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Adolescent Early Intervention and Treatment Summit
Sacramento, CA November 8-9, 2017
Paula Riggs MDProfessor and Director, Division of Substance Dependence
Department of PsychiatryUniversity Colorado School of Medicine
Developmental Considerations Early Intervention and Substance Treatment in
Adolescents
Developmental Considerations Early Intervention and Substance Treatment in
Adolescents
Disclosures Disclosures ~2~
• Scientific Advisory Board for Smart About Marijuana (SAM)
• Senior Scientific ConsultantCDPHE/NIDA supported RCT of medical cannabis for veterans with service-related, non-treatment responsive PTSD
Learning Objectives Learning Objectives ~3~
Developmental Considerations• Prevention, Early Intervention, and Adolescent Substance
Treatment
Systems-Level Approach• What is “integrated” care and why do we need it?• What would it look like if we had it?• Where are we now?• Where do we need to go from here?• Is there a roadmap to get from here to there?
Learning Objectives Learning Objectives ~4~
Systems-Level Approach• What is “integrated” care and why do we need it?• What would it look like if we had it?• Where are we now?• Where do we go from here?• Is there a roadmap to get from here to there?
Developmental Considerations• Prevention, Early Intervention, and Adolescent Substance
Treatment
~5~
If we could build a behavioral healthcare system from the ground up
…knowing what we know today…….
What would it look like ?
Consensus among researchers and clinicians that addiction and many other psychiatric disorders are neurobiologically-based medical illnesses similar to other chronic medical diseases such as diabetes, cardiovascular disease, hypertension, asthma
Medical advances in the treatment of most chronic diseases involves universal screening, public education, prevention, and early identification of risk factors and interventions to reduce risk
Early intervention at first signs /symptoms of the disease to prevent further progression
Lifestyle and behavior often contribute to disease onset, severity, prognosis
Medical management and treatment require changes in behavior and lifestyle
• Medical model is the roadmap
• Psychiatry –operate as fully functional medical subspecialty providing integratedsubstance/mentalhealth treatment
What is integrated care and what would it look like if we had it?
What is integrated care and what would it look like if we had it?
6
Will you join me
in a brief tour of
that paralleluniverse
~7~
Addiction
Mental Health
Medical Healthcare
funding
This universe is dysfunctional, non-integrated silo’dsystem of care
Medical Healthcare
Cardiology
Endocrinology
Pulmonary surgery
GIPsychiatry
Behavioral Healthcare
(substance/mental health)
Pediatrics
In this parallel universe, psychiatry is fully integrated into mainstream healthcare functioning as multidisciplinary medical subspecialty addressing substance and other psychiatric disorders
What is integrated care and what would it look like if we had it?
What would it look like if we had it?What would it look like if we had it?
8
Universal and regular repeated screening in primary care settings across development/lifespan includingschool-based health clinics (SBHC)
Early identification of risk factors
Effective prevention and risk reduction interventions
Early detection and treatment at first signs/symptoms of illness (e.g. intervention for harmful or risky use)
• Repeated screening in medical settings across development
• Identify those ‘at risk’
• Provide earlier stage treatment to prevent progression
What would it look like if we had it?
Chronic Disease Model of Care provides continuity of care across the continuum of care
What would it look like if we had it?
Chronic Disease Model of Care provides continuity of care across the continuum of care
• Common assessment battery –characterize patients; systematically track patient outcomes (repeated outcome measures)
• Clinicians/practitioners trained in evidence based practice • Continuity of care across the continuum of care• Practice parameters and standards of care are clearly defined and updated to reflect
medical /research advances • Regular and systematic program and performance evaluation; quality improvement
measures
HospitalDetox
ResidentialRehab
IOPRehab Outpatient continuity of care Tele-Monitoring
In this universe substance /mental health treatment looks a lot like prevention, treatment and continuity of care provided for patients with diabetes, cardiovascular disease, and other chronic medical conditions Early
relapse detection
0123456789
Pre During During During Post
Treatment Research Institute
Outcomes In Hypertension, Diabetes, Cardiovascular Disease
Pre During Treatment Post
02468
10
Pre During During During PostTreatment Research Institute
Outcomes In Addiction
Pre During Treatment Post
We have the wrong model!We must adopt a chronic disease model of care consistent with current
research and fully integrated within the medical healthcare system
Very serious use2,300,000 million in treatment
Little to no use
23,000,000With “addiction”
40,000,000“harmful use”
Screening andearly interventions integrated into medical healthcare
PreventionScreening
Where are we now?
< 10 % of those who could benefit from substance treatment receive it
• We’ve primarily developed treatment for the most serious end of the spectrum without a meaningful continuum of care
• Comorbidity is the rule yet, integrated SUD/MH treatment is lacking
Lack early interventions to reduce harmful use in primary care and other medical settings
• School-based health clinics (SBHCs) are underappreciated and under-utilized as primary care settings
• 95% of adolescents with SUD are in still school but universal screening and school-based substance treatment is lacking
SBIRT won’t work until we have > integration
Very serious use2,300,000 million in
treatment
Little to no use
23,000,000with “addiction”
40,000,000“harmful use”EARLY
INTERVENTION
PREVENTION• Universal screening• Early risk identification; risk
reduction
Our “hit rock bottom” approach approach is antithetical to medical advances in treating other chronic diseases
• Effective screening• Brief interventions for at
risk or those with harmful use
Where are we now?
• Clinical workforce shortage
• Lack adequate training
• Poor compensation
• High turnover
• Increase treatment access/availability
• Medical basis of addiction /mental illness will reduce stigma and the need for additional layers of ‘confidentiality’ protection Mental Health
Parity and Addiction Equity Act (2008)
It’s the LAW but still not enforced
Where do we go from here?
Develop or adapt existing evidence based treatments as earlier intervention implemented in medical settings/healthcare systems*
ENCOMPASS
IntegratedTreatmentfor Adolescentsand YoungAdults
Research-based approach to concurrently treating co-occurring psychiatric disorders
Can be feasibly adapted and implementation in community-based substance, outpatient mental health, or school-based settings
Research Practice • MET/CBT, 16 weeks
• Incentives paid $25 per visit; free tx*
Could not apply additional incentives/contingencies to enhance abstinence rates
Psychiatric treatment Constrained by single
pharmacotherapy/placebo Could not individually tailor treatment as
clinically indicated
Relapse prevention/ continuing care
Constrained by research protocol
• MET /CBT 16 weeks
• CM Incentives “fishbowl”
Compliance
Abstinence
Non‐drug alternative activities
Psychiatric treatment
Broader range of options
Psychotherapy
Pharmacotherapy
Relapse prevention/continuing care
Involvement in non‐drug alternative activities sustained drug‐free lifestyle
School-based adaptation
Developmental Considerations Early Intervention and Substance Treatment in
Adolescents
Developmental Considerations Early Intervention and Substance Treatment in
Adolescents
16
Most substance /psychiatric disorders are pediatric onset • ½ of all psychiatric disorders have an onset before age 15• ¾ onset before 24• Most adults who suffer from chronic addiction started
using as teenagers• National average age of marijuana onset = 14 • 85% of young adult IV heroin users report that they started
with non-medical use of Rx opioids as adolescents• ¾ of new heroin users report antecedent use of Rx opioids
Most childhood-onset psychiatric disorders increase risk for adolescent SUDAdolescent substance abuse increases risk of developing co-occurring psychiatric disorders
17SchoolFamily Peers Community
Pre natal
Birth 5 10 15 20 25
OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES
Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety
Substance Use Disorders
PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic
Teen Intervene
SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT
TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds
Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities
later school start time
School-based –screening, earlier intervention, increase tx access,reduce health disparities
Screening, early tx
18
Moran et al Amer. J Pub Health 2017
Here is a link to the Rescue's youtube page:https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_rescueagency&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=OShb1tsKFwDfD05snvIkYtHH4YNWaKOJOYhW9fl1NqQ&e=
Finally here is a link to a live recorded presentation by Jeff Jordan:https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_watch-3Fv-3D1TPkWVAK3wM-26t-3D3s&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=C8HGyBhPA2RAeDdHhir1l8Xay5CF3semCwKVwTVKJTQ&e=
19
https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_rescueagency&d=DwICaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=5CmzgpPaQZ_BjK9RGybCd3dKOd2_smK9UZaGNCG6wQs&m=tcOhtcJqN18VXkId-dNz6JMjKOvoEPiYCLx6V4HLA6s&s=OShb1tsKFwDfD05snvIkYtHH4YNWaKOJOYhW9fl1NqQ&e=
https://agentsofchangesummit.com/
20SchoolFamily Peers Community
Pre natal
Birth 5 10 15 20 25
OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES
Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety
Substance Use Disorders
PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic
Teen Intervene
SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT
TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds
Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities
later school start time
School-based –screening, earlier intervention, increase tx access,reduce health disparities
Screening, early tx
Pre-natal THC
exposure- “miswiring” fetal brain development-Persistent neurocognitive deficits-lower academic achievement
Tortoriello et al 2014
Fetal Development INFANCY LATENCY PRE-TEEN ADOLESCENCE
Persistent neurocognitive deficits, reduction in IQ comparable to environmental lead exposure
• 4x risk of psychosis• 2x risk depression,
anxiety disorders in young adulthood
• Increases risk of addiction to drugs tried later (5x AUD)
• Deleterious development female reproductive system ; sperm motility
Developmental Considerations Early Intervention and Treatment” MJ Impact on Brain and Neurocognitive Development
Inadvertent ingestion by infants-12 year olds resulted in 17 hospital admissions 2009-2011
NONE prior to 2009
Pediatric MJ Exposures in a Medical MJ State Wang et al JAMA 2013
• Impulse, motor control
• decision-making
• verbal fluency • Short term
memory• Sustained
attention• Response
time• psychosis• Inc. stroke
6 x increase in MJ use among women of childbearing age nationally Wilkinson 2015 NAS, 2017
If there was a neurotoxin in the air or the water that at least 50% of our kids were being exposed to
... and 1/6 of these, exposed at levels associated with significant reductions in IQ, learning problems, academic underachievement, and persistent neurocognitive deficits
Begs the Question?
6-8 point reduction in IQ associated with regular adolescent MJ use comparable to 7.4 point reduction associated with environmental lead exposure (10 mg/dc) Meier et al 2012; Canfield et al 1996
“…IQ declined by 7.4 points as lifetime average blood lead concentrations increased from 1 to 10 μg per deciliter.
24SchoolFamily Peers Community
Pre natal
Birth 5 10 15 20 25
OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES
Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety
Substance Use Disorders
PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic
Teen Intervene
SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT
TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds
Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities
later school start time
School-based –screening, earlier intervention, increase tx access,reduce health disparities
Screening, early tx
5x increase in neonatal opioid abstinence syndrome in past decade
In many states Medicaid only covers maternal treatment for OUD pre-delivery not post-delivery
Peri-natal ADOLESCENCE
• Adolescent-onset substance use increases risk of progression to chronic addiction, opioid, polysubstance, and psychiatric comorbidity
• Psychiatric Disorders • 50% start before age 15• 75% before age 25
• 85% of young adult IV heroin users report that they started with non-medical abuse of Rx opioids during adolescence yet no appreciable increase in adolescent treatment admissions for OUD … suggests they bypass existing treatment
• Need school-based screening, early intervention, treatment
Developmental Considerations for Early Intervention and Treatment Opioid Crisis
• 3/5 overdose deaths in US are opioid-related
• Opioid deaths > MVAs
• 2015- 22,000 deaths (62 /day)
• ¾ new heroin users report antecedent Rx opioid
CDC 2017 Reddy et al Obstet Gynecol 2017
26
Opioid Crisis
27SchoolFamily Peers Community
Pre natal
Birth 5 10 15 20 25
OB/GYN PEDIATRICS FAMILY MEDICINE SCHOOL-BASED HEALTH CLINIC COLLEGE HEALTH SERVICES
Dysregulation, ADHD, LD , ODD, CD, Depression/Anxiety
Substance Use Disorders
PREVENTION Good Behavior Game Brief Intervention Peer group tailoredLifeskills MJ Checkup messaging, not generic
Teen Intervene
SCREENING TWEAK, T-ACE (pregnancy) BSTAD, S2BI (adolescents) ASSIST, AUDIT
TREATMENT Family, CBT, medication MET/CBT , CM, family (MST,FFT)childhood psychiatric ds
Parent education • 8-9 hours sleep vs 6 hours-(3x more likely to initiate drug use)• Pro-social, non-drug activities
later school start time
School-based –screening, earlier intervention, increase tx access,reduce health disparities
Screening, early tx
PSYCHIATRY
28
With Shared Vision, We Can Get There From Here
THANK YOU FOR YOUR ATTENTION
QUESTIONS?
COMMENTS?
DISCUSSION?
THANK YOU FOR YOUR ATTENTION
QUESTIONS?
COMMENTS?
DISCUSSION?
29
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