Joanna Quigley, MD
Associate medical director for Child and Adolescent Ambulatory Services, University of Michigan, Ann Arbor, MI
Dr. Quigley has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: To start us off, how does addiction differ in adolescents vs adults? Dr. Quigley: In adolescents it can be subtle. For example, there are culturally normative behaviors with alcohol and cannabis use, and kids get missed because people write it off as “just partying.” They miss the fact that the substance use has become extremely impairing. Adolescents are generally healthy; they don’t tend to present with pancreatitis or other adult diseases that can be clues to a substance use issue. A lot of times adolescents with substance use disorders (SUDs) don’t hit the surface until they have a legal consequence or a school consequence. A kid may present with depression or anxiety to the primary care office, and then you only learn about the substance use upon further questioning.
CATR: How do you feel about the DSM-5 changes? Can we use the DSM criteria as our guide, or are they too centered on adult addiction? Dr. Quigley: It’s been a cultural shift, but I think the DSM-5 is useful in terms of framing psychiatric disorders on a spectrum. While the revisions included some adolescent data, a lot was validated based on adult data, so there is some controversy around how developmentally appropriate some of the changes are in describing adolescent use. In adolescents, you may not see tolerance, withdrawal, or cravings as an indicator of a use disorder, as you might see in adults. But I think the way SUDs are now described in the DSM-5 can still be very applicable for what goes on with our adolescent populace.
CATR: Let’s move on to screening for adolescent addiction. What are some of the tools you’d recommend here? Dr. Quigley: There are several screening tools validated for adolescents. A new one, the electronic Screening to Brief Intervention (S2BI), looks at frequency of use (see www.drugabuse.gov/ast/s2bi/#/). It screens for nicotine and tobacco, alcohol, marijuana, and others. The CRAFFT questionnaire is used a lot in primary care, but it is also a great tool in general child psychiatry and addiction treatment practices (see the sidebar below). NIAAA also has a 2-question test that looks at alcohol use (https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf).
CATR: As part of screening, what are some specific questions we should be asking adolescents? Dr. Quigley: Since they already often seem two steps ahead of us, with adolescents it can be really helpful to use direct routes. Be very specific in your questions. For example, don’t just ask, “Do you smoke?” Ask, “Are you using any nicotine products? What are you using in your vape?” Adolescents are adjusting the contents of some of these vape products to include cannabidiols, and increasing the levels of nicotine. If you don’t ask the vaping question, you won’t realize that they’re actually exposed to a very significant amount of nicotine, or another substance, that’s escalating over time.
CATR: Would you take the same approach to prescription medications? Dr. Quigley: For a specific medication, you can ask, “Have you ever found yourself taking more than you’re prescribed, and how did that make you feel?” Ask substance-specific questions and focused impairment questions such as, “How often are you thinking about using?” “Do you find yourself not getting as high as you used to?” When it comes to screening adolescents for substance use issues, as clinicians we need to work in a narrative interview mode.
CATR: That’s a great approach. Can you tell us more about what you’re seeing when it comes to kids either abusing their own prescriptions, or finding ways into their parents’ or grandparents’ medicine cabinets? Dr. Quigley: I do a lot of psychoeducation with parents. It’s alarming when you look at suicide risk. If I have a child who is depressed, I tell parents that medications in the home need to be secured. That goes up another notch when I know there’s a substance use issue. Just like adults, kids with SUDs will find ways to access a substance, and often the most accessible substance is what is in grandma’s medicine cabinet. Whether it’s stimulants, opioids, benzodiazepines, or any other psychotropic, parents of kids with depression or any SUD need a locked box that no one else has access to. Another thing you can tell parents is, “You have power over things such as the car keys.” Driving under the influence is obviously a huge safety concern, so you need to tell parents—even with only the slightest suspicion that their child is using substances—to enforce taking the keys.
CATR: That’s good advice. What else should we tell parents? Dr. Quigley: In a very direct manner, they should tell their kids, “When you drive on cannabis, you’re impaired,” or, “Taking other people’s pills can be a risk for arrest on criminal drug diversion charges.” Crystallize examples of what can happen with access and diversion. I’m very up front with adolescent patients. I tell them that we have a state monitoring system, and I’m going to check it to see if a patient is asking for too many refills. It’s really important to spend the extra time in educating families about the consequences.
CATR: Do you have other thoughts about parental involvement in the evaluation and treatment process? Dr. Quigley: Unless there’s something fundamentally toxic in the dynamic between parent and child, constant parental involvement is vital, and the family component of treatment can be essential to the adolescent’s success (Rowe CL, Child Adolesc Psychiatr Clin N Am 2010;19(3):563–576). As we know, relapse frequently occurs. It’s at those times that strong family support helps the adolescent get back on track. What we find with some of our adolescents, too, is that there’s a parent or family member who’s also dealing with an untreated SUD. This becomes an opportunity to get care for that family member and can be quite powerful in motivating the adolescent to remain sober. If, for example, an adolescent sees that his dad probably also needs some help, the adolescent will understand that he’s not the only one targeted in this situation—and seeing his dad try the 12 steps can be really motivating.
CATR: What else do you tell your adolescent patients about the dangers of substance use? Dr. Quigley: I also talk with adolescents about buying from their friends. I tell them, “You don’t know what it is you might be buying.” Xanax candy bars have been laced with fentanyl. I just say point blank, “You need to know this has been going on and you’re risking accidental overdose, and you could die.”
CATR: From a screening and assessment standpoint, what else would you recommend we do? Dr. Quigley: I use motivational interviewing (MI) techniques, but I’m also engaging around why patients are still using. For example, if it’s cannabis, find out what role the cannabis is playing in the teen’s life. Often, we’ll discover there may be concurrent anxiety or an untreated mood disorder. I also do urine drug screens, and as I mentioned, I’m checking our surveillance system for other prescriptions. In utilizing MI and trying to talk to the adolescent, ask general questions to gauge the patient’s engagement with drugs and beliefs. For example, you could say, “Your parents seem to be really worried about your substance use; what do you think about that?” Additionally, you could ask questions such as, “You state that you have researched a lot about cannabis and believe that its risks are overrated. Do you think there’s any evidence that your cannabis use has had a negative impact on your day-to-day life?”
CATR: Let’s shift to co-occurring disorders. Can you talk about risk factors for addiction in adolescents who also have ADHD? Dr. Quigley: The data on ADHD have been confusing at times. Meta-analyses have shown an association between childhood ADHD and development of SUDs in adulthood (see lead article “Adolescents With ADHD and Substance Use Disorders: A Primer” on page 1). However, the association between a SUD and ADHD in terms of risk is multifactorial. There are some data showing that if you treat ADHD, you reduce that risk (Quinn P et al, Am J Psychiatry 2017;174:877–885). The final result is that I often feel comfortable using a stimulant in treating a kid with ADHD, even when the adolescent is smoking cannabis—just as long as we also address the cannabis issue.
CATR: Can you tell us more about your approach to urine screening? Dr. Quigley: I’ve been in many situations where a patient has told me, “Oh, I’m just using weed,” and then I do the urine and there’s cocaine and stimulants. Then we’re having a very helpful conversation that steers our intervention in a very different direction. I don’t think it’s perfect, but I almost always do urine screening. Parents can do their own surveillance at home with an over-the-counter test they can buy from a pharmacy. Testing creates a sense within the family that the parents are watching and there are consequences—for example, if the adolescent tests positive, the car keys are not given out.
CATR: Our adolescent patients who are using cannabis or other substances don’t necessarily have an SUD, but we also know there are other risks that can later affect their lives. Can you talk about this? Dr. Quigley: The really important thing to remember is that the earlier a patient starts using, the higher the patient’s risk of developing an SUD as an adult (see the TEDS Report at https://bit.ly/2I3Loyl). The longer we can go without exposing those reward systems in the brain to the substance, the more protective it is for the adolescent. Adolescent brain development is an incredibly dynamic and active time. And that period of dynamic activity, which is driven by high levels of dopamine, lasts into a person’s early 20s. Reward systems are flourishing before your prefrontal cortex can turn the brakes on. Adolescents engage in thrill seeking and are more impulsive, and have a harder time thinking through decisions.
CATR: So, let’s now talk about treatment. What are some of the challenges here? Dr. Quigley: It can be really difficult to access treatment programs. Before recommending the right program, you need to look at severity of use. Is it mild, moderate, or severe? Have there been legal consequences? Probation may play into treatment, but even in that initial encounter an addiction treatment specialist can say, “I’m concerned about your use. What do you think about your use? What does your family think about your use?” That’s when you initially get the response, “Well, I don’t think it’s a problem.” I’ll then ask, “Do you think you could quit for 2 weeks and do OK?” Before recommending a treatment program, see how the patient does with that challenge. If the patient actually can’t quit for 2 weeks, then I’d recommend adolescent-oriented treatment groups. An IOP setting or a partial program can really focus on not only on the substance use, but co-occurring disorders, which are so common in our adolescent population. For more severe use, the patient may need detox and residential care. Because use can escalate so fast, constantly reassessing the risk is very important.
CATR: What are your thoughts about the developmental appropriateness and/or changes that might be needed for a 12-step program for adolescents? In my mind, a 12-step program doesn’t always fit these kids. Dr. Quigley: We need to be open-minded and flexible with these kids. I have the luxury of being in an area where our college campuses have specific programming oriented toward the young adult and adolescent population. That’s how they run their groups, and so I will utilize that. There’s also an alternative program called SMART Recovery (see https://www.smartrecovery.org). SMART Recovery seems to have a slightly different approach using some of the 12-step tenets, but it feels accessible to some of the adolescents: Their program has less of a focus on the faith component, which I think is more attractive for some teens. I think it really depends on who’s facilitating the program, how it’s being incorporated, and whether teens feel comfortable with that group. It’s a mixed bag, and I don’t think traditional Alcoholics Anonymous works for some of these adolescents.
CATR: Any closing thoughts? Dr. Quigley: Don’t underestimate the power of substances. It’s very important to keep bringing substance use up as you continue working with an adolescent. When working with young patients, even if you don’t immediately suspect they are at risk for an SUD, bring up these questions. Having a clear understanding of whether your patient has an SUD or is at risk for one is critical to the overall care plan—especially as we try to understand why suicide rates are climbing.