Adolescent drug addiction: suggestions for the primary care physician

David Chim

HK Pract 2009;31:97-99

Adolescent drug abusers represent a challenging population for the primary care physician, and this is emerging as a major concern for public health. While traditional drugs of abuse such as heroin and cocaine are on the decline in the United States, abuse of prescription drugs is on the rise.¹ Prescription drugs are easily accessed by young persons by pilfering from their parents' medicine cabinets.² The primary care physician (PCP) is often the first source of medical screening and treatment the adolescent drug addict will have access to. As practitioners of family medicine, we must be prepared to face the special task of screening and treating this special population who have unique needs stemming from their immature neurocognitive and psychosocial stage of development. Our intervention will likely have a direct impact on the public health aspect of the addiction epidemic. The following are some highlights the well-informed family physician should keep in mind when confronted with our youth and young adult patients with substance abuse or dependence.

Addiction is a brain disease, not just a maladapted social behaviour. The adolescent brain matures at about 25 years old.³ Adolescent addiction develops in an immature brain, and stymies normal brain maturation. The normal, drug-free brain undergoes a long-term process of development from birth to early adulthood. The resulting refinements of neurochemistry and neural pathways are represented developmentally as behaviour changes: maturing adolescents go from more compulsive actions to more reasoning before action. Key brain regions highly associated with decision-making, self-control, planning, and judgment experiences extensive development during adolescence.

Addicts will have decreased ability to restrain impulsivity and to reflect upon the consequences of behaviour due to interference of brain maturation. In addition, tolerance and dependence develops at a faster rate in the adolescent brain. PCPs should remind patients and their parents that individuals who begin drinking before the age of 15 are four times more likely to develop alcohol dependence than those who begin drinking at age 21.⁴

Adolescents are at higher risk of addiction. PCPs should focus in their history taking key risk factors for substance abuse or dependence including a family history of addictive disease; a history of psychological physical and/or sexual trauma; any concurrent or pre-existing psychiatric disorders; and any evidence of attention deficit or other learning disabilities. In California, the 80,000 plus foster care children are an especially vulnerable group developing substance abuse and dependence; it is estimated about 5000 of these children per year become part of the homeless, addicted population when they reach adulthood.⁵

Our principal goal is prevention by discouraging, delaying, or detecting substance misuse. PCPs must be flexible in their approach to adolescent addicts; to be judgmental and have zero tolerance for drug misuse will inevitably lead to a high detection and treatment failure rate. In the best case scenario, the PCP will discourage any potential addict from developing dependence by educating the patient and his or her family on the tremendous risks of taking addictive drugs. However, with more adventurous adolescents, emphasis must be placed on delaying their onset of regular substance use, to allow their brains to mature normally in order to have a chance to become successful later in life.

When discouraging and delaying use fails, the next step is early detection of high-risk use. Once detected, interventions such as pharmacotherapy and cognitive behavioural therapy should be implemented in a timely manner to prevent further substance misuse progression. PCPs who have limited experience in this field, or who are facing severe cases, should not hesitate to refer to specialists immediately in order to limit damage to the patient physical and psychological health.

In the future, family medicine practitioners will most likely need to conduct adolescent annual examinations with age appropriate educational materials and psychological surveys in addition to evaluations of weight, height, etc.

Your intervention will often be effective, save lives, and decrease public health costs. While this may seem rather obvious, the lay public, adolescent or adult, often do not realize massive amounts of stimulants or depressants may immediately end their lives, or lead them down an irreversible path of health failure, or other severe consequences to themselves or others.

In the Kaiser Permanente Medical Centers, one of the premiere models of primary care in California, 56% of those in treatment recorded 30 consecutive days of abstinence from drugs and alcohol 6 months after treatment.⁶

In the United States, two national studies further prove the efficacy and effectiveness of treatment. The Office of National Drug Control Policy in 2002 reported medical intervention resulted in 48% decrease in drug use as well as 53% decrease in medical visits due to drugs; in addition, there was an 80% decrease in criminal activity. According to the National Institute of Drug Abuse, for every one-dollar spent on addiction treatment, twelve dollars is saved in healthcare and drug-related crime.⁷

Youth treatment must address both addiction and psychiatric illness. The co-occurrence of substance abuse and mental disorder is rather common among adolescents, and treatment requires the complete and seamless integration of psychiatric care. It is estimated about 80% of adolescents with substance abuse have concurrent psychiatric disorders in the United States.⁸ The argument about treating one condition before the other is outdated. The general consensus among addiction specialists is that both the addiction and psychiatric illness must be addressed at the same time, regardless of speculation of whether or not one causes the other.

Addiction is a Family Disease. As a group, adolescents are highly sensitive to psycho-social cues, especially from family and peers. To maximize success, treatments will often need to incorporate parental involvement, and perhaps school and other activities the patient is involved in. Family physicians are often the gatekeepers to comprehensive assessment and treatment. Special attention must also be given to the addict parents. They are often addicts themselves, which causes their children to become mentally ill and more susceptible to addiction. Children of addicted parents should be one of the first target groups for screening and treatment. PCPs and their ancillary care associates who provide intensive education, family counselling, and monitoring will effectively counter this growing concern of public health.