The physician continues to play a pivotal role in the struggle against drug abuse. It is unusual to find a physician, especially a pediatrician, who has not directly or indirectly been involved with a teenager who is using or abusing an illicit drug. This is despite the fact that a number of specialized professionals, allied health workers and lay counselors are now available with an expertise which often exceeds that of the physician. This central role of the physician is a consequence of the unique position that he occupies in the helping hierarchy. It is the physician who is usually consulted for primary evaluation and who is trusted with confidential family information. Through his longitudinal involvement, he is often aware of the intricacies of the interrelating developmental events of his teenage patients' growth. The physician is also involved with the teenager at the time of crises resulting from accidental or voluntary self-destructive behaviors. Physicians, then, despite the demands of their primary specialty and busy schedules, need to continue to maintain awareness of drug abuse issues. Of particular importance are the issues of prevention, causality, toxicological crises, evaluation and management protocols and referral resources. This issue of Pediatric Annals provides a topical review of several areas of substance abuse which allow the pediatrician or generalist physician to better serve the drug abusing adolescent and his or her family. The contributions have been selected to provide perspective and update knowledge in several aspects of licit and illicit drug use by teenagers and young adults. Although by no means comprehensive, each article will stimulate further thought and questions.
Early in the 1960s, a phenomena of contemporary adolescents confronted the generalist physician. This phenomena was characterized by the haphazard exploration of a number of psychoactive substances of both licit and illicit origin. Behavioral states resulting from the use of these ''street drugs" were further complicated by the medical profession's ignorance about their chemical nature, the multiple impurities present due to illicit manufacture, the variability of dose and the street practice of "polypharmacy." The resultant human catastrophes often presented to emergency rooms of hospitals for crisis management of the toxic state. In response, the medical community developed educational programs to update the physician in "street pharmacology." Schools, churches and youth-related social agencies organized prevention-oriented education programs. Storefront, crisis and free clinics evolved as an alternative to traditional medicine. Innovative treatment programs were created often outside the mainstream of the traditional, helping professions. The medical profession, perceived as a legitimized drug dealer, developed a cautious attitude toward the use of prescribed psychoactive agents in all segments of the population, not only adolescents and young adults. Illegal production and importation increased to meet the demand. Choice of drugs changed, prices became inflated and the notion of drug user, doper or other colloquial label became an acceptable social identity among young people.
Although the media has popularized adolescents as the dominant drug using population, adults continue to demonstrate significant prevalence of drug use. If alcohol, tobacco, and abuse of prescribed tranquilizers, sedatives and stimulants are included, the over 25-yearold age group dominates.1 This group provides the modeling lor social lifestyles, stress behaviors, attitudes and beliefs for developing young people. The adolescent and young adult as a substantial consumer of social and recreational goods in the marketplace, becomes a direct and indirect target of corporate interest. Although not promoting a specific illicit product, a me ta- message develops - living better through chemistry - the use of behavior altering substances, including alcohol, as recreational vehicles.
Viewed lrom the perspective of psychobiological development, adolescence represents one of the last chances for integrated education. This view proposes that integration of factual material into life belief and value systems is at a maximum when individual change rates are also maximum. A parallel situation exists with the fetus during the organ anläge stage when it is most sensitive to teratogenesis from the intrauterine, maternal and environmental influences. Nurturance, healthy internal and external ecology, and preventative education form the essence of pediatrie and obstetrical care for healthy fetal growth and outcome. Adolescence is not dissimilar in many respects. The gestation is biopsy chosocial, -the growth rates rapid, and the milieu consists of the family, school, peer group, etc. This last great burst of growth energy provides the substrate for integrative education, which can best be done within the developmental fabric of the adolescent experience.
Early efforts by health professionals were aimed at identification of substance abusers in crisis with dysphoric behavioral reactions or life-threatening physical consequences. Immediate efforts were made to identify the pharmacology of the illicit drugs, to understand motivations for use, and to develop toxicological protocols for intervention. This information-seeking behavior on the part of professionals was paralleled by concomitant, erratic, drug-seeking behavior on the part of adolescents. It was during the 70s that professionals, parents, and teenagers began to catch up with each other and develop some rational approaches to drug use and abuse. It became clear that intervention and management programs were most effective when applied within the contextual fabric of adolescent and family development. Inasmuch as change is inevitable within both, the skilled clinician may influence the direction of this change.
Adolescence, as a process of individual and social change, contributes to the vulnerability of this subgroup of the population. The drugs favored by teenagers are those which are euphorogenic, reality avoiding, mind expanding, and experience enhancing. These properties, considered within the context of adolescent development, enhance the probability of a pharmaco-biologic symbiosis. The family, often redefined and stressed, no longer can mediate the adolescent's social experience. Media, music and a society of paradoxical messages and circumstance, shape the adolescent experience. The adolescent, often confused and yet developm en tally driven, adopts in-and-out-of control behaviors to individuate, relate and emancipate.
Recent trends in drug use by high school seniors have been well documented by the University of Michigan's Institute for Social Research.2 This study reports the current prevalence of drug use among American high school seniors and trends in use since 1979. Of significance in their 1980 survey was a sharp drop in regular cigarette smoking by American young people. This decline was significant for both males and females. A decrease in daily marijuana use was also noted along with less significant drops in annual and monthly marijuana use. The use of PCP declined markedly along with a slight decrease in the use of inhalants such as amyl and butyl nitrites. Stimulants however, continue to show a steady upward rise in abuse, most notably among females. Overall, the proportion of seniors using some illicit drug other than marijuana continued to rise.
With nearly two thirds of high school seniors surveyed having used an illicit drug, the need for additional answers as to etiology, is apparent. Is the use of drugs by certain adolescents dependent upon specific personality correlates within that individual? The studies in this area have been somewhat conflicting, and the correlation may be more dependent upon methodology, than upon the presence or absence of the personality variables themselves. Some investigators have found a larger number of emotionally disturbed adolescents in the drug abusing population3 while other studies do not confirm this.4'5 The latter studies could not find any psychological characteristics specific to drug use. Clinicians working with adolescents are well aware of the fluidity of personality variables among young people and the strong influence of the peer group on behavior. In fact, studies done in this area show that drug abuse by the immediate peer group strongly increases the likelihood of initiation of drug use, especially marijuana, by any non-drug using teenager joining that group.6'7 One study indicates that drug use by close friends is the single most significant contributing factor in initiating drug use in an individual teenager (peer pressure).8
A number of studies of family stability and use of medications have provided some interesting data. The use of medication and drugs by parents, especially during times of emotional crisis, encourages the adolescent's modeling of that parental pattern of stress response.' Street et al,10 have suggested that a correlation exists between adolescent drug use and a teenager's negative perception of the family. Other studies have identified a number of factors such as lack of family cohesion, breakup of family units, and continued non-resolved family problems as contributants to the development of patterned drug abuse among adolescents and young adults. 11
Viewed from the paradigm of social psychology, the developmental tasks of adolescents have become increasingly complex. This has largely been due to the changing technology within society and the unavailability of roles and occupations for young people moving from the educational tract to the job market. Today's teenager and young adult, within the continuously constricting employment market, cannot always make a smooth transition from being a successful student, to experiencing success in establishing a work identity. Employment or vocation, which provides an adequate income, strongly influences an individual's ability to assume individual, social and family responsibility. Independence and responsibility are basic characteristics of mature functioning in Western society. Thus, new definitions and markers of maturity (adulthood?) are evolving in response to limited employment opportunities, which increasingly emphasize avocational and leisure time activities. Social change, as history has shown, has its greatest impact on those who have the least sense of identity or definition within that society. In Western culture, that is the adolescent.
Contributants to the initiation or perpetuation of drug abuse by adolescents is dependent upon these social factors. With the prolongation of the educational process comes a feeling of boredom and generalized alienation. Confrontation with the successful dominant members in society often produces a sense of powerlessness. This sense of powerlessness often leads the adolescent to "power-tripping" in a variety of ways, both acceptable and unacceptable. Gangs, like athletic team membership, provide a sense of belonging, identity and power. Weapons, like the pen, may grant a sense of control and power over a system which, by its complexity, promotes impotence. Drugs lessen the discomfort of the anomìe and facilitate the search for the inner identity - the opportunity to re-create.
Viewed from the biopsychosociaJ vantage point, there is no doubt that the texture of the teenage years has markedly changed from those experienced by the average physician. The physician's own adolescent experience, although generally similar, was acted out mainly within the educational system, with success and subsequent identity. It is this generic, developmental struggle, which, if understood by the physician, will be most helpful in understanding teenagers. The stresses of developmental change are experienced within a changed reality for the majority of today's teenagers. Reality is characterized often by a nonsupportive or divided family unit which has limited time for nurturance of its members. A changed reality represents the availability of somewhat constricted alternatives to recreation and pleasure-seeking activities. Reality is influenced by a markedly prolonged educational experience, and thus, the adolescent preparatory process. It is these and other factors which contribute to a felt experience by the adolescent of social anonymity and lack of value. The struggle for a sense of identity and purpose in past decades centered around issues of family and school. Within the sociocultucal environment, the search for identity largely centers around the social activities of the peer group and the age appropriate cultural norms promulgated by the profit motive of commercialism.
A number of influences, both conscious and unconscious, are involved in a young person's decision to use drugs. As a consequence, patterns of use vary from being strictly experimental or situational (recreational) to those characterized by compulsive drug-seeking behavior. Of utmost importance is the realization that adolescents and young adults do not use drugs to create problems either for themselves or for those who care about or for them. Adolescents do use drugs as solutions to incidental or chronic problems and situations. To focus attention only on drug-using behavior will rarely be successful. Drug use at best is faulty problem-solving and viewed developmentally may lead to psychological maturational arrest. Any attempt to change a drug use pattern in a teenager must also introduce the availability of alternative solutions to what can be best identified as the contributing, interrelating dynamics to that individual's use of drugs.
How can one best frame these concepts for easy and practical application? The use of a Venn diagram captures the multifactorial nature of drug abuse. The Venn diagram was originally conceived as a model to frame public health problems. The Venn diagram addresses the three primary issues of interrelating causality - the agent, the host (individual) and the environment (Figure 1). For the purposes of application to substance use and abuse, the agent is the licit or illicit drug, which in general, has the characteristics of euphoria, sedative disinhibition, or stimulation. The individual, of course, is the human organism going through a period of rapid biopsychosocial development. This individual within the context of our discussion is the teenager, adolescent, or young adult. The environment is comprised of all those factors, both experienced and imagined, which influence the adolescent during this period of rapid development. The most important of these factors are family, peer group, school, church, community organizations and media.
Viewed from this multifactorial paradigm, one can now work out the relative contributants to any individual drug abuse pattern in a young person. These contributants will vary the shape of the individual's problem (solution) as characterized by the flower resulting from the degree of overlap. The shape of the problem, so to speak, directs the development of intervention and management plans. This approach, clinically combined with good interviewing and counseling skills, has shown to be of great value and increases the physician's impact. The pharmacological information about drugs can be obtained from a number of literature sources. One always needs to verify that the behavioral outcome manifested by the individual is congruent with the alleged drug ingested.
Figure 1. Venn diagram.
Figure 2. Multifactorial paradigm.
The following case report demonstrates the use of the multifactorial paradigm and development of an integrated management plan by the pediatrician.
C. R., a 15-year-old male, was seen fora school athletic physical examination. He had been followed by his present pediatrician since the age of nine, when the family had moved from Chicago to Los Angeles. He had experienced excellent health in the interim, with only occasional respiratory infections correlating with viral epidemics in the community. He had developed good health habits, maintaining an above-average degree of physical activity and exercise.
During the course of the health assessment, the mother indicated that C. R. appeared to be losing interest in school and his grades were beginning to fail. Although concerned, both mother and father trusted in C.R.'s sense of responsibility and had not taken any action. The mother felt that the failing grades were probably due to his busy schedule and his recent interest in girls. When questioned further, she also related that C. R. was losing interest in church, where he previously had participated with enthusiasm and commitment.
In talking with C. R. alone, both during the historytaking and the physical examination, several things became apparent. Not only was his commitment to church waning, but also his participation in school athletics. After re-establishing the confidentiality of the doctor-patient relationship, he admitted to skipping classes as he felt that they were boring and no longer a challenge. In fact, two or three of his friends would do the same thing, buying a couple of beers and "partying."
Asked whether he had tried any other drugs besides beer, he admitted to the occasional use of marijuana and on one occasion sherms (a Sherman cigarette dipped in PCP). No dysphoric reactions had been experienced, except for occasional intense coughing with hemoptysis on deep inhalation of the smoke.
C.R.'s family consisted of mother (a predoctoral student in psychology), father (a physician), and a 19year-old sister, presently away from home attending a university. C. R. indicated that he and his mother did not really get along as well as they had previously. He felt that she was continually intruding into his affairs, overrestricting his freedom, and not trusting him. Dad continued to be busy with his practice, but complained that he didn't have enough time for his son. They used to jog together, but recently C. R. had lost interest in this. Instead he was jogging less frequently and going on longer runs alone.
The physical evaluation was normal, including a problem-oriented evaluation of his history of hemoptysis. Of concern to his pediatrician was the changing behavior, which viewed longitudinally was somewhat atypical for C.R. During the ensuing week, and before C.R.'s next appointment, the mother called in a panic. C.R. had been suspended from school for skipping classes and having marijuana in his possession.
C.R. is not at all an atypical presentation, but could have been easily missed if the pediatrician had not been developmentally aware and clinically astute. With the knowledge that the peer group plays ah important role for the 15-year-old, more information was elicited in this area. What values and attitudes were being communicated to C.R. by his friends? What new situations and experiences were being offered to help him in his individuation from family and parents? The answers are obvious in the above report but the dynamics not clear. Viewed from the multifactorial paradigm, two contribulants are suspect, both which are environmental influences (Figure 2).
The peer group is suspect, not only from developmental understanding, but also from the knowledge that drug use within the peer group is the single most important influence initiating drug use. The family is also suspect, as it appears to have become dysfunctional. The older sister has moved out of the house - changing dynamics with the mother focusing attention and control on C.R. The father is "married" to his profession, would like some separation from it which he hopes to accomplish through his relationship with his son. C.R., on the other hand, while having great respect for his dad, needs his separateness too.
After discussion with C. R. on the phone, he agreed to a family meeting at the next appointment. Assessment confirmed suspicions of the pediatrician, eliciting a history of marital discord, which had become more acute since the older sister moved out. It was clear after the family assessment that the patient was really the family unit and not C.R. An individual relationship, however, was important to help him through the crisis of change. The family was seen by the pediatrician for one-half hour sessions over the next six weeks with the focus on the parental and marital subsystems. As is often the case, C.R.'s behavior seemed to worsen initially. He began to stay out late at night and on one occasion did not come home. Subsequently, his behavior both at home and school changed and, although still drinking the occasional beer, he gave up the marijuana.
Although the inherent euphoric properties of marijuana are quite seductive to the teenager, C.R. did not appear to have any special need for them at that point in time. It could always be argued that in light of the experienced family tension due to marital discord, he was becoming depressed and withdrawn. Viewed from the dynamics of adolescent ecology, the interrelating, multifactorial causality is more complete and allows intervention at many levels. Although the identification of the family as the patient seems obvious in retrospect, it is often overlooked in prospect.
The individual contributants were those inherent to adolescent development itself and not to any psychopathology. C. R.'s maturational goal was indivia uation or gaining a separate sense of self. Mid-to-late adolescents have a need to emphasize their differences in relation to their parents. The cycle is often completed in the mid-tolate 30s, when we all have to learn to accept our similarities.
In this illustration, the physician felt competent in managing the problem. His awareness of the developmental issues and ability to treat the family system contributed to his competence. Having the longitudinal view of C. R. since the age of nine and the privilege of being his physician, provided a unique view of the problem. The presenting complaint was not that of drug use - but the request for a routine athletic physical. A systematic review of relevant issues raised some concern on the part of the physician. This by serendipity was confirmed, within the week, by the mother's phone call. If the latter had not occurred, it woukthave been judicious to have a family interview to better define the problem for which C. R. had developed a solution. If the physician had lacked the necessary family skills, he could have referred to the appropriate therapist, but with the attendant risk of non-compliance on the part of the identified patient or the family.
Not all drug abuse problems present with clear-cut etiological contributants or respond to the limited skills of the pediatrician. The physician then assumes the role of evaluator, advocate and case-manager. The following case report illustrates this situation.
M. T., a 16-year-old female, was originally seen by her private pediatrician at her mother's request. M. T. had been complaining of fatigue, toss of appetite, and had been generally irritable. She had actually assaulted her younger brother. A history taken by the pediatrician was suspiciously negative despite the presence of healed superficial abrasions on both wrists and clinical and laboratory evidence of hepatitis. He noted questionable "track-marks" in the left antecubital fossa. Although he had seen M. T. intermittently over the past five years for a number of well-child and problem-oriented visits, he felt that a bond of trust or mutual respect had never developed. At one point when she was 13 years old, he had noted her preoccupation with the morbid and grotesque. He had suggested a psychiatric/ psychologic evaluation, but the family had not followed through. Realizing his own limited professional resources, the pediatrician referred M. T. to the Division of Adolescent Medicine at Children's Hospital of Los Angeles for further evaluation and management.
Figure 3. Application of the multifactorial paradigm.
The initial interview was a difficult one, characterized by much hostility, silence and denial. Physical evaluation confirmed non-?, non-B hepatitis, without hyperbilirubinemia, and only mild enzyme elevation. The patient denied any IV drug use, admitted to occasional marijuana and alcohol use. A urine screen by TLC demonstrated the presence of diacetyl morphine and metabolites.
The physician was impressed by the strange appearance and affect of M. T., but attributed this to her involvement in the punk rock scene. She recently had dropped out of school against her parents' wishes and had immersed herself in electric guitar lessons. Her ambitions were to be a lead guitarist in a punk rock group.
Her family was of upper socioeconomic status. The mother was a homemaker and active in community projects, the father was a successful businessman. She had one sibling, an eight-year-old brother. During the initial family interview which M. T. refused to attend, the mother's concern for her daughter became very apparent. She expressed dissatisfaction with their relationship. Since she was a child, M. T. always seemed different and often acted in bizarre ways. Occasionally she would withdraw for long periods of time and have very little to do with her friends. No one in the family was aware of M.T.'s drug use or attempts at self-mutilation. The father, although concerned, felt that he had lost any control over his daughter's behavior and was ready to allow her to move out and live with a friend.
The physician realized at the end of the family interview that the problem needed more expert intervention than he was capable of providing.
He did see his role as advocate for M. T., despite her distrustful and hostile perception of him. Hecontinuedto see M. T. on a weekly basis, partly to follow up on her hepatitis and partly in the hope of establishing trust with her. His plan was to use the latter to refer her to a heroin detoxification program. Following this, expert psychiatric evaluation and intervention was indicated, particulady in light of the long history of bizarre behavior. Each clinical contact was limited to 30 minutes. Following a brief physical examination, the physician spent his time learning more about M.T.'s world and kept away from the highly charged area of drugs. Even when he had confronted her earlier with the positive urine drug screening, she had denied use and said that it must be a mistake.
Late one evening, the physician was called by M.T.'s friend and told that she was acting strangely. The friend admitted that M. T. had just shot up some heroin and was breathing rapidly. M. T. was seen in the emergency room and utilizing the crisis and his developed trust (M.T. had asked her friend to call him), resources were mobilized following her rapid response to naloxane. The physician had a brief meeting with M.T. and her family that evening. The following day, the family made arrangements for her to enter a methadone detoxification program. She was subsequently referred to a psychiatrist and continues to be drug free.
The complexity of this drug problem and the patient's solution is unusual. It illustrates the role of both pediatrician and ephebiatrician as evaluators and case managers. Each realized his professional limitations but utilized clinical experience and judgment to effect a transfer of M.T. to appropriate resources. Neither took the simplistic stance that it was up to the family and teenager to take responsibility to carry out their respective recommendations. The ultimate referral was made at a time of crisis, both for M.T. and her family. Utilizing this crisis energy, effective referral was made.
Applying the multifactorial paradigm (Figure 3), the important variables addressed by the pediatrician were those of the adolescent and the drug.
The environment was important, and assumed an even greater role as treatment progressed. The initial concerns were those of the bizarre behavior history of the teenager, which went beyond the usual developmental acting-out behaviors. There was strong suggestion of major psychiatric pathology requiring expert interpretation and intervention. Unless experienced, it is beyond the expertise of most physicians to manage a teenager who is physiologically addicted. Although the drug protocols are fairly straightforward, the necessary concomitant emotional and social support are often lacking. Withdrawal from any psychoactive drug incites behaviors, which even under the best of circumstances, are difficult to manage. Outside a controlled environment, the good intentions of an inexperienced physician become selfdefeating.
As treatment progressed, it was apparent that M.T. was a disturbed young woman. She was considered by the psychiatrist to be schizophrenic with paranoid features. Her use of heroin, to which she was introduced by one of her father's friends, provided a self-medication which eased the pain of her daily living. She developed relationships poorly, especially with those in authority, but blended well with the bizarre culture of the punk rockers. Although a certain risk was present in the judicious waiting period elected by the physician, earlier action had a high chance of non-compliance and probable flight from traditional help.
In conclusion, the adolescent as a drug user presents the physician with a dilemma. Rather than being presented with a problem - he is presented with a solution. It is usually the dominant culture which identifies drug use as a problem. The physician then, concomrtantly evaluates for physical consequence of the drug use, and the problem to match the dysfunctional solution developed by the adolescent. Etiologies, multifactorial and in a dynamic system of change, require evaluation of all components of that particular adolescent's developmental ecology. The Venn diagram may be used as a framework for analysis. Management must include the introduction of alternate solutions for the problem arising out of normative developmental crisis.
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