1. Background etc Alcohol and drugs....rising evidence of neurobiological and social vulnerability, versus purely ‘behavioural and morally objectionable’ Brain circuitry and reward centres, euphoria with drugs focussed around brain areas involved in natural reward (food, sex and imbibing fluid)

2. Background etc Tolerance (delayed and rapid) and sensitisation (cocaine seizures and psychosis) Withdrawal manifestations of established homeostatic changes in the brain caused by chronic use. Potentially lethal in alcohol and hypnotics. The use of long acting substances to manage withdrawal. Dependence. All those which cause dependence share action on reward centres. Specifically DA in the nucleus accumbens. DA crucial but also 5HT, Opioids, GABA and Glutamate

3. 1960’s prevalence massive increase social movements etc (1975 70% of USA adolescents tried drugs by end of high school) Late 70’s downward trend. Increased appreciation of harm. 80’s and 90’s climbed again (prevention programmes waned, attention and finance focussed on terrorist threats) Cannabis, inahalants, LSD, cocaine, heroin Late 90’s all declined except one...Ecstasy Late 2000’s estasy declining and other designers and ‘legal highs’ increasing.

4. Risk Factors (JAACAP 1997) Genetic SUD high in children of parents with Alcohol misuse. This could be direct inheritance or an association with ASPD in parents leading to conduct disorder, aggression and SUD in children

5. Risk Factors (JAACAP 1997) Individual Difficulties with planning, attention, abstract reasoning, foresight, judgement, self monitoring and motor control. These factors seem similar to ADHD with CD to me

6. Risk Factors (JAACAP 1997) Family Maternal depression and anxiety. High rates of parental SUD

7. Risk Factors (JAACAP 1997) Peer relationships Less significant than previously thought in predicting drug use or misuse. Association may be because substance misusers select similar friendship groups

8. Resilience Factors (JAACAP 1997) Intelligence Problem solving ability Social facility Positive self esteem Supportive family relationships Positive role models Affect regulation

9. Groups particularly at risk : Young Offenders Looked After Children Young Homeless Children whose parents misuse drugs Those who truant or are excluded from school Young people involved in prostitution Teenage mothers Young People with Mental Health Problems Care Leavers Abused children Family disintegration (Health Advisory Service 1996)

10. Co-morbidity is the rule...... ADHD 20-30% Major depression 25-50% Conduct Disorder 50% plus Bulimia 10-20% Anxiety disorders 20-30%

11. Treatment CBT and Motivational Interviewing are the thing.

12. ADHD significant risk factor for SM Risk higher is co-morbid Conduct Disorder Risk very high for cocaine and nicotine Stimulant Rx does not increase SM, it may protect from it

13. Stimulants can be used Long acting stimulants best Atomoxetine little abuse potential Tricyclics and clonidine high risks and low evidence

14. Dysthymia and major depression common Adult studies SSRI’s help in reducing depression and alcohol misuse 2 open studies of FLX in young people showed reduction in craving and frequency and severity of alcohol misuse FLX has a good safety profile even in non- abstinent adolescents with poly-drug misuse (Lohman 2002)

15. Depression and SM RCT of FLX and CBT versus PLAC and CBT N=126. Age 13-19 with major depression and substance abuse or dependence Randomised : 20mg FLX or PLAC for 16 weeks Both 20 sessions CBT Weekly drug screens and CDRS Mean CDRS scores significantly down in both groups. More in FLX group Drug use decreased in both groups : No difference Riggs et al Univ of Colorado 1997

16. Practical suggestions : Ideally wait 4 weeks after detoxification before medication But early treatment with SSRI’s can make a difference Use of CBT and SSRI’s may help both SM and depression Not yet enough evidence to suggest routine use of SSRIs to reduce alcohol misuse in Young People

17. SM and PTSD Very often missed self medication common BDZ dependence is common Transfer to long acting BDZ Consider trial of SSRI or Mirtazapine In anxiety disorders and SUD, the presence of PTSD features predicts good outcome with SSRI’s Alcohol abuse not uncommon Specific PTSD treatment often required after management of SM

18. SM and Psychosis Lithium in Bipolar and co-morbid alcohol and cannabis use : significant reduction in SM (Geller et al 1998) Open study CLOZ reduces SM in schizophrenia and comorbid SM Specific treatments for SM like Motivational Enhancement effective in Schizophrenia

19. 15 year old girl. Referred by her drugs worker. Young person requests a psychiatric view of her difficulties Alcohol use is heavy and harmful bottle vodka per day. Cannabis use daily for 4 years Intermittent E’s, Amphet and Cocaine Separate up and think about assessment. What are you looking for

20. Post traumatic symptoms numbing, vigilance, arousal, flashbacks, insomnia Depressive symptoms School failure What do you do next ?

21. Family separation when 7. Lived with mother and sister. Mother’s new partner avoided. No relationship built. 2 suicide attempts aged 7 and 9. One by stuffing tissues into her mouth and one by throwing self into swimming pool What else do you want to know

22. As a child was physically abused by father Watched mother being physically and sexually abused by father Father terrifying man Although lives abroad still uses young person to manipulate her mother How are you going to treat her ?

23. Does alright. Good work with drug and alcohol worker Engages with individual therapist Then sudden deterioration. Why ? What kind of thing would you look for

24. Trip out to party with friend Frightening experience where 4 adult men try to have sex with her a friend She fights her way out but friend is raped in front of her You want to give her an antidepressant Which one and why What are your concerns