Substance Use Disorders - Alicia Kowalchuk, DO, FASAM TCHAPP Conference January 22nd, 2021 No Disclosures - Texas Children's Hospital
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Substance Use Disorders Alicia Kowalchuk, DO, FASAM TCHAPP Conference January 22nd, 2021 No Disclosures
Acknowledgements
InSight SBIRT Residency
BCM FASD Practice and Training Program
Implementation Center
• Roger Zoorob, MD
• Sandra Gonzalez, PhD, MSW James Bray, PhD
• Mohamad Sidani, MD Vicki Waters, MS, PA-C
• Susan Gardner Nash, PhD
Substance Abuse and Mental Health Services
• Luis O Rustveld, PhD Administration Grant Number UT79T1020247
• Kiara K Spooner, DPH
CDC-RFA-DD14-1402
Learning Objectives • Identify recent trends in substance use and substance use disorders in adolescents. • Describe evidenced-based screening for substance use in children and adolescents through the Screening, Brief Intervention, Referral and Treatment (SBIRT) model. • Discuss the prevalence, identification and management of Fetal Alcohol Spectrum Disorders (FASDs).
Terminology
AUD: alcohol use disorder AEP: alcohol exposed pregnancy
OUD: opioid use disorder SEP: substance exposed
pregnancy
TUD: tobacco use disorder
TEP: tobacco exposed pregnancy
SUD: substance use disorder
FAS: fetal alcohol syndrome
MAT: medication assisted
treatment NAS: neonatal abstinence
syndrome
MOUD: medications for opioid
use disorder
FASD: fetal alcohol spectrum
disorders
2019-20 Monitoring The Future
Survey of 8th, 10th, 12th Graders
Johnston, L. D., Miech, R. A., O’Malley, P. M.,
Bachman, J. G., Schulenberg, J. E., & Patrick, M. E.
(2020). Monitoring the Future national survey results on
drug use 1975-2019: Overview, key findings on
adolescent drug use. Ann Arbor: Institute for Social
Research, University of Michigan.
Monitoring The Future Survey of 8th, 10th, 12th Graders 2019 2020
2019 Monitoring The Future
Survey of 8th, 10th, 12th Graders
Johnston, L. D., Miech, R. A., O’Malley, P. M.,
Bachman, J. G., Schulenberg, J. E., & Patrick, M. E.
(2020). Monitoring the Future national survey
results on
drug use 1975-2019: Overview, key findings on
adolescent drug use. Ann Arbor: Institute for
Social
Research, University of Michigan.
Monitoring The Future
Survey of 8th, 10th, 12th Graders
2019 Data 2020 Data
Today’s teens are NOT
drinking like their
parents did
Alcohol still most
widely used
substance by teens
59% have tried by end
of high school
25% have tried by 8th
grade
Monitoring The Future
Survey of 8th, 10th, 12th Graders
2019 2020
Marijuana remains
most frequently used
illicit drug by teens
Overall use has
remained relatively
flat since increase in
2000s
Daily use increasing
with highest rates
since 1991 currently
at 6.9% for 12th
graders
Monitoring The Future Survey of 8th, 10th, 12th Graders 2019 2020
Substance Use Trends in Adolescents –The Pandemic Update (early data) CDC data shows increases in substance use across substances and age groups including adolescents Online survey of Canadian adolescents 3 weeks pre and post pandemic social distancing measures implemented: -alcohol, cannabis, and vaping -overall alcohol use increased but binge drinking decreased -vaping decreased a -overall cannabis use decreased but frequency of use in those continuing to use increased -nearly half of ongoing users used alone, ~a third used with friends via online connections, ~a quarter continued in person use with peers Tara M. Dumas, Wendy Ellis, Dana M. Litt, What Does Adolescent Substance Use Look Like During the COVID-19 Pandemic? Examining Changes in Frequency, Social Contexts, and Pandemic-Related Predictors, Journal of Adolescent Health, Volume 67, Issue 3, 2020, Pages 354-361, ISSN 1054-139X, https://doi.org/10.1016/j.jadohealth.2020.06.018.
An Epidemic and a Pandemic Meet…
In Youth Overall aka Adults
Drug Overdoses, Ages 15-24 Number of Deaths, 2018 81 K+ overdose deaths 06/2019-05/2020 PEAK
Total Overdose Deaths 4,633
Female 1,481 https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html Topics: CDC
Newsroom, Press Release, COVID-19 Publication Date: 12/17/2020Last Updated: 12/21/2020
Male 3,152 Attribution: Content provided and maintained by the US Centers for Disease Control and Prevention
Alcohol1 85 (CDC). Please see our system usage guidelines and disclaimer.
Cocaine 859
Heroin and other illicit opioids2 3,177
There are no reports of teens or young Average drinks per day +27% (0.74 to 0.94
adults dying from an overdose of marijuana drinks/day)
alone. But there are many reports of
Marijuana marijuana users seeking treatment in
Exceeding guidelines +21% (29 to 36%)
emergency rooms, reporting uncomfortable Binge drinking +26% (22 to 27%)
side effects from consuming high THC levels Decreased access: bars and restaurants restricted
in smoked marijuana or marijuana edibles.
Increased access: curbside and delivery restrictions
Prescription Drugs: lifted, increased unstructured time, decreased
Benzodiazepines (e.g. sedatives)
899 access to other activities
Common Prescription Opioids (pain
relievers)3
790 ‘Quarantinis’, Zoom happy hours, stress
Deaths have been reported. However, while
Increased especially among adults with children in
some state and local governments (and the home, those who were previously drinking
Synthetic Cannabinoids (K2/Spice) other groups) collect this information, total below excessive levels, and residents of Western
nationwide numbers are not currently
available. states
(Barbosa C, Cowell A, Dowd W. How has drinking behavior changed during the COVID-19
pandemic? Results from a nationally representative survey. RTI International, July 2020)
NIDA. 2020, October 7. Drug Overdoses in Youth. Retrieved from
https://teens.drugabuse.gov/drug-facts/drug-overdoses-youth on 2021,
January 19The Synthetics • Heroin: 2 MEQ • U-47000 aka ‘Pink’: 10 MEQ • Fentanyl: 100 MEQ lethal dose 2mg • Carfentanyl: 100,000 MEQ lethal dose 20 micrograms • [$1000 pill press (5K pills/hr) + $250 die molds for oxycontin and xanax + $100 fentanyl 25gm + $900 other chemicals = $2250] >>> [1mg fentanyl per pill = 25K pills at $10 per pill = $250,000]
Where do we find fentanyl
Typical illicit pill operation
Typical illicit pill operation
Whatever you want them to be
Hydrocodone Assorted Rx drugs Morphine or OxyContin
Mario Hello Kitty XanexThe Perinatal Opioid epidemic
• 1999: 1.5 in 1000 deliveries mother with OUD
• 2014: 6.5 in 1000 deliveries mother with OUD
(CDC MMWR 2018)
• Overdose is now the leading cause of perinatal mortality for
women
• Every 25 minutes another newborn is diagnosed with Neonatal
Abstinence Syndrome (NAS)
• 2016-18 National Survey on Drug Use and Health (NSDUH):
• Past Month Opioid Misuse in Women 15-44yo:
• Pregnant: 1.2% 2016 INCREASED to 1.4% 2017 DECREASED to 0.9% 2018
DECREASED to 0.4% in 2019
• (Marijuana use in pregnancy is INCREASING)SUDs & Families
Live with ≥ one adult Exposed to alcohol
with a SUD problems in families
19Children of Parents with Substance Use Problems
• Sleep problems
• Gastrointestinal problems
• Headaches
• Musculoskeletal pain
• Enuresis
• Vague symptoms such as weakness, dizziness, fatigue or lack
of appetite
• Accidents, injuries and poisonings
• Most often present with NO symptoms
Introduction to SBIRT 20SBIRT: Screening, Brief
Intervention, Referral &
Treatment
• Make routine, team approach
• Discuss confidentiality limits
• Use evidence-based screen: CRAFFT-N
• Screen for family SUD: ‘What substance use concerns do you have about
anyone in your family, if any?’
• Brief Intervention models: BNI, 5A’s, FRAMES, MI
• Referrals: familiarity with community resources, mutual aid groups for
long term recovery support and bridge to treatment services
• Treatment: provide medications for alcohol, benzodiazepine, nicotine and
opioid use disorders
• Buprenorphine approved for OUD patients age 16+Create a stigma-free practice
Avoid stigmatizing language in
Normalize addressing substance use practice literature and patient
and SUDs as routine care conversations
• make it a routine ‘ask’ (SBIRT) • Stigmatizing: abuse,
eg new patient forms and dirty/clean, addict,
annual screening medication assisted
questionnaires treatment (MAT)
• offer SUD treatment, eg • Non-stigmatizing: use
medication therapy for disorder, drug test
nicotine, alcohol and opioid positive/negative,
use disorders person/patient with SUD,
• Consider integrated practice office-based opioid treatment
models (OBOT), medications for,
MOUDTrauma Informed Care
• Current and past trauma common in patients with SUD
• Up to 90% of women, in residential treatment settings
• Structured counseling programs eg Seeking Safety
• Avoid re-traumatization
-Patient control of their narrative and body key
-Respect patient autonomy
-Ask permission for physical touch
-Support of patient right to refuse, to answer a question, submit to part
of exam is essential
-Encourage and empower
-Strength-based and solution focused therapiesSBIRT Screening for
Children and Adolescents
Set stage for screening
• Talk with child/adolescent alone
• Address confidentiality
Age Specific Process
• 9 to 11 y/o ask about friends’ use
• 12 and up, follow SBIRT Three Step Process (with CRAFFT)
Introduction to SBIRT 24Setting the Stage for Screening
• Talk with adolescent alone
• Address confidentiality issues up front
• Adolescents can consent to SUD treatment
• Family involvement key to long term success
• Individual clinician’s decision on what constitutes
sufficient risk of harm to notify parent or guardian
Introduction to SBIRT 25Age Recommendations
• Ages 9 to 11 years*
─ Ask “Do you have any friends who drank beer, wine, or any drink
containing alcohol in the past year?” then “How about you – have
you ever had more than a few sips of…”
─ Any drinking = high risk; FOLLOW UP
• Ages 12 and above
─ CRAFFT+N
─ crafft.org/get-the-crafft/
*Recommended by the NIAAA - Alcohol & Brief Intervention for Youth: A Practitioner’s Guide
Introduction to SBIRT 26Standard Drink Chart
27DSM V: Substance Use Disorder
Mild 2-3, Moderate 4-5 or Severe 6+
For at least 12 months:
• Role impairment (e.g. failed • Using more than intended
work or home obligations) • Unsuccessful attempts to cut
• Hazardous use (e.g. driving down
while intoxicated) • Excessive time related to
• Cravings alcohol (hangover, etc)
• Social or interpersonal problems • Impaired social or work
due to substance activities due to alcohol
• Tolerance • Use despite physical or
• Withdrawal symptoms psychological consequences
Introduction to SBIRT 28The Pleasure-Reward Center
Adolescents
5%
10%
44%
Adolescents who More referrals from
GET TREATMENT courts than health
when they need it care providers
30Tobacco (Nicotine)
Cessation
• Routinely screen all adolescents for nicotine use
• ‘Do you smoke cigarettes, use other tobacco products or vape?’
• ‘Do you see yourself quitting smoking in the next 30 days?’
• Offer treatment:
-behavioral: QUITLINE, on-site counseling (integrated practice), 5As or
FRAMES, American Cancer Society Fresh Start
-medications: nicotine replacement therapies (NRT), bupropion,
varenicline
• Follow up: reinforce success, normalize relapseOpioid Use Disorder (OUD)
Treatment
• Methadone maintenance: licensed Opioid Treatment Program (OTP) 18+
• Buprenorphine maintenance 16+
• Agonist MAT = GOLD STANDARD TX OF OUD IN PREGNANCY
• Opiate antagonist: naltrexone 18+
• Decreased opioid use; decreased retention in treatment; suicide risk in
early treatment (NIDA CTN X:BOT study)
• ?Detoxification
• Partial hospitalization/Residential/Intensive outpatient
• (Narcotics Anonymous/ Methadone Anonymous)
• www.samhsa.gov – treatment locatorOEND: Opioid Overdose
and Naloxone Distribution
• OEND is for anyone :
-using opioids to get high
-with an OUD
-on chronic opioid therapies
-taking agonist or partial agonist MOUD ie methadone or buprenorphine
• OEND is also for anyone with a loved one they are concerned about
opioid overdose risk
• Naloxone half life 30-90 minutes; all opioids have longer half lives than
naloxone so important to get overdosed person emergent medical care
even if they respond to naloxone
• Nasal spray, auto injector, vial and syringe formulations
• State-wide standing order in TexasCultural
ambivalence
and lack of
skills keep us
from inquiring
about
substance use
problems
34Parent or Family SUD
The Most Important Question You Never Asked
Have you ever been concerned about
the drinking or drug use of someone in
your family?
Introduction to SBIRT 35The Answer
No Yes
Repeat the Provide
Explore Provide
question in prevention
the issue support
1 year message
Introduction to SBIRT 36Intervening When Parents Have SUD
• Validate concern
• Offer support
• With adolescents
― Support autonomy and decision making
37• "Ain't nothin' in the middle
of the road
• but yellow stripes and dead
armadillos."
• Jim Hightower
• Former Texas Agriculture CommissionerWhy Parent’s Avoid It
“I experimented with alcohol and drugs when I was
young and I turned out OK.”
“If I tried them, how can I tell my child not to try
them?”
“It’s just a phase - he/she will grow out of it.”
Introduction to SBIRT 39Screening for and
management of FASD
• FASDs are as prevalent as autism
• FAS is on the severe and visible end of the FASD spectrum
• Intellectual, behavioral and emotional changes due to alcohol exposure
in utero are more common than full FAS
• The developing brain is sensitive to alcohol exposure across trimesters
• FASDs are permanent
• Early diagnosis, management and support are key to improved outcomes
• Screening most reliable in early childhood especially for full FAS (facial
dysmorphisms more easily discerned in 3 to 7 year old age range)
• Early Childhood Intervention (ECI) assessments free and can be done in
child’s home age 2 months to 3 years
• Consider FASD in adult patient with suggestive comorbiditesCriteria for Diagnosing FAS
• With or WITHOUT confirmed fetal exposure to
alcohol, diagnosis requires documentation of
• All three dysmorphic facial features
smooth philtrum, thin vermillion border, small palpebral fissures
• Pre- or post-natal growth deficit
• Structural, neurologic, or functional central
nervous system (CNS) abnormality
Bertrand J, Floyd RL, Weber MK. Morbidity and Mortality Weekly
Review. October 28, 2005/54;1-10#1 Facial Abnormalities of FAS
1. Smooth philtrum
2. Thin vermillion
border
3. Small palpebral
fissures
Photo courtesy of Teresa KellermanLip-Philtrum Guide
Developed by University of
Washington FAS Diagnostic &
Prevention Network
Guide 1 – Caucasians
Guide 2 – African Americans
Back side provides face &
height-weight tables from the
FASD Diagnostic Guide (2004)
Order from
http://depts.washington.edu/fasd
pn/htmls/order-forms.htm
http://fasdcenter.samhsa.gov/educationTraining/courses/CapCurriculum/competency2/facial2.cfmMeasuring the Palpebral Fissures
Astley, et al. Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children
With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, Oct 2009.Astley, et al. Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, Oct 2009.
#2 Growth Deficits in FAS • Timing • Prenatal or Postnatal • At any one point • Degree • ≤ 10th percentile adjusted for age, sex, race or ethnicity, and for gestational age • Height or Weight (or Head Circumference)
#3 CNS Abnormalities of FAS
Structural
Abnormality
Head Circumference
≤ 10th percentile
Clinically meaningful
brain abnormalities
observed through
imaging (reduction in
size or change in
shape of corpus
callosum, cerebellum,
or basal ganglia)
Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10.
photo: Clarren, 1986.Corpus Callosum Structural Abnormality
A: 14 year old control subject: Normal corpus callosum
B: 12 year old with FAS: Thin corpus callosum
C: 14 year old with FAS: Agenesis of the corpus callosum
Mattson, S.N.; Jernigan, T.L.; and Riley, E.P. 1994. MRI and prenatal alcohol exposure: Images provide insight
into FAS. Alcohol Health & Research World 18(1): 49-52. (used with permission)#3 CNS Abnormalities of FAS Neurologic Abnormality • Motor problems or seizure NOT from a postnatal insult or fever • Other soft neurologic signs outside normal limits Functional Abnormality • Global cognitive or intellectual deficits (IQ
What are FASDs?
“FetalAlcohol Spectrum Disorder” is
NOT a diagnostic category, but rather
an umbrella term describing a range of
effects that can occur in a person
whose mother drank alcohol during
pregnancy
Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005 / 54;1-10.Areas of the Brain that can be Damaged in
Utero by Maternal Alcohol Consumption
Warren & Foudin. Alcohol Research & Health 25(3):153–158, 2001.
Alcoholism: Clinical & Experimental Research, May 16, 2011.Major Effects of Alcohol by Trimester
Courtesy UCLA RTC.Actual Age: 18
Expressive Language ----------------------------------- 20
Comprehension ------- 6
Money, time concepts ------- 8
Emotional maturity ---- 6
Physical maturity ---------------------------------- 18
Reading Ability ------------------------------- 16
Social Skills ---------------- 7
Living Skills --------------------- 11
Vineland Adaptive Behavior Scales…. Even Beyond Early Childhood
• Disrupted Schooling
• 43% of teens with FASDs are at high risk of having school interrupted by
suspension, expulsion, or from dropping out
• Conduct Problems
• Antisocial Behaviors
• Inability to follow rules, lying, and stealing
• Secondary Disabilities
Mental health problems-more than 90%
Alcohol and other drug problems-35%
Disrupted school experiences->60%
Juvenile justice 60%
Juvenile confinement 40%
Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore:
Brookes Publishing. ISBN 1-55766-283-5
GOAL
Independent LivingProtective Factors • Living in a stable and nurturing home for over 72% of life • Being diagnosed with FAS before age six • Never having experienced violence • Remaining in each living situation for at least 2.8 years • Experiencing a "good quality home" from age 8 to 12 years old • Having been found eligible for developmental disability (DD) services • Having basic needs met for at least 13% of life • Having a diagnosis of FAS (rather than another FASD condition) Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN 1-55766-283-5.
Multidisciplinary Approach is Critical
• Medical Treatment
• Mental Health Treatment
• Pharmacotherapy
• Behavioral Therapies and Interventions
• Skilled Nursing Services
• Physical, Occupational, and Speech Therapy
• Educational Interventions
• Early Intervention Services
• Exceptional Ed
• Teacher In-Service Training
Green JH. Fetal Alcohol Spectrum Disorders: Understanding the Effects off Prenatal Alcohol Exposure and Supporting
Students. Journal of School Health. March 2007;77:103-108.Information and
Treatment Resources
• National Organization on FAS (NOFAS)
(202) 785-4585 www.nofas.org
• Local Alcohol and Drug Treatment Resources
http://findtreatment.samhsa.gov/locator/home
• CDC FAS Home Page www.cdc.gov/fasd
• FASD- Texas NeuroRehab Center - (800)-252-5151
http://texasneurorehab.com/behavioral-treatment-for-children-and-
adolescents/residential-neurobehavioral-treatment-for-children-and-
adolescents/specialty-diagnoses/fetal-alcohol-spectrum-disorders/
• Texas Office for Prevention of Developmental Disabilities
http://topdd.texas.gov/
• Baylor College of Medicine FASD Practice and Implementation
Center (PIC) – contact project manager, Katherine Thomas,
Katherine.Thomas@bcm.eduHouston Resources for Adolescent
SUD
• Council on Recovery Houston: treatment matching, IOP
• www.councilonrecovery.org or (713)942-4100
• Harris County Youth Services: part of CPS, runaways, school programs
• www.hc-ps.org or (713) 394-4000
• Memorial Hermann Prevention and Recovery Campus: comprehensive
from detoxification through aftercare
• www.mhparc.org or (713)939-7272
• Palmer Drug Abuse Program: free, 12 step, IOP, crisis intervention
• www.pdap.com or (713)301-0516
• Teen and Family Services: sliding scale fee, IOP
• www.teenandfamilyservices.org or (713)464-3950
SBIRT: Referral to Treatment 58Resources for staying current
• https://pcssnow.org/
• Waiver training and implementation resources
• http://www.bu.edu/aodhealth/index.html
• Summary of latest SUD related research, 6 times yearly
• https://addiction.surgeongeneral.gov
• “Addressing Addiction in America” comprehensive reference
• https://www.samhsa.gov/
• Treatment locators
• Treatment Improvement Protocols (TIPS)
• National Survey on Drug Use and Health
• Drug Abuse Warning Network (DAWN) data reports
• https://www.cdc.gov/
• Alcohol, other substance exposed pregnancy prevention and treatment, FASD
• Vital Signs and MMWR reports
• Office on Smoking and Health
• http://monitoringthefuture.org/
• Adolescents and young adult substance use surveys by cohorts
• http://prescribetoprevent.org/
• Opioid overdose prevention resourcesYou can also read
