Continuing Medical Education committee members and those involved in the planning of this CME Event...

Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.

Marya T. Schulte:

I have no financial relationships to disclose

- and

I will not discuss off label use and/or investigational use in my presentation

Marya T. Schulte, Ph.D.University of California, Los Angeles - Integrated Substance Abuse Programs

Semel Institute for Neuroscience and Human Behavior

(1) Define Alcohol Use Disorder (AUD) and describe prevalence rates for alcohol use and AUD among teens and young adults.

(2) Understand the risk factors and consequences associated with drinking.

(3) Describe gender and racial/ethnic differences in drinking patterns and risk for development of AUD.

(4) Learn about prevention and intervention strategies for reducing dangerous drinking in youth.

A problem pattern of alcohol use leading to clinically significant impairment or distress, manifested by 2 or more of the following in a 12-month period:

◦ Alcohol drunk in larger amounts or for a longer time◦ Persistent desire or unsuccessful efforts to cut down◦ Inordinate amount of time obtaining alcohol◦ Craving (strong desire to use alcohol)◦ Failure to fulfill work, school, or home obligations◦ Continued use despite social or interpersonal problems◦ Societal, occupational, or recreational activities reduced◦ Recurrent use when physically hazardous◦ Continued use despite physiological or psychological problems◦ Tolerance◦ Withdrawal

13.9% 12- month & 29.1% lifetime

◦Men 17.6% 12-month & 36% lifetime

◦White 14.0% 12-month & 32.6% lifetime◦Native American 19.2% 12-month & 43.4% lifetime

◦Younger 26.7% 12-month & 37% lifetime Heaviest drinking in early adulthood (18-29 year olds)

◦Treatment/help seeking among AUD adults 7.7% 12-month & 19.8% lifetime

Grant, Goldstein, Saha et al., 2015

“Alcoholic drink”◦ Shot of liquor, glass of wine, can of beer

Binge drinking◦ 4 or more for women◦ 5 or more for men

Chronic drinking◦Daily or almost daily consumption of alcohol

Drinking has become a daily habit

By the time of high school graduation…

66.0% have tried alcohol

60.2% have had an alcoholic drink in the past year

41.4% have been drunk in the past year

19.4% report 1+ binge drinking episodes in past 2 wks

1.9% report daily drinking for at least 1month at some point in their lives

Monitoring the Future, 2014

Current, Binge, and Heavy Alcohol Use among Persons Aged 12 to 20, by Gender: 2013

SAMHSA, 2014

Past month alcohol use◦ 15.2% Asian◦ 17.8% African American◦ 17.8% Native American or Alaskan Native ◦ 20.6% Hispanic ◦ 25.8% White/Caucasian

Binge drinking◦ 7.6% Asian◦ 8.4% African American◦ 13.9% Native American or Alaskan Native◦ 13.5% Hispanic◦ 16.8% White/Caucasian

◦ SAMHSA, 2014

Brain maturation◦Reward sensitivity

Increased risk-taking & sensation-seeking

Development of self-regulation skills

Endocrine changes/puberty◦ Impact of alcohol on BAC

Brown & Tapert, 2004;Schulte, Ramo & Brown, 2009

Environmental changes◦Driving◦ Entering high school/moving away for college

Increased autonomy from parents/family◦ Personal decision-making◦Greater peer influence

Social role changes◦Development of romantic/sexual relationships◦Gender expectations

Parental monitoring Perceptions of peer use

Brown & Tapert, 2004;Schulte, Ramo & Brown, 2009

◦Irritability/restlessness◦Confusion/memory problems◦Poor motor coordination/slurred speech◦Lowered inhibition◦Relationship problems◦School performance

◦Accidents and injuries Car accidents, falling, drowning

◦Illegal behavior Driving drunk Physical/sexual assault

◦Risky sexual behavior Unwanted, unintended, and/or unprotected sexual activity Multiple partners

◦Death Car accidents, accidental overdose, homicide and suicide

National Survey on Drug Use and Health, 2014

Adolescent brains are undergoing significant change

Neuronal pruning◦ Loss of neurons for increased efficiency ◦Up to 50% of neuronal connections are lost in some regions◦ Some new connections are formed

Prefrontal cortex is not fully pruned/developed until mid-20s

Amygdala shows less pruning◦ This impacts decision-making and impacts adolescent

behavior!

Alcohol CAUSES structural and functional brain changes

Brain changes CAUSE increased drinking

Behavior becomes compulsive and persists despite serious consequences

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Common comorbidities◦Depression, anxiety, ADHD, ODD, CD, eating disorders

Often predate onset of AUD

Increases risk for relapse

May require medication to treat

Less likely to suffer from the complications of protracted use◦Medical problems, social/occupational disruption

Use is more episodic and less likely to be chronic

More likely to use other drugs in addition to alcohol

Difficult to parse apart consequences of drinking from effects of developmental changes/problems◦Can mimic or exacerbate effects of alcohol

Substance use history◦ Licit and illicit drugs

Biological Physical health, pubertal stage

Psychological/neuropsychological Psychiatric comorbidity, cognitive functioning, emotional well-

being Social

Social skills, family functioning, peer affiliations, legal status, school adjustment, recreational activities

Do not use judgmental or argumentative language

Be aware of your tone◦Fear is a bad motivator

Describe each result and its meaning

Work as a team◦Solicit feedback from parents and teen◦Remain open to their feedback and needs

Be prepared for strong emotional reactions

Miller & Rollnick, 1991

Assess motivation and meet them where they are at

Involve family members

Provide structure and accountability

Assess and treat comorbid psychiatric disorder(s)

Environment supportive of recovery

Individual therapy◦Cognitive Behavioral Therapy

Relapse Prevention

◦Motivational Enhancement Therapy Motivational Interviewing

◦Contingency Management

Family approaches◦Adolescent Community Reinforcement Approach◦Multidimensional Family Therapy◦Brief Strategic Family Therapy◦ Family Behavior Therapy◦ Functional Family Therapy

NIDA, 2014

Few in need of treatment actually receive services!

Motivation◦ Treatment not self-initiated

Parental buy-in

Logistical◦ Transportation, geography

Normalization of drinking◦Association with positive events

African American and Hispanic youth are less likely than white teens to receive and complete treatment

Minority youth are less likely to:◦ have health insurance ◦ be identified and referred to treatment◦ have treatment facilities nearby

Minority youth may be:◦more mistrustful of providers◦ experiencing more life stressors of greater severity

Saloner et al., 2014; Cummings et al., 2014

Enforcement of minimum legal drinking age laws

National media campaigns targeting youth and adults

Reducing youth exposure to alcohol advertising

Increasing alcohol taxes

Regulation of alcohol outlet density

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Uses universal screening (S) with validated brief self-report questionnaires to identify those at-risk for substance use problems

Teens with positive screens are given a brief intervention (BI) and/or a referral to treatment (RT)◦ Intervention delivers personalized feedback about the risks and

consequences of excessive drinking◦Referral dependent upon severity of problem use

School-based prevention

◦Developmentally appropriate and accurate information

◦Structured skills training◦Family and community involvement◦Multiple sessions over multiple years◦Cultural sensitivity

Dangerous drinking continues to be a problem among American youth

Alcohol use differs by gender and race/ethnicity

Assessment and treatment should use a developmental approach and account for individual needs

Prevention, or at least early intervention, is the best medicine!

THANK YOU!