SUBSTANCE ABUSE AND TALKING WITH TEENS ABOUT SEX
From the Annual Review in Family Medicine, presented February 4-6, 2007, by the University of California, San
Francisco, School of Medicine
| SUBSTANCE ABUSE: STREET DRUGS, CLUB DRUGS, AND BURNING MAN —Karl A. Sporer, MD, Clinical
Professor of Medicine, University of California, San Francisco, School of Medicine
|
| Heroin-related problems in San Francisco: ≈15,000 injection drug users; black tar heroin—transported from
Mexico; gummy; not well processed or purified; easily accessible; in New York City, heroin transported from Colombia
and more purified; soft tissue infection number 1 reason for admission to San Francisco General Hospital
(SFGH; clinic and programs implemented to manage problem; hospital-based needle exchange program found ineffective);
overdose—250 deaths at SFGH in 1995 (more deaths from heroin overdoses than from car accidents,
gunshot wounds, and stabbings combined); opiate substitution treatment with methadone shown to diminish overdose
death rates; ≈5 botulism cases per week (injection drug user presents with weakness and inability to lift head;
cranial nerve palsy); patient unconscious with pinpoint pupils and respiratory depression (patient blue; diagnostic
accuracy ≈98%); naloxone (Narcan)—use only if patient blue; seizure rate 2% to 4%; asystole rate 1 in 500; behavioral
issues in 30%; slower absorption and less likelihood of behavioral problems with intranasal delivery
|
| Pharmacokinetics of heroin overdose: heroin highly lipophilic; entire dose enters brain and quickly metabolized
into 6-monoacetylmorphine; potent; rapid “rush” and respiratory compromise
|
| Overdose prevention: street users report overdosing once every 6 mo, and report witnessing overdose every 6 wk;
mortality rate 10% when overdosing user cared for him- or herself (eg, packed in ice); user in dying process for
several hours (usually at home with other people present); education—educate about vulnerable times (eg, after
treatment or jail); responsibility to peers who turn blue; calling 911; even 15 min of peer counseling (about, eg,
breathing, recovery, vulnerability) shown to disperse knowledge through community; educate about use of naloxone
at home; educate about postincarceration risk (2 wk postincarceration, risk for death from overdose increased
20 times); educate about recognition of overdose, mouth-to-mouth resuscitation, and what not to do; prescription
naloxone—intramuscular (IM) dose effective; withdrawal symptoms likely (call 911); effective duration for heroin
but not for other drugs (eg, oxycodone [OxyContin]); opiate substitution—methadone problematic (must be obtained
in clinic; inconvenient; stigma); buprenorphine maintenance may be used in office-based practice (8-hr class
with separate Drug Enforcement Administration [DEA] license required; 30-100 patients allowed); number of
deaths from overdose at SFGH decreasing from 250 to 90 per year
|
| Opiate analgesic abuse: oral opiate and analgesic addiction rates increasing; hydrocodone (Vicodin), acetaminophen
with codeine (Tylenol with Codeine), or OxyContin used by high school students; number of deaths increasing;
users often middle-class (including 70% of people using buprenorphine)
|
| Buprenorphine: partial agonist; tightly bound at mu receptor; heroin ineffective after taking buprenorphine; high
receptor affinity; agonist effect at low doses, antagonist effect at higher doses; safer drug for office-based practice;
used for maintenance or detoxification; can be used for 7-day painless withdrawal from opiates; patients tend to do
better with maintenance; no problems with overdose in San Francisco; if given to patient under influence of opiate,
partial agonist effect causes rapid withdrawal syndrome (exercise caution when starting course; patients must have
mild-to-moderate withdrawal syndrome); give analgesia for pain (eg, from broken clavicle or kidney stone)
|
| Club drugs: heroin epidemic waning, use of club drugs increasing; used on weekends, with recovery during Sunday;
users functional during week; heroin and cocaine users usually men, club drug users 50% women and 50%
men; users tend to be young, employed, students, and have place to live
|
| Ecstasy (3,4-methylenedioxymethamphetamine; MDMA): 30,000 to 40,000 users during weekend in San Francisco;
commonly used by college students; low-grade amphetamine-like drug; serotonin reuptake inhibitor; available
in tablets; shipped through Belgium (via airplane) by Russian and Israeli organized crime syndicates; 1 in 4 chance
that ecstasy purchased in San Francisco may be mixed with dextromethorphan; effects—energetic effect; sympathomimetic
effect; increased heart rate; enlarged pupils; diaphoretic effect; bruxism and dry mouth (users grind teeth
and often have pacifiers and lollipops at clubs); robust aesthetic senses (visuals and textures); “love drug”; users become
loquacious and affectionate; duration of effect 4 to 5 hr; sexual disinhibitor (but difficult to achieve erection
and orgasm; sildenafil [Viagra] or γ-hydroxybutyrate [GHB] often used adjunctively); multiple drug use common
with club drugs; severe adverse event occurs in 1 of every 20,000 uses; problems include hyponatremia, serotonin
syndrome, and auditory hallucinations; urine toxicity screening test positive for ≈48 hr after use; hyponatremia—
case 1) woman 22 yr of age at dance club falls with seizures; no history of seizure disorder; paramedics place
woman on spine board; glucose normal; Glasgow Coma Scale (GCS) 6 to 8 and improving; woman intubated and
admitted to hospital; computed tomography (CT) normal; sodium level 119 mEq/L; hyponatremic complications
distinctly predominant in women; patients improve with normal saline; case 2) girl 14 yr of age became confused after
taking 2 hits of ecstasy with friends at sleepover party; developed severe brain swelling, herniated, and died; uncommon
scenario; serotonin syndrome—agitation; confusion; hyperthermia; may result in death; long-term effects
on cognitive function and depression uncertain
|
| γ-hydroxybutyrate: 4-carbon molecule; similar to γ-aminobenzoic acid (GABA); neuroinhibitory transmitter; used
as sleep aid; effects—alcoholic high for 4 hr with no hangover; hypersexuality side effect; doubling dose results in
patient becoming profoundly comatose (GCS 3 with normal breathing); involved in high-profile sexual assault
cases; problems with addiction and withdrawal; use increasing; patients present with breathing and profound GCS
(intubate patient, perform CT, and admit to intensive care unit [ICU]); patients improve in ≈3 hr; high drug levels
in blood and urine
|
| Burning Man: speaker attended to research club drugs; “techno-pagan” festival in Black Rock Desert in Nevada; 2-
wk community gathering; ≈23,000 attendees build ephemeral art; highly organized, with dispatch center and complete
emergency services (eg, police and fire departments); ticket price includes camping spot; participants must
bring own water and food; no commercialism; 3 miles in diameter; ritual of burning man (effigy)
|
| TALKING WITH TEENS ABOUT SEX —Erica B. Monasterio, MN, FNP, Clinical Professor, Division of Adolescent
Medicine, Department of Pediatrics and Family Health Care Nursing, University of California, San Francisco,
School of Nursing
|
| Introduction: “my approach is not your approach”; be honest, sincere, interested, and willing to listen; adolescents
reluctant to disclose information when unsure of confidentiality; explain what confidentiality means in terms they
understand, and discuss situations where confidentiality may be breached
|
| Key points: assume nonjudgmental stance (eg, express concern and assess risk); use open-ended questions; ask specific
questions to delineate behaviors, risks, and strengths
|
| Confidentiality: communicate conditional confidentiality; clearly establish what patients have right to consent to,
what confidential services means, and in which situations what particular information might be communicated;
laws differ by states; convey message of “I have to report this in order to get you help that you may need” vs “I
have to report this because it’s the law”
|
| Sexual history: use language and intervention appropriate to patient’s level of sophistication and social and cognitive
developmental stage; engage in conversation before taking sexual history; give warning before discussing sexual
issues (eg, “we’re moving into that confidential area now”); inform patient questions must be asked for health
reasons; give permission to not answer certain questions (eg, about sexual abuse), and be available when patient
ready to talk; avoid making assumptions; include questions that are inclusive of youth who have same-sex sexual
orientation or behaviors; give patients time and space to talk and to ask questions; younger adolescents often do not
respond well to open-ended questions (eg, may shrug or nod; be more directive if needed); thank patients for asking
questions and show appreciation for willingness to share information; asking about friends depends on environment
and patient population; normalizing behaviors helpful (eg, “many young people masturbate, do you have any
questions about that?”); look for and acknowledge nonverbal indicators of discomfort (eg, “do you need me to
move on?”); integrate education and prevention messages into assessment process; respond to risks; use educational
aids and keep them handy; use materials that youth can relate to
|
| Opening questions: develop sense of teenager’s place in sexuality continuum; “have you ever had a crush on anybody?”;
“have you, or are you in, a serious relationship?”; ask what “serious relationship” means to patient; “are
you attracted to guys, girls, or both?”; “have you ever had sex?” (if answer yes, ask “what is it that you have
done?”); be explicit to assess risk; “how old were you the first time you had sex?”; early sexual debut red flag for
history of childhood sexual abuse; adverse outcomes (eg, multiple partners, sexually transmitted infections [STIs],
unplanned pregnancies) related to early sexual debut; “do you have sex with guys, girls, or both?”; sexual orientation
(attraction) and sexual behaviors not same thing (consider, eg, men having sex with men for money; tailor intervention
accordingly); determine intentions about sex and tailor intervention accordingly; sexual abuse and
assault—“has anyone ever touched you in a way that made you feel uncomfortable? or forced you to have sex?”;
“have you ever had sex unwillingly or when you didn’t want to?” (if yes, help empower individuals to say no); explore
nature of relationships and communication with partners; couples who communicate less likely to engage in
risky sexual behavior; “how do you feel about your sexual life?”; determine whether adolescent has adult (eg, parent)
to turn to about sexual issues; ask about number of partners in life to determine risk for STIs and number of partners
in last 3 mo to determine sexual patterns; ask about contraception; “have you ever been pregnant/gotten
someone pregnant?” (ask about outcome); ask about sexually transmitted diseases (STDs), treatment, and partners;
ask about “survival sex” (ie, trading sex for money, drugs, or place to stay)
|
| Responses that indicate strength: intent to abstain from sexual intercourse until late adolescence or young adulthood;
not currently sexually active, or, alternately, using reliable approach to reduce risk for pregnancy and STIs;
sexual debut at ≥15 yr of age; presence of adult teen can talk with about sexual issues
|
| Responses that indicate risk: sexual debut at age ≤14 yr of age; history of sexual molestation, assault, or abuse;
engagement in unprotected sex; history of pregnancy, STI, or STD; talking solely with peers about sexual issues
|
| Lesbian, gay, bisexual, and transgender youth: respect youth’s right to confidentiality; no permission to disclose
if patient chooses to “come out”; encourage support system; be available when needed; do not push disclosure
when patient not ready; explore issues related to disclosure, support, and responses; determine whether
patient sexually active and explore specific behaviors; share reasons why culture or testing may be needed, but
do not make assumptions about patient; source of risk—risk not from sexual identity or orientation; epidemiology
and biologic vulnerability (eg, mucosal cells in anus, friability, higher rate of HIV among men who have sex
with men); social stigma and lack of support
|
 | Domains of risk: STD and HIV; pregnancy (discuss contraception; most adult lesbian women report having had
heterosexual sex [generally in adolescence]); risk for cervical and breast cancer due to barriers to access to routine
gynecologic care; mental health (prevalence of suicide); substance abuse with early polysubstance use; violence
and victimization in schools
|
| Making choices about interventions: determine whether patient needs intervention or support; determine whether
problem related to youth’s choices, provider’s discomfort with patient’s sexual orientation, family, school, or social
or community problem; tailor intervention accordingly; determine best person to intervene; consider comfort
and experience with gays and lesbians and knowledge of resources; teach young patient how to interact effectively
with health care system (empower youth to take responsibility to “work with” health care providers); involve
parents as much and as often as possible to reinforce health education and strengthen relationship with
patient; obtain permission when disclosing confidential information
|
Suggested Reading
Boothby LA et al: Buprenorphine for the treatment of opioid dependence. Am J Health Syst Pharm 64:266, 2007;
Burack R: Teenage sexual behaviour: attitudes towards and declared sexual activity. Br J Fam Plann 24:145, 1999;
Haignere CS et al: High-risk adolescents and female condoms: knowledge, attitudes, and use patterns. J Adolesc
Health 26:392, 2000; Kelly BC et al: Prevalence and predictors of club drug use among club-going young adults in
New York city. J Urban Health 83:884, 2006; Kowaleski-Jones L et al: Sex, contraception and childbearing
among high-risk youth: do different factors influence males and females? Fam Plann Perspect 30:163, 1998; Leigh
BC et al: Sexual behavior of American adolescents: results from a U.S. national survey. J Adolesc Health 15:117,
1994; Michaud PA et al: Alternative methods in the investigation of adolescents' sexual life. J Adolesc Health
25:84, 1999; Rosenson J et al: Patterns of ecstasy-associated hyponatremia in California. Ann Emerg Med 49:164,
2007; Shafer MA et al: Psychosocial and behavioral factors associated with risk of sexually transmitted diseases,
including human immunodeficiency virus infection, among urban high school students. J Pediatr 119:826, 1991;
Sieving R et al: Cognitive and behavioral predictors of sexually transmitted disease risk behavior among sexually
active adolescents. Arch Pediatr Adolesc Med 151:243, 1997; Sieving RE et al: Adolescent dual method use: relevant
attitudes, normative beliefs and self-efficacy. J Adolesc Health 40:275, 2007; e15-22. Epub 2007 Jan 24. Sporer
KA et al: Prescription naloxone: a novel approach to heroin overdose prevention. Ann Emerg Med 49:172, 2007;
Sporer KA: Acute heroin overdose. Ann Intern Med 130:584, 1999; Sporer KA: Strategies for preventing heroin
overdose. BMJ 326:442, 2003; Villarruel AM et al: Predictors of sexual intercourse and condom use intentions
among Spanish-dominant Latino youth: a test of the planned behavior theory. Nurs Res 53:172, 2004.
Educational Objectives
| The goal of this program is to prevent heroin overdose, increase awareness of the rising use of club drugs, and improve
approaches to talking with teens about sexual behavior. After hearing and assimilating this program, the participant
will be better able to:
|
| 1. List components of an effective overdose prevention program.
|
| 2. Discuss appropriate uses of naloxone, methadone, and buprenorphine.
|
| 3. Recognize effects of club drugs, such as ecstasy and γ-hydroxybutyrate.
|
| 4. Evaluate teenage sexual behaviors, risks, and strengths by asking appropriate questions.
|
| 5. Choose the appropriate intervention for lesbian, gay, bisexual, and transgender youth at risk.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Sporer and Mrs. Monasterio spoke in San Francisco, CA, at the Annual Review in Family Medicine, presented
February 4-6, 2007, by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation
thanks the speakers and the University of California, San Francisco, School of Medicine, for their cooperation in
the production of this program.
|
