December 13, 2011

Turning the tide of youth addiction

A renowned doctor and scholar takes a look at a growing national threat and offers solutions 

By Joseph Shrand
The ocean can be relentless, eroding beaches and threatening the homes built upon its shores and cliffs. We’ve learned that we cannot fight nature; we have to work with it. The same may be said for adolescents and addiction: We have to understand the developing brain to first recognize why drug and alcohol use is so prevalent and dangerous in this age group, then design an approach that turns that knowledge to our favor.
Current Trends
So where and how powerful are the tides of teen drug use in America today? The trends are followed by the Monitoring the Future Study (MTF), which has been tracking kids since 1975 and exploring the “behaviors, attitudes and values of American secondary school students, college students and young adults.” Nearly one million kids in 8th, 10th and 12th grades have filled out the MTF survey, or about 18,000 a year across the country—numbers large enough to suggest a trend in the use of drugs among these populations.
The 2010 data is mixed. The use of some drugs and alcohol are on the rise, others remain steady and some such as tobacco is decreasing. But in general, kids today are using more now than in 2009, skewed in part by the rise in marijuana and prescription drug use.
Although fewer than two out of every 100 kids smoke weed daily (6.1 percent), this is the highest level of marijuana use since the early 1980s. The trend is steadily increasing in 8th graders and has incrementally increased since 2007. Why? As long as kids perceive pot as a safe and benign drug, they will continue to use it. In fact, among 12th graders, fewer kids smoked cigarettes in the past 30 days than smoked weed. The current perception of the safety of marijuana is increasing, foreshadowing that the use will likely increase.
After marijuana, prescription and over-the-counter medications account for most of the top drugs abused by 12th graders in the past year. The perception seems to be, if it’s in the medicine cabinet and if Auntie Jane and Uncle Harry take it, how dangerous can it be?
Many kids are now abusing Percocet, taking it orally, snorting it, smoking it or shooting it up. Although some kids may have gotten hooked through prescription use and pain management, most first smoked weed, then wanted the more intense high Percocet offered. The availability of Percocet, coupled with its highly addictive buzz, has made this a very dangerous drug. 
The use of drugs such as Ecstasy had gone down for many years when kids perceived it as dangerous. “Doesn’t it put holes in your head?” a lot of kids used to ask. But as that trend changed, so did the use. Among 8th graders, the lifetime use increased from 2.2 to 3.3 percent. And although alcohol use has continued to decline among high school seniors, an alarmingly high percentage still imbibes (71 percent of 12th graders in 2010).
The latest news from The National Center on Addiction and Substance Abuse (CASA) at Columbia University in New York about teenage drug and alcohol use is not good. One in four Americans who began using any addictive substance before 18 are addicted, compared with one in 25 Americans who started using at age 21 or older. The CASA report found that 10 million high school students—75 percent of the total—have used addictive substances including tobacco, alcohol, marijuana or cocaine; and 20 percent of them meet the medical criteria for addiction. In fact, CASA is dubbing adolescent substance abuse as the No.1 public health problem in the United States.
Understanding the Teenage Brain
In general, there are three things a teenager wants: to feel pleasure, to take risks and to be social. These three desires, combined with a brain that is more impulsive and driven by emotions rather than forethought and reflection, is an unfortunate set up for drug use.
The brain matures in such a way that, for a period of time when we are in our teens, our impulses and feelings often overwhelm the part of our brain responsible for making decisions. The adolescent is at sea in this limbic ocean of emotion, with the compass of cortical control struggling to navigate a course to safe harbor.
Tim Wilens, associate professor of psychiatry at Harvard Medical School, has been studying substance use in adolescents for many years along with a team of others at Massachusetts General Hospital. Wilens has been analyzing data from a long-term study of adolescents with bipolar disorder and a matched set of non-mood disordered youth. The findings are consistent with what we now know about the developing teenage brain: Emotional instability leads to a higher likelihood of substance use disorder.
“I am struck by the high rates of cigarette smoking and substance use disorders in this group that appears to be directly related to deficits in emotional regulation,” says Wilens. “It should not be surprising then, when reviewing the neurobiology of brain development, [that] a dissymmetry seems to exist between the prefrontal regions of the brain and the emotional/limbic centers of the brain. Thus, youth use substances to blunt intolerable affects or enhance pleasure or reward without a balanced oversight function of the frontal areas.”
In short, the adolescent brain has an emotional and impulse center that is more mature than the rational thinking center, a developmental phenomenon that reveals why some teens do what they do and why adults scratch their heads in wonder. Limbic logic rules over cortical control.
An amazing illustration of this limbic logic was demonstrated by a 16-year-old girl who had overdosed on a concoction of various prescription drugs. Caught with the pills in school, she sat in the waiting room of the principal. She was about to get in serious trouble. “I started to think if I got caught with drugs on school property, especially like a baggie full that looked like I was trying to sell the stuff, I was going to get expelled,” she said. “There goes college! So I started to get a little panicked.”
Here is a perfect example of a brain caught in the developmental turmoil in which impulses emerge before a well-formed thought. Unbelievably, the young lady flushed all those pills down her esophagus instead of, say, a nearby toilet.
Despite their growing ability to abstract, to write poetry, to explore the nuance of American History or to learn a language, adolescent brains are still all about here and now. That young woman didn’t want to get in trouble now, even though taking all those pills could have killed her. 
Turning the Tide 
The good news is there are ways to turn the tide of youth addiction so that fewer kids use drugs and those that do are effectively treated. In addition to ramped up prevention and education efforts, there also needs to be appropriate modeling and treatment opportunities in place for adolescents and their families.
Prevention & Education


Perception drives substance use. For example, kids have learned that cigarettes are dangerous. Through concerted effort of public health programs, the lifetime use of tobacco has gone from 75 percent of kids having tried a cigarette in 1976 to 42 percent in 2010. And only 4.7 percent of the 12th grade class of 2010 smoked more than half a pack per day, compared to 19.2 percent in 1976.

When perceived as harmful or viewed with disapproval by peers, a drug is less likely to be used by an individual kid. Kids broadly disapprove of heroin and crack cocaine. Marijuana has a high approval rating, seen as relatively safe. There is an important message in the public education of tobacco use.
The difficulty that teenagers have in appreciating the long-term impact of the substances they are now putting into their bodies remains a function of their developing prefrontal cortex. But the decrease in cigarette smoking following intense public education efforts indicates that teens can and will get the message.
Such educational measures must be applied for a more widespread understanding of the devastation caused by other drugs. Kids today recognize weed as a harmless drug. But it is more than psychologically addictive and has earned its reputation as a gateway drug due to its effects on brain function that leads to use of stronger substances.
As adults, we enjoy the ability to curtail our knee-jerk limbic logic with an appreciation of consequences. We must model this mindfulness and cortical control, helping our kids understand the dilemma they face through no fault of their own but simply as a result of evolution. Indeed, it is how we perceive and treat our kids that will ultimately teach them how to navigate the currents and not be drawn down into the whirlpool of addiction. We can’t change nature, but we can be the influence that helps our kids learn to enjoy the waters safely.
Treating our Youth
There are a number of options for treating adolescent addiction, ranging from intensive settings where a teen can stay for months, to infrequent visits with an outpatient provider and support groups (see “Four Approaches That Work”).
Ultimately, any approach we design to treat youth addiction and facilitate long-term recovery should be informed by the recognition of how our brains evolved and their amazing relationship with the world around us. With this in mind, we can design programs that help to exercise the adolescent brain, especially the prefrontal cortex.
We must also recognize that we all want to feel valuable to someone else. This desire for social connectedness can actually perpetuate addiction, as drugs create an artificial shortcut to what appears to be affiliation.
Fortunately, the desire to be connected is also a golden gate to sobriety. When all is said and done, changing the way we treat one another may have the ultimate impact on changing the course of this devastating tide. 
The Imax Approach
I have created an approach to treatment that harnesses the human desire to feel valuable and the simple fact that the human brain does not activate anger when it feels respected. Called the Imax Approach, this philosophy is influenced by theories of attachment and theory of mind (the human interest in what other people are thinking and feeling) and stems from the belief that every person is doing the best they can at this moment in time. No one chooses to do worse than his best.
Four domains influence the Imax:
  • the home environment;
  • the social environment;
  • how you see yourself, how you think others see you, how you see others and how you want to be seen;
  • and the integration of your biology at this moment in time, your brain and your body.
These four domains interact fluidly with each, all the time, to impact the Imax. As the Imax changes, it affects the choices you make in the domains. Recognizing that substance abuse does not happen in a vacuum, the Imax looks at these four domains that continuously interact and influence who we are and what we do: the home and social environments, our self-concept and our biology.
The novel aspect of Imax is the idea that, in response to these influences, we are always doing the best we can. Using the Imax Approach, we rekindle our teens’ sense of value by seeing them as doing the best they can, while holding them responsible and accountable for every action. We don’t like that they do drugs and alcohol, and we don’t condone it, but we respect that given the influences on their lives, at this moment in time, this is the best they can do.
When you truly see someone as doing the best they can, amazing things can happen. The Imax Approach moves us from the world of prejudice and judgment to the interconnected world of wonder and of respect. These are the keys to the future of treatment: capitalizing on the deep human desire to feel valuable to another human being, to feel proud and accomplished. To be recognized as contributing to society. To be the recipient of gratitude. To simply feel valued by another human being.
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