SUBSTANCE ABUSE IN ADOLESCENTS - CLINICAL SUSPICION AND MANAGEMENT
Dr. Ksh. Chourjit Singh *
Prof. of Paediatrics, RIMS, Imphal National Executive Board Member 2005 National Chairperson, Growth & Development Chapter IAP*
Introduction
Accounts of use and abuse of substances including alcohol, coca leaves, opium and cannabis, are as old as human civilization. Physicians, philosophers, theologians, poets and politicians have long debated the merits and harmful effects of such substances. The increasing and widespread use of chemical substances by young people in order to alter mood state has been a feature of the 1990s. Western society's most accepted mood altering substance, alcohol, is specifically marketed to the young people in the form of 'alcopops'. Stimulants and hallucinogens ('dance drugs') were fundamental to the emergence of the pre-dominant youth culture the 'rave' scene. Heroin addiction among adolescent has become endemic in towns. Sniffing glue and inhaling aerosol gas remains a major cause of mortality amongst the young.

Official costs of illicit drug misuse in the UK are conservatively estimated at between £ 3-4 billion a year. For the alcohol the costs are £ 2-3 billion. Neither figure takes into consideration normal incalculable costs, such as education under achievement, family break-up and social disharmony.

Although there is now abundant data on prevalence of adolescents substance use, little is known about its consequences, how it can be prevented and how it can be treated. Compared to treating adults, substance misused by adolescents is less likely to require medical treatment of dependence and is more likely to be a symptom of a behavioral or conduct disorder. As such, treatment involves a range of therapeutic interventions pursued by multiple disciplines and is less substance oriented.

SUBSTANCES COMMONLY USED:
    Stimulants - Amphetamine, cocaine
    Depressants - Sedatives, hypnotic, alcohol
    Hallucinogens - LSD
    Cannabis - Ganja/marijuana, hashish/charas, bhang
    Narcotics - Heroin, morphine
    Analgesics - Codeine, pethidine
    Commonly abuses are alcohol, ganja bhang, amphetamine and heroine
WHY DRUGS?
INDIVIDUAL FACTORS:
There are three areas of interest to understand why adolescent are using drugs or intoxicants.
  1. Youth Culture
  2. Changing pattern of family life
  3. The gap between the young people and adults in control of the society

The drug produced anxiety and depression in the individual person, which is again a mental and psychological problem for them. Parents get frustrated with their addict wards. Adolescent period is a period of great change physically, socially and psychologically. During this period, the individual looks for status, anxiety for the future, craves for exploitation of the new test of life and lifestyles, individual identity and recognition of importance or existence.

PSYCHOLOGICAL FACTORS:
The psychological factors and mental state of mind of adolescents have a very easy access to get them hooked by narcotics and psychotropics drugs. In today's environment, the adolescents are facing a number of psychological problems, which is not properly understood by elderly persons. Thereby, drugs are found the easiest means to ventilate their problems. There is increasing lack of communication between parents and adolescents. In present day society, there is cloud of uncertainty of the future because of unemployment, insecurity and lack of opportunities and facilities as well as in many parts of the world, youths are psychologically and mentally ill due to bad situation of law and order. The mother has to take the responsibility and father only comes in when a crisis occurs. Due to lack of chance of exposing personal problems to family members or friends and other give rise to loss of interest in all aspects and blaming them for all family problems also hurt them psychologically and mentally.

SOCIO-CULTURAL FACTORS:

  1. Symbolic to maturity
  2. Availability of drugs
  3. Independence from parental domination
  4. Unable to root out drug trafficking
  5. Peer group for fun
  6. Lack of recreational facilities
  7. Stress reduction and escapism
  8. Family problem and imitating parents behaviour
  9. Exploding the limits of new cognitive abilities
  10. Change in family system from joint to nuclear family
  11. Problems of affluent families (Children are not allowed to spend more than what they need for themselves)

MENTAL FACTORS:
  1. Increasing complexity of modem society
  2. To believe blindly to false stories about the pleasure of drugs
  3. Feeling of avoiding low esteem

  4. The effect of media invasion
  5. Lack of religious mind
  6. Information oriented education rather than values of life
  7. Blaming attitude and rejection by parents
  8. Family problem and imitating parents behaviour
  9. Exploding the limits of new cognitive abilities
  10. Change in family system from joint to nuclear family
  11. Problems of affluent families (Children are not allowed to spend more than what they need for themselves)

CLINICAL SUSPICIION / HOW TO IDENTIFY DRUG ABUSE:
Recognition of drug abuse is a symptom complex. Early identification of taking a drug or more drugs may be very difficult in the beginning due to wide variable patterns of adolescence. They always try to conceal their thoughts and actions. Later on there maybe changes in personality, behaviour patterns and his environment. Early significant changes such as gradual lost of interest in studies and poor performance, repeated failure in examination and drop-out from school, college as well as in sports and general evasiveness. Unexplained changes in the habits and mood, sometimes while washing clothes, there may be enough evidences of drug in the pocket, development of clandestine friendship of other age group. There maybe signs of loss of appetite and weight or hygiene, not taking interest in the surrounding, not behaving properly as they do in the past with the other member of the family, incidence of petty theft in the family and the irritability, excitability, anxiety, tremor and sleepiness will also be notice. Frequent changes of occupation, indiscipline at the working place, creating trouble to the employers and the individual insecurity feeling will be develop. Incase of intravenous drug abusers there may be signs of injections at different sites, sometimes he will hide his forearm and the many a time bloodstains maybe seen in the clothings. These are definite signs of drug abuse. The detection can also be done easily by the parents, teachers and the even talking their friends. Sometimes they may refuse to consult doctors for their deteriorating health.

TREATMENT:
Whilst older adolescents do not commonly present for treatment at their own initiative, younger adolescents are more likely to be referred by a parent or concerned professional. This could include teachers, youth workers, social workers, educational psychologists, family doctors and child psychiatrists. At least some of these disciplines are likely to have important roles in treatment, which usually entails addressing multiple targets through a co-ordinated multi-agency approach with statuary and non-statuary, specialist and generic services.

REQUIREMENTS OF YOUNG PEOPLE'S SUBSTANCE MISUSE SERVICES:
  • Provide advice and treatment that is sensitive to the specific needs of children and young people and is separate from adult services.
  • Be appealing to young people to encourage self-referral.
  • Be available out of school hours and at convenient and non-stigmatizing sites.
  • Have staffs who are experienced with working both with young people and substance misuse.
  • Provide a holistic approach to treatment within the context of addressing other reeds the young person is likely to have.
  • Have established routes of referral, co-ordination and collaboration between education, social services, voluntary services, police, family doctors, pediatricians and child psychiatrists.

  • Routinely involve the family in treatment.
GENERAL INTERVENTIONS
Harm Reduction
The aim of treatment is to prevent harm resulting from substance misuse. For most misused substances, eliminating harm would entailed stopping substance use completely. Whilst abstinence may be a goal of treatment, especially in younger adolescents and for the more dangerous substances, to restrict treatment to those who are willing or able to stop using would exclude the vast majority of users and so ignore most of the harm to individual and society that results from substance use.

Harm reduction (or harm minimization) is a pragmatic response to substance misuse. For a heroin injector, the immediate goal might be to stop using injecting equipment used by others. Subsequent intermediate goals might be to reduce and stop injecting by undergoing a period of methadone maintenance, followed ultimately by gradual detoxification from methadone. Intermediate goals will also usually be required to address other areas.

Principles of harm reduction may be applied with a treatment context. Examples include public media, broadcasts on the dangers of drinking and driving, providing information to club goers on how to avoid hydration if taking Ecstasy, and instructing drug users what action to take if a friend overdoses.

Needle and Syringe exchange
The threat of an HIV epidemic catalyzed rapid expansion in drug treatment services. The spread of HIV is a greater threat to individual and public health than drug misuse. Accordingly services which aim to minimize HIV risk behaviour by all available means should take precedence in the development plans (Advisory council or the Misuse of drugs, 1988).

The most important development in HIV (and hepatitis) prevention amongst drug users has been the widespread development of needle and syringe exchange schemes. Young injectors who are unable to stop need to be provided the clean equipment and exchange scheme offer valuable opportunities to engage young people in treatment.

Motivational Enhancement
Adolescents may show no motivation to address their substance misuse. Indeed, their use of drugs and alcohol may be their main or only source of pleasure. Further substance misuse runs a chronic relapsing course and motivation waxes and wanes. A stage of change model has been proposed which recognizes pre-contemplation, contemplation and action phase (Prochaska and DiCleminte, 1992). Motivational interviewing technique (Miller and Rollmick, 1991) accepts that ambivalence to change is the norm with theme being advantages and disadvantages to continued substance use. By examining and challenging adolescents perceptions of the advantages and disadvantages, the balance may be shifted in the direction of change.

Family Therapy
A fundamental tenant of treating young substance misuses is to involve the family. There may be obstacles including reluctance by the adolescents or by the parents. Nevertheless, such issues are likely to be relevant to the young person's substance misuse and family's acceptance of being involved in treatment is likely to be therapeutic in itself.

Several theory based family therapist have been shown to be effective in improving parent adolescent relationships and reducing substance use including systems based, strategic and behavioral models (Weinberg et al, 1998). Families are also likely to benefit from practical advice on issues such as setting limits and conflict resolution. Attendance at family support groups is likely to be helpful.

Relapse Prevention
Relapse prevention is an important component of treatment, which involves examining factors implicated in previous relapses, anticipating 'high-risk' situations, devising strategies to deal with these situations and putting them into practice (Marlatt and George, 1979). Behavioural techniques involving contingency contracting may be useful.

Management of Co-morbidity
Both the substance misuse and psychiatric disorder will need treatment plans. Psychiatric disorders may require more intense treatment. Special vigilance is required with pharmacological treatment (Myles and Wilner, 1999). Methylphenidate has a high potential for abuse, some antidepressants may have adverse interactions with stimulant and precautions should be taken to prevent overdose of prescribed medications. Depressive disorders in substance misusers may respond well to cognitive behaviour therapy (Kaminer et al, 1998). Co-morbidity requires intensive treatment to all aspects of the adolescents problems (whatever the aetiological factors, there is need to alleviate distress and behavioral disturbance with anti-psychotic medication). Substance induced psychotic symptoms will usually subside within a few days of abstinence. Persisting psychotic symptoms in the absence of continued drug use indicates alternative causation.

In the relatively infrequent instances where adolescents have become dependent on alcohol and experience withdrawal symptoms, detoxification is required. This is best achieved using reducing doses of benzodiazepines (typically chlordiazepoxide or diazepam). Vitamin B supplementation should also be prescribed. With daily support from a health worker, detoxification can often be achieved without admission to hospital.

Disulfiram (Antabuse) may be a useful adjunct to relapse prevention. Disulfiram acts as a deterrent by producing unpleasant physical symptoms if alcohol is consumed. Compliance with disulfiram treatment is best achieved by ensuring the drug is administered daily by a parent or caregiver. Acamprosate is a new medication, which reduces relapse following detoxification and is thought to have an anti-craving effect.
SPECIFIC INTERVENTIONS
Alcohol Heroin detoxification
Heroin dependence in young adolescents is not uncommon, over one-third of teenage heroin users are aged under 16 (Parker et al, 1998 b). Whilst detoxification using reducing doses of methadone remains the most common method amongst adult, the potential for fatal overdose, prolonged withdrawal symptoms from methadone and a tendency for reducing doses to become maintenance makes methadone far from ideal in this age group.

LOFEDEXINE is a clonidine analogue that has proved effective in reducing most of the symptoms of opiate and is the treatment of choice in adolescents. Detoxification can usually be achieved in community settings with daily support and monitoring of blood pressure. Adjunct to LOFEDEXINE in the form of anti diarrheal and night sedation may be required.

Failure at completing detoxification in the community may require inpatient admission. Rapid methods of opiate detoxification using opiate antagonists (naltrexone or naloxone) may offer the best chance of completing detoxification but should only be used in hospitals.

A daily dose of 50 mg naltrexone will prevent relapse into opiate dependence. Compliance is enhanced if naltrexone administration is supervised by an adult. Unless following rapid detoxification using antagonists, naltrexone will precipitate severe withdrawal symptoms if initiated less than a week following last opiate use.

Methadone Maintenance
Methadone maintenance substantially reduces illicit drug use, injecting and crime, whilst improving physical health and social functioning of heroin users (Ward et al, 1998). It should not be a first line treatment for adolescents. Extreme caution must be taken when initiating treatment in young heroin misusers. Dependence must be established beyond doubt by sequential drug urinalysis and observation of withdrawal symptoms. The starting dose of methadone should be low and titrated upwards slowly according to response. Methadone should be dispensed on a daily basis and its administration should be supervised by a parent, carer, pharmacist or health professional.

Buprenorphine has recently been introduced as an alternative to methadone. It has the advantage of being safer in overdose and is easier to withdraw from. Buprenorphine is likely to be increasingly used for the treatment of adolescent heroin dependence.

Inpatient and Residential facilities
Inpatient treatment is indicated for adolescents who are suicidal, acutely psychotic, severely impaired because of their substance misuse or psychiatric illness, a danger to themselves or others or unable to receive appropriate assessment or treatment in the community (American Academy of Child and Adolescent Psychiatry, 1997).

Residential adolescent substance misuse services are helpful for those who lack psychosocial support or have relapse after inpatient treatment. Usually a stay of several months is recommended. Sadly residential facilities are scarce.

PREVENTION:
Preventing substance misuse involves reducing both supply and demand. Reducing supply is essentially about legislation and law enforcement. For legal substance e.g., alcohol and tobacco there is good evidence that increasing their price, restricting advertising and limiting availability (e.g., by having limited licensing hours) reduces overall consumptions. Education and treatment will reduce demand. Stopping initial use (primary prevention) and preventing escalation of substance use (secondary prevention). A further aim of prevention is to reduce the harm to individual substance users and the general population that are a consequence of substance misuse (tertiary prevention).
References :
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  3. Prochaska, J.Q., and DiCleminte, C.C. (1992) stages of change in the modification of problem behaviours. Programmes of Behaviour Modification, 28,183-218.
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  9. Ward. J., Mattick, R. and Hall, W. (1998) Methadone Maintenance Treatment and other opioid Replacement Therapies. Amsterdam: Harwood Academic Publishers.
  10. American Academy of child and Adolescent Psychiatry (1997) practice Parameters for the assessment and treatment of children and adolescents with substance use disorders. Journal of American Academy of child and adolescent Psychiatry, 36, 1403-1565.
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