Pediatric Resident Academic Half Day June 7, 2012 Ellie Vyver, MD, FRCPC Division of Adolescent...

Pediatric Resident Academic Half Day

June 7, 2012

Ellie Vyver, MD, FRCPC

Division of Adolescent Medicine

Objectives To examine substance abuse in the larger

context of social determinants of health To learn about adolescent susceptibility to

the effects of substances To have an understanding of risk and

protective factors as well as resiliency To be familiar with national, province and

local rates of substance use To develop an approach to the adolescent

using substances

The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011: Youth and Young Adults – http://publichealth.gc.ca/CPHOreport

SUMMARY

Canadian youth are leading healthy lives

Subpopulations like aboriginal youth, street involved youth, or sexual minorities are more vulnerable to particular health or socio-economic issues

Cost of Substance Abuse Results of the Costs of Substance Abuse in

Canada 2002 study released in 2006 Abuse of tobacco, alcohol and illegal drugs

cost Canadians about $40 billion ($18 billion in 1992)

Cost to Alberta was $4.4 billion ($1.6 billion in 1992)Tobacco $1.8 billion for AB (Canada $17 billion)Alcohol $1.6 billion for AB (Canada $14.6 billionIllegal drugs $1 billion for AB (Canada $8.2

billion)

Cost of Substance Abuse

Costs by category for Alberta:Indirect costs (productivity losses): 63%Direct health care costs: 23%Direct law enforcement costs: 11%Other direct costs: 3%

Developmental Tasks of Adolescence

Development of self-esteem and a healthy identity Emancipation from parents to autonomous

behaviors Formation of a sexual identity Meaningful social and peer relationships Seeking vocational goals Establishing moral and ethical values

Adolescent Brain Development and Susceptibility Period of significant brain development

Increase in white matter volume○ M>F○ Reflects increased myelination

Increase in gray matter volume in preadolescence followed by decrease○ Changes in frontal lobe involved in

development of executive functioningEmotional regulationPlanning and organizingResponse inhibition

Giedd et al., Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci 1999;2:861

Gogtay N., Giedd JN., Lusk L., et al. Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Science 2004;101(21):8172-8179

Dopamine

Synthesis in Preadolescent < Adolescent < Adult

Large increase in levels and activity during adolescence

Large role in reward circuitry of the brain that fuels drug addiction

Hippocampus

Increases significantly in size during adolescence

Levels of dopamine in the hippocampus show large increase

Involved in new memory formation

Risk and Protective Factors Terms used to identify aspects of

individuals or their environments that make development of a given problem more or less likely

Health Canada, 1999

Risk Factors

Defined as either life events or experiences that are statistically associated with an increase in problematic behaviour such as substance use

Protective Factors

Defined as the life events or experiences that mitigate the effects of risk factors and reduce the likelihood of problematic behaviour

Increase RESILIENCY

Resiliancy

The ability to overcome adversity

Risk and Protective Factors Can be categorized into five different

domains:

1. Individual

2. Family

3. Peers

4. Schools

5. Community

Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE: Monitoring the Future national survey results on drug use, 1975–2006. Volume I: Secondary school students. Bethesda, MD: National Institute on Drug Abuse; 699. (NIH Publication No. 07-6205)

Domain Protective Factors Risk Factors

Individual High intelligenceAchievement orientedOptimistic view of futureGood coping skills

Prosocial valuesPerception most peers don`t useTreated ADHDHigh religiosityPerception drug use has risks

Untreated mental health/behavior problemsSchool problemsGenetic vulnerabilityEarly pubertal developmentRebelliousnessPerception that most peers useUndiagnosed/untreated ADHDLow religiosityPerception drug use as low riskAfter school employment

Family Clear messages about no useParents model appropriate useStrong attachmentParental monitoringSupportive parents

Unclear messages, expect useSubstance abuseAlienated from familyPermissive or coercive parentingLots of conflict

Domain Protective Factors Risk Factors

Peers Do not useProsocial values

Peers usePeers alienated from community

Schools Offer opportunities for success and involvementFeel connected to schoolPersonnel seen as fair and caring

Poor quality

Feel alienated from schoolPersonnel seen as uncaring

Community Adequate recreational activitiesStrong community institutionsMedia realistically portrays harmsCounter marketing

Lack or recreational activitiesCommunity institutions lackingMedia portrays as normative and promotes positive expectanciesLack of community norms about useSubstance abuse commonDrugs easily availableSocioeconomic deprivation

TRENDS

Top 3 Substances

ALCOHOL

CANNABIS

TOBACCO

ALCOHOL

National Alcohol Use Data

CAS 0415-24

CADUMS 08

15-24

CADUMS 09

15-24

CADUMS 10

15-24

N = 2,085 1,443 955 3,989

Alcohol

Lifetime Use

90.0[85.4-93.2]

83.5[79.7-86.8]

81.8[77.6-85.4]

79.0[76.8-81.1]

Past 12 month Use

82.9[79.8-85.6]

78.4[74.2-82.1]

75.5[70.8-79.6]

71.5[69.1-73.9]

Age of initiation (years)

15.6[15.4-15.7]

15.6[15.4-15.8]

15.9[15.7-16.2]

15.9[15.8-16.0]

Alberta Data for Alcohol Use

CANNABIS

National Cannabis Use Data

CAS 0415-24

CADUMS 08

15-24

CADUMS 09

15-24

CADUMS 10

15-24

N = 2,085 1,443 955 3,989

Cannabis use

Cannabis – past year 37.0

[33.4-40.6]32.7[28.3-37.4]

26.3[22.0-31.1]

25.1(*)[22.8-27.3]

Cannabis - lifetime

61.4[57.7-65.0]

52.9[48.1-57.6]

42.9[37.9-48.0]

41.4(*)[39.6-43.2]

Age of initiation (years)

15.6[15.3-15.8]

15.5[15.2-15.8]

15.6[15.2-16.0]

15.7[15.5-15.8]

How do Alberta Youth Compare? The majority (83.7%) of students in Grades 7

to 12 report that they are not currently using cannabis

16.3% of students indicate that they have used cannabis in the past 12 months

Males (16.7%) and females (16.0%) are equally likely to report using cannabis

Older students are more likely to use cannabis.

Highest use in Calgary compared to rest of province

TOBACCO

Alberta Youth and Tobacco Overall, rates of smoking among students in

Grades 7 to 12 are lowMost students (95.3%) are not current smokers.Older students are more likely to smoke

Among all students, 69.7% reported they had never tried smoking tobacco.

Equal proportions of males and females are non-smokers (95.4% and 95.2% respectively)

The percentage of all students who had ever smoked a cigarette, even just a few puffs, increased from 10.0% among students in Grade 7 to 47.8% in Grade 12

Calgary has the lowest rate of current smokers (5.2%)

Illicit Drugs

Illicit Drug Use in 15-24 y.o. Past-year use of at least one of cocaine

or crack, speed, hallucinogens, ectasy, and heroin decreased from 11.3% in 2004 to 7.0% in 2010.

The rate of past year use of any drug excluding cannabis is almost nine times higher than that of adults (7.9% vs. 0.8%)

Alberta Youth and Illicit Drugs Majority of Alberta students (78.7%) have not

used illicit drugs (excluding cannabis) Illicit drugs most frequently used are MDMA

or ecstasy (3.7%) and hallucinogens (4.0%) Males (19.1%) and females (23.6%) have

similar rates of illicit drug use (excluding cannabis)

Increase in the proportion who use illicit drugs (excluding cannabis) as grade increases. 8.9% in Grade 7 27.4% in Grade 12

Calgary has one of the highest rates of illicit drug use in the province

SALVIA

Salvia Salvia divinorum Herb found in Southern Mexico; leaves are

very potent Atypical psychedelic "la pastora" / "the shepherdess", "the leaves

of the shepherdess", "diviner's mint“, "diviner's sage“

Smoked or leaves chewed Often tried once and not again as can cause

very dramatic and frightening hallucinations

“BATH SALTS”

Bath Salts 3,4-methylenedioxypyrovalerone (MDPV) Stimulant Effects comparable to amphetamines Most often taken by insufflation but reports of

taken orally Liked for its euphoria and increased sense of

mental alertness, productivity, sociability, creativity, and sexual arousal

Associated with compulsive, repeated dosing: “FIENDING”

With fiending or high doses more likely to cause hallucinations and psychotic behaviours

Erowid.org

What are the medical issues to consider? What tests do you plan to order? Are there any questions you’d like to ask before ordering these tests? Will you contact her parents?

oWhat will you tell them? How will you tell them?o What assumptions might you make about her family?

What is the legislation in Canada about calling parents?

A 15 year old female presents to the ER intoxicated. Ambulance was called by her friends after she was found passed out outside at a party. Her parents are not yet aware that she is in the hospital.

Approach

Confidentiality HEEADSSS Screen for problematic use Disclose drug screening tests Give results without parents present Motivational interviewing

Consent to Treatment

Consent is a “process” by which patients and/ or their parent or guardian are provided with a clear understanding of a proposed procedure or treatment and the options available. This is done in the context of the medical needs of the patient. The process results in a decision by the patient or parent/ guardian to otherwise what would be assault.

Criteria for valid consentCriteria for valid consent

nn CompetencyCompetency

nn Mental capacityMental capacity

nn Information disclosureInformation disclosure

nn SpecificitySpecificity

nn ClarityClarity

Competency GuidelinesCompetency Guidelines

nn Cognitive abilityCognitive ability

nn ClarityClarity

nn ConsistencyConsistency

nn UnderstandingUnderstanding

Age of Consent?Age of Consent?

For medical careFor medical care

Not in Canada; except Quebec

The LegislationThe LegislationBasic premise: Basic premise:

Any person of any age can request medical care.

HCP responsible for:HCP responsible for: Providing information for informed consent

Determining that the young person is capable to consent

HEEADSSS

H – Home Environment E – Education and Employment E – Eating A – Activities D – Drugs S – Sexuality S – Suicide/depression S – Safety from injury and violence

Screening for Problematic Use CRAFFT

C – Have you ever driven a CAR or driven with someone else while high or drunk?

R – Do you ever use drugs to RELAX, feel better, or fit in?

A – Do you ever drink or get high ALONE?F – Do you ever FORGET things while drinking

or using drugs?F – Do your FAMILY or FRIENDS ever tell you

to cut down on drinking or drug use?T – Has your alcohol or drug use ever gotten

you in TROUBLE?

Stages of Drug Use

Stage 0: No drug use Stage 1: Experimentation Stage 2: Regular use Stage 3: Abuse (as defined in DSM-IV) Stage 4: Dependence (as defined in

DSM-IV)

Maintenance StageMaintenance Stage

““I am aware of what I need to do to I am aware of what I need to do to prevent relapse”prevent relapse”

Relapse StageRelapse Stage““I need to review what I need forI need to review what I need for change to occur”change to occur”

Precontemplation StagePrecontemplation Stage

“ “ I do not need to change. I don’t have aI do not need to change. I don’t have aProblem, they do”Problem, they do”

Contemplation StageContemplation Stage

““I may have somethingI may have somethingI would like to change”I would like to change”

Preparation StagePreparation Stage

““I am looking at what I needI am looking at what I needTo do in order to change”To do in order to change”

Action StageAction Stage

““I am doing what is neededI am doing what is neededIn order to change”In order to change”

Stages of Change Model Stages of Change Model (Prochaska and DiClemente)(Prochaska and DiClemente)

From the client’s perspectiveFrom the client’s perspective

Pierre Leichner M.D.

Stages of Change Model Stages of Change Model (Prochaska and DiClemente)(Prochaska and DiClemente)

From the helper’s perspectiveFrom the helper’s perspective

Maintenance StageMaintenance Stage

Relapse StageRelapse Stage

Precontemplation StagePrecontemplation StageContemplation StageContemplation Stage


Action StageAction Stage

--Active listeningActive listening-Provide recognition and support-Provide recognition and support-Be prepared for relapse-Be prepared for relapse-Monitor and revise plan -Monitor and revise plan

--Active listeningActive listening-Reviewing progress-Reviewing progress-Maintaining positive attitude-Maintaining positive attitude-Support learning from past events-Support learning from past events

--Active listeningActive listening-Looking for common ground-Looking for common ground-Providing information and feedback-Providing information and feedback-Do not expect action-Do not expect action

--Active listeningActive listening-Giving feedback / information-Giving feedback / information-Encouraging exploring issues-Encouraging exploring issues-Weighing pro’s and con’s for change-Weighing pro’s and con’s for change-Do not expect action-Do not expect action

--Active listeningActive listening-Elaboration of plans and goals-Elaboration of plans and goals-Developing decisional balance-Developing decisional balance-Identifying supports-Identifying supports-Do not expect action-Do not expect action

--Active listeningActive listening-Supporting change activities-Supporting change activities-Encouraging rewards for action-Encouraging rewards for action-Supporting countering activities-Supporting countering activities

Pierre Leichner M.D.

The Real Stages of Change Model


Maintenance StageMaintenance StageAction StageAction Stage

Relapse Relapse StageStage

Precontemplation StagePrecontemplation StageContemplation StageContemplation Stage

Motivational Interviewing What is it?

Evolved from experience in the treatment of problem drinkers

First described by William Miller in 1983 in an article published in Behavioral Psychotherapy

Elaborated by Miller and Stephen Rollnick: Motivational Interviewing: Preparing People for Change (2nd edition) (Miller/Rollnick) (April 2002) (First edition in 1991)

Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (Marmite, 2005) reviewed 72 studies on MI and showed efficacy

Annabelle Blanchet M.D.

MIT - How to do it?

Directive, client-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence

Central purpose is the examination and resolution of ambivalence, and the counselor is intentionally directive in pursuing this goal.


MIT – General Principles (DARES)

Develop Discrepancy

Avoid Arguments

Roll with Resistance

Express Empathy

Support Self-efficacyAnnabelle Blanchet M.D.

Develop Discrepancy

The patient rather than the listener should present the arguments for change

Change is motivated by a perceived discrepancy between present behavior and important personal goals or values


Roll with Resistance & Avoid Arguments

Avoid arguing for change

Resistance is not directly opposed

New perspectives are invited but not imposed

The patient is a primary resource in finding answers and solutions

Resistance is a signal to respond differently


Express Empathy

Acceptance facilitates change

Skillful reflective listening is fundamental

Ambivalence is normal


Support Self-efficacy

A person's belief in the possibility of change is an important motivator

The patient, not the counselor, is responsible for choosing and carrying out change

The counselor's own belief in the person's ability to change becomes a self-fulfilling prophecy


MIT & Youth

High ambivalence

Developmentally - questioning authority

Cohersive approach likely unsuccessful

The invulnerable teen

The maturing brain and lack of experiences


Treatment - What works? Limited evidence related to efficacy of

treatment approaches for adolescents Concurrent mental health problems

need to be included as part of treatment Challenges:

Retention/attrition: drop out rate as high as 50-67%

AccessRelevance

Treatment

Youth substance use programs should not use the same treatment approaches that are used for adults

Treatment should encompass elements of family, school, peers, and community

Consistent theme in the literature regarding the importance of addressing family issues

Treatment plan that is flexible and responsive to the unique needs of the individual youth

Treatment

Research dose not indicate which treatment modalities are most effective

Options include:Individual outpatient counsellingFamily-centered practiceExperiential learningWilderness-basedDetoxification and stabilizationResidential

Treatment

Harm Reduction

Vs

Abstinence-based

Harm Reduction

Focus shifted away from eliminating use Aims to reduce related risks by

modifying the behaviour (which may include eliminating use)

Accepts that youth may choose to use substances

Acknowledges the potential health and psychosocial risks

Addiction Services for Youth

PChAD Act

The Protection of Children Abusing Drugs Act Act came into effect in Alberta July 1, 2006. Purpose is to give parents and guardians an

option to help their children (under age 18 years) whose substance use has causedSignificant physical, psychological or social harm

to themselves OR physical harm to others

ANDRefusing voluntary addiction treatment services

What have we learned? Canadian youth are generally living healthy

lives and transitional well into adulthood Many social determinants influence health Subpopulations like aboriginal youth, street

involved youth, or sexual minorities are more vulnerable

Alcohol, cannabis, and tobacco are the most commonly used substances and use of them has been decreasing over time

Key approaches are motivational interviewing and harm reduction

Pediatric Resident Academic Half Day June 7, 2012 Ellie Vyver, MD, FRCPC Division of Adolescent...

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