Adolescent, women, geriatric population

1. SUBSTANCE ABUSE
IN SPECIAL POPULATION SUCH
AS ADOLESCENT, WOMEN,
GERIATRIC
DR. MANISH KUMAR GOYAL
RESIDENT
UNDER GUIDANCE OF
DR. SURESH GUPTA
SMS MEDICAL COLLEGE
JAIPUR

2. CONTENT
1. INTRODUCTION
2. SUBSTANCE ABUSE IN ADOLESCENT
3. SUBSTANCE ABUSE IN WOMEN
4. SUBSTANCE ABUSE IN GERIATRIC
POPULATION
5. TAKE HOME MESSAGE
6. REFERENCES

3. INTRODUCTION
 Special populations are groups who face particular
risks from substance use based on personal
characteristics such as age or gender.
 The growing awareness of client "special
populations" in drug treatment programs has begun
to affect policy and planning decisions. The unique
needs of special population clients are often left
unnoticed and unattended. Special populations
have been identified as people with particular needs
related to ethnic, cultural, gender, age, or health
status. They have also been defined as
"populations that are traditionally underserved or
unserved. '‘
 Here we going to discuss about substance abuse in
adolescent, women and geriatric population groups.

4. SUBSTANCE ABUSE IN ADOLESCENT
BACKGROUND AND IMPLICATIONS
 Adolescent and children substance abuse can bring
immediate and late onset consequences.
 The acute effects of intoxication can be devastating:
1. Substance-related motor vehicle accident
2. Sharing needles,
3. High risk behaviour like sexual risk taking
 Age of initiation into substance abuse is progressively
falling.
 Early initiation of alcohol and drug use is associated with
1. Poor prognosis
2. Life long pattern of irresponsible behaviour

5.  Family and the community have to bear the social costs
like:
Increased morbidity and mortality, Increased criminality,
decreased productivity and absenteeism.
 Understanding of substance abuse problems during
adolescence is critical to study any approach aimed at
lessening adverse effects.
 Any substance abuse at this age is likely to interfere with
the normal child development and may have a lasting
impact on the future life.
 Adolescent substance use has been relatively neglected in
clinical practice and in research studies practice.

6. EPIDEMIOLOGY
 WHO – “Adolescence, age period between 10 – 19 years
for both sexes, married & unmarried people.”
 WHO estimates that globally 25 to 90% children have
used at least one substance of abuse.
 Lifetime prevalence of Substance use disorders in
children and adolescents is 11.4%.
 Common drugs abused in Indian adolescents are:
1. Alcohol
2. Tobacco
3. Minor tranquillizer
4. Analgesics
5. Cannabis
6. Inhalants

7. WHY THEY USE SUBSTANCES…
 Tendency to experiment and have novel experiences. (more
likely to use a substance just to see how it feels like)
 A heightened sense of invulnerability (nothing can happen
to me)
 A high influence and imitation of role models (e.g. movie
stars, celebrities etc)
 Rebelliousness for the existing norms and rules; Search for
an Identity
 Seeks the approval of peer group or friends much more
than family (may use substances to fit in the group)
 Higher cognitive functions (decision making, reasoning,
impulse control) are still undergoing maturation.

8. RISK FACTORS
1. GENETIC AND ENVIRONMENTAL
INFLUENCES
 Adoption study literature shows that substance
dependence in adoptees is:
Significantly correlated with alcoholism in biological
fathers. A positive family history of substance use disorder
is a strong predictor for substance use and dependence.
2. PRENATAL SUBSTANCE EXPOSURE
 Prenatal exposure to substance is associated with:
 Cognitive and behavioral self-regulation difficulties in
children
(Knopik, Sparrow, Madden et al., 2005)
 Increased risk of adolescent substance use and abuse
(Biederman, Monuteaux, Mick et al., 2006)

9. 3. CHILD MALTREATMENT AND ABUSE
 Childhood neglect, physical abuse (PA), sexual abuse
(CSA) are predictive of:
Early onset tobacco, alcohol, marijuana and other
illicit drug use.
4. MARITAL CONFLICT, PARENTAL DIVORCE AND
REPARTNERING
 Parental divorce, subsequent repartnering and marital
conflicts are associated with increased rates of :
Initiation and heavier use of the substances.

10. 5. PARENTING INFLUENCES
 Parenting behaviors predictive of early initiation and
substance abuse during adolescence :
 Inconsistent, ineffective discipline, poor supervision and
monitoring
 Parent –child conflict
 Low levels of parent support and parent– child attachment
 Permissive or tolerant attitudes about substance use
6. PEER INFLUENCES
 Deviant peers have a direct influence through peer
pressure and socialization.
 Deviant peers provide both modeling and
reinforcement for substance use.
 Substance using adolescents seek out peers who also
use substances, a form of social homophily.

11. 7. EXTERNALIZING DISORDERS
 Externalizing disorders are major risk factors predicting
the initiation of substance use and the development of
abuse and dependence.
 These disorders are :
1. Conduct disorder
2. Oppositional defiant disorder (ODD)
3. Attention deficit hyperactivity disorder (ADHD)
4. Anxiety disorder
5. Social phobia
6. Post traumatic stress disorder
7. Mood disorder

12. RISK FACTORS & PROTECTIVE FACTORS

13. STAGE THEORY
 Stage theory proposes that:
1. There is a temporal ordering of substance
experimentation
2. Lower order substances which are more
commonly used precede the use of higher
order substances
 A licit/legal substance such as alcohol or
cigarettes is used first
 It is followed by marijuana which is usually the
first illicit substance
 This stage is followed by use of other illicit
substances like opioids, cocaine, stimulants etc.

14. GATEWAY HYPOTHESIS
This theory proposes that:
 Use of marijuana facilitates the entry into other illicit
substance use
 This effect can be explained by:
1. Heavy cannabis users have preexisting traits that
predispose them to the use of a variety of different
substances.
2. Marijuana use results in socialization into an illicit drug
subculture which creates favourable attitudes toward
the use of other illicit drugs.

15. ASSESSMENT OF ADOLESCENT
SUBSTANCE USE
 Research suggests that face-to-face interview assessment
leads to underreporting of substance use by adolescents
 Strategy which should be used in assessment:
1. Use a self-administered questionnaire during an
interview
2. Obtain drug use history information
3. Supplement it by toxicology screens
 Establishing rapport with the adolescent is critical in order
to increase the chance of self-disclosure of drug use.

16.  The interview with the parents or caretakers should be
used to obtain a history of:
1. Presenting complaint
2. Early development history
3. Assess family dynamics
 Private interview with the adolescent is important in
facilitating strong treatment alliance.

17. TREATMENT OF ADOLESCENT
SUBSTANCE ABUSE

18. PROBLEMS WITH ADOLESCENT SUBSTANCE
ABUSE TREATMENT STRATEGIES
 Adolescents with substance abuse:
1. Do not self-refer for treatment
2. Are defiant
3. Minimize their drug use
 Ethical challenges of clinical research with minors
include:
1. Requirement to obtain parental consent for participation
2. Potential for confidentiality breach in obtaining parental
consent.
 Available evidence for pharmacotherapy is based almost
entirely on adult, rather than adolescent samples.
 Evaluations of the efficacy of pharmacotherapies have
produced equivocal results regarding their efficacy in
adolescents.

19. SPECIFIC THERAPEUTIC APPROACHES
Motivational Interviewing:
Motivational interviewing techniques have been
demonstrated to promote:
 Treatment engagement
 Strong treatment alliance
 Patient generated treatment goals

20. COGNITIVE-BEHAVIORAL THERAPY
 Cognitive-behavioral therapy (CBT) is effective in
treating adolescent substance use disorders
 In CBT following characteristics need to be identified:
1. Reinforcers of substance use
2. Skills deficits
3. Specific cognitive distortions associated with
substance use

21.  CBT should be provided to:
1. Enhance coping strategies to deal effectively with
drug cravings and negative affects
2. Strengthen problem solving and communication skills
3. Identify and avoid high-risk situations
 An important feature of CBT is its emphasis on
developing new behaviors that are:
 Enjoyable
 Incompatible with drug use

22. CONTINGENCY MANAGEMENT
 This approach encourages healthy changes in behavior
by rewarding adolescents for objective evidence of
abstinence such as negative urinalyses.
 It regards substance use as operant behaviors that are
reinforced by the effects of the drugs involved.
 Following the operant conditioning model, the
adolescent’s drug use will subside when tangible
incentives are offered for abstinence.

23. MULTISYSTEMIC THERAPIES
 Treat adolescents within the context of their
environment
 Try to modify multiple environmental factors contributing
to SUDs
 Multisystemic therapy is an approach that addresses
1. Social and family influences of drug use
2. Associated antisocial behaviors

24. CONCLUSION
 Understanding of substance abuse problems during
adolescence is critical
 Deviant peer affiliation is one of the best predictors of
early onset substance abuse during the adolescent
years
 Currently the research on adolescent SUD treatment is
dominated by psychosocial-based modalities
 Family systems based treatments and motivational
enhancement therapy approaches have received the
most empiric support compared with other modalities.

25. SUBSTANCE ABUSE IN WOMEN
 In humans there are numerous sex differences in
almost every facet of SUD.
 For most drugs of abuse, men consistently have
higher rates of use, abuse, and dependence
compared to women, with an overall odds ratio of 2:1
 Lower prevalence of substance abuse in females is
explained by less exposure and fewer opportunities
but women progress from substance use to SUD
faster than men, a phenomenon termed
“telescoping.”
 Females are more vulnerable than males to the
reinforcing effects of psychostimulants, opiates, and
nicotine during each phase of the addiction cycle:

26. Substance Use by Pregnant Women
 Substance use during pregnancy may harm not only
the mother but also the growing foetus. After delivery
neonate may suffer from withdrawal symptoms.
 Choose medicines judiciously for deaddiction as drugs
itself may have teratogenic effects.

27. Gender Differences in Dependence Potential
 Males are more likely to become dependent on
• Marijuana
• Alcohol
 Females are more likely to become dependent
on
• Anxiolytics
• Sedatives
• Hypnotics

28. Gender Differences
Due to circulating estrogens and progesterones.
 Several of the reinforcing effects of amphetamine, such as
euphoria and increased energy are potentiated in women
during the follicular phase compared to the luteal phase and
are positively correlated with estrogen levels.
 Women have been reported to have a greater capacity for
dopamine synthesis and reuptake through the DAT relative
to men.
 Gonadal hormones can regulate the density of dopamine
terminals in the nucleus accumbens and dorsal striatum.
 Progesterone attenuates dopamine release and responses
to drugs of abuse.
 High circulating plasma levels of progesterone are
associated with decreased cravings following drug and
stress-related cues.
 Women may be more vulnerable to relapse during the
follicular as compared with luteal phase.

29. Differences in Relapse
 Women relapse for different reasons than men
• Stress, weight gain, negative emotions
• Intimate partner issues
• Issues with children or ongoing parenting
• Isolation and poor social support.
• Untreated psychiatric disorders, especially depression
and trauma-related symptoms (PTSD)

30. Gender Differences in Medical
Consequences of Substance Use
 Females have higher rates of liver problems including
cirrhosis, HTN, anaemia, GI problems
 Higher rates of HIV and STDs
 Higher risk of breast cancer and heart disease
 Higher risk of lung cancer and COPD
 Higher rates of infertility, repeat miscarriages and
premature delivery

31. Gender Differences in Co-Occurring
Disorders
 Women with substance abuse show higher rates of
major depression, social phobia, post-traumatic stress
disorders, and eating disorders compared to men.
 Alcohol dependent women show higher comorbidity in
all diagnoses except for antisocial personality and
pathological gambling (higher in alcoholic men).
 Women have a primary mental health disorder that
antedates the onset of substance abuse disorder more
often than men.

32. Gender Differences in Treatment Entry,
Retention and Completion
 Women are less likely than men to enter substance
abuse treatment.
 Reasons include sociocultural, socioeconomic factors,
child custody issues, availability of gender-specific
treatment programs etc.
 Women have been shown to have greater improvement
in medical problems and more likely to seek assistance
after relapse.

33. SUBSTANCE ABUSE IN THE
ELDERLY POPULATION
 2.3% of elders meet criteria for substance abuse.
 Alcohol and prescription/over the counter
medications are the common substances that are
being abused by elder population. Illicit drug use
in this population group is comparatively rare.
 Tranquilizers and opioid analgesics are prescribed
drugs that are frequently abused.
 Benzodiazepines, a type of tranquilizing drug, are
the most commonly misused and abused
prescription medications.

34. Substance abuse in the elderly has been
received little attention. WHY?

35. SCREENING & DIAGNOSIS
 As outline previously substance misuse remains largely
under recognized and undertreated among older adults.
 It has been suggested that adults over the age of 60 be
screened for alcohol and prescription drug use as part
of their routine mental and physical healthcare (Blow
1998).
 Routine screening including toxicology screening
(urine, salvia) enables identification.
 Although the diagnostic criteria for substance use
disorders are the same for younger and older adults,
some of the criteria may be less relevant for the latter.
 For example, problems related to work or the family
may not be relevant for a retired or widowed older adult.

36. Common Signs and Symptoms of Potential
Substance Misuse and Abuse in Older Adults
 Anxiety
 Blackouts, dizziness
 Depression, mood swings
 Disorientation
 Family problems
 Financial problems
 Headaches
 Incontinence
 Legal difficulties
 Memory loss
 Poor hygiene
 Falls, bruises, and burns
 Idiopathic seizures
 Sleep problems
 Social isolation
 Poor nutrition

37. COMORBIDITY AND DIFFERENTIAL DIAGNOSIS
 Alcohol problems and depression are common
comorbid conditions in late life. Depression symptoms
can precede (primary or independent depression),
occur simultaneously (indeterminate), or develop as a
consequence (reactive or secondary depression) of
significant alcohol use.
 Alcohol-related dementia may be difficult to
differentiate from Alzheimer disease due to a lack of
well-specified criteria. Withdrawal of the substance
tends to stabilize cognitive and functional status for
substance related cognitive impairment and not for
dementias.
 Sleep disorders also frequently co-occur with
excessive alcohol use. Alcohol use and aging are both
associated with changes in sleep patterns.

38. TREATMENT
 Older adults respond as well as or better to
treatment than middle-aged adults, and
they are more likely to complete the
treatment.
 Older patients with less severe disease can
be treated most appropriately in primary
care and mental health care settings,
where it has been shown they would be
more apt to engage in care.
 Patients with more severe disease should
be treated in conjunction with specialty
care.

39. BRIEF INTERVENTION/ THERAPIES
 Practical techniques that may be useful as an initial
treatment approach with at-risk and problem drinkers
across a range of clinical settings.
 Hallmark of brief interventions is to encourage
individuals to change their behavior through motivational
interviewing.
 Brief interventions are time limited and
nonconfrontational in their approach.
PSYCHOSOCIAL TREATMENTS
1. Cognitive behavioral therapy,
2. Motivational enhancement therapy,
3. 12-step facilitation

40. PHARMACOTHERAPY
 Pharmacological treatment is similar to young adults,
but few points are to be considered before starting
medicines.
○ The pharmacokinetics and pharmacodynamics of
most drugs are altered to an important extent in the
elderly. These changes in drug handling and action
must be taken into account.
○ The elderly often have a number of concurrent
illnesses and may require treatment with several
drugs. This leads to a greater chance of problems
arising because of drug interactions.
○ It is reasonable to assume that all drugs are more
likely to cause adverse effects in the elderly than in
younger patients.
○ All medicines should be start with a low dose and
increase slowly.

41. TAKE HOME MESSAGE
 All the special populations have increased
vulnerabilities at various levels.
 Fear of stigma leads to under-diagnosis and
under utilization of existing de-addiction services.
 They have a greater risk of complications and
comorbidity.
 Special population should be properly assessed
for any substance abuse by the help of detail
history and screening tools and should be treated
keeping in mind the level of risk associated with
substance use and its treatment.

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