Adolescent Chemical Dependency

Adolescent Medicine

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Adolescent Chemical Dependency

farnes A. Farrow, MD*

Adolescent chemical dependency has become a discrete, medically recognized diagnosis that, like its adult counterpart, is characterized as a progressive disorder accompanied by loss of control over drugs and alcohol that results in clinically identifiable consequences that interfere with normal adolescent and family development. '5 . 20 The predominant disease model of alcoholism and drug addiction that forms the basis of diagnosis and treatment in adults is useful for adolescent substance abusers. Nonetheless, even if one accepts the premise of genetic predisposition to alcoholism and chemical dependence and the disease model, most clinicians in the field recognize the importance of childhood prevention and early identification to alleviate some of the factors that produce the serious problems accompanying chemical abuse during adolescence and adulthood. The degree of physical and emotional sequelae seen in chronic drug abusers and alcoholics is, to some degree, related to duration of abuse and susceptibility to complications. Susceptibility to liver damage from excessive alcohol intake, e. g., has been shown to be increased in certain racial and ethnic groups and to be familial in some cases. 14, 26 Adult health care providers are familiar with the devastation of physical and emotional health in adults with life-long consumption of alcohol and illicit substances. Ylany clinicians who treat end-stage chemical dependency and alcoholism in adults recognize that these adults, now disabled by years of ingestion of toxic substances, once were healthy children and adolescents who ultimately wasted their potential and capabilities, This realization makes it all the more important that physicians take advantage of the window of opportunity during adolescence to identify problems early, to assess young people for risk of chemical dependency, and to advocate for those youth who are in need of treatment. PRESENTATION OF THE ADOLESCENT WITH CHEMICAL DEPENDENCY JM is a 15-year-old caucasian male who was brought to the emergency room by ambulance. At the time of arrival, he was lethargic and intermittently combative and disoriented. According to the ambulance driver, the patient was found uncon'Associate Professor, Departments ofInternal Medicine and Pediatrics; Director, Division of Adolescent Medicine, University of Washington School of Medicine, Seattie, Washington

Medical Clinics of North America-Vo!' 74, No. 5, September 1990

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scious at the home of a male companion who had stated that the patient had been drinking beer and had taken several pills. The friend indicated that the patient had consumed a large quantity of beer and other liquor over a short period of time. There was no history of head trauma or recent medical illnesses. The ambulance driver had transported this patient 2 months prior to a suburban emergency room in an intoxicated state. Physical examination was significant for an accelerated heart rate and blood pressure of 140/90. Pupils were mid-line and sluggishly reactive, and the patient responded appropriately to noxious stimuli. After appropriate treatment in the emergency room, the patient was observed for several hours and released to home. His blood and urine screens were normal with the exception of a urine toxicology screen positive for Quaalude, tetrahydrocannabinol (THC) and cocaine and a blood alcohol level of 310 mg%. This case illustrates a typical and all-too-common presentation to the health care system. The ability of adolescents to recover quickly from acute toxic insults from ingestion of alcohol and drugs often lessens our concerns about physical and neurologic injury. These young patients often present with other acute complications of drug and alcohol ingestion, including acute gastritis with hematemesis and acute pancreatitis. Epigastric pain and protracted nausea and vomiting that produce gastrointestinal hemorrhage are additional manifestations of acute erosive gastritis. In combination ingestions or with sedative hypnotics, suppressed respiration and vomiting and suppressed consciousness together may produce aspiration. Worthy of special note are the acute complications of "crack" or "rock" cocaine intoxication, which have seen a dramatic increase in prevalence among adolescents. The acute manifestations of severe cocaine intoxication are convulsions, cardiac arrhythmias, and hyperthermia. 2, 7, 8 Not unique to adolescent abusers, cocaine initially causes a stimulation of neurotransmitters followed by a depressive phase. Diaphoresis, tachycardia, dilatation of pupils, and pallor are due to vasoconstriction and direct effects of cocaine on the autonomic nervous system that produce sympathetic overactivity. Tremor and convulsions are often preceded by dysphoric agitation, which may be a first sign of overdose. A variety of arrhythmias have been described. 10 The acute effects of cocaine ingestion are not long-lasting; manifestations of 2 to 3 hours' duration after exposure are most often due to other substances such as phencyclidine (PCP), amphetamines, phenolpropanolamine, or other additives. 2 There have been several good reviews on the treatment of acute intoxication in otherwise healthy young people. 7 17 A variety of other chemical substances are used by adolescents, and it is not within the scope of this article to review the acute and chronic complications of all of the drugs teenagers abuse. There are a number of up-to-date review articles in books that cover the subject. 4 , 5, 15,27

WHAT THE PHYSICIAN NEEDS TO KNOW The American Academy of Pediatrics' (AAP) Committee on Adolescence commented on the role of the pediatrician in substance abuse counseling. 21 The same recommendations apply to adult health care providers who care for adolescents and young adults. The AAP Committee recommendations indicated that physicians should become more familiar with the important issues of adolescent substance abuse because they are so often asked for advice by parents, community agencies, and educational institutions. The physician has the following five major areas of responsibility with respect to adolescent substance use and abuse: 1. The physician should have some familiarity with the trends and extent of adolescent drug use.

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2. He or she should possess the skills to define problem behavior and determine risk of abuse. 3. He or she should aecurately place an adolescent on the continuum of use and stage problem behavior. 4. He or she should address the issue as part of routine health care. 5. He or she should be aware of professional and community resources for further assessment and treatment. Each of these recommendations is addressed separately. TRENDS IN ADOLESCENT DRUG AND ALCOHOL USE There have been a number of important shifts in the patterns of use and abuse of drugs and alcohol by teenagers and young adults since the early 1960s. The adolescent population has become a polydrug using and abusing group for the 75 to 95% of youth who have experience with substances. Alcohol remains as the preeminent drug of choice, with the most recent high school surveys showing that better than 90% of high school seniors have had experience with alcohol and consider themselves "drinkers. "9. 12 Studies of the patterns of cocaine use among adolescents show a steady increase in use throughout the 1980s, in large part due to the production and sales of inexpensive forms of the drug. 29 At all levels, especially in schools, the concern over polydrug use and abuse among students has escalated. [8 Although the habitual use of alcohol and cocaine has risen, there is some evidence that in the last 5 years problem use of marijuana related to daily consumption has decreased substantially among adolescents." Another significant shift has been the degree to which teenagers have incorporated drug and alcohol use into their socialization experience and social development. Concerns about the "epidemic" use of illicit substances and alcohol by young people have partly been lost to the more pervasive "endemic" use of a variety of substances in the everyday activities of social interaction. This shift has made it difficult to assess the true nature of the problem for adolescents and often heightens suspicion on the part of parents about their adolescent children's use of these substances and promotes a trip to the physician's office. (j It should be remembered that the highest use rates for all categories of drugs, with the exception of solvent abuse and abuse of other inhalants, is in the 18- to 25-year-old age group.5 When adolescents graduate from high school and enter colleges or universities or enter the work place, their substance abuse problems are often ignored or hidden. There has been some emphasis in recent years on employee-assistance programs (EAP) for young employees who evidence alcohol and drug problems in the work place. A similar programmatic intervention has not been as widely applied among university students. Lastly, of considerable concern are the increased numbers of young women who are identified as heavily involved and chemically dependent. 2R In general, one sees increasing numbers of young female adolescents and younger teens as a group involved with alcoholism treatment services and attending meetings of Alcoholics Anonymous and Narcotics Anonymous. PROBLEM DEFINITION IN ADOLESCENCE Strictly speaking, drug use, specifically alcohol use, is illegal in all jurisdictions in the United States for individuals under 21 years of age. Using that legal definition alone to define problem use is inadequate. Traditional large-sample surveys have

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relied on quantity and frequency of use of a particular drug to define problem behavior. Student surveys, for instance, differ from one survey to the next in defining problem alcohol use based on how many times per month a student is intoxicated. Quantity and frequency of use appear to be only two important factors in defining current difficulties with a substance and are not generally predictive of alcoholism or chemical dependency in adulthood. Physical dependence manifested by withdrawal symptoms and tolerance occurs consistently only with several categories of substances such as opiates and sedative hypnotics and is often not identifiable in young abusers. Clinical evidence of physical dependency, with all of its acute and chronic signs and symptoms, is usually indicative of a greater problem and a worse prognosis. 3 Evidence of psychological dependence is more prevalent during adolescence and involves identifying to what degree the young person has incorporated drug and alcohol use into his or her daily activities and to what degree drug-seeking behavior exists. Chemically dependent adolescents, from an early age, use drugs to cope with stress and anxiety, to deal with family adversity and conflict, and to lubricate their social interactions in a variety of individual and group situations. In addition, most of these youngsters have developed innumerable ways and devices for obtaining illegal substances and alcohol through strangers and adult acquaintances. They become part of networks that make drugs and alcohol readily accessible. Problem drug and alcohol use during adolescence must further be defined in its cultural and environmental context. Some religious, restrictive families will refer an adolescent for evaluation and treatment of drug abuse after one episode of intoxication; in contrast, thousands of inner-city, urban, generally minority youth are involved in more lethal drug activities and do not come to the attention of medical or psychiatric professionals until they have many acute complications, are arrested, or contract an HIV-related disorder. In addition, there have been some studies relating risk for problem youth to birth order, family size, and religious background. 23. 25 All of the factors mentioned help define problem use and chemical dependency in adolescence. Quantity and frequency of use, psychological dependency, cultural and environmental context, and identification of any physical complications are all important parts of the definition. CHARACTERISTICS OF ADOLESCENT SUBSTANCE ABUSERS AND PREDICTION OF RISK Adolescent drug and alcohol use falls on a broad continuum from abstinence to chemical dependency. The best estimates of the number of teenagers who are truly chemically dependent is less than 1% of all users. This number in itself is significant, as are the implications for the need for evaluation and treatment. Recent research has estimated that 10 to 15% of adolescents under 18 years of age have definable problem use of alcohol and other drugs; approximately the same number are habitual users.'6 At the other end of the continuum is the adolescent who has little or no experience with alcohol or other drugs prior to 18 years of age, comprising 10 to 15% of the population. The remainder of the population "experiments" with various drugs at some time during their adolescence and adjusts their use in nonproblematic ways as they grow older. For the "experimenter" engaging in other types of risk-taking behavior, moving away from family-centered activities, placing greater value on social activities rather than on academic performance, and engaging earlier in "transition-marking behaviors" are important in the characterization. l l There are identifiable indicators of risk that more accurately predict which adolescents will move along the continuum toward problem use and chemical

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dependency. A number of identifiable family and social factors tend to promote drug abuse in these young people, including a family history of alcoholism and drug abuse, early peer choices about drug use and deviant behavior, and high availability of drugs in the adolescent's home environment. Additionally, there are some drugindependent factors that, as a group, may be important to identify. These factors include parental conflict that produces anxiety and guilt in the child; early alienation from family, community, and school, often evidenced by poor academic performance or attendance; a decrease in family-centered activities; abandonment of outside recreational interests; and runaway behavior.' Parenting styles and parental personality traits may be added to the list, especially those styles characterized by inconsistent and impulsive parenting or outright abusive treatment. No single one of these background factors has a high degree of predictive value, although many chemically dependent youth grow up in families with these characteristics or live these experiences.

INCORPORATING THE ISSUE INTO ROUTINE PATIENT CARE Modern-day drug and alcohol education and prevention are no longer based on imparting basic knowledge about the pharmacology of illicit drugs and alcohol. This approach appears not to affect an adolescent's attitudes and behaviors in a desirable manner. !vIoderate approaches incorporate, in addition to this more "cognitive" approach, an "affective" and "behavioral" approach. The affective component takes into account the child's attitudes and values and the child's perception of his parent's values. The behavioral component assesses the adolescent's current behavior in relation to resisting drug and alcohol use in social situations and assesses the youngster's behavioral skills and communication ability. In a like manner, a cognitive, affective, and behavioral approach should be taken as part of a routine health history with adolescents and young adults about their drug use. Regardless of the reason for the general health visit to the physician, a clear history should be obtained with respect to the degree of drug knowledge and experience after an appropriate statement of confidentiality is made. The history of drug and alcohol use often is best obtained as part of the review of systems and in the context of asking questions about organ systems. For example, questions about tobacco use can be asked while one asks about respiratory symptoms. Questions about what drugs are used and quantity and frequency of use should be followed with questions about the adolescent's attitudes toward drug and alcohol use in general and where the adolescent "draws the line" and is not willing to experiment with certain categories of substances. For those adolescents who have little or no personal experience with substances, this line of questioning provides some insight into the value system and the relative resistance that the young person has to future drug and alcohol use. It is important to note here, however, that the course of adolescent development is a highly changeable and dynamic one, and attitudes and behavior change dramatically from 1 year to the next with any individual young patient. Attitudes and values should continue to be assessed as the adolescent grows older and is exposed to more social experiences and peer pressure. Physicians should assess the ease with which these young patients discuss drugtaking behavior. Investigating this behavioral component with the adolescent patient often takes the form of suggesting hypothetical situations involving drug and alcohol use to assess the extent of the child's communication skills, specifically refusal skills, to avoid drug use. A number of adolescents have already developed resistance to drug-taking and have developed helpful skills at young ages to resist drug-use situations they feel to be dangerous or inappropriate.

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The cognitive, affective, and behavioral approach requires less time to incorporate into a line of questioning than it does to describe. When it is applied to the context of a routine medical history, it can be an effective way of assessing where the adolescent is, what his or her risk for drug abuse is, and what additional services are required.

ASSESSMENT OF THE PROBLEM USER AND DRUG SCREENING The indices of problem drug use in adolescence fall into several large categories, including medical complications, difficulties in school, legal problems, and difficulties with family and peer relationships. A checklist of areas that should be covered when confronted with an adolescent or young adult who has a significant polydrug use problem is proVided in Table 1. This information can be obtained from the patient either in a structured interview or by using one of the many adolescent assessment questionnaires available. l9 Regardless of the approach, assessment of chemical dependency and problem behavior relies on identifYing as many negative consequences of the drug use as possible, appropriate to the adolescent's level of development. Maturational development is generally retarded or halted when adolescents become chemically dependent. Therefore, one may be assessing a chronologic 20 year old who is emotionally 14 years old. Normal adolescent development can be affected significantly by chemical abuse. Baumrind and Moselle l provide an excellent review of the impact of substance abuse on the developing adolescent. Making an accurate assessment of chemical dependence in the adolescent may be further complicated by denial and a lack of trust in the physician as an agent of the adolescent's parents. This mistrust can be aggravated when the adolescent is referred for drug screening.

DRUG SCREENING Drug screening for the use of illegal or illicit drugs has become very popular in the work place, in the school environment, and in athletic programs. The pros and cons of involuntary versus voluntary screening of adolescents have been discussed and have produced policy statements from various professional associations and societies involved in the care of adolescents. 24 The preponderance of opinion is that involuntary drug screening should not be carried out by physicians who care Table 1. Indices of Problem Drug Use in the Adolescent: The Clinical History Physical-Medical Amnesic episodes ("blackouts") Withdrawal symptoms Accidents or injuries while intoxicated Acute toxic reactions (overdose, vomiting, delirium, abdominal pain) General health concerns School School performance (change in grades) School attendance Use of drugs during school Extracurricular activities Memory and concentration difficulties School behavior and disciplinary problems

Legal Problems Juvenile Court record Drug-related criminal activity Traffic accidents/citations Friends with criminal history Family and Peer Relationships Parent-child conflict over drug use Chemical use of family members Time spent in family-centered activities Peer chemical use Relationship with opposite sex Activities with friends Peer concern about patient's drug use

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for adolescents suspected of using drugs to identify candidates for treatment or to identify wrongdoers for purposes of punishment. If urine screening is done voluntarily or is part of an overall monitoring and treatment protocol, proper screening procedures and laboratory testing are n:ecessary. This requires careful attention to the collection of specimens, storage and labeling, laboratory procedures, and avoidance of errors in communication of the results. The protection of confidentiality needs to be assured. In chemically dependent adolescents, observation by same-sex observers for the collection of urine specimens is usually indicated. Accurate laboratory analysis of specimens and reporting of "positives" depend on the threshold concentration or "cut-off' point used in the screening tests and the detection limits for certain urine drug screens. The detection limits for urine drug screening are presented in Table 2 and the threshold concentrations are presented in Table 3. Saxon et aJ22 have recently published a review of the uses of urine screening for drug abuse. ADOLESCENT CHEMICAL DEPENDENCY TREATMENT: REFERRING THE PROBLEM PATIENT Virtually all of the treatment modalities applied to alcoholic and chemically dependent adults have been applied to children and adolescents in need of treatment. ~any of the adolescent inpatient treatment programs have not been adequately evaluated, and large-scale treatment outcome studies are only now being carried out by the National Institute of Drug Abuse (NIDA) and the Alcoholism Drug Abuse and Mental Health Administration (ADAMHA). Programs that intervene with adolescents early and provide them with an eclectic therapeutic treatment approach, including individual, group, and family therapy, incorporate a core of 12step treatment approaches, and provide strong physical health and recreational alternatives and intensive after-care support produce the best outcomes. Knowledge of a particular program's treatment philosophy is important prior to referring an adolescent for further assessment and treatment. Many programs have a strong religious base to their treatment approach, and others focus heavily on the disease of chemical dependency to the exclusion of family involvement and make no attempt to address contributing factors such as sexual abuse, being a child of an alcoholic, being gay or lesbian, or the often present underlying depression and suicidal Table 2. Detection Limits for Urine Drug Testing DOSE

SCREENING

DRUG

(MG)

DETECTION Tl\IE

FREQUENCY

Amphetamines Barbiturates Short-acting Phenobarbital Benzodiazepines Long-acting (diazepam) Short-acting (triazolam) Cocaine Methadone Methaqualone Morphine (opiates [IV)) Tetrahydrocannabinol metabolites Marijuana (1 time/wk) Marijuana (daily)

30

1-120 hr

1-2 times/wk

100

At least 4.5 days 6-24 hr

1-2 times/wk 1-2 times/wk

10

7 days 24 hr 8-48 hr 7.5-56 hr 60 hr 84 hr

1 time/wk 2-3 times/wk 2-3 times/wk 2-3 times/wk 1-2 times/wk 1 time/wk

7-34 days 6-81 days

1 time/mo 1 time/mo

30

0.5 250 40

150 10

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Table 3. Threshold Concentrations* DRUG

Barbiturates Amphetamines Methadone Benzodiazepines Propoxyphene hydrochloride Phencyclidine Cocaine Parent Benzoylecgonine (cocaine metabolite) Opiates Morphine Codeine Cannabinoids (as total metabolites) Methaqualone

El\ZYME

RADIO

THIN-LAYER

IMMUNOASSAY

IMMUNOASSAyt

CHROMATOGRAPHY:j:

0.3-2.0 0.3-1.0 0.3 0.3-2.0 0.3 0.08

0.2-3.4 1.0

0.025-0.10

0.5-1.0 0.3-0.5 0.5 1.0 0.5 0.1-0.2

25.0 0.3

0.45 0.3

1.0 1.0

0.3 loO 0.1

0.3 0.16 0.1

0.25 0.25 0.075-0.1

0.3

0.075

1.0

0.1

*In grams per milliliter of urine. t Abuscreen. f'Traditional" thin-layer chromatography. Sensitivity varies widely, depending on the system used.

ideation. A comprehensive approach is almost always indicated, thc key premise being that the adolescent will remain abstinent throughout the trcatment process in order to deal more effectively with other difficulties. The recovery process for adolescents is no less difficult than it is for adults; in part, it depends on the duration of involvement in recovery and the commitment to post-treatment support, which often involves a major change in the adolescent's living situation and frequent attendance at meetings of Alcoholics Anonymous or Narcotics Anonymous. For those adolcscents who come from intact and motivated families, outpatient individual, family, and group therapy may be helpful. In most communities, an alcohol and drug treatment resource directory or telephone line is usually available. The physician who sees any number of chemically dependent adolescents or adults should keep an up-to-date treatment resources list and make a personal visit to these treatment resources in order to become personally familiar with the staff and treatment philosophy. It is also appropriate for clinics and practitioners to have appropriate, up-todate material that is aimed at all patients, regardless of age, to inform them of the health consequences of drug use. In addition, the motivated physician should be involved in public prevention activities and community policy-setting matters.

SUMMARY Adolescent chemical dependency is now a recognized, diagnosable entity. In most respects, it mimics the diagnosis in adults. The practicing physician has some obligation to be familiar with changing trends in drug use and should have the skills to define problem use and assess risk. The physician should also address the issue as part of routine clinical interactions with patients and be aware of community resources for further assessment and treatment. Finally, the physician should be an advocate of the young patient and be helpful to parents in understanding the problem, but he or she should not be the parent's agent when asked to commit the

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adolescent for treatment or carry out drug abuse screening. The problem of adolescent substance abuse is a pre-eminent social problem. The problem must be addressed on many fronts. The role of the physician provides a key component of the solution.

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11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

22. 23. 24. 25. 26.

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27. Strassman RJ: Adverse reactions to psychedelic drugs. J Nerv Ment Dis 172:577, 1984 28. Thompson KM, Wilsnack RW: Drinking and driving problems among female adolescents: Patterns and influences. In Wilsnack SC (ed): Alcohol Problems in Women: Antecedents, Consequences and Interventions. New York, Guilford Press, 1984 29. White HR: Longitudinal patterns of cocaine use among adolescents. Am J Drug Alcohol Abuse 14:1, 1988

Address reprint requests to James A. Farrow, MD Division of Adolescent Medicine WJ-lO University of Washington School of Medicine Seattle, WA 98195