Adolescent Substance Abuse PowerPoint for UCAYA

1. Adolescent Substance Abuse
Mike Guyton, MD
Assistant Clinical Professor/Academic Faculty in
General Pediatrics

2. Overview
• Myths, Misconceptions, and the Adolescent Brain
• Common Drugs of Abuse
– Alcohol
– Marijuana
– Tobacco
• Emerging Trends in Substance Abuse
• Co-morbid conditions with Substance Abuse
– Depression and Anxiety
– Bullying
– High Risk Sexual Behavior
• Prevention Strategies/Resources

3. Drug Myths and Misconceptions
• Drug addiction is a choice
• Substance use is just a
phase during adolescence
• Marijuana is safer than
traditional tobacco
products
• Teenagers are drinking
alcohol and doing drugs
now more than ever

4. Drug Facts
• Illicit drug use among teenagers remains high, largely due to
increasing popularity of marijuana.
– Rising marijuana use reflects changing perceptions and attitudes.
• Nonmedical use of prescription and over-the-counter medicines
remains a significant part of the teen drug problem.
– Purple Drank/Sizzurp/Lean
• Alcohol use among teens remains at historically low levels.
• Fewer teens smoke cigarettes than smoke marijuana.
• Other forms of smoked tobacco are becoming popular, however.
– Hookah Water Pipes, Small Cigars

5. The Biology of Adolescence
• In general, adolescence
includes ages 10-25
• Lack of frontal lobe
lack of judgment
• Behavior controlled by
response to impulses
– Amygdala/Limbic System

7. Alcohol
• The most widely used/abused drug among US adolescents
– In US, children and adolescents account for 11% of total alcohol
consumed
– Almost 40% of HS students report current use; ¼ binge drink
• Multitude of negative health effects associated with abuse
– Acute Effects
• Nervous System Depression, Hypoglycemia, Dehydration, GI
– Chronic Effects
• Chronic Liver disease, Nutritional deficiencies, Impairment in
Cognition
• Many negative societal outcomes as well
– Fatal MVA’s, aggression, suicidal behavior, unplanned
pregnancies, sexual assault

8. How much is too much?
• Legal limit in SC is 0.08
• Reaching limit depends
on many factors
– Age and Gender
– Weight
– Rate of consumption
– Metabolism
– Hydration

9. Standard Drinks

10. Binge Drinking Facts
• In general, risk of experiencing
problems is greater for binge
drinkers
– School, social, legal, etc.
• Youth who start drinking
<15yo are 5X more like to
develop alcohol dependence
or abuse
– Vs those after 21yo
• Data from 2011 Youth Risk
Behavior Survey
– 16% of youth 12-20 report
binge drinking
– In high school students, 22%
reported binge drinking in the
last 30 days
Standard Drink Measurements (0.6-oz
of pure alcohol):
• 12-oz of beer (5% a.c)
• 8-oz of malt liquor
• 5-oz of wine (12% a.c.)
• 1.5-oz of 80 proof liquor
Binge Drinking = 4+(women) or 5+(men)
drinks on one occasion

11. Binge Drinking
• Neknominate
– Most popular in the
UK/Ireland, trend
spreading over 2014
– Believed to be directly
responsible for 5 deaths
in the UK
– Each nomination more
intense, daring, or
humiliating than the last

12. Tobacco
• Leading preventable cause of disease, disability, and death in US
– Causing/related to 1 in 5 deaths in the US
– 41,000 non-smokers die annually due to passive smoke exposure
• Active ingredient is Nicotine
– The most addictive substance in existence; withdrawal
– Toxic/Fatal in certain quantities
– Stimulates adrenal glands/nervous system
• blood pressure, heart rate, respiration
• Cigarette smoking alone accounts for 1/3 of all cancers, in addition
to those caused by smokeless tobacco
• Passive smoke exposure also linked with health compromise
– Heart disease risk (25-30%) and Lung cancer risk (20-30%)

13. Tobacco Carcinogens

14. Marijuana
• Most common illicit drug used in the US
– Increasingly popular among teenagers
• Use is extremely controversial
– Schedule 1 per Federal Government
– Approved for medicinal use in 21 states
– Approved for recreational use in 2 states
• Nervous System effects are the most well known
– THC attacks the cannabinoid receptors in the brain  affect
pleasure, memory, thinking, concentration, and coordination
– Overstimulation  altered perceptions, “high”
– Affects brain development in heavy/chronic users
• Loss of, on average, 8 IQ points between age 13-38 when started in
teenage years

15. Lesser Known Facts
Recognized Medicinal Uses
• Chemotherapy related
Nausea and vomiting
• Appetite Stimulation
• Cancer Pain Relief
• Anxiety and Sleep
Long Term Health Effects
• Substance Addiction
• Carcinogen Exposure
– Benzopyrene
– Benzanthracene
• Increased respiratory
infections
• Increase risk of CVD
• Mental Illness
• Infertility/Pregnancy
Related concerns

17. Emerging Trends in Substance Abuse
http://www.drugabuse.gov/

18. Emerging Trends
Days of Yore
• Cigarettes
• Alcohol
• Cocaine
• Heroin
• Marijuana
New Kids on the Block
• Bath Salts
• Inhalants
• K2/Spice
• MDMA
• Steroids
• Krokodil
• Natural Substances
– Caffeine
– Spices

19. Bath Salts
• Drugs containing 1+
synthetic cathinones
– Amphetamine-like stimulant
• Marketed under many
names; used in several ways
– Ivory Wave, Vanilla Sky, White
Lightning
– Orally, Inhaled, Injected
• Symptoms of “excited
delirium”
– Elevated HR/BP, Euphoria,
Paranoia, hallucinations,
panic attacks

20. Traditional Caffeine Use
• Traditionally, soda and tea have been the main sources of
caffeine for kids and adolescents
– ~73% consume caffeine on a given day
• Mean caffeine intake among adolescents and young adults
in the US has remained stable over the years
– Actually decreased among young kids over the last 10 years
• Proportion of intake from soda has decreased, but intake
from coffee and energy drinks has markedly increased
– Coffee: 10%  24% (2009-2010); Energy Drinks: 0%  6%
(2009-2010)
• AAP has a very clear statement
– “Stimulant-containing energy drinks have no place in the diets
of children and adolescents”

21. Caffeine of 2014: Caffeine Powder
• Hit the headlines in March 2014
– Fatal overdose by a senior high school student
• Caffeine powder is pharmaceutical grade
– Basically 100% pure; safe amounts can not be measured with
traditional household/kitchen measuring tools
• Some potential uses have been discussed
– Added stimulatory/concentration effects
– Help in losing weight
• Side effects are varied
– Arrhythmia
– Seizures
– AMS
– GI Symptoms: Nausea, Vomiting, Diarrhea

22. How does caffeine powder measure
up?
Caffeine Powder
• 1/16 tsp = 190mg
• 1/8 tsp = 380mg
• ¼ tsp = 760mg
• 1tsp = ~3,000mg
Traditional sources of Caffeine
• Coffee = 80-175mg
• Tea = 15-60mg
• Red Bull = 80mg
• Mountain Dew = 55mg
• Diet Coke = 45mg
• 5-hour energy = ~210mg
1tsp of Caffeine Powder = ~25-30 cups of
Coffee

23. The E-Cig Craze
• First nicotine based E-
cigarette was created in
2003
• Cost ranges from $10 to
hundreds of dollars
• The trend, known as
“vaping,” is set to surpass
the sales of regular
cigarettes in the next 10
years
• Doctor Plug
• Office Plug

24. E-cig? Never heard of them!
What's the Difference
• Vapor vs Smoke
– No burning means no CO
• Nicotine Levels
– Not as predictable
• Lack of Carcinogens
• Reusable
– Charging stations, cartridges
• Cheaper
– $600/year vs $1,000/year
What's the Problem
• Not FDA regulated….yet
– Family Smoking Prevention and
Tobacco Control Act
• Health Risks of Nicotine Alone
– Lethal at certain doses
– Multiple forms of exposure
• Impact on Lungs
– Decreased lung function,
increased airway resistance,
cellular changes
• Risks not related to Vaping
– Accidental poisoning of
children

25. How does this affect our Adolescents
• Between 2010-2012, ever use of e-cigarettes among U.S. youth
doubled 3.3%  6.8%; current use doubled 1.1%  2.1%
• Well known that adolescents are impressionable, stubborn and for
the most part invincible
– Majority of adolescents (64%) see the harmfulness of cigarettes as
dose-dependent and on a continuity
• Curiosity is a hallmark of this period of development
– Estimated 30% of youth are curious about cigarette smoking
• Brain is still making pathways that can be interrupted
– In animal studies, deficits in serial pattern learning, attention and
impulsivity, and memory were seen after exposure to nicotine
– Also, increased anxiety and depression

27. Combining Curiosity and Exposure
• Youth exposure to TV E-cig ads
increased 256% from 2011 
2013
– Reaches 24 million youth
• Cable television accounts for
the largest source of exposure
• Depicts e-cigs with vapor that
looks similar to smoke
– Visual Cue  urge to smoke
• Ads harp on smoking being an
adult behavior
• All this combined can alter
and create new social norms
about tobacco, thus
influencing smoking behaviors

28. Current Burden of Mental Illness
Among Youth
• Depression
– Point prevalence in those 4-17yo estimated to be 3-3.5%
– Lifetime prevalence as high as 7-8%
• Relapse as high as 40% in 2 years
– F:M 2:1; increased risk to those born in latter half of 20th century
• Anxiety
– Usually co-morbid with depression
• Estimated to be current in ~3% of those 3-17yo
• Suicide
– 3rd leading cause of death among all children and adolescents in
the US
– In 2010, rates estimated to be 4.5/100,000 youth 10-19yo
– Overall, rates of pediatric suicide are increasing

29. Depression, Anxiety, and Substance
Abuse
• Association is multifaceted
– Anxiety/Depression may increase substance use;
substance use may affect course and severity of
anxiety/depression
• Stress highly linked with relapse
– HPA axis shows responses that can promote relapse
• Many neurochemical components shared between
depression/anxiety and substance use disorders
– Dopamine
– Catecholamines
– GABA receptors

30. What Makes Identification Tough
• Kids/Adolescents have many reasons to hide
their feelings of depression/anxiety
– Fear of Stigma
– Belief that depression is not treatable by primary
care docs
– Depression is not a “real” illness, but instead a
personal flaw
– Concerns about confidentiality
– Do not want medication or involvement of a
psychiatrist

31. Teen suicide tries increased after FDA
toughened antidepressant warning

32. The Study
• Harvard Medical School followed 2.5 million teens/young adults between
2000-2010
– Published in The BMJ June 18, 2014
• Use of SSRI’s fell by 25%-30%
– Young adults and teens respectively
• Suicide attempts rose 22% in teens and 34% in young adults
• At the heart, its all about communication
– Treating depression in teens with SSRI’s has been proven safe and
effective time and time again
– Appropriate follow-up must be an integral part of the management
plan
– View SSRI treatment as a temporary measure, and communicate that
to the patient
– Don’t neglect to role of psychotherapy as well

33. Bullying
• “Repeated infliction of harm on younger, smaller, or less
powerful peers”
• 10% of students grade 6-12 have reported bullying in
varying environments
– School, on the way to school, online, extracurricular
activities/sports
• Both the bully and victim are affected
– Victim: Physical injury/symptoms, lapse in concentration,
anxiety depression, poor self esteem, high school absence
– Bullies (long term): incarceration, social/financial/personal strife
• Bullying  Vulnerability  Impulsivity  substance abuse

34. Anabolic Steroids
• Official name is Anabolic-Androgenic Steroids (AAS)
– Synthetic variants of testosterone
• Prevalence trend has been overall stable from 2010-2013
– Ranging 1.1%-2.1% for 8th-12th grade adolescents; as high as 5.4%
– Sexual Minority Boys have a prevalence of 21%
• Abusers usually “cycle” use but use higher dosages than those
medically prescribed
• Many long term side effects
– Stunted growth
– Gynecomastia
– Testicular atrophy
– Androgenic effects
– Infertility
– Increased risk of prostate cancer

35. High Risk Sexual Behavior
• Link between substance use and high risk sexual
behavior
– Decreased inhibitions  poor decision making
• Compounded by natural curiosity about sex and
biological impulsivity
– Lack of prefrontal cortex control
• Interventions should be multifaceted
– Education on safe/responsible sexual practices
– Assessment of degree of substance use
– Screening for episodes of domestic violence
• Sexual minorities particularly at risk

36. Prevention Strategies
• Routine medical care
• Don’t be afraid to ask
questions
• Educate yourself on the
common signs of
substance abuse
• Focus on reduction of risk
factors
– Teaching life skills at school
– Education/discussion on
co-morbid conditions

37. Common Signs of Substance Abuse
• Physical Signs
– Bloodshot eyes
– Weight loss
– Deterioration in personal hygiene
– Tremors, slurred speech
• Behavioral Signs
– Increased withdrawal from others
– Loss of enjoyment in activities previously liked
– Sudden changes in friends
– Change in school/work performance
– Unexplained need for money
• Psychological Signs
– Anxiety/Fear/Paranoia for no reason
– Sudden mood swings
– Lack of motivation

38. Resources
• Greenville Family Partnership
• Local Law Enforcement: Greenville County Police
Department/Greenville City Police Department
• CDC: www.cdc.gov
• National Institute on Drug Abuse:
www.nida.nih.gov ;
www.nida.nih.gov/students.html
• Partnership for a Drug Free America:
www.drugfree.org