https://www.stuvia.com/user/nursecare
1
CMN 554
Module 3 Primary Study Guide (Substance
Abuse)
Sadock Chapter 55.5
Adolescent Substance Use
Introduction Pg Disorders
3857
Substance use disorders (SUDs) account for about 6 percent of all deaths worldwide and cost
an estimated $700 billion in the United States, alone.
The vast majority of adults (approximately 80 percent) with chronic addiction started using
drugs or alcohol as teenagers.
• Although the majority of adolescents in the United States report experimenting with
drugs or alcohol before graduating from high school, most do not progress to a SUD.
• The estimated risk of developing an SUD by the age of 18 is 23.8 percent.
• Risk of progression to an SUD is increased in those who have pre-existing disruptive
behavior disorders or other mental health problems, academic problems, and/or have
experienced chronic adversities or maltreatment during childhood.
Adolescent-onset SUDs are more likely to progress to chronic addiction in adulthood and also
increase the risk of developing mood and anxiety disorders as well as antisocial personality
disorder.
• At-risk youth can be identified in children as young as 3 to 5 years of age, often
presenting with impulsivity, aggression, hyperactivity, inattention, poor persistence,
and emotional lability.
• This constellation of symptoms, characterized as “behavioral dysregulation,” is highly
heritable and a strong family history of SUD is often present.
• Such children often continue to have poor self-control, develop disruptive behavioral
disorders (oppositional defiant disorder [ODD], attention-deficit/hyperactivity
disorder [ADHD], conduct disorder [CD]) in later childhood, and are at high risk of
developing SUDs during adolescence.
It is important for school personnel, pediatric primary care, and mental health clinicians to
screen children for risk factors and refer for evaluation and interventions that may prevent or
reduce their risk of early-onset SUD.
It is also important to highlight that repeated use of drugs or alcohol can alter brain function in
ways that reinforce or promote continued use and development of SUD even in youth without
known risk factors.
• For example, youth with chronic painful medical conditions, acute or prolonged
injuries, or multiple medical or dental surgical procedures may be at risk of developing
addiction to prescription opioid pain medications even in the absence of pre-existing
apparent genetic or environmental risk factors.
Research advances over the past two decades have led to the understanding that addiction as a
1
https://www.stuvia.com/user/nursecare
,https://www.stuvia.com/user/nursecare
2
neurobiologically based medical illness.
• Initial exposure to substances of abuse increases firing in the dopaminergic pathways
of the ventral striatum, producing a subjective “high” that promotes further drug use.
2
https://www.stuvia.com/user/nursecare
,https://www.stuvia.com/user/nursecare
3
•However, with prolonged and repeated drug use, dopaminergic neurotransmission
gradually diminishes, producing less intense “highs,” greater post-use dysphoria, and
intense drug craving precipitated by substance-specific withdrawal symptoms.
Drug craving can also be triggered by environmental “cues” (i.e., conditioned stimuli) that have
frequently been paired with substance use (i.e., conditioned response).
• At this stage, neural circuitry in the dorsal striatum, rather than the ventral striatum,
drives compelling mental preoccupation, decision making, and drug-seeking
behaviors that promote habitual use making it much more difficult to consider reducing
or discontinuing use.
Greater understanding of the neurobiology of addiction as well as genetic and environmental
contributions to adolescent-onset SUD have informed the development of more effective
substance prevention and treatment.
This chapter focuses on specific aspects of the etiology, epidemiology, prevention, and treatment
relevant to adolescent SUDs.
Prevention
All prevention interventions are universal, school-based prevention interventions that are
generally adopted school-wide and delivered by teachers trained in the intervention and
delivered in the classroom setting.
The Institute of Medicine (IOM) recognizes three categories of prevention interventions:
(i) universal prevention targets the population as a whole
(ii) selective prevention targets high-risk groups of individuals
(iii) indicated prevention targets individuals who manifest risk behaviors or early signs and
symptoms of the illness.
Cochrane review only the following three interventions were determined to have sufficient
evidence to be deemed efficacious or effective:
(i) The Unplugged Program (directed toward 12 to 14 years old)
(ii) Life Skills Training Program (directed toward 13 to 17 years old
(iii) Good Behavior Game (directed toward 6 to 7 years old).
Project Toward No Drug Abuse (directed toward 14 to 17 years old)
Indicated school-based prevention intervention known as the Teen Marijuana Check-Up
(TMCU).
Meds Targeting Co-Occurring Disorders (Table 55.5-2) Review the chart on page 3860 Expand
Table
Table 55.5–2. Medications Targeting Co-Occurring Psychiatric Disorders in Adolescents with
Substance Use Disorders
3
, 4
Targeted
Medication RCT Disorder Main Outcomes
Fluoxetine Riggs et MDD • Randomized 123 adolescents/young adults
al., 2007 (aged 13–19 years) to fluoxetine (20 mg daily dose)
or matching placebo.
• Participants in both groups received weekly
individual MET/CBT as outpatient substance
treatment during the 16-week trial.
• Compared to placebo, subjects treated with
fluoxetine had significantly greater reductions
in depression severity based on CDRS-R scores
(primary depression outcome measure) and
higher rates of depression remission (70% vs.
52%).
• Higher than expected depression remission in
both groups suggests that the individual
MET/CBT (targeting SUD) received by
participants in both groups may have
contributed to depression treatment
response.
• Significant reductions in substance use were
seen in both groups but no group difference.
• Regardless of treatment assignment,
participants whose depressions remitted by
the end of treatment showed significantly
greater reductions in substance use compared
to nonremitters, whose substance use did not
significantly decline from baseline levels of use
despite comparable treatment compliance and
completion.
Lithium carbonate Geller et Bipolar • Randomized 25 adolescents/young adults
al., 1998 disorder (aged 12–18 years) with dipolar disorder and
co- occurring SUD to 6 weeks of treatment with
lithium or matching placebo.
• Lithium treatment was efficacious for both
bipolar disorder and comorbid substance
use disorder in adolescence.
• Longer-term follow-up study needed.
Pemoline Riggs et ADHD • Randomized 69 adolescents/young adults (aged
al., 2004 13–19 years) with ADHD and SUD recruited
from the community to Pemoline titrated to a
once daily 37.5-mg dose or matching placebo.
4
1
CMN 554
Module 3 Primary Study Guide (Substance
Abuse)
Sadock Chapter 55.5
Adolescent Substance Use
Introduction Pg Disorders
3857
Substance use disorders (SUDs) account for about 6 percent of all deaths worldwide and cost
an estimated $700 billion in the United States, alone.
The vast majority of adults (approximately 80 percent) with chronic addiction started using
drugs or alcohol as teenagers.
• Although the majority of adolescents in the United States report experimenting with
drugs or alcohol before graduating from high school, most do not progress to a SUD.
• The estimated risk of developing an SUD by the age of 18 is 23.8 percent.
• Risk of progression to an SUD is increased in those who have pre-existing disruptive
behavior disorders or other mental health problems, academic problems, and/or have
experienced chronic adversities or maltreatment during childhood.
Adolescent-onset SUDs are more likely to progress to chronic addiction in adulthood and also
increase the risk of developing mood and anxiety disorders as well as antisocial personality
disorder.
• At-risk youth can be identified in children as young as 3 to 5 years of age, often
presenting with impulsivity, aggression, hyperactivity, inattention, poor persistence,
and emotional lability.
• This constellation of symptoms, characterized as “behavioral dysregulation,” is highly
heritable and a strong family history of SUD is often present.
• Such children often continue to have poor self-control, develop disruptive behavioral
disorders (oppositional defiant disorder [ODD], attention-deficit/hyperactivity
disorder [ADHD], conduct disorder [CD]) in later childhood, and are at high risk of
developing SUDs during adolescence.
It is important for school personnel, pediatric primary care, and mental health clinicians to
screen children for risk factors and refer for evaluation and interventions that may prevent or
reduce their risk of early-onset SUD.
It is also important to highlight that repeated use of drugs or alcohol can alter brain function in
ways that reinforce or promote continued use and development of SUD even in youth without
known risk factors.
• For example, youth with chronic painful medical conditions, acute or prolonged
injuries, or multiple medical or dental surgical procedures may be at risk of developing
addiction to prescription opioid pain medications even in the absence of pre-existing
apparent genetic or environmental risk factors.
Research advances over the past two decades have led to the understanding that addiction as a
1
https://www.stuvia.com/user/nursecare
,https://www.stuvia.com/user/nursecare
2
neurobiologically based medical illness.
• Initial exposure to substances of abuse increases firing in the dopaminergic pathways
of the ventral striatum, producing a subjective “high” that promotes further drug use.
2
https://www.stuvia.com/user/nursecare
,https://www.stuvia.com/user/nursecare
3
•However, with prolonged and repeated drug use, dopaminergic neurotransmission
gradually diminishes, producing less intense “highs,” greater post-use dysphoria, and
intense drug craving precipitated by substance-specific withdrawal symptoms.
Drug craving can also be triggered by environmental “cues” (i.e., conditioned stimuli) that have
frequently been paired with substance use (i.e., conditioned response).
• At this stage, neural circuitry in the dorsal striatum, rather than the ventral striatum,
drives compelling mental preoccupation, decision making, and drug-seeking
behaviors that promote habitual use making it much more difficult to consider reducing
or discontinuing use.
Greater understanding of the neurobiology of addiction as well as genetic and environmental
contributions to adolescent-onset SUD have informed the development of more effective
substance prevention and treatment.
This chapter focuses on specific aspects of the etiology, epidemiology, prevention, and treatment
relevant to adolescent SUDs.
Prevention
All prevention interventions are universal, school-based prevention interventions that are
generally adopted school-wide and delivered by teachers trained in the intervention and
delivered in the classroom setting.
The Institute of Medicine (IOM) recognizes three categories of prevention interventions:
(i) universal prevention targets the population as a whole
(ii) selective prevention targets high-risk groups of individuals
(iii) indicated prevention targets individuals who manifest risk behaviors or early signs and
symptoms of the illness.
Cochrane review only the following three interventions were determined to have sufficient
evidence to be deemed efficacious or effective:
(i) The Unplugged Program (directed toward 12 to 14 years old)
(ii) Life Skills Training Program (directed toward 13 to 17 years old
(iii) Good Behavior Game (directed toward 6 to 7 years old).
Project Toward No Drug Abuse (directed toward 14 to 17 years old)
Indicated school-based prevention intervention known as the Teen Marijuana Check-Up
(TMCU).
Meds Targeting Co-Occurring Disorders (Table 55.5-2) Review the chart on page 3860 Expand
Table
Table 55.5–2. Medications Targeting Co-Occurring Psychiatric Disorders in Adolescents with
Substance Use Disorders
3
, 4
Targeted
Medication RCT Disorder Main Outcomes
Fluoxetine Riggs et MDD • Randomized 123 adolescents/young adults
al., 2007 (aged 13–19 years) to fluoxetine (20 mg daily dose)
or matching placebo.
• Participants in both groups received weekly
individual MET/CBT as outpatient substance
treatment during the 16-week trial.
• Compared to placebo, subjects treated with
fluoxetine had significantly greater reductions
in depression severity based on CDRS-R scores
(primary depression outcome measure) and
higher rates of depression remission (70% vs.
52%).
• Higher than expected depression remission in
both groups suggests that the individual
MET/CBT (targeting SUD) received by
participants in both groups may have
contributed to depression treatment
response.
• Significant reductions in substance use were
seen in both groups but no group difference.
• Regardless of treatment assignment,
participants whose depressions remitted by
the end of treatment showed significantly
greater reductions in substance use compared
to nonremitters, whose substance use did not
significantly decline from baseline levels of use
despite comparable treatment compliance and
completion.
Lithium carbonate Geller et Bipolar • Randomized 25 adolescents/young adults
al., 1998 disorder (aged 12–18 years) with dipolar disorder and
co- occurring SUD to 6 weeks of treatment with
lithium or matching placebo.
• Lithium treatment was efficacious for both
bipolar disorder and comorbid substance
use disorder in adolescence.
• Longer-term follow-up study needed.
Pemoline Riggs et ADHD • Randomized 69 adolescents/young adults (aged
al., 2004 13–19 years) with ADHD and SUD recruited
from the community to Pemoline titrated to a
once daily 37.5-mg dose or matching placebo.
4
