly 1 in 3 with a current Rx report “gaming” the system
to obtain Rx stimulants from a doctor

23. Key Findings – Perceived Benefits and Risks
And, in your opinion, has using a prescription stimulant for
nonmedical use helped you…
(Asked Among Misusers)
58%
37% 35%
23% 24%
6% 5%
56%
45%
23%
17% 14% 15%
6%
0%
20%
40%
60%
80%
100%
Stay awake Obtain a higher
grade on an
exam, paper, etc.
Improve your
performance at
work
Gain a
competitive edge
Lose weight Has not helped
me at all
Other
Prescribed Misusers Non-Prescribed Misusers
61% overall say it helped them obtain a
higher grade, improve work
performance or gain a competitive edge
Misusers report that Rx stimulants have generally helped
them achieve the intended results
23

24. Key Findings – Perceived Benefits and Risks
What is your current cumulative GPA?
(Asked Among Students)
9%
20%
30% 29%
12%
5%
13%
32%
39%
11%
0%
20%
40%
60%
80%
100%
Under 2.5 2.5 to 2.99 3.0-3.49 3.5-3.99 4.0 or above
Student Misusers Student Non-Misusers
Students Misusers vs. Non-Misusers GPA
24

25. 67%
67%
63%
59%
52%
58%
57%
48%
50%
45%
32%
13%
1…
14%
15%
19%
1…
17%
22%
21%
21%
19%
80%
79%
77%
74%
71%
73%
74%
69%
71%
66%
52%
39%
47%
39%
41%
53%
40%
29%
36%
35%
34%
32%
27%
20%
20%
19%
20%
19%
22%
25%
18%
18%
21%
65%
66%
60%
60%
73%
59%
51%
61%
53%
53%
53%
58%
60%
57%
53%
50%
52%
48%
42%
46%
41%
30%
17%
15%
15%
16%
19%
16%
18%
24%
20%
19%
19%
75%
75%
71%
70%
69%
68%
66%
66%
66%
60%
50%
65%
67%
61%
58%
54%
57%
55%
50%
49%
46%
35%
15%
12%
16%
16%
20%
17%
18%
21%
21%
23%
20%
80%
79%
77%
74%
74%
74%
73%
71%
70%
69%
55%
Key Findings - Perceived Benefits and Risks
63%
61%
58%
55%
52%
54%
51%
45%
47%
43%
32%
14%
16%
15%
16%
19%
16%
18%
22%
20%
20%
20%
77%
77%
74%
71%
71%
70%
69%
68%
67%
64%
52%
Addiction
Endangering your health
Overdosing
Upsetting your parents
Not being able to sleep
Getting into trouble with
the law
Compromising your future
Anxiety or panic attacks
Losing the respect of
friends or family
Depression
Eating disorders
Students Non Students Misusers Non Misusers
Here are some risks that can be associate with nonmedical use of prescription stimulants. Based
on what you know about prescription stimulants, please indicate how much you agree or disagree
that this is a risk associated with nonmedical use of prescription stimulants…
Total 18-25
Strongly Agree (8-10) Somewhat Agree (6-7)
25

26. Key Findings – Perceived Benefits and Risks
Regardless of perceived risks, Stimulant Misusers are far more
likely to also engage in other risky behaviors
24%
17%
5%
21% 18%
8%
26%
16%
5%
52%
45%
20%18%
9%
2%
0%
20%
40%
60%
80%
100%
Binge drinking Used marijuana for
nonmedical use
Use prescription pain
relievers
Total 18-25 Students Non Students Misusers Non Misusers
% Engaged In These Activities P30 Days
26

27. Implications for Prevention
• This research indicates that Rx stimulants are generally used
to help manage busy lives – study / social life / jobs. In this
respect they are fundamentally different from many other
drugs and substances – perhaps more integrated into daily life
and tougher to “grow out of”
• Challenge
– Low experienced risk, significant perceived benefits
– Normalized socially, with peer leaders among users
– Role of some prescribers
– Readily available
27

28. Implications for Prevention
• No one solution, but several important strategies:
– Prescribers
• Make prescribers aware of the extent to which symptoms are exaggerated
to obtain medication
– Parents
• Educate parents on prevalence, risks, extent of stimulant misuse in
combination with Rx pain relievers
• In transition from high school to college, counsel their kids with ADHD to
hold on to their medication and comply with prescriber’s instructions
– Educators
• Educate students on effective time management
• Campus prevention programs stressing minimal actual benefits
– Peers
• Young adults with ADHD resist sharing / selling medication as detrimental
to their own health
28

29. 29

30. Sean Clarkin
Director of Programs
sean_clarkin@drugfree.org
(212) 973-3523
30

31. Trends in Youth and
Rx Drug Abuse
Sean Clarkin MBA
Roy Van Tassell MS LPC
Dr. William Holmes M.D.
Moderator Nancy Hale

32. Disclosures
Dr. William Holmes has financial relationships
with proprietary entities that produce health
care goods and services. The financial
relationships is that he is the Sr. Medical
Director of Cenpatico

33. Disclosures
Roy Van Tassell MS LPC has financial relationships
with proprietary entities that produce health care
goods and services. The financial relationship is that
he is Director of Trauma and Evidence-based
Interventions for Cenpatico

34. Objectives
• Chart the prevalence of Rx stimulant abuse among
young adults
• Identify young adult’s reasons and methods for
abusing Rx stimulants
• Understand the role of trauma in the etiology of
adolescent and young adult substance abuse
• Outline strategies for reducing the risk for substance
abuse and mental health disorders among youth in
custodial care
34

35. Violence as a Pathway to Substance Use
Summary of Impacts on Children in 1 Year*
• 6 in 10 children exposed to violence
• Almost 1 in two children assaulted (46%)
• 1 in 10 maltreated (Physical, Emotional, Sexual,
Neglect or family abduction)
• 1 in 10 saw one person in family assault another
• 1 in 16 children sexually abused
• 1 in 10 had 5 or more direct victimizations
*Children’s Exposure to Violence: A Comprehensive National Survey;
Finklhor, Turner, Ormrod, Hamby, Kracke,
Office of Juvenile Justice and Delinquency Prevention 2008 www.ncjrs.gov
35

36. MH Needs of Children in Foster Care
• On any given day the U.S. averages about 400,000
children in foster care nationwide
• 23% of maltreated kids age 17 and under have
behavior problems requiring clinical treatment 3x
rate of the general population
• In a study of foster youth ages 14 and 17, 63% met
criteria for at least one mental health diagnosis.
• Kids in FC make up 3% of those under 18 with
Medicaid, but receive 32% of the behavioral
services for that age group
U.S. Children’s Bureau, 2012, ACF 2012 Oversight of Psychotropic Medication
for Children in Foster Care;

37. PTSD and Children in Foster Care
• PTSD rate varies by type of trauma event
• One study of foster care, found PTSD for 60% of
sexually & 42% of physically abused kids
• Also 18% of those w/neither PA or SA still had
PTSD, e.g. due to parental substance use, DV,
community violence, or other exposures.
• A study of kids ages 6-8 entering foster care
found that one out of three met criteria for PTSD
Dubner and Motta 1999, Marsenich, 2002, Dale et. al., 1999.

38. 38NCTSN vid

39. Substance Use and Foster Care
Few studies specifically identify prescription drug
abuse in FC
• A 2006 study found the rate of drug dependence in
FC youth was 5 times that of kids never in Fos. Care
• CWLA in 2008 found 40%-80% of child welfare
involved families had drug and alcohol problems
• Of youth in FC 34% have illegal drug use vs. 22% of
non foster care youth
Pilowsky & Wu 2006, CWLA 2008, National Survey of Drug Use & Health, 2005

40. Trauma Exposure as a Long Term Pathway
to Substance Use
• Over 21-25% of foster care alumni suffer from PTSD, a rate
higher than U.S. war veterans
• One study found 54% of foster care alums have mental
health and substance problems and 19% had 3 or more
mental health problems
• The same study found 64% of mother’s and 45% of fathers
of FC Alums had substance abuse problems before or
during FC
• In 2013, 23,000 youth aged out of FC, those with no
permanency are at highest risk of homelessness
incarceration and substance use
Kolko et. al., 2010, Pecora et al., 2005, Northwest Alumni Study Casey Family Programs,
Childrens rights.org 2013

41. Trauma’s Lasting Impacts
Throughout life children exposed to violence, trauma / PTSD:
• More substance use problems and DV
• Use more mental health services (Inpt, OP, Res Tx)
• Less likely to complete secondary or advanced education
• More trouble attaining and holding stable employment
• More disrupted –less trusting relationships
• More problems with criminal justice system
• More verbally, physically abusive to their others/own children
• Experience more homelessness & substance use
• Longer the exposure, worse the outcomes
• More life long physical health care services
• On average will die 20 years younger

42. Trauma Specific Treatments
• There are numerous child and adolescent treatment
interventions with strong evidence base of effectiveness
• Models range from birth to 21 some with or w/o parent
• For individual, group, family, early childhood and
incarcerated youth.
• A range of community based and parent education and
support interventions, those with evidence should be first
line choices
• The earlier child needs can be identified the earlier
intervention can occur

43. Non- Pharmacological Interventions
A few names you may hear: Range Birth to 21
– Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
– Alternatives for Families Cognitive Behavioral Therapy
– Child Parent Psychotherapy (CPP)
– Cognitive Behavioral Intervention for Trauma in School
– Parent Child Interaction Therapy (PCIT)
– Child and Family Traumatic Stress Intervention (CF-TSI)
– Structured Psychotherapy for Adolescents Responding
to Chronic Stress (SPARCS)
– Trauma Affect Regulation: Guidelines for Education and
Therapy Adolescent (TARGET-A)
– Attachment, Self-Regulation and Competency (ARC)

45. Issues of Med in Foster Care: Why
Important?
• There is strong evidence of high use of
psychotropic med use in foster care
• Texas experience with this…
• Emotional and behavioral care needs for
children in Foster care
• Are medications helpful? Needed for kids in FC?
• Naturally, increased prescribing may lead to
increased use and potential for diversion of
meds and misuse / abuse

46. Psychotropic Medications (PMs)
and Foster Care
• Studies of PMs in foster care are out of date and
often geographically specific (within & between
states)
• Studied rates varied from 13%-52% of kids in care
• PM use affected by age, gender, behavior, placement
– Age: (more PMs and more types as kids age)
– Gender: (3x more males vs. female)
– Behavior (internalized vs. externalized)
– Placement type (more restrictive = more PMs)
ACF: Oversight of Psychotropic Medication for Children in Foster Care;
Title IV-B Health Care Oversight & Coordination Plan 2012

47. Psychotropic Medications and
Foster Care
• Youth in foster care with Medicaid get 3 times the
Psychotropic Medications (PMs) of other
Medicaid qualified youth
• The same study found 41% got three different
classes of PMs almost 16% got 4 classes
• 22% got 2 or more meds in same PM class
regardless of diagnosis
• Yet these children have significant mental health
and behavioral treatment needs
Zito, et. al. Pediatrics, 2008

50. Use of Medication in Foster Care:
Responses
• Importance of quality evaluation /assessment
(e.g. does hyperactive behavior mean ADHD?)
• Increased awareness of EBTs and education
about trauma is essential
• Problems with availability / access to EBTs for
some children
• QI programs focus on med use and
management

51. PMUR - Psychotropic Medication
Utilization Review
• Goal: Improved use of appropriate medication
treatment
• Elements of PMUR:
– Pharmacy data
– Parameters
– Review of clinical information
– Contact with prescribers

52. PMUR - Psychotropic Medication
Utilization Review
• Results (TX specific right now, just beginning
to use in other states)
• Future goals:
– Connecting correct meds with given diagnosis
– Monitoring medication compliance
– Monitoring / evaluating use of non-medication
intervention effectiveness

53. Developed by: Texas Department of Family and Protective Services and
The University of Texas at Austin College of Pharmacy
with review and input provided by:
™Federation of Texas Psychiatry Texas Pediatric Society
™Texas Academy of Family Physicians Texas Medical Association
And Rutgers University—Center for Education and Research on Mental Therapeutics
September 2013
A Collaborative Texas Initiative

54. Attention to a National Problem
A National Response
• The Fostering Connections to Success and
Increasing Adoptions Act of 2008 requires all
states to increase their oversight of the health
and mental health of foster care children,
including initial and follow up health
assessments to determine whether a child
needs additional help (e.g. specialized trauma
services)
The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Public Law (P.L.)
110-351) amended title IV-B, subpart 1 of the Social Security act

55. Foster Care and Substance Use
Questions?
55
William Holmes MD
wholmes@cenpatico.com
Roy Van Tassell, MS LPC
rvantassell@cenpatico.com

56. Trending Topics Track:
Trends in Youth and
Rx Drug Abuse
Presenters:
• Sean Clarkin, MBA, Director of Programs, Partnership for
Drug-Free Kids
• Roy Van Tassell, MS, LPC, Director, Trauma and Evidence-
based Interventions, Cenpatico
• William D. Holmes, MD, Senior Medical Director, Cenpatico
Behavioral Health, and Medical Director, Foster Care
Services, Cenpatico
Moderator: Nancy Hale, President and CEO, Operation UNITE