Adolescent Psychiatry - Volume 3, Issue 2, 2013

Background and objectives: Rates of opioid misuse among adolescents have risen to epidemic proportions. A prescription opioid analgesic is the second most commonly chosen substance among those initiating substance misuse, next only to marijuana. Soaring rates of treatment admissions among youth with opioid problems and reports of overdose deaths from prescription opioid analgesics and heroin make this issue of substantial public health concern. The objective of this article is to provide both clinicians and administrators a succinct and comprehensive review of the topic to assist them in incorporating evidence-based treatments, including medications to address the complex needs of this highly comorbid but treatable population of youth. Methods: This article will synthesize the published literature on the epidemiology of heroin use and misuse of prescription opioids among youth in community samples; summarize findings on demographic and social characteristics and cooccurring problems in multiple arenas such as academic, substance use, psychiatric, criminal activity and risk for hepatitis- C and HIV infections; briefly review access, diversion patterns and progression of opioid use; provide an overview of the existing medication-assisted treatment efficacy literature; and factors that impact treatment outcomes. Results: The main findings are summarized in this article. The author offers guidance for clinical consideration and future directions for research. Conclusions: Physicians, especially adolescent psychiatrists, are well positioned to effectively treat this highly comorbid population and potentially arrest its persistence into adulthood, which in turn bears high direct and indirect societal costs.

Background and Objectives: Over the past decade, non-medical use of novel drugs has proliferated worldwide. In most cases these are synthetic drugs first synthesized in academic or pharmaceutical laboratories for research or drug development purposes, but also include naturally occurring substances that do not fit the typical pharmacological or behavioral profile of traditional illicit substances. Perhaps most unique to this generation of new drugs is that they are being sold over the counter and on the Internet as “legal highs” or substitutes for traditional illicit drugs such as cannabis, cocaine, amphetamines, MDMA, and LSD. The purpose of this review is to provide an overview of novel drugs in current use, including the epidemiology of use and toxicologic and pharmacological properties, and to offer some guidelines to clinicians who see patients experiencing adverse effects from these drugs. Method: We review the known scientific literature on recently introduced synthetic drug types, synthetic cannabinoids and synthetic cathinones, and the hallucinogen Salvia divinorum. Results: These substances comprise part of a rapidly evolving and controversial drug market that has challenged definitions of what is legal and illegal, has benefitted from open commercial sales without regulatory oversight, and is noteworthy for the pace at which new substances are introduced. Conclusions: This emerging trend in substance use presents significant and unique public health and criminal justice challenges. At this time, these substances are not detected in routine drug screens and substance-specific treatment for cases of use-related toxicity are not available. Clinicians are encouraged to learn characteristic signs associated with misuse of novel drugs to recognize cases in their practice, and are recommended to use a symptom-specific approach for treatment in each case.

Background: Cannabis (marijuana) is used by half of all adolescents. Commonly held beliefs that this psychoactive substance is harmful to adolescents coexist with views that cannabis is a harmless natural substance that has beneficial effects. These culturally-ingrained attitudes can have more powerful effects on policy and behavior than experimental evidence. It is important to address the potential imbalance between the influence of cultural attitudes and objective data especially during this period when official sanction of cannabis is in transition across the United States. Methods: This review presents the scientific literature on neuropsychological functioning in adolescents who use cannabis. These experimental data are organized along the constructs of the cognitive systems domain delineated by the Research Domain Criteria (RDoC) of NIMH. Review of data on social and emotional functioning in cannabis-using adolescents is not a focus of this article. Results: Adolescents who use cannabis regularly and heavily have impairments in a number of areas of cognition that include attention, declarative memory, and cognitive control. Some impairments may be dose dependent, worse the younger the age of initiation, and persistent in abstinence. The ways in which gaps in this literature hinder the interpretation and broad application of the findings are described. Conclusions: There are sufficient research data to raise concerns that regular cannabis use is detrimental to mental functioning of adolescents. The literature suggests that because the adolescent brain is developing, it is more sensitive to any adverse effects of cannabis. Still, further research is needed to better understand cannabis and the brain, specifically accounting for neurocognitive functioning before initiation of cannabis, different degrees of use, and the long-term consequences of use and abstinence.

Abstract: Background: Prevention of youth tobacco use remains as important now as it has in the past. About one in ten high school students report smoking in the last month, down from 28% in 1996, but the rate of decline has flattened in recent years. Method: This review summarizes selected policies that are effective in tobacco use prevention. Results: Effective policies include broadly directed tobacco price increases, limits on youth exposure and access to tobacco, restrictions on tobacco marketing content and location, restrictions on public smoking, and school and community based prevention education and skills building programs. Policies in smaller settings, such as family “no smoking” rules with parental monitoring and health care provider practices can also be protective. Conclusions: Multiple resources are available to support tobacco control activities.

Background/objectives: Cigarette smoking remains the leading cause of preventable death in the United States with the vast majority of adult smokers starting prior to the age of 18. Despite the public health relevance and implications of studying smoking in adolescents, little is known about the initiation of quit attempts, the process of relapse, and the most efficacious treatment interventions in this high-risk and underserved population. Issues such as retention in research studies and accuracy of self-reports have prompted investigators to explore innovative technology-based systems to integrate into treatment studies and services delivery. Methods: This paper will review the remote monitoring of smoking through means of ecological momentary assessment, biochemical verification of smoking verified through video capture, physiological monitoring, and mobile-delivered interventions using self-reported smoking outcomes in adolescents, when applicable. Results: Use of remote monitoring methods in adolescent smokers has been limited thus far, though monitoring technology in adults has shown promise for understanding relapse and delivering treatment interventions. Conclusions: Comprehensive technology-based systems that do not rely primarily on self-report to monitor smoking would be a highly fruitful and innovative avenue to explore with adolescent smokers. Technology integration holds great promise to improve health-related research, treatment delivery, cost-effectiveness, and just-in-time interventions, but its novelty comes with unique problems and concerns to be carefully considered.

Background: Universal screening of adolescents for substance use and subsequent brief intervention has been recommended as a component of routine medical care by several professional societies, although the evidence base for such practice is less robust than that for adults. Method: We review the literature and synthesize research findings on screening and brief intervention with adolescents. Results: Several screening tools have been validated for use with this age group. While brief intervention with adolescents has not been studied as extensively as with adults, research to date suggests that interventions are promising and may be most effective if appropriately targeted based on screen results. Conclusions: Outpatient mental health treatment is an opportunity to present highly relevant messages targeted at preventing or reducing substance use to children and adolescents who are at high risk of developing substance use disorders, and also to identify and intervene with patients who may already have a substance use disorder. Further evaluation to determine the efficacy of these brief interventions in the outpatient mental health setting is needed.

Background: Substance use disorders (SUDs) often begin in adolescence and follow a long relapsing-andremitting course. Not only are SUDs prevalent, but existing evidence-based treatments for SUDs show a mean withinsubject effect size of less than medium magnitude. Emerging research provides support for the use of mindfulness-based treatments to target SUDS in adults, and these treatments could hold promise for adolescents. The practice of mindfulness involves awareness, attentiveness, and acceptance of experiences occurring in the present moment. Method: This article will provide a detailed description of mindfulness, discuss potential mechanisms of action, and review literature that supports the application of mindfulness-based interventions to the treatment of adolescents with SUDs. Results: Studies support the use of mindfulness in adults with SUDs. Research exploring the use of mindfulness in adolescents is beginning to emerge. Conclusions: By facilitating the ability to experience and thus tolerate negative emotions, thoughts, and sensations (including urges or cravings), mindfulness fosters the capacity to respond flexibly and adaptively to internal and external triggers for substance use. Because difficulty tolerating negative affects is a neurodevelopmental aspect of adolescence and a factor in vulnerability to SUDs, mindfulness-based treatments may be particularly appropriate for adolescents with SUDs.

Objectives: To ascertain behaviors and attitudes of high school students regarding prescription and over-thecounter medication misuse. Methods: We administered the Medical University of South Carolina Inventory of Medication Experiences (MIME), a newly developed self-report instrument, in demographically diverse high schools in Charleston, SC, to assess the feasibility of its administration and determine characteristics associated with medication misuse among high school students. Results: A total of 3182 students completed the MIME (93% completion rate). Nearly one-third (31%) reported misuse of a medication more than once a month. There were no significant correlations of overall misuse with grade level, age, or parent’s education level. White students and those who were over 18 in 12th grade were significantly more likely to misuse medications than were African-Americans and students who were in the appropriate grade for their age. Misuse was also more likely if a participant was prescribed medication (yes=46%, no=21% p< .001), if a family member was prescribed medication (yes=40%, no=26% p< .001), and if a family member had ever offered their prescribed medication to the student (yes=91%, no=29% p< .001). Conclusion: Medication misuse may be more pervasive than originally thought, with a notably high level among those most familiar with medications.

Background: The number of medical marijuana patients is increasing. This increase raises important concerns about how medical marijuana use may affect parenting. Methods: Thirty-two adult medical marijuana patients participated in focus groups. The focus groups were audio-recorded and transcribed. The transcriptions were coded by a team that met regularly to resolve coding differences. Codes related to parenting were used to develop a conceptual model for this manuscript. Results: Six of 11 participants who identified being parents reported that using marijuana helped them to be calmer with their children and to manage difficult emotions related to parenting. At the same time, most medical marijuana patients did not want their children to use marijuana. Their concerns about their children led to different strategies related to storing medical marijuana securely and how to communicate with children about medical marijuana use. Conclusions: These findings show that many medical marijuana patients are concerned about their children using marijuana and may be open to strategies to addressing this issue with their children. These findings also show that some medical marijuana patients may benefit from alternative strategies for managing difficult emotions related to parenting.

Background: Retention and compliance are hurdles in many clinical trials designed for adolescents. Factors that may improve these issues in a challenging population may lead to increased data and power in much needed adolescent substance abuse research. Methods: Within a large-scale smoking cessation study for adolescents, physician continuity (PC) was examined to determine its effect on retention, compliance, and cessation. Results: In an analysis of 98 participants, participants with physician continuity throughout the study were more likely to attend more treatment visits and be medication compliant. It was also found that PC had no effect on participant smoking cessation. Conclusions: It appears that PC may be one way to increase retention and compliance within an adolescent clinical trial, without interfering with the specific aim of the research study (in this case, smoking cessation).

Objective: Mental health care providers are in a unique position to detect, prevent, and offer brief interventions for adolescents with substance use problems. While substance use and mental health disorders commonly co-occur, few pediatric mental health professionals possess the necessary training to identify and treat substance use issues. The goal of this paper is to provide guidance for mental health professionals working with adolescents on how to detect, intervene, and refer adolescents for substance use treatment. Method: A series of clinical case examples and vignettes provide scenarios for helping educate providers in screening for substance use, preventing/delaying substance use initiation, delivering brief early interventions, and motivating adolescents for specialized substance use treatment when necessary. Conclusions: The importance of discussing substance use with each adolescent, being attuned to common warning signs of substance use, taking caution in prescribing medications with abuse potential, importance of family involvement, and use of motivational interviewing techniques are discussed.

Background: Misuse and abuse of prescription drugs in the child and adolescent population is a growing health problem that can have devastating consequences. Bupropion is an antidepressant approved for the treatment of depression and smoking cessation in adults; however, it is also used off-label as mono- or adjunct therapy in children and adolescents for the treatment of depression and attention-deficit hyperactivity disorder (ADHD). Like other prescription drugs, bupropion has also shown abuse potential, but there are concerns for decreased seizure threshold as an adverse effect. Seizures in the context of recreational abuse have been reported in adults but little is known about this phenomenon in adolescents. Method: We report three cases of adolescents who presented to a tertiary medical center with seizures in the context of a history of recreational abuse of bupropion. We review the intended use of bupropion and the potential for abuse, as well as the side effect profile for providers in consideration of its use in adolescents. Conclusions: There is a potential for seizures in the use/misuse/abuse of bupropion. Prescribing health providers should warn all patients of this adverse effect and also query history of substance use prior to prescribing bupropion.