Co-Occurring Substance Abuse and Mental Illness In Adolescents

 There is a high rate of co-occurrence of mental illness and substance abuse. This paper will explore current trends of co-morbidity, focusing specifically on the co-morbidity of depression and opiate use, treatment recommendations, and what current research indicates for future treatment. Furthermore, this paper will investigate the origins and pharmacology of heroin and other opioids, the illicit drugs that are currently sweeping the nation and causing an overdose epidemic of critical proportions.

History of Heroin in the United States

There is evidence as long ago as 3000 BC that the opium poppy was cultivated for its active ingredients. Four naturally occurring alkaloids can be isolated from the opium poppy: morphine, codeine, papaverine, and thebaine. Chemists manipulated these chemical and were able to produce a range of semi-synthetic opioids, known today as dihydrocodeine, naloxone, and oxycodone. Synthetic derivatives, such as fentanyl and methadone, were developed during the twentieth century and increased the inventory of available analgesic medicines (Pathan & Williams, 2012).

The drugs in the opioid family are classified by their effects on opioid receptors and the type of receptors they interact with. Receptors are primarily found in the central nervous system, and to a lesser extent throughout the body. Opioids are classified as agonists, partial agonists, and antagonists. Agonists work with receptors to produce a maximum response from the receptor. Morphine is an agonist, and provides pain relief. Agonists continue to cause an effect as long as they are ingested; there is no maximum dose at which the receptor does not work with the substance (Pathan & Williams, 2012). Partial agonists, such as buprenorphine, bind to receptors, but cause only a partial response despite amount of the drug ingested. Partial agonists are effective for preventing withdrawal symptoms for addicts and do not produce a feeling of euphoria. Antagonists bind to receptors and prevent other agonists from binding. Antagonists, such as naloxone, produce no functional response but block the effects of agonists (Pathan & Williams, 2012).

Heroin is a derivative of morphine, an agonist in the opiate family. Heroin has no legal medicinal use in the U.S., and occasional and limited prescriptive use in the United Kingdom (MacLaren, n.d.). In 1897, heroin was first synthesized from morphine and found to be twice as strong as the original drug. Over time, heroin was marketed over the counter as a cough suppressant and pain reliever for painful respiratory illnesses. It was eventually used for pain in childbirth, injuries, and some mental disorders. Professionals soon noticed that patients needed increased dosages over time, and would often continue taking the drug after their illness had passed, suffering withdrawal symptoms when ceasing use. By the beginning of the twentieth century, heroin had become a serious societal problem. Use of the drug grew as it was included in many over the counter products and there were no regulations imposed upon its sale or use (MacLaren, n.d.). By 1924, opium importation was outlawed and restrictions and regulations were imposed on prescribers. It became illegal to prescribe heroin to known addicts. In 1970, Congress passed the Controlled Substance Act, consolidating a number of laws outlawing illicit drugs and imposing regulations based on the medicinal value, potential for harm and potential for addiction (MacLaren, n.d.).

Co-Morbidity of Drug Use and Mental Illness

Researchers have long studied the motivation behind drug use and the relationship between drug use and mental illness. Individuals with depressive disorders and substance abuse exhibit a mortality rate that is four times higher than average. Overdose is the most common cause of death, the chances of which increases two-fold with the presence of a depressive disorder (Bogdanowicz et al., 2015).

Recent neuroscience offers a unique view of the relationship between psychiatric disorders and substance abuse. Heroin use causes a blunted cortisol response. This indicates evidence of an altered neuroendocrine response to stress (Brady & Sinha, 2005). Research is consistent in that individuals with difficulty managing stress and emotional difficulty are more prone to substance use disorders. When the body is craving a drug, the feeling includes high levels of anxiety and stress, as well as a biological response that suggests an automatic connection between depressive symptoms and substance abuse disorders (Brady & Sinha, 2005).  Neuroendocrine and neuroimaging studies show specific dysregulation in the frontal limbic system. This area is associated with stress and reward pathways, both factors in depression and substance abuse disorders. This commonality may contribute to apparent relationship between depression and substance abuse. Neuroadaptations related to stress and reward pathways caused by substance abuse may influence a susceptibility to depression, substance abuse disorders, or both (Brady & Sinha, 2005). While scientists are investigating the relationship of neurobiological factors on substance abuse and mental illness, it remains clear that these are highly influenced by socioenvironmental factors.

Groups at Risk

The average adolescent opioid user is a white male, often from a family with low income, a history of parental or personal incarceration, exposure to familial drug use, a history of depression or anxiety, and parents with low involvement and presence in the adolescent’s life (Lipari & Hughes, 2015). Interpersonal violence such as sexual assault, physical assault, or a history of traumatic events during childhood contribute to symptoms of post-traumatic stress disorder. PTSD symptoms increase the likelihood of depression, other mental illness, and substance abuse (Kilpatrick et al., 2003). Teenagers often begin drug use with painkillers, either prescribed to themselves or obtained from others, and progress to heroin and fentanyl, which may be less expensive and easier to obtain (Lipari & Hughes, 2015). Although statistics for adolescents are significantly lower than those for adults, the numbers remain astounding. In 2013, the Substance Abuse and Mental Health Services Administration estimated that 10,000 children between the ages of 12-17 were dependent on heroin, and the numbers have increased substantially over the last four years. Adolescents may consider painkillers safer than illicit drugs and begin using them as a response to depression, bullying, or peer pressure. A great number of addicted teens do not seek help because they are afraid of the stigma attached to drug use. Some think or hope that the problem will resolve on its own, while other teens do not perceive a need for substance abuse help until the issue has escalated beyond their control (Wu, Blazer, Li, & Woody, 2011).

Those who struggle with depression seem to be more at risk to develop substance abuse disorders. Conversely, those with substance abuse disorders are at a higher risk of developing depression. Chronic stress seems to be the common denominator between the two. Co-morbidity increases in those addicted to or using illicit drugs, while symptoms of withdrawal overlap with symptoms of mental illness, confusing the issue further (Brady & Sinha, 2005). The distinction between symptoms of depression and substance use becomes blurry over time.

Screening, Societal Support, and Prevention

Prevention is the best course of action for children and adolescents, but is not always available. Many teenagers are at risk due to socioenvironmental factors and addressing these issues is imperative to preventing future drug use and addiction (Knopf, 2016). Teenagers who suffer from depression are at greater risk of experimenting with illicit substances. Knopf (2016) denotes that a mere 50% of children with mental illness receive any kind of treatment. Teens may use drugs or alcohol to manage anxiety, depression, and trauma. It is clear that teen well-being is central to the prevention of substance use.

Research has identified ten factors that statistically lead to higher adolescent resilience, health and wellness (Knopf, 2016). These include academic support, a strong stand against bullying in the community, and educational programs to address nicotine and alcohol prevention. Screening, intervention and referral to treatment, in particular, focusing on depression and prescription drug misuse, and appropriate funding for mental health services support teens in need. Laws preventing underage alcohol sales, the enacting of Good Samaritan laws, and sentencing reform also protect and support at-risk adolescents in the community (Knopf, 2016).

The American Academy of Pediatrics recommends that pediatricians engage in routine screening for substance abuse and depression, brief intervention and referral to treatment beginning at age ten and continuing through adolescence. This pro-active approach is beneficial and may identify symptoms prior to the issue becoming too problematic to ignore (Knopf, 2016).

Considerations for Counseling Professionals and Future Implications

Autonomous substance abuse disorders are rare in teenagers. The majority of teens with substance abuse disorders have a co-occurring mental illness, most often depressive disorder. Treatment considerations must account for developmental concerns and family involvement (Knopf, 2016). Individually tailored treatment that includes anti-overdose harm reduction, such as overdose training for families and school personnel (Bogdanowicz et al., 2015), is more effective than intervention that focuses singularly on substance abuse or depression. Further, research has found that family engagement is directly related to therapeutic changes for children coping with substance abuse disorders and depression (Cohen-Filipic & Bentley, 2015).

Integrated treatment for adolescents with co-occurring disorders ensures that mental health and substance abuse are addressed in the same setting and in tandem. Integrated treatment negates the difficulties found when the client must go to a different setting for each issue and care may not be compatible with the other. Adolescents may be dependent on an adult for transportation to treatment centers, and reduction of complications increases the chances for treatment success (Drake, O’Neal, & Wallach, 2008).

Interventions include individual therapy, group therapy, family intervention and case management, residential or intensive outpatient treatment, contingency management, and legal intervention when necessary (Drake et al., 2008). Statistics suggest the group counseling, contingency management, and long term residential treatment are most efficacious for adolescents. Other types of integrated care exhibit positive effects on mental illness outcomes, but a lack of improvement in co-occurring substance abuse (Drake et al., 2008).

Bellack, Bennett, Gearon, Brown, & Yang (2006) argue that an evidence-based, multi-faceted harm reduction approach to address specific needs of dual disorders will offer the most effective and meaningful long-term results. Empirical data is limited, but early studies indicate success with motivational interviewing to reduce substance abuse combined with regular contingency drug testing and structured, realistic short-term goals (Bellack et al., 2006). Social skills, drug refusal skills training, and relapse prevention enhance the benefits of this intervention. Bellack et al. (2006) indicate that substance abuse treatment is paramount to overall treatment of co-occurring disorders for lasting success. Dual disorder interventions must include a focus on societal causes, physical environment, cultural influences, and ideological barriers to change.

As new interventions show promising results and more research is completed, clinicians must keep in mind that empirical data strongly maintains that a strong relationship between counselors and other professional and the families of those with co-morbid substance abuse disorders and depression is necessary to the successful treatment of adolescents and young adults (Cohen-Filipic & Bentley, 2015). Societal stigma toward those with mental illness that results in exclusion and prejudice may cause significant feelings of guilt and shame in parents. Clinicians must be attuned to how parents perceive themselves and the counseling process as a whole, and strive to exhibit a non-judgmental, non-blaming atmosphere. Empathy and support is integral to the process, along with emphasizing to the parents that they are an essential part of the recovery process (Cohen-Filipic & Bentley, 2015). While the adolescent may be the technical client, supporting parents and families is salient to the child’s long-term recovery.

Conclusion

Society tends to view those with severe mental illness as cognitively incompetent and treatment is often focused on protective care, rather than focused on the individual’s experiences, values, and preferences (Drake et al., 2008). Our culture places great emphasis on autonomy and independence at the expense of the need for supported housing and services for those in recovery. These supports are more common in the field of substance abuse disorders, but underutilized in the mental health field. More research is needed in this area, but recent trends show great promise. Current research indicates that a balanced, integrated approach to both substance abuse and mental illness, often in a residential setting, combined with family support and harm reduction education will be a powerful intervention for adolescents in the future.

References

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