Teen Drug Abuse - Prescription or Not

Teen Drug Abuse - Prescription or Not

Differences between nonalcoholic offspring of alcoholics (family history positive, FHP) and matched offspring of nonalcoholics (family history negative, FHN) have been identified on a variety of behavioral, cognitive, and neurological measures. Compared to FHN teens, FHP adolescents and young adults demonstrate more disturbed school careers, impulsivity, rebelliousness, and nonconformity (National Survey on Drug Use and Health, 2006); poorer neuropsychological performance (Worden & Slater, 2009); and significantly lower amplitude in P300 brain waves, which are believed to measure selective attention (Cicero, et al. 2005). Further, following ingestion of alcohol, sons of alcoholics report less body sway and less subjective intoxication (Grant, et al., 2005), higher levels of flushing (McBride, 2011), and decreased P300 amplitudes when performing difficult tasks (Foster, et al., 2009).

Not all individuals with a family history of alcohol dependence become alcohol and/or drug abusers, however, and genetics alone cannot account for the transmission of alcoholism and drug abuse (Grant, et al., 2005). Among both FHP and FHN adolescents, a number of potential environmental and personal factors moderate alcohol and drug use.

Environmental Risk Factors Modeling

Environmental factors may operate independently as well as in interaction with biological factors in producing risk for the development of substance abuse (Grant, et al., 2005). The effects of modeling and social reinforcement on the initiation of adolescent alcohol and drug use seem indisputable (Worden & Slater, 2009). For example, the majority of adolescents drink alcohol for the first time with parents or relatives at home (National Survey on Drug Use and Health, 2006), and parental modeling has a significant impact on the adolescent's attitude toward alcohol (Foster, et al., 2009). Further, peer support and instruction are responsible for a substantial portion of initial adolescent marijuana use (McBride, 2011) as well as decisions to continue to use after initiation (Foster, et al., 2009).

Family Functioning

Family environment also appears to be related to adolescent substance use. Children who report a lack of closeness, support, and affection from their parents are more likely to begin to use drugs and to maintain the abuse of those drugs (Grant, et al., 2005). Other family factors associated with adolescent substance abuse include parent-adolescent conflict (Fishman & Kreis, 2007) and lack of family cohesiveness (Worden & Slater, 2009). Reiger, et al., (2008) summarized the available evidence by noting three major areas of disturbance among families of adolescent problem drinkers: parental deviance or antisocial behavior, parental disinterest and lack of involvement with their child; and lack of affectionate and supportive interaction between parents and children. Conversely, a positive, loving bond between parent and child is linked to a reduced likelihood of the child's drug use (McBride, 2011). Thus, family functioning appears to be important in initiation of substance use and progression from use to abuse.

Literature Review

Although most studies documenting a relationship between stressful life events and alcohol or drug abuse have been conducted with adults, psychosocial stress is also associated with adolescent alcohol and drug abuse (McBride, 2011s). Higher levels of stress may actually precipitate alcohol and drug abuse by adolescents (Cicero, et al. 2005). A significant correlation between the extent of life stress experienced by the family and adolescent substance abuse has been found, even after controlling for substance-related stress (National Survey on Drug Use and Health, 2006). Further, in a series of studies (McBride, 2011), Brown found that adolescents in drug abuse treatment and nonabusing teens with an alcoholic parent have more negative life experiences, and subjectively rated those events as less desirable, than nonabusing teens from nonalcoholic families.

Social Support

Over the past two decades, research has established that the availability of social relationships is related to health status, personal adjustment, and social behavior, including risk for adolescent alcohol and drug abuse. In the absence of adequate social supports, modeling, and reinforcing alternative coping efforts, some teens begin to use alcohol and other drugs to cope with stress (Foster, et al., 2009). Adolescents with a substance abusing parent may be especially likely to use drugs as a coping technique. The combined experience of parental alcohol abuse and dysfunctional social modeling may lead to inadequacies in social functioning, including impaired ability or willingness to solicit support from persons within and outside the family (McBride, 2011). Additionally, adolescents with social support networks composed of alcohol or drug abusers not only acquire behavior patterns consistent with their resource network, but also develop beliefs and values consistent with a drug-use lifestyle.

Personal Risk Factors: Temperament and Personality

The major personality correlates of adolescent drug use cluster into rebelliousness, autonomy striving, liberalism, willingness to try new experiences, and independence. Other personality or temperament characteristics associated with substance use include high sensation seeking, low self-esteem, low impulse control (Worden & Slater, 2009), behavioral disinhibition (National Survey on Drug Use and Health, 2006) and nonconventionality (Drug Enforcement Administration, 2005). Longitudinal studies (McBride, 2011) suggest that these characteristics precede drug use and act as risk factors for alcohol and drug abuse.

Emotional Health

Adolescent substance abuse is associated with a variety of deviant behaviors, including several forms of psychopathology (Grant, et al., 2005). For example, alcohol- and drug-abusing adolescents commonly display symptoms of depression, including suicidal ideation, anxiety, and anger. Further, adolescent alcohol and drug abuse often appears as one of a constellation of disruptive problem behaviors. Researchers (Drug Enforcement Administration, 2005) have found a relationship between drug consumption and criminality, including stealing, assault, and malicious damage. The association of substance abuse and conduct disorder -- type behaviors persists even when deviant acts related to substance use (e.g., stealing while under the influence) are excluded (McBride, 2011).

Drug Expectancies

Another personal variable that predicts onset of adolescent substance involvement and progression to problematic use is effect expectancies. Alcohol expectancies consist of those effects attributed to alcohol that the individual anticipates experiencing when drinking. Alcohol effect expectancies play a mediational role in the development of use patterns by influencing drinking decisions (Morrison, et al. 2007). These anticipated consequences, acquired through multiple sources (i.e., peers, family, media, personal experiences) explain in part the process whereby distal risk factors (e.g., family history of alcoholism) influence evolving drinking behavior of youth. Expectancies of adolescents (particularly global positive effects, social changes, and enhancement of cognitive and motor performance) are most closely related to teen drinking patterns (National Survey on Drug Use and Health, 2006) and predict alcohol abuse as adolescents mature (Worden & Slater, 2009). Although expectancy research on other drugs of abuse such as marijuana and cocaine is less developed, evidence to date suggests that drug effect expectancies are also linked to personal drug use patterns (Morrison, et al. 2007).

Interactionist Theories of Adolescent Substance Abuse

Adolescent alcohol and drug abuse has been conceptualized from a number of different perspectives; the most prevalent models consider the development of substance abuse as a complex process with many interacting risk factors, including biological predisposition, environmental risks, and personal vulnerabilities (McBride, 2011). Support for the interactionist perspective comes from the pioneering work of Jessor and colleagues (Johnston, et al. 2006), who view alcohol and drug involvement as one of a series of problem or deviant behaviors of adolescents. Their problem behavior theory holds that adolescent problem behavior, including problem drinking and drug use, can be explained by three major sources of psychosocial variation: personality (e.g., lower value on academic achievement, higher value on independence; greater alienation, less religiosity); perceived environment (e.g., less parental control, greater friends' approval and lower parental disapproval of problem behavior); and behavior patterns (e.g., higher actual involvement in various problem behaviors). Within this framework, the problem behaviors have consistently been found to have high rates of co-occurrence, and the best predictors of future problem behaviors appear to be combinations of motivationally oriented personality and situational variables. Further, teens who mature out of problem drinking as young adults demonstrate a change in personal and environmental factors toward greater conventionality (Johnston, et al. 2006).

A second interactive developmental theory of substance involvement (Grant, et al., 2005) specifies that biological, interpersonal, intrapersonal, and sociocultural characteristics influence personal behavior directly or indirectly (McBride, 2011). The biological influences consist of genetically determined characteristics as well as the status of the organism (e.g., acute or chronic states of health or illness). Psychological status, cognitive style, and personality traits constitute the intrapersonal system. Features of the interpersonal system influencing substance involvement include intimate support, modeling factors, social reinforcement, and one's sense of identity and belonging. Finally, the sociocultural domain molds social expectations and sanctions and environmental stressors. A dimension of time is implicit in the framework, such that various patterns of causal influence can be expected at different stages of use (e.g., initiation vs. maintenance vs. abuse vs. cessation vs. relapse) and at different stages of development before, during, and after adolescence.

The third major developmental interactionist position (Ajzen, 2010) has primarily been used to understand adolescent alcohol use but can be extrapolated to account more generally for substance involvement. Zucker and his colleagues have delineated a model including direct and indirect influences: sociocultural and community (e.g., social class, ethnic and religious influences, neighborhood values); family and peer (e.g., personalities and interaction patterns of parents and peers, child-rearing patterns, peer socialization, and parental/peer modeling of alcohol use); and intra-individual (e.g., genetic predispositions, cognitive and personality variables) (Morrison, et al. 2007). Drinking is seen as influenced directly only by intra-individual factors. These in turn are influenced by the social variables (directly through intimate groups and both indirectly and directly by the sociocultural and community environment). Conversely, drinking behavior is expected to influence intra-individual attributes, which will in turn influence other domains.

When considering a model for adolescent substance abuse, it is important to incorporate differential effects of factors in relation to the developmental stage of the adolescent. The relative contribution of factors included in interactions and theories vary as youth progress through adolescence and into young adulthood. For example, peer group influences are more important in adolescence than during childhood, whereas parental influences may become increasingly indirect. Similarly, personality characteristics and drug effect expectancies may become more stable with increasing experience with evolving social roles and may consequently have a greater impact on substance abuse during later adolescence. Also, experimentation with substances may markedly alter (expand or contract) opportunities to gain experience with the diverse new roles and tasks unfolding over the course of adolescence.

Abuse and Dependence Concepts

Any substance that alters mood, perception, or brain functioning might be considered a drug of abuse (Johnston, et al. 2006). Generally, abused drugs are self-administered to produce a change in affective state or consciousness. All abused substances can lead to psychological dependence, in which the user experiences the subjective feeling of needing the drug to adequately function or to maintain a sense of well-being. Extended use of some drugs can lead to physical dependence, with physiological adaptation to the drug's presence. One aspect of this physical dependence is tolerance: as nervous system cells adapt to the presence of a drug, higher and higher doses of the drug are required to achieve the same effect. Drugs of the same class (based on predominant nervous system effects) usually show cross-tolerance such that if tolerance to a particular drug has developed, it will be evident when another drug of the same class is administered. However, the picture is different if the two drugs are administered at the same time. In this case, the drugs potentiate each other. This is an important concern, as teens frequently use several drugs in concert (Grant, et al., 2005) and such use can and does lead to unintentional overdose and death.

Another important aspect of physical dependence is withdrawal, in which physical symptoms appear when a drug is abruptly removed from the body. There are characteristic symptoms of withdrawal for each drug class. Although the withdrawal syndrome may be less prevalent than among adults (Johnston, et al. 2006), withdrawal symptoms are common (Morrison, et al. 2007). Affective and cognitive features, rather than physiological symptoms, predominate among adolescents during acute withdrawal from multiple substances. Therefore, the clinician should not rely on signs of physical dependence in assessing adolescent drug abuse or dependence.

Isolated instances of adolescent alcohol or drug use do not necessarily imply abuse or dependence. The DSM-IV (Drug Enforcement Administration, 2005) identifies the following problems as indicative of substance dependence: marked tolerance, characteristic withdrawal symptoms, substance use to avoid or relieve withdrawal symptoms, taking the drug in large amounts or over longer periods than intended, desire and/or unsuccessful efforts to cut down on use, a great deal of time spent obtaining, using, and recovering from the substance, giving up or reducing important activities because of substance use, and continued use despite knowledge of problems.

DSM-III-R (Morrison, et al. 2007) criteria for dependence involved possessing any three of the above symptoms persistent over a month long. DSM-IV has changed this to three or more problems occurring at any time in the same 12-month period. The more general diagnosis of substance abuse indicates a maladaptive pattern of use, including continued use despite knowledge of problems or recurrent use in dangerous situations.

Such categorical distinctions are useful, though the DSM-IV criteria are based on adult symptoms. Recent studies of DSM-IV abuse and dependence criteria among adolescents suggest a stage or sequence model at the development of substance dependence (Worden & Slater, 2009). Further, because youth experiencing alcohol and/or drug related problems who are entering treatment do not uniformly meet criteria for DSM-IV abuse or dependence diagnosis, an alternative diagnostic structure ultimately may be advantageous for youth. Examination of contingencies and the topography of substance involvement and typical negative consequences may be more useful in the evaluation process of substance-abusing teens. For example, the nature of the responsibilities of adolescents varies from that of adults, and many manage to avoid drug-related interference with activities typically to diagnose adults. On the other hand, even socially acceptable substance use by adults (e.g., social drinking) is illegal for adolescents, and a gradual deterioration in performance and participation in school are common consequences of involvement. A careful consideration of drug use and its impact (e.g., on school, family, emotional and social functioning) is called for.

Although there are no pathognomonic symptoms of drug use or abuse, clinicians are often asked to help parents or responsible institutions assess potential drug problems among adolescents. In general, increasing the knowledge of authorities with regard to symptoms of intoxication, withdrawal, and abuse/dependence for commonly used drugs is the first step in this process. The second step is to identify abnormal behaviors and their time course that give rise to concern for the youth. Because drug abuse may produce psychiatric symptoms (e.g., depression, anxiety, mania, delusions, and paranoia), drug problems are often misdiagnosed as psychiatric disorders. Abrupt symptom onset and marked alterations in symptoms (e.g., mood extremes) suggest that drug use may be involved.

The following section summarizes effects of the predominant substances of abuse for youth. Several cautionary notes are in order, however. As previously noted, physiological withdrawal symptoms are less pronounced among adolescents. Most street drugs are not pure and a portion do not contain the supposed major substance (Drug Enforcement Administration, 2005). Also, physical and behavioral effects of a drug can vary a great deal with factors such as health, length of use, dose, and environment. Finally, adolescent drug abusers commonly use more than one substance, thereby complicating the clinical picture.

Counseling and Treatments via Prescription

For many years following the findings of the DoH, American doctors could prescribe all manner of substances to those addicted to drugs with virtual impunity. Indeed, the first controls on the prescribing behavior of doctors only came into force during the 1960s due, in the main, to the over-prescription of heroin, leading to large quantities of licit drugs being diverted into the illicit drug market. While this legislation may have curbed the autonomy of some doctors, it was not a serious problem for the majority, due to the fact that during the 1960s and into the early 1970s the numbers of problematic drug users were relatively small, and those being treated were often referred to specialist services. This meant that the vast majority of doctors, especially general practitioners (GPs), rarely, if ever, saw a drug addict. The outcome of this scenario was that the issues of how, when and why to prescribe for drug addicts never became a pressing question for the majority of doctors.

However, as has been documented (Ajzen, 2010), the number of problematic drug users 'surged' during the late 1970s and into the 1980s, leading to the then DHSS encouraging GPs to become more involved with problematic drug users. Clearly, this placed GPs in a predicament, as many of them had never been asked to deal with a group that some see as 'problem patients' and, perhaps crucially, at that time too few medical undergraduates had received even basic education in treating problematic drug users (Centers for Disease Control and Prevention, 2006). As a result, many GPs were left isolated and lacking advice or direction. Those who would accept drug addicts as patients were sometimes inundated with addicts, all demanding treatment. Some GPs quickly became disillusioned; many made injudicious prescribing policies; many more simply retreated behind long-held prejudices (Johnston, et al. 2006).

Given the rise in recreational drug culture and a concomitant growth in problematic use, this situation could not be allowed to continue. This was recognized in the DHSS (1982) report Treatment and Rehabilitation. In turn, two years later the DHSS published Guidelines of Good Clinical Practice in the Treatment of Drug Misuse (Worden & Slater, 2009). These were updated and renamed in 1991, appearing as Drug Misuse and Dependence: Guidelines on Clinical Management (Morrison, et al. 2007) and were again up-dated in 1999. It is to the 1999 document that attention now turns.

The DoH guidelines

Robertson (2008:325) emphasizes the importance of the 2006 revisions and notes their timeliness, claiming that there was a real and pressing need for the 1999 review owing to the fact that with [t]he demise of the Addict Index and the revocation of the statutory requirement for American doctors to notify the Chief Medical Officer of cases of addiction, many national and international events seem to threaten and confuse clinicians and policy makers…. These Guidelines, therefore, are opportune and bear a considerable responsibility…. There should be no doubt, therefore, that they are…heavy weight…and are likely to give rise to substantial changes in clinical practice in the U.S.

At a very basic level, the importance vested in the 2006 document can be seen in its size in comparison to that of its predecessors: it runs to some 138 pages compared to the 57 the 2006 guidelines contained. Obviously, the authors intended it to be a comprehensive and authoritative tome, able to be used a source of reference for all manner of drug-related information.

Running through its content, the 2006 document begins with an overview of the current situation, including the growth of illicit drug use as well as an outline of the rights and responsibilities of doctors towards the drug user, highlighting the fact that doctors who refuse to treat patients because they have a moral objection to that patient's lifestyle are in danger of adopting unethical practices (Centers for Disease Control and Prevention, 2006). It then goes on to note government policy changes. Importantly, the document then makes a clear distinction between three types of doctor, the generalist, the specialized generalist and the specialist.

The DoH guidelines encourage doctors to police problematic drug use by employing a combination of four approaches: managing and treating withdrawal; agreeing to and servicing a maintenance regime; cultivating and maintaining the compliance of the patient; retaining the power to prescribe. As with the MDA, the DoH document is a large and complex volume and what follows is merely a broad summary, designed to provide a sense of the general direction in which the work moves.

Patients with problematic drug use can present to the doctor for a broad range of reasons, but generally share the common desire for treatment designed to improve their health. This is recognized by the DoH (Fishman & Kreis, 2002), which categorically states that the primary aims of treatment are to 'assist the patient to remain healthy' until they can live a drug-free life, and to 'reduce the use of illicit or non-prescribed drugs'. The first task for the doctor is to assess the nature and extent of drug related problems, to establish patterns of use, determine the patient's motivation to change and then to determine the need for substitute medication. The DoH also stresses the need to assess the patient's expectation of treatment.

For the patient, once the decision has been made to cease or reduce drug use, one of the first effects will be the onset of withdrawal symptoms, the nature, intensity and speed at which these symptoms occur being heavily dependent upon the type of drug being used. Although some addicts can withdraw without substitute drugs (Fishbein & Middlestadt, 2008), the vast majority of addicts will require some help with detoxification and the withdrawal symptoms associated with this process. In order to relieve these symptoms, doctors can dispense 'temporary prescription[s] of other drugs to reduce withdrawal symptoms' (Johnston, et al. 2006). The guidelines offer suggestions for a number of substitute drugs for the various types of addiction problems.

Once the decision to prescribe has been taken, the next question is 'how much?' Clearly, the patient's health will be paramount, so the dose has to be one that will not place the patient in jeopardy of overdosing, especially with methadone, a drug commonly prescribed to opiate addicts. The DoH guidelines suggest doses based on the severity of the withdrawal symptoms, with overall aim of minimizing the suffering endured by the withdrawing addict. Once the initial withdrawal period is over, the doctor, following consultation with the patient, must then decide on the next step in the policing of problematic drug use.

As Reiger, et al., (2008) note that for some addicts abstinence will be achieved relatively quickly, with the patient and doctor agreeing to a reduction regimen, whereby the patient will receive prescriptions of substitute drugs that gradually reduce in amount until the point is reached where the patient becomes drug-free. For the majority, however, it is usually necessary to establish a maintenance program. This is a long-term approach to problematic drug use that can, in some cases, continue for a number of years before the patient is ready to reduce their prescription drug intake. The patient will receive a regular supply of a prescription drug that is of an appropriate dose. The amount of drug will be enough to stave off withdrawal symptoms, provide a measure of stability, yet not be sufficient to induce 'signs of intoxication' (Reiger, et al., 2008).

However, despite the DoH's recognition of the benefits of this strategy (Morrison, et al. 2007), they also warn doctors against using this approach as a 'treatment of first choice for the patient presenting for the first time' (Drug Enforcement Administration, 2005). Thus, obtaining a maintenance prescription requires the addict to have at least undergone one other form of drug treatment regime prior to being considered for the maintenance option. In this manner, doctors are able to 'police' those who obtain access to a long-term and regular supply of drugs. This restriction of access to maintenance regimes can be seen as one way to ensure patient compliance.

Compliance is a very important aspect of the medical profession's approach to treating this client group. The DoH guidelines contain a section on the consequences of non-compliance and on improving compliance. For example, the DoH guidelines offer a number of points of advice concerning the manner in which the doctor can build the trust and confidence of the addicted patient, thus aiding compliance. These include building a relationship via weekly appointments in the initial stages, turning into fortnightly or monthly appointments once stability has been achieved. However, the DoH also advises doctors to employ other tactics that can be seen to be more controlling (Reiger, et al., 2008).

Thus, more controlling tactics might include random urine tests designed to ascertain if the patient is still using illicit drugs, daily pickups of the substitute drug, and supervised consumption of the substitute drug, the latter constraints only being relaxed when 'the doctor can be satisfied that compliance can be maintained' (Fishbein & Middlestadt, 2008). In defense of the medical profession's insistence upon compliance, there are very good reasons as to it being at the centre of treating addicts. As the DoH notes (Mogil, 2011), non-compliance can lead to overdose and death, as well as the diversion of licit drugs on to the illicit market.