Screening for Alcohol Use in Adolescents

The US Preventive Services Task Force^[1] recommends screening and counseling interventions directed at unhealthy alcohol use by adults, and the National Institute on Alcohol Abuse and Alcoholism^[2] as well as the American Academy of Pediatrics^[3] recommend alcohol use screening of adolescents. Alcohol is the most commonly abused substance in teens, and much has been published about binge drinking in adolescents, generally referred to as 3-4 drinks over a 2-hour period on any given day. Underage drinking is also associated with the most common causes of adolescent death, including unintentional injuries, homicides, and suicides.

Study Summary

Hingson and colleagues surveyed practitioners to determine the proportion of adolescents who receive screening and counseling for alcohol use. These data were collected as part of the NEXT Generation Health Study, which sampled 10th graders in high schools in the United States in 2010

The students were in multiple school settings (public, private, etc.) across 9 US Census divisions. Recruitment was by school, and 58% of the schools that were approached participated. The average age of respondents was 16.2 years, and 55% were girls. The demographics were 42% white, 34% Hispanic, and 18% black, with small percentages of other racial or ethnic groups.

Students were asked whether they had a check-up with a physician in the last year and whether they were asked at that visit about their use of alcohol, smoking, or drugs, and degree of exercise. Students were also asked whether, during the healthcare visit, they were advised about the risks associated with unhealthy behaviors and received advice to stop drinking. Students were also asked to complete a recall of alcohol consumption in the preceding 30 days. They were asked how many times they got drunk and how many times they had 5 or more drinks (boys) or 4 or more drinks (girls) on any occasion during the previous month. Other questions pertained to frequency of other drug use, cigarette smoking, and the number of days in the previous week that they exercised for at least 60 minutes.

The students’ responses to the survey are summarized in the table below

Table. Student Responses to Survey

A correlation was found between physicians asking about drinking and subsequent provision of counseling to reduce or stop drinking, suggesting that asking the question leads to further discussion with students who are frequent drinkers, binge drinkers, or who are often drunk. However, students who reported drinking at least 6 times within 30 days were more likely to be advised about alcohol-related risks (odds ratio, 1.8; 95% confidence interval, 1.1-3.0

Despite the high frequency of physician visits, only half of 12- to 15-year-old adolescents were asked about drinking. Fewer than half were counseled about the effects of drinking. Those with higher frequencies of drinking, binge drinking, or frequent episodes of being drunk were more likely to have been asked about alcohol consumption and to have been counseled about it.

Viewpoint

I reviewed this study not to point out how infrequently providers screen for alcohol and other substances of abuse but to remind us all how commonly 10th graders drink alcohol, use drugs, and smoke tobacco. Even when problem drinking behaviors were identified, adolescents were advised about the risks or urged to stop drinking much less often than similar advice was given to students who smoked or used drugs frequently. The National Institute on Alcohol Abuse and Alcoholism provides a useful resource for clinicians who would like to increase their level of knowledge and comfort in screening and counseling adolescents in office settings.

Much of the recent attention on the nation’s prescription drug epidemic has focused on corrupt or negligent doctors. But there’s another significant problem in the medical community — many physicians are routinely prescribing powerful drugs like Vicodin and Oxycontin because they don’t know how addictive and dangerous they can be.

A two-year program at Kaiser Permanente has drastically reduced the number of prescriptions for these brand name drugs by teaching front-line doctors how to safely prescribe pain medication.

The Centers for Disease Control and Prevention says since 1999, the number of prescription drug deaths nationwide has more than tripled. 

That drama is playing out in communities across the country.  Every day, about a hundred calls come into theAction Family Counseling drug treatment center in the Santa Clarita Valley. Most are pleas for help in kicking addictions to prescription pain killers that are frequently turning deadly.

“We’re having an explosion of opiates – heroin and pain killers,” says ACTION founder Cary Quashen. “In fact last year we had 15 deaths, but then Simi Valley, La Canada, Pasadena – it’s everywhere.”

Quashen, who also is the head of behavioral health at the nearby Henry Mayo Newhall Memorial hospital, says teens and young adults get hooked on mom and dad’s supply. Once that dries up, youngsters turn to the streets, where the price tag for one brand-name pill can run between $80 and $100.

“They’re spending a lot of money when really all they have to do is smoke a little bit of heroin; for a fraction of the cost ­they’re getting the same exact high,” says Quashen.

The skyrocketing number of heroin addicts among affluent teens who start first with prescription pain pills is disconcerting for doctors, such as family practitioner Elian Paiuk.

“The tension we’re always under is to make sure we’re helping to relieve their suffering but that we’re not doing something that will cause harm,” says Paiuk.

Paiuk practices at Kaiser Permanente in Panorama City. He says during his medical school training in the late 1990s, patient advocates and even the California legislature were among those pushing doctors to provide something more for patients’ pain.

“Pain became the fifth vital sign along with blood pressure and pulse,” says Paiuk, “and we were supposed to be paying more attention to it. And that was actually reinforced very heavily during my training that we needed to actually prescribe more pain medication.”

It seemed to be a rationale response to a medical culture that most agreed did not treat pain enough. But then things spiraled out of control.  Dr. Steven Steinberg is regional chief of family medicine at Kaiser Permanente Southern California. He co-founded what may be the nation’s first large-scale effort to reduce prescriptions of brand name narcotics. Steinberg says it was an idea that was born almost by accident, two years ago, when he and a colleague began looking into Kaiser doctors’ prescribing patterns.

“We got this report and number one we saw a giant spike of usage [of] Oxycontin,” says Steinberg.

Vicodin prescriptions, too, were sky-high – and not just at Kaiser.  Steinberg says the pressure on doctors to provide better pain care to patients collided with a nationwide marketing push by drug companies to doctors and hospitals.

A perfect storm resulted, and before long, he says, bottles of these powerful pain pills became nearly as commonplace as Tylenol, in medicine cabinets and in student backpacks.

“So our first mission was, we want to stop the drugs than can basically be resold into our schools,” Steinberg recalls. “Stopping Vicodin was number one, stopping Oxycontin was number two.”

Steinberg and his colleagues began carrying out their mission through a program that teaches Kaiser doctors how to safely prescribe pain medication. They learn facts about narcotics often overlooked in med school and residency.

They learn that these popular pain pills are – milligram for milligram – as potent as morphine; that above 120 milligrams a day, they can lead to addiction and death; and that the bigger the bottle of pills, the more likely they’ll be shared with family and friends or diverted to street sales, and into the hands of teens.  Steinberg says two years into his program, it seems to be working.

“And what we’ve seen is about a 75 to 80 percent reduction in the prescribing of brand name Oxycontin within Kaiser Permanente,” he says. “It represents a significant decrease in the amount of Oxycontin that’s floating around southern California.”

Steinberg says Vicodin prescriptions, too, are down –  by a whopping 95 percent. Kaiser doctors are now more likely to offer patients generic prescriptions that have little, if any, street value, as well as alternative treatments such as physical therapy.

Kaiser’s Dr. Pauik is a graduate of Steinberg’s training. Among the takeaways he now employs:  limiting patients to one-month supplies of strong painkillers.

“That way we have the patient coming back more frequently,” says Paiuk, “and if there’s a problem starting to come up , we catch it must faster because there’s only one month of pills at a time and it reduces the amount of pills in circulation at any given time.”

Paiuk and Steinberg say they know of no other program that’s similarly aimed at the national prescription drug epidemic. They say the training can easily be adopted by most any medical practice. Those who treat addiction say there’s no time to lose.

“In this country, every 19 minutes somebody is dying from a drug overdose,” says Cary Quashen. “We really better get a curb on this fast because we’re losing too many of our kids.”

The CDC says that in 2010, 12 million people reported using prescription pain pills for something other than their intended purpose, and the most recent CDC data show that overdoses from such abuse claim nearly 15,000 lives a year.

Prescription drug abuse remains a significant problem in the United States.

What is driving this high prevalence?

Multiple factors are likely at work:

Misperceptions about their safety. Because these medications are prescribed by doctors, many assume that they are safe to take under any circumstances. This is not the case. Prescription drugs act directly or indirectly on the same brain systems affected by illicit drugs. Using a medication other than as prescribed can potentially lead to a variety of adverse health effects, including overdose and addiction.

Risks of commonly abused prescription drugs

Available options for effectively treating addiction to prescription drugs depend on the medication being abused. Approaches to treating pain reliever addiction are drawn from research on treating heroin addiction, and include medications combined with behavioral counseling. A recent large-scale clinical trial supported by NIDA showed that Suboxone (buprenorphine + naloxone), prescribed in primary care settings, helped about half of participants reduce their pain reliever abuse during extended Suboxone treatment. Another promising approach includes longacting formulations of medications, such as Vivitrol, a depot formulation of the opioid receptor blocker naltrexone, recently approved by the FDA to treat opioid addiction. With effects that last for weeks instead of hours or days, long-acting formulations stand to aid in treatment retention and abstinence.

Although no medications yet exist to treat addiction to CNS depressants or to prescription stimulants, behavioral therapies proven effective in treating other drug addictions may be used. NIDA is also supporting multiple studies to identify promising medications for stimulant addiction.

NIDA Supported Research on Prescription Drug Abuse

NIDA’s multipronged strategy to reverse prescription drug abuse trends complements and expands our already robust portfolio of basic, preclinical, and clinical research and educational and outreach initiatives. NIDA-supported researchers are conducting large-scale epidemiological studies investigating the patterns and sources of nonmedical use of prescription medications in high school and college students. Results suggest that prevention efforts should include a focus on the motivations behind the abuse, which often have an age and gender bias.

NIDA is also leading efforts to develop pain medications with diminished abuse potential, such as those that bypass the reward system of the brain. This is particularly important in light of returning veteran and growing elderly populations. To that end, NIDA is supporting research to better understand how to effectively treat people with chronic pain, which may predispose someone to become addicted to prescription pain relievers, and what can be done to prevent it among those at risk.

The ultra-ambitious, overbooked teen is becoming increasingly common, as college acceptance becomes more competitive and the job market more dire. Modern teenagers often feel pressure to do it all, and better than anyone else: make straight A’s, ace the SATs, excel at sports or music or art and still have time for fun and friends. Unproductivity has become impractical, sleep a waste of time.

Which is why healthy teens across the country are turning to stimulants like Adderal, Ritalin and other medications traditionally prescribed to treat attention-deficit/hyperactivity disorder (ADHD). When used for reasons other than those intended, ADHD drugs are believed by some to increase concentration, focus, wakefulness and short-term memory, allowing teen-agers to be hyper-productive and, some say, smarter. For this reason, the drugs—along with a newer drug, called Provigil, prescribed as an aid to chronic drowsiness—have become known as “cognitive enhancers,” “neuroenhancers” or “smart drugs.” Students report doing better in school—whipping through term papers, speaking more in class—and conveniently needing far less sleep. And since the drugs are FDA-approved and so widely prescribed (most kids are likely to have classmates who take prescribed ADHD medications, which is often where they get them), teenagers tend to view the drugs as relatively harmless.

As illegal drug use declines nationwide, prescription drug abuse is climbing—with stimulants near the forefront—in affluent suburbs and at elite colleges. In 2005, a study led by John Knight, MD, director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston, found that 7 percent of college students surveyed used stimulant medications for non-medical purposes. Similar studies have shown levels of use as high as 35 percent at individual schools. “Prescription stimulant misuse is the fastest growing segment of the drug abuse problem, and growing exponentially,” says Knight. “It’s going to be the epidemic of the next decade or two or three.”

According to Knight, medications for treating ADHD, when used as directed, are among the safest around. When misused by kids who don’t have the disorder, however, the results can be damaging, and in some instances deadly. “Compare it to a person with normal vision wearing eyeglasses,” Knight says. “At first, the eyeglasses will magnify vision. But soon, they’ll damage the eyes to the point where the person can no longer see straight without them.” Side effects can include nervousness, headaches, sleeplessness, depression and decreased appetite.

And while Knight allows that misuse of stimulants can marginally improve certain areas of focus, those improvements don’t last. The brain has a way of correcting itself, he says; this is called tolerance. Soon, a teen needs to take twice as much medication to get the same effect. (In contrast, kids who do have ADHD typically stay on a stable dose for years and years.) Some young people seeking to feel “high” from stimulants begin to grind the pills and snort or inject them—this gets the drug into the bloodstream immediately, enhancing its effect—which can lead to cardiac arrest. Others “graduate” to street drugs, like cocaine and heroin. “By the time most kids come to see us at the hospital, they’ve reached a very sad place,” says Knight.

What’s worse, is “there is absolutely no scientific proof these drugs, when not prescribed for ADHD, aid performance,” says Knight. “What we have are reports of individuals saying they did better in school. But did they do better in school, or did the drug just make them think they did better? It’s a stimulant. Stimulants make you feel better about things.” In fact, many kids admit that when studying on cognitive enhancers, their papers are too wordy, their participation in class more scattershot. They can spend hours over-eagerly writing and rewriting a single paragraph until it’s “perfect.”

An increasing number of kids are taking stimulants simply because they like the high they provide. And there are those who use drugs to make up for social excesses that might otherwise have a negative effect on their studies: With the help of cognitive enhancers, the modern-day superkid studies all week, dances all weekend and has no need for sleep. Until, that is, she crashes.

“The problem with the prescription drug epidemic is that kids are only getting the first part of the message,” says Knight. “Yes, the drugs are FDA-approved. They are safe and effective when prescribed by doctors, but the key phrase there is ‘when prescribed by doctors.’”
Popular TV shows, like “Gossip Girl” and “Nurse Jackie,” depict generally sympathetic characters misusing prescription pills without significant consequences; these have made the drugs seem less dangerous, and a little more glamorous, than ever before. But, warns Knight, unprescribed use almost always leads to problems and, in the worst cases, addiction or even death. In this story, the ending is never happy.

I find, as I get older, that my experiences along the way have firmed up some opinions. Some of these opinions are good perhaps, and some are probably not so good, but they are mine nevertheless and I will leave it to others to form their own opinions about which is which. I have perception problems with the outside world and emotional ties to my own ideas that sometimes prevent me from seeing the consensual reality we call truth, so you are on your own in this regard. That notwithstanding; I manage to stumble along in my day to day life trying to separate the true from the false as best I can, knowing full-well that I could be wrong at any time.

Why I tell you this is because I have recently stumbled across an item that I believe has enormous potential to raise people’s awareness about where they live and what kind of society we have become. It is a documentary film titled “The House I Live In” by director Eugene Jarecki, and it won the top honor for Documentary Films at the “Sundance Film Festival” in 2012. I never said I was fast and, as usual, I’m just now discovering this film many months after it’s triumph at Sundance. Oh well, everything in its’ own time. The film is part history and part current events as it takes us through the underlying assumptions, decisions and ramifications of the “War on Drugs” as it has developed over the last forty years. The law of “Unintended Consequences” runs rampant throughout this narrative as well-intentioned people struggle to legislate behavior they do not understand, and spend money they do not have, to reach goals that are unachievable. The persistence and perniciousness of the underlying belief system has to be seen to be believed. It shows how little; human concepts have evolved, since medieval times and the dangers inherent in codifying them into law. I urge every citizen of the US to watch this film and, more importantly, see to it that their elected representatives watch it as well.

I realize that many readers of this blog live outside the United States and may not be US citizens, but I assure you the “War on Drugs” has had an impact upon your lives as well. If you are a citizen of a country with a participatory form of Government, I urge you to get a copy of this film and pass it along to your local lawmakers. If you live in a place that does not value citizen input or worse, represses it, please know that we are all in this together and you will not be forgotten.

Here is a link to the official trailer. and here is a link to a place you can see and/or purchase the film online. It also airs on US national television on the PBS “Independent Lens” program Monday April 8, 2013 at 10:00 PM EST. Check your local listings for the time where you live.

Also; if you are the proactive type and believe that good communication leads to better government, please feel free to forward this information along to your elected officials. If the US Congress is serious about balancing the Federal Budget, the 1 trillion dollars in savings that would be shortly realized by discontinuing the “War on Drugs” would go a long way toward that goal. We might even be able to afford proper healthcare for the mentally ill and addicted people we currently warehouse in various correctional facilities throughout North America. What a concept!

So-called “Internet addiction” is associated with increased depression and even druglike withdrawal symptoms, new research suggests.

A study of 60 adults in the United Kingdom showed that those who were classified as high Internet users had a significantly greater decrease in positive mood after logging off their computers than the participants classified as low Internet users.

“Internet addiction was [also] associated with long-standing depression, impulsive nonconformity, and autism traits,” report the investigators, adding that the latter is “a novel finding.”

“We were actually expecting that people who used the net a lot would display enhanced moods after use — reflecting the positive reinforcing properties of the net,” coinvestigator Phil Reed, DPhil, professor and chair in the Department of Psychology at Swansea University in the United Kingdom, told Medscape Medical News.

“So the key finding of an immediate increased negative mood, the withdrawal effect, was something of a surprise. But the more we looked into the literature, the more it seemed to fit the notion of an addictive disorder,” added Dr. Reed.

He noted that the main takeaway message for clinicians is that some people may experience disruptions to their lives from excessive Internet use — and that this can affect both their psychological and physical health.

In addition, patients “may need help exploring the reasons for this excessive use and what functions it serves in their lives.”

The study was published online February 7 in PLoS One.

Novel Psychopathology

“Over the past decade, since the term became widely debated in the medical literature, ‘internet addiction’ has become regarded as a novel psychopathology that may well impact on a large number of individuals,” write the investigators.

As reported last year by Medscape Medical News, the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will include Internet use gaming disorder in its Section 3, which is for conditions deemed to require further research.

In fact, excessive Internet use has become a cause of concern in countries all over the world.

China recently announced plans to develop criteria for Internet addiction diagnosis. The country is also implementing stricter regulations on Internet cafes.

“Internet addiction has become a serious problem in China,” said Li Jianwei, an official with the Ministry of Culture, in a recent article published in China Daily.

Downside of Technology

“We have had a long-standing interest in uses of computer technology to help children and young people with autism spectrum disorder and special educational needs. These uses have always been very positive,” said Dr. Reed.

“However, the emergence of literature suggesting that this helpful tool might also produce problems for some people seemed to warrant some attention. In fact, the flagging of [this] disorder as a potential problem in the new DSM-5 also means that we need to know more about this issue,” he added.

For this study, 60 adult volunteers (mean age, 24 years; 55% women) underwent the following tests:

the 20-item Internet Addiction Test,

the Positive and Negative Affect Schedule (PANAS) questionnaire to measure moods,

the Spielberger Trait-State Anxiety Inventory total score (STAI-T/S),

Beck’s Depression Inventory (BDI),

the Oxford Liverpool Inventory of Feelings and Experiences (O-LIFE), and

the Autistic Spectrum Quotient Questionnaire (AQ).

All participants were then allowed to use the Internet for 15 minutes. Immediately after this exposure, they again completed the PANAS and STAI questionnaires.

Subgroups were created for those deemed problematic and/or high Internet users (n = 32) and those found to be low Internet users (n = 28).

Druglike Withdrawal

Results showed strong associations between Internet addiction and depression on the BDI, autism traits on the AQ, and schizotypal impulsive nonconformity on the O-LIFE — and weaker associations between this type of addiction and long-standing anxiety, as measured by the STAI-T/S.

Compared with baseline, the high-Internet-use group showed a significantly greater drop in positive mood than did the lower-use group (P < .001).

“The immediate negative impact of exposure to the internet on the mood of internet addicts may contribute to increased usage by those individuals attempting to reduce their low mood by re-engaging rapidly in internet use,” write the investigators.

“It is also worth suggesting that this negative impact on mood could be considered as akin to a withdrawal effect,” they add.

Dr. Reed noted in a release that for these people, the feeling is similar to “coming off illegal drugs like ecstasy.”

“These initial results, and related studies of brain function, suggest that there are some nasty surprises lurking on the net for people’s well-being,” he said.

The researchers note that key reasons why many of these individuals use the Internet so much is to access pornography and gambling Web sites — which have been shown in the past to potentially lead to addictive states.

“It may be that any results relating to ‘internet addiction’ are actually manifestations of other forms of addiction,” they write.