Consumption of tobacco, alcohol and drugs in adolescence

Epidemiology

The drugs most consumed by students aged 14 to 18 are alcohol, tobacco, cannabis and tranquilizers or sleeping pills.

The most recent data come from the State Survey on the Use of Drugs in Secondary Education (ESTUDES 2010) (1); in it, the drugs most consumed by students aged 14 to 18 have been: alcohol, tobacco, cannabis and tranquilizers or sleeping pills. 81.2% had taken alcoholic beverages at some time in their lives, 44.6% tobacco, 35.2% cannabis and 17.3% tranquilizers.The proportion of current consumers of these substances, that is, those who have consumed them in the 30 days prior to the survey, was 58.5%, 32.4%, 20.1% and 5.1%, respectively. .

The use of the other substances (cocaine, ecstasy, hallucinogens, volatile inhalants, heroin, etc.) was less widespread, with the prevalence of consumption once in life between 1% and 6%.

Compared to previous surveys, there was a significant reduction in cocaine and ecstasy use, a slight decrease in the consumption of volatile inhalants, a stabilization in the consumption of alcohol, tobacco, cannabis, amphetamines, hallucinogens and heroin and a significant increase in the consumption of tranquilizers. or sleeping pills.

In 2010, the downward trend in tobacco consumption that began in 2004 is confirmed and the perception of risk increases with the daily consumption of tobacco and its physical repercussions. Surveys in adolescents in our environment show that 1 in 5 boys and 1 in 3 girls smoke daily at 16 years old. In developed countries, the pattern of onset is similar in both sexes, producing the experiment of smoking between 12 and 14 years. Subsequently, natural history shows that girls have higher consumption rates, reaching a maximum between 15 and 16 years; whereas, in boys, the increase is much more gradual until the age of 18. Although at these ages the percentage of girls smokers is higher than boys, the consumption of these is higher. Some longitudinal studies suggest that habit consolidation among those adolescents who experience would be much higher among girls.

Cannabis is the illegal drug with the earliest start, it is 14.6 years old and the most widespread among adolescents between 14 and 18 years old. Boys consume more than girls all illegal drugs; whereas, among women, daily tobacco consumption is more frequent (16.4% of girls smoke compared to 13.3% of boys), of alcohol (59.4% of girls have used alcohol in recent years) 30 days, while the boys did it in 57.7%) and tranquilizers. In illegal drugs, it is observed that differences in prevalences by sex are more marked as consumption is more frequent or intensive in favor of men. The greatest increases in the extent of alcohol, tobacco and cannabis use occurs between 14 and 15 years.

A significant proportion of schoolchildren present polydrug behavior. Alcohol has a significant presence among cannabis and cocaine users. The combinations of cannabis, alcohol, tobacco and cocaine are some of the most common polydrug behaviors.

Regarding the overall rate of admission to treatment in 2009 in the whole of Spain for substance abuse or dependence was 115 cases per 100,000 inhabitants. With respect to the drug that motivates the treatment, the situation changes radically in recent years; heroin (37.4%) stops being for the first time in 2005 the drug that motivates the highest number of admissions to treatment to cede the position to cocaine (45.6%). However, among those under 18, the substance that causes the greatest number of treatments was cannabis (78.4%), followed by cocaine (15.5%).

Drugs of abuse

Depressant, stimulant and psychodisleptic drugs.

The drugs have been classified according to different categorization systems, here we choose the classification according to their effects on the central nervous system due to its didactic simplicity.

• Depressant drugs: depressants of the central nervous system are those that attenuate or inhibit the brain mechanisms of wakefulness and can produce different degrees of inactivation, from relaxation, sedation and drowsiness, to hypnosis, anesthesia and coma, depending on the dose. Some drugs, in addition, have specific effects, such as the production of anesthesia. The most frequent would be alcohol, anxiolytics, opiates and hypnosedatives.

• Stimulant drugs: substances that produce euphoria that manifests with well-being and improvement of mood, increase in energy and alertness, as well as an increase in motor activity and a stimulation of the cardiovascular system. There is an improvement in intellectual performance and a decrease in the subjective feeling of fatigue and appetite. They are associated with an increase in heart rate, blood pressure and mydriasis. Major stimulants would be cocaine and amphetamines and, minor stimulants, nicotine and caffeine.

• Psychodysleptics: are disturbing drugs of consciousness, also called hallucinogenic. They alter the perception of reality, produce strange sensations, illusions and even visual and auditory hallucinations. Examples are: hallucinogenic mushrooms, LSD, cannabis …

However, there are several substances widely used today that have characteristics of several groups, this is often seen in synthetic drugs, MDMA is both stimulant and hallucinogenic and ketamine is depressing and hallucinogenic (Table I ).

Neurobiology of addiction

Substance dependence is a disease of the central nervous system, due to the neurobiological dysfunction of mesoencephalic, limbic, cortical brain structures and brain circuits involved in motivation and behavior.

The so-called brain reward circuit is composed of structures related to the mesolimbic dopaminergic system, in direct connection with other neurotransmission systems, such as the endogenous, serotonergic and gabaergic opioid system. This circuit is activated in response to primary stimuli, such as food and sex, which are of paramount importance for the survival of the species (Volkof, 2005) (2).

The administration of psychoactive substances also produces the activation of this circuit; so that, alcohol, opioids and cannabinoids produce an inhibition of the GABA interneurons of the ventral tegmental area (3) thus releasing the DA neurons that release DA in the nucleus accumbens, being this neurochemical effect the neurobiological substrate of the positive reinforcing effect of said drugs. Psychostimulants block the reuptake of monoamines (DA, NA and 5.HT) and amphetamines also produce release of their deposits in this same circuit.

With the development of the addictive process, the chronic administration of drugs would lead to a down regulation of said circuit and to a recruitment of stress factors that contribute to negative emotional states, thus increasing the needs of a repeated consumption of drugs. the substance (Fig. 1).

Figure 1. Circuit involved in dependence and behaviors.

This circuit sends signals to the prefrontal cortical zone, which is where most of the cognitive processes that enable us to make decisions and modulate impulsive acts are performed.

According to the review by Chambers et al. (2003) (4), numerous findings lead to the conclusion that during adolescence there is a functional preponderance of the dopaminergic system over serotonergic. In addition, in this period there are profound changes in the frontal lobe that favor the development of functions such as working memory, abstract thinking and ability to solve complex problems, but the cognitive functions that allow the inhibition of impulses have not yet experienced such a development. spectacular. These changes occur through an integrated process of overproduction and elimination of synapses and receptors (Lynch, 2006).

The prefontral gray matter undergoes a remarkable increase from the first years of life to preadolescence. Between adolescence and young adulthood, prefrontal gray matter is reduced in volume, however, prefrontal white matter increases linearly from 4 to 20 years of age. It is interesting to note that the reduction of prefrontal gray matter observed at the end of adolescence is selective and is guided by the influence of the individual’s environment;indicating the importance of the environment to model neurobiological processes. Especially in early periods of the life cycle.

Beyond the immediate reinforcing effect, substances consumed during the second decade of life interfere in neurodevelopment. This interference would have a great importance if it fixed a lifetime of biological vulnerability to addictions. This possibility is consistent with the inverse relationship between the age of onset of addiction and its severity and subsequent chronicity.

The results of an increasing number of studies indicate that the effects of psychoactive substances during adolescence tend to persist, so that they condition adulthood. This phenomenon suggests an alteration or stoppage of neurodevelopment. Thus, addictions related to the consumption of substances susceptible to abuse during adolescence could be understood as adjustments of neurodevelopment. There is also mounting evidence that adolescents are more sensitive to the addictive effects of substances of abuse. As a consequence, during this stage of life, it is more likely that the first consumptions will be followed by a rapid increase in doses and an accelerated development of addiction.

Comorbidity

Problems of aggressiveness / impulsiveness during childhood or early adolescence contribute causally to the development of addictions in adolescence.

The comorbidity between psychiatric pathology and drug use is very high; the prevalence, according to various studies, ranges between 61% and 88%. A significant proportion of patients visited in child and adolescent mental health centers present risk consumption.

The presence of basic psychiatric psychopathology is a risk factor and a possible causal factor for the onset of a substance use disorder (SUD). There are a large number of follow-up studies that allow us to affirm that the problems of aggressiveness / impulsivity during childhood or early adolescence contribute causally to the early consumption of substances and the development of addictions in adolescence.

The comorbidity of psychiatric pathology and TUS worsens the prognosis, the response to treatment, increases the relapse rates of both disorders and worsens adherence to treatment (5).

The most common pathologies associated with the consumption of toxins in adolescents are externalizing disorders: conduct disorder, negativist-defiant disorder, attention deficit hyperactivity disorder; against the so-called internalizing disorders, such as anxiety and affective disorders. But both types of disorders: externalizing and internalizing appear with a prevalence 2-3 times higher than in the non-consumer population. The presence of externalizing mental disorders and the subsequent development of addictions is an unquestionable fact. However, the association between depressive or anxiety disorders in the early stages of life and the subsequent appearance of addictions is a more controversial fact and there are only studies that justify it in depression and nicotine dependence (6).

The existing relationship in psychopathology and substance use disorder is multiple. The presence of psychopathology may precede the onset of a toxic problem, may be the consequence of a preexisting TUS, may moderate the severity of a TUS or of psychiatric pathology or may originate from a common factor of vulnerability.

Some of the clinical characteristics of the most frequent comorbid disorders are:

• Behavioral disorder: it is present in 50-75% of patients with SUD. 30-50% will evolve to antisocial personality disorder in adulthood. Normally it precedes the start of TUS. Most have another associated disorder, such as ADHD or affective or anxiety disorders.

• Attention deficit hyperactivity disorder: it is present in 30-60% of adolescents with SUD.

• Bipolar disorder: in 30-40% of adolescents with SUD. There are difficulties in the diagnosis due to atypical presentations with impulsivity, irritability, hyperkinesia and behavioral alterations.It is important to take family history into account in order to make a diagnosis.

• Depressive disorder: between 15-30% of adolescents with SUD. The comorbid presence increases the risk of attempted suicides and completed suicides. Precedes the TUS (50% first refer to depressive symptoms) and remits less only with abstinence than in adults.

• Anxiety disorder: it appears in 7-40% of adolescents with SUD. The order of appearance depends on the disorder. Social phobia usually precedes the start of toxic consumption;whereas, panic disorder or generalized anxiety disorder usually appear after the onset of SUD.Often there is the presence of a PTSD (post-traumatic stress disorder) prior to the onset of TUS.

The evaluation of the mental state of the patient in the first and second decade of life can be an important help to handle the case in the most appropriate way in adulthood. Early onset addiction is a clinical marker of mental disorders characterized by aggressiveness / impulsivity.In current practice, this idea is present in terms of antisocial and borderline personality disorder.Also, we must take into account the possibility that there was an ADHD or a bipolar disorder before the addiction arose and for this we must take into account the external informants and the family history of these same disorders. With the addiction already established, the treatment of bipolar disorder or ADHD will not have the same effect on the consumption of substances as the treatment of these same disorders in childhood or the beginning of adolescence (7).

Patterns of drug use

The precocity in the use of substances is one of the predictors of dependence in adolescence.

There is a wide range of variables or risk factors that must be taken into account to explain the initiation and maintenance of drug consumption: individual, social factors and those related to the substance itself (Table II).

The literature on the initiation of drug use highlights that the experimentation of these substances occurs normally during adolescence. As in the other human behaviors, in the consumption of drugs can be observed quite well defined development sequences, these stages are the result of the interaction between individual (biological and psychological) and social factors that would facilitate or interrupt the progression in the consumption. Kendal, in 2002, modifies his theory of the escalation hypothesis, where he assumed that the consumption of alcohol and tobacco led to the consumption of marijuana and, from this, the consumption of cocaine and heroin, and concludes that: 1) there is a relationship significant between the consumption of legal drugs (alcohol and tobacco) and the subsequent consumption of cannabis,and between the consumption of cannabis and the subsequent consumption of heroin; and 2) although there is a relationship, relationship (statistics) can not be confused with causality.

The consumption patterns of the adolescent are dynamic and evolve, being able to lead to a consumption free of risk or to a problem of addiction or abuse. In this aspect it has been found that age is a variable strongly related to drug use; and the precocity in the use of substances one of the predictors of abuse in adolescence. Among personality traits, a consistent relationship has been found with consumer behaviors in adolescents that score more in the search for sensations and that has been related to the real need for greater stimulation (derived from bio-physiological factors) than characterize these subjects (8). There are other personality variables linked to drug use, although not as consistently, as they are: high level of insecurity, low self-esteem, predominance of external locus of control, low tolerance to frustration and certain beliefs and attitudes.

We can then talk about a progression in the consumption of substances that involve different facets of adolescent life:

• Experimental or social use: adolescents are moved by curiosity, fun, excitement to perform a prohibited act and the need to be accepted by the group.

• Regular use: the adolescent actively seeks the pleasurable effect of the use of substances.Consumption begins to be more regular (weekends) and some deterioration in academic performance and acceptance of standards may begin.

• Substance abuse disorder: consumption increases in frequency, appearing during the week.His group is made up of consumers and the adolescent begins to know how and where to obtain alcohol and other types of drugs, so that this absorbs a large part of his time. There is a deterioration in the functioning of the adolescent, both at school and at home, with the progressive failure to comply with his obligations. A change in behavior occurs, becoming reserved and dishonest. At this point, the adolescent already meets criteria according to the DSM-IV-TR of substance abuse disorder.

• Substance dependence disorder: according to the DSM-IV-TR (9) the search for substances and consumption absorb most of the adolescent’s life and consumption is maintained despite the negative consequences that it produces. Withdrawal symptoms may appear despite being less frequent than in adults. Adolescents are able to remain abstinent for some period, however, relapse leads to a rapid loss of control over consumption (Table III).

The DSM-IV criteria for substance abuse and dependence are the same for adults and adolescents. However, there are some authors who raise doubts about the categorical distinction of abuse and dependence in adolescents. They believe that in adolescents the history of consumption is shorter, making it more difficult for somatic complications of withdrawal syndrome to appear, which limits the diagnostic sensitivity of current criteria, especially when it comes to differentiating abuse from dependence. On the other hand, the social repercussions do appear early. Along this same path is the American Psychiatric Association that, in the draft of the proposals for the diagnostic criteria of the DSM-V (10), which aims to become the fifth edition of the Diagnostic and Statistical Manual of mental disorders for the year 2013, states that the dependency term should be used restrictively to indicate the presence of physiological dependence. They propose to consider the grouping of drug abuse and dependence as a single disorder of different intensity and clinical severity. It is proposed to eliminate the criterion of legal problems for diagnosis, as well as to incorporate a new diagnostic criterion defined as “craving for consumption”.

Detection and early intervention in Primary Care

It is recommended to ask adolescents about the possible use of tobacco, alcohol and drugs at least once a year.

Primary Care is the gateway to the National Health System. Among its primary tasks is the prevention of the disease in any of its manifestations. The doctor’s challenge is to identify the problem in early stages and intervene in a timely manner. The Substance Abuse Committee of the American Academy of Pediatrics recommends doctors:

to. Ask and advise routinely about substance abuse in the consultations of children and adolescents.

b. Possess the necessary skills to recognize risk factors and signs of addiction in their patients.Identify behaviors that involve high risk of consumption.

c. Be able to assess the nature and extent of the problem.

d. Offer advice or referral to another level.

To achieve these ends we have the ideal conditions in:

Healthy Child Program. It consists of the standardized follow-up of the child with the aim of detecting early possible physical, psychic and social alterations in its presymptomatic stage. In this framework, primary prevention is placed. Its objective is to favor the protection factors. The pediatrician will carry out a progressive education to all the children and their relatives in the different health controls:

• Prenatal advice on tobacco, alcohol and other drugs, performed by midwives and doctors in the reviews of pregnant women.

• In reviews of the healthy child, the concept of passive smoking will be emphasized, repeating it in the successive pharyngeal and bronchial pictures of the child (the child’s medical history should contain information regarding the parents’ smoking habits). Parents will be advised in approaching the adolescent (11).

• In consultations with adolescents, it will be a priority to create an environment conducive to approach the adolescent, ensuring confidentiality and listening. The prevention carried out from the school will be supported.

The Previnfad working group recommends asking adolescents about the possible use of tobacco, alcohol and drugs at least once a year. This anamnesis will be done in the different opportunistic consultations for health problems. The advice will be aimed at the negative aesthetic aspects: teeth darkening, bad breath, poor sports performance, possibility of addiction. All this must be recorded in the clinical history.

Medical contact with the child at risk. As of adolescence, contact with the doctor becomes more sporadic; therefore, he should take advantage of consultations for acute pathologies, request for certificates, sports activities, etc. It will require a good degree of empathy, create an atmosphere of trust, ensure confidentiality, start an interview by general topics and open questions. Although the visit is usually initiated in the presence of relatives, the doctor must provoke the opportunity to be alone with the patient. Except in situations of urgency, it is rare that children who start drinking go to their regular doctor asking for help. They often consult non-specific symptoms: malaise, decreased school performance, behavioral changes. Physical symptoms are also frequent, such as coughing, eye irritation … The use of drugs is typically associated with other risky behaviors, such as premature and promiscuous sexual activity, irresponsible driving, theft, being part of gangs, etc., which will make us suspect that use of drugs (Table IV).

In this framework, secondary prevention will take place , consisting in the early detection of the use of substances, in order to intervene as soon as possible on the adolescent and his environment, offering him adequate attention. To do this, the pediatrician must have previously identified vulnerable children and at-risk families.

The evaluation of the consumption implies defining the frequency, places, social situations, antecedents, consequences and attempts and failures of the control of consumption of each substance.

In order to carry out an early diagnosis, the following steps must be carried out:

• Screening protocol, which will be applied to subjects considered to be at risk (family members with disorders due to substance use, marginal groups, character changes, etc.). Here the interest in detecting and differentiating adolescents who have started an experimental or regular use of substances that should be treated from the pediatric office and adolescents who already have an abuse or dependence on substances and who should be derived from them, would be particularly important. immediately to the Drug Addiction Centers.

There are several short screening instruments adapted for adolescents, but few, that are validated in Spanish: CPQ-A (Cannabis Problem Questionnaire in Adolescents): a self-administered questionnaire that evaluates cannabis use and the CAST (Cannabis Abuse Screening Test) scale (12 ), self-applied scale of 6 items that could be used to determine the prevalence of problematic cannabis use and which is currently under study by the National Plan on Drugs.

• Comprehensive evaluation protocols, in cases where the need for intervention has been identified. Requires referral to the specialized resources mentioned above. In these cases the Teen-ASI (Teen-Addiction Severity Index) should be applied : it is a semi-structured interview that evaluates the severity in 7 different areas. It is used in follow-up studies.

Treatment

There are few studies on the efficacy of psychopharmacological treatment for substance use disorder in adolescents.

Studies directed at the effectiveness of treatments for substance use disorder in adolescents often have methodological limitations that lead to the difficulty of reaching definitive conclusions.What is proven is that carrying out a treatment is better than not treating.

The results of follow-up studies indicate that relapse rates are between 35-85%. One of the factors associated with higher relapse rates is the presence of a prior conduct disorder.

The maintenance of abstinence in adolescents produces a decrease in interpersonal problems, improve academic performance and adaptation to social norms and activities. For all these reasons, treatments are tried to cover all the areas affected by drug addiction from different perspectives:

Psychosocial approach. Favorable results of various intervention programs begin to appear where the protocols evaluated include different therapeutic techniques: motivational therapy, cognitive-behavioral therapy, systemic therapy …, constituting examples of multimodal intervention.

Among them, the model of the change process of Prochaska & DiClemente (11), created for the treatment of tobacco dependence, is applicable to any behavior necessary to modify. It is a therapeutic intervention in which through an empathic relationship and without confrontation, helps the patient to move in the different phases of motivation for change (precontemplative phase, contemplative phase, preparation phase, action phase and maintenance phase), through a series of specific approaches for each stadium. Use the motivational interview with a direct assistance style, focused on the client, which aims to provoke a change in behavior, helping to explore and resolve ambivalences (Table V).

Depending on the stage in which the adolescent is in relation to consumption, the interventions will be different:

• Experimental use: psychoeducation and advice should be carried out warning of the risks that the consumption of substance supposes. It would be advisable to do this at the level of your reference pediatric center, once the situation has been identified.

• Regular use : group and individual therapies, family and “abstinence contracts” are used in which rewards and punishments are agreed between parents and adolescents. Urine toxic tests can be performed unexpectedly. This form of consumption should be detected early to avoid its evolution and should be the pediatrician who assesses the ability to monitor their devices or referral to centers specialized in drug addiction.

• Substance abuse and substance dependence disorders should be treated in Drug Addiction Centers, where there are specific programs for adolescents and young people, where comprehensive care is provided, through interdisciplinary interventions at the health, psychological, social and occupational levels and an evaluation multidimensional, so that they can cover the needs of patients in the different areas affected by addiction. For this, they also have services such as therapeutic communities, support floors, hospitalization units, etc., created to meet the needs of the adolescent when outpatient treatment is insufficient or the need for greater containment or separation from the family. Stabilization is achieved.

Psychopharmacological treatment. There are numerous studies on the efficacy of psychopharmacological treatment in adults, but they are scarce in the case of adolescents. This has produced a generalization of the results to the adolescents, so the use of drugs without the indication approved by the regulatory bodies is the norm. The approach of the disorder by substance dependence, includes the realization of a detoxification and then the detoxification of the substance. One of the characteristics of consumption at these ages is polydrug use, which is a limitation when considering specific treatments. In addition, we must take into account that in adolescents the lack of motivation, ambivalence and poor adherence and poor therapeutic compliance are more frequent. This treatment must always be associated with the psychosocial approach.

Depending on the type of substance, the psychopharmacological treatment varies:

• Nicotine consumption disorder: pharmacological interventions in this population are poorly studied, but there are some trials that compare the use of nicotine patches, nicotine gum and placebo, demonstrating a higher rate of nicotine nicotine withdrawal, reducing Withdrawalsymptoms, craving and being well tolerated. Studies begin to appear with the use of bupropion (13) in which a longer duration of abstinence is observed; In addition, because it is effective in the treatment of depression and ADHD, its use can be recommended in the case of adolescents with SUD and any of these comorbid pathologies.

• Disorder by consumption of psychostimulants: the studies that guide the pharmacological treatment of detoxification of these substances (cocaine, amphetamines and other psychostimulants) are scarce. There is no evidence to suggest the use in adolescents of the drugs used in adults such as disulfiram, topiramate, baclofen, modafinil and tiagabine. At present, there is no evidence for the use of fluoxetine (and SSRI) as a preventive of the neuronal damage induced by ecstasy “blue children”, but in the process of detoxification associated with gabapentin.

Our best tool for cocaine use is to achieve and maintain abstinence from alcohol; since, this is a powerful inducer of cocaine craving and also the substance produced with the consumption of alcohol and cocaine, cocaethylene, has greater capacity to produce negative side effects during intoxication, than the consumption of each substance separately.

• Cannabis use disorder: due to the debate that still exists about the presence or absence of the withdrawal syndrome, it makes the studies regarding the treatment scarce. In adolescents, there are no controlled studies that support specific strategies for detoxification. Partial agonists or antagonists (cannabidiol) or cannabinoid receptor antagonists are promising strategies pending adequate studies. Special interest is the appearance of psychotic symptoms in adolescent cannabis users that require high doses of neuroleptics and abstinence to achieve psychopathological stabilization and which, at present, is the psychiatric pathology by which patients attend or are referred to centers. specific drugs.

• Alcohol consumption disorder: enolism in adolescents occurs in the form of episodic consumption, which appears related to high impulsivity. Adolescents are able to maintain abstinence but, once they start drinking, they are unable to stop it (binge-eating or binge ). It is frequent polydrug use and alcohol appears as a powerful inducer of craving (craving for the drug). In this type of consumption, anticraving agents such as naltrexone at a dose of 50 mg / day are useful for the treatment of detoxification (14). It is recommended the monitoring of transaminases and the control of the increase of cortisol and gonadotropins that it produces to avoid a possible repercussion in the growth and development of the adolescent. Naltrexone has been shown to be effective in this population and present good tolerability, as well as to significantly reduce the number of alcoholic beverages ingested and craving.

For the detoxification, benzodiazepines of long half-life are used. The use of anticonvulsants increasingly used in adults has not been shown to be effective in this population.

• Opioid consumption disorder: detoxification will be performed on hospital admission regimen.In our environment, the most commonly used drugs are agonists with a long half-life, mainly methadone. However, this practice in adolescents is not supported by any bibliographic reference unlike the use of buprenorphine, which allows its use (in medical record) after 15 years. This substance is currently presented in the form of a sublingual tablet associated with naloxone to prevent its use through inappropriate routes, since its introduction in Spain in 2007 its use is increasing. A greater efficacy of buprenorphine in the maintenance of abstinence and adherence to treatment is observed (15), it was also shown that a longer duration of treatment was associated with better long-term results in relation to abstinence and adherence. Regarding detoxification, studies are scarce, although the lines of recommendation are aimed at avoiding the use of drugs.

Follow-up visits should be frequent, especially if there is comorbid psychiatric disease. At each visit there should be a control of psychiatric symptoms, frequency of consumption (it is advisable to schedule periodic toxicological controls), social stressors, compliance with the medication and the appearance of possible adverse effects.

Patients with substance use disorder are more likely to have side effects to the medication because of the possible combination with the substances of abuse. In addition, the probable abuse of the prescribed treatment should be taken into account, which is why it is recommended to use drugs with the lowest addictive risk.

conclusion

Pediatricians should be well informed of the resources available to them to guide and refer patients who require it. The American Academy of Pediatrics offers practical criteria that indicate the possibility of treating adolescents in primary care or being referred to specialized centers.

The adolescent can be controlled in the primary care center if the use of drugs is done intermittently or experimentally. Provided that no significant psychopathology is appreciated or it is only an adjustment reaction. When he shows adequate development in his tasks and there is absence of antisocial behavior (Fig. 2).

Figure 2. Progression in the consumption of substances in adolescents.

It will be necessary to refer to a Specialized Service if the drug abuse is very significant, if there are associated psychopathological alterations, if there is a stagnation of the academic and social activities and due to the lack of experience or time of the Primary Care professional.

On the following website belonging to the National Plan on Drugs, we can find the location and telephone numbers of drug addiction centers distributed throughout the Spanish geography: www.pnsd.msc.es

Bibliography

The asterisks reflect the interest of the article in the author’s judgment.

1. PNSD. Ministry of Health and Social Policy. State Survey on the Use of Drugs in Secondary Education; 2010

2. Kalivas PW, Volkof ND. The neural basis of addiction: a pathology of motivation and choice. AM J Psychiatry. 2005; 162 (8): 1403-13.

3. Churchwell JC, Carey PD, Ferrett HL. Abnormal striatal circuitry and intensified novelty seeking among adolescents who abuse methamphetamine and cannabis. Dev Neurosci. 2012; 34 (4): 310-7.

4. *** Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability. Am J Psychiatry. 2003; 160: 1041-52.

5. *** Pérez de los Coobos Peris J. Dual Disorders: addictions related to mental disorders in childhood or adolescence. A challenge of assistance and prevention. Ars Medica Group; 2008

6. Dieker LC, Vesel F, Sledjeski EM, et al. Testing the dual pathway hypothesis for substance use in adolescence and young adulthood. Drug Alcohol Depend. 2007; 87: 83-93.

7. ** Burnett-Zeigler I, Walter MA, Ilger M, et al. Prevalence and correlate of mental health problems and treatment among adolescents seen in primary care. J Adolesc Health. 2012; 50 (6): 559-64.

8. Vidal-Infer A, Arenas MC, Daza-Losada M. High novelty seeking predicts grater sensitivity to the conditional rewarding effects of cocaine. Pharmacol Biochem Behav. 2012; 102 (1): 124-32.

9. American Psychiatric Association. DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders.Barcelona: Masson; 2003

10. Bobes J. Addictive and drug-related disorders: Draft DSM-V. Seminars of Sociodrogalcohol XXXVII.

11. Hayatbakhsh R, GM Williams, Bor W. Early childhood predictors of age of initation to use cannabis: a birth prospective study. Drug Alcohol Rev. 2012; 14, in press.

12. Fernández-Artandi S, Fernández-Hermida JR, García-Cueto E. Adaptation and validation in Spanish of Adolescecent-cannabis problems Questionary (CPQ-A). Addictions 2012; 24 (1): 41-9.

13. Evers KE, Paiva AL, Johnson JL, et al. Results of Transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools. Addict Behav. 2012; 37 (9): 1009-18.

14. ** George E, Woody MD, Sabrina A, et al. Extended vs Short-term Buprenorphine-Naloxone for treatment of opioid-Addicted Youth. A randomized Trial. JAMA 2008; 300 (17): 2003-11.

15. Deas D, May MP, Randall C, et al. Naltrexone treatment of adolescent alcoholic: an open-label pilot study. J Child Adolesc Psychopharmacol. 2005; 15 (5): 723-8.

Recommended bibliography

– Stager MM. Substance abuse. In Kliegman RM, Behrman RE, Jenson HB, Staton BF. Eds: Nelson Textbook of Pediatrics. 19th ed, Philadelphia, Pa: Saunders Elsevier; 2011: chap 108.

It is a good textbook of pediatrics, in which the addictions chapter collects the epidemiology, types of drugs and therapeutic approach in a clear and concise way.

– Ramos Atance JA. Psychiatric aspects of cannabis use. Madrileña Research Network on cannabis. Spanish Society of Cannabinoid Research. Department of Biochemistry of the UCM; 2007

In-depth study on all aspects of cannabis: studies in experimental, genetic and clinical animals and the various psychiatric pathologies to which it is associated. The volume of clinical cases commented continues. Free in PDF.

– Principles of Drug Addiction treatment: A Research Based Guide (Second edition). National Institute of Drug Abuse. US Department of Health and Human Service. NIH Publication, No. 09-4180. Revised April 2009.

Simple guide that serves as a first approach to the topic of addictions created by the paradigmatic American institution dedicated to drugs of abuse.

Clinical case

Anamnesis

Reason for consultation: a 19-year-old patient who comes to the drug dependency center accompanied by the parents for presenting a disorder due to cannabis dependence and having required 2 psychiatric admissions.

History of the disease: the patient begins the use of marijuana at 15 years of age and since the age of 17 meets criteria of dependence with daily consumption of 4-5 joints; He has twice tasted hallucinogenic mushrooms; Alcohol consumption in a social environment without criteria of abuse and dependence on smoking since the age of 17.

Contributes reports of psychiatric admission 16 months ago with the diagnosis at discharge of psychotic episode probably induced by drugs (cannabis) with symptoms of great restlessness, dysphoria, challenging attitude and no awareness of disease.

6 months ago it requires new admission for urgency in this case for symptoms compatible with manic episode again probably induced by cannabis and that was characterized by significant dysphoria, pressure to speech, acceleration of thought and ideas of megaloid type, in some cases clearly delirious. At the beginning it presented temporary disorientation. Plaintive, inadequate and manipulative attitude with problems to reconcile and maintain sleep and that required mechanical containment on several occasions. As the chart is being remitted, the patient is allowed to leave the weekend where the patient escapes from home, consuming cannabis again and presenting serious alterations in behavior, being remitted to the hospital by 112 and requiring high doses of psychotropic drugs to achieve the improvement of the table and specifying for it a month and a half of hospital admission.

Your treatment at discharge is: Risperidone Consta 37. 5 mg: 1 ampoule / 14 days, olanzapine 7.5: 1-0-0, olanzapine 10: 0-0-1, valproic acid chrono 500: 0-0-2 , biperiden 2: 1-0-0 and clonazepam 0.5: 1-1-2.

Personal history

Physicians: annual inguinal hernia surgery.

Psychiatric: admission in 2010 with diagnosis at discharge of cannabis-induced psychosis. Admission in 2011 with diagnosis of manic episode induced by cannabis.

Diagnostic suspicions of ADHD at various times during its development. Sporadic contacts with private psychiatrists since adolescence due to behavioral alterations with physical and verbal heteroagressivity, especially in the family environment. The family describes him as restless, capricious, manipulative, with little tolerance for frustration.

Family background

Mother great grandmother deceased by suicide. Maternal grandmother diagnosed with recurrent depressive disorder in psychopharmacological treatment with several suicide attempts. Maternal aunt diagnosed with bipolar disorder and prima with borderline personality traits.

Exploration

When he goes to the center the patient shows a restless, capricious attitude, with a tendency to manipulation and verbal aggression, little tolerance to frustration and impulsiveness. It presents mild affective dullness and psychomotor slowing with a tendency to drowsiness and has gained 10 kg since the last admission. No psychotic or manifest symptomatology was observed. No awareness of their addictive problems, admitting only that “it has been possible to spend a little in recent months” and no awareness of their psychiatric problem. In the appointments it is scarcely collaborative, going to them exclusively when it is brought by the parents.

Supplementary tests

Blood and urine tests: normal. Thyroid hormones: normal.

The MCMI-III and HTP tests are applied. Results MCMI-III: Axis II no significant scales, but high score in T. antisocial (Pt = 72). In Axis I, significant scores on the anxiety scale (Pt = 75), alcohol consumption (Pt = 75) and substance use (Pt = 77).HTP results: excessively simplified drawings, typical of a defensive posture, so it is difficult to draw conclusions. Even so, indicators of difficulties in the expression and emotional communication are appreciated. Like high distrust of others and difficulties in establishing links.

Diagnosis

Axis I. Cannabis dependence. In early partial remission (ICD 10, F12).

Manic episode induced by cannabis (ICD 10, F12.55). Provisional V / S bipolar disorder.

Axis II. Impulsive and antisocial personality traits.

Evolution

Its evolution is marked by the limited awareness of the problem it presents and by its personality traits that make it difficult to create a therapeutic relationship that allows working on its problems. In the appointments he presents a challenging and defiant attitude, without getting involved in them. He comes only when the mother brings him to the center for urine tests and his only interest is in withdrawing the medication because of the side effects that cause him and that prevent him from focusing on the studies. The limits necessary for the patient are worked with the parents and the prizes are a consequence of being abstinent. Maintains abstinence at a general level, with punctual consumption whenever you are allowed to leave the weekend. The medication is gradually withdrawn until its suspension after 11 months of treatment. During the withdrawal he has not presented either psychotic or manic symptoms, being exclusively slightly more impulsive and irritable. Once the medication is withdrawn and the studies approved, he refuses to return to the center, abandoning the treatment.

Discussion

We are faced with a patient paradigm of dual pathology and, therefore, with a complicated diagnosis, prognosis and treatment. In the first place, his age makes it difficult for us to make a diagnosis of personality disorder, but his traits are having a very negative influence on the evolution and treatment of his other pathologies: dependence and psychotic symptoms. Likewise, that the manic episode occurs in the context of cannabis use, makes it difficult to diagnose bipolar disorder but, taking into account the family history of affective disorders and the sensitivity of presenting psychotic symptoms before minimum consumption, we must be on our guard and be able to be with the patient in follow-up before the probability of presenting a bipolar disorder. Therefore, our definitive diagnosis should be deferred and will depend on the evolution of the patient, we maintain the diagnosis of induced disorder that has a better prognosis for the patient and we try to study it in sustained abstinence.

From the studies of Regiers et al. in 1990 we know that cannabis is the most commonly used illegal drug among patients with mental disorders. Baetghe et al (1) and Strakowki et al (2) add that cannabis is the most used drug in patients affected by bipolar disorder. The data obtained in several studies indicate that the use of cannabis in adolescents presents a robust association with bipolar disorders, especially in the form of manic symptoms, although these are of moderate intensity and / or with a dysphoria component. In mania, cannabis worsens the clinical picture in severity, the need for hospitalization, frequency and length of episodes (3).

At present, no data are available to indicate the presence of a common genetic basis, although it does have a neurobiological basis, as Wilens (4) indicates in his studies.

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