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The Disease of Addiction: A Critical Pediatric Prevention Issue

      Welcome to 2017! My hope is that all of you are entering the New Year refreshed and reenergized for a year that will bring much change and opportunity. Many of us made resolutions to start on a new chapter of self-improvement. One of my resolutions involves mobilizing the pediatric APRN community around a costly national tragedy that cuts across all geographic, socioeconomic, and racial lines—the disease of addiction. The direct and indirect financial costs in the United States stemming from addiction are more than $700 billion annually (Substance Abuse and Mental Health Administration [

      Substance Abuse and Mental Health Services Administration. (2016b). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm

      ), greatly exceeding the $216.6 billion per year cost for cancer (
      American Association for Cancer Research
      Cancer in 2014.
      ), the $322 billion per year cost for diabetes (
      American Diabetes Association
      The cost of diabetes.
      ), and the $316.6 billion per year cost for cardiovascular diseases ().
      According to the
      American Society of Addiction Medicine
      Public policy statement: Definition of addiction.
      , Short Definition of Addiction, para. 1-2), addiction is defined as follows:…a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
      In 2014, 27 million people ages 12 years or older had used an illicit drug in the past 30 days, which corresponds to about 1 in 10 Americans (10.2%). This represents an increase in the use of illicit drugs that can be primarily attributed to the nonmedical use of prescription pain relievers and marijuana use (

      Substance Abuse and Mental Health Services Administration. (2016b). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm

      ). Eleven percent of adolescents meet diagnostic criteria for a substance abuse disorder before age 18 (
      • Merikangas K.R.
      • He J.P.
      • Burstein M.
      • Swanson S.
      • Avenevoli S.
      • Cui L.
      • Swendsen J.S.
      Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
      ). Underage alcohol use among young people ages 12 to 20 and binge and heavy alcohol use among young adults ages 18 to 25 remains a concern. In 2014, 22.8% of underage people were alcohol users, 13.8% were binge alcohol users, and 3.4% were heavy alcohol users (

      Substance Abuse and Mental Health Services Administration. (2016b). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm

      ). In addition, there is an alarming increase in infants suffering from neonatal abstinence syndrome. The number of birthing mothers using or dependent on opiates rose nearly 5-fold from 2000 to 2009 (
      National Institute on Drug Abuse
      Dramatic increases in maternal opioid use and neonatal abstinence syndrome.
      ).
      These statistics confirm that addiction is a pediatric disease. In more than 9 out of 10 cases, addiction originates or is triggered by psychoactive substance use before the age of 21 years, a period of rapid growth and development of the brain (
      • Denisco R.C.
      • Kenna G.A.
      • O'Neil M.G.
      • Kulich R.J.
      • Moore P.A.
      • Mehta N.P.
      Screening and brief intervention in primary care settings.
      ). Any use of alcohol, nicotine, or other drugs by adolescents is risky. Substance-using adolescents differ from nonusers on neuropsychological performance, brain tissue volume, white matter integrity, and functional brain response (
      • Squeglia L.M.
      • Jacobus J.
      • Tapert S.F.
      The Influence of substance use on adolescent brain development.
      ). The risk of becoming addicted is greater the younger the age of first use. Those who use addictive substances before age 15 are 6.5 times as likely to develop addiction as those who delay use until age 21 or older (28.1% vs. 4.3%;
      National Center on Addiction and Substance Abuse at Columbia University
      Adolescent substance use: America's #1 public health problem.
      ).
      The median age of initiation of illicit use in adults diagnosed with any substance abuse disorder is 16 years. About 50% of initiation of use occurs between ages 15 and 18, and it is rare for there to be initiation of use after age 20. Most adult U.S. smokers begin smoking before age 18, and the onset of daily smoking is uncommon after age 25. Earlier onset of substance use also predicts greater addiction severity and morbidity, including substance abuse disorders with multiple substances (
      • Chambers R.A.
      • Taylor J.R.
      • Potenza M.N.
      Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability.
      ). Recent studies on the effects of toxic stress and adverse childhood experiences show that adverse childhood experiences are a significant risk factor for the development of substance abuse disorders (). The publication “Blueprint for Children: How the Next President Can Build a Foundation for a Healthy Future,” an important document that NAPNAP is proud to have provided comments for during drafting and to endorse, includes recommendations for addressing the critical issue of substance abuse prevention.
      It is no longer possible to dismiss adolescent experimentation with substance use, including alcohol, marijuana, and nicotine in any form, as unavoidable and harmless rites of passage. These facts place much of the responsibility for the prevention of the most costly and devastating chronic illness in the United States with pediatric providers. We must give addiction prevention the attention it deserves, develop the necessary competencies, and incorporate these into our interactions with preteens, teens, and their families. Pediatric providers should educate patients and their families about the risk factors and early signs of substance use and problematic substance abuse.
      Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, time-efficient, and effective practice that has been shown to identify, reduce, and prevent substance misuse and the disease of addiction. The five-question screening tool can easily be incorporated into existing adolescent screening practices. There is substantial evidence for the effectiveness of brief interventions using motivational interview techniques for reducing harmful drinking and risky substance use (
      Substance Abuse and Mental Health Services Administration
      Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT).
      ,
      • Whitlock E.P.
      • Polen M.R.
      • Green C.A.
      • Orleans T.
      • Klein J.
      U.S. Preventive Services Task Force
      Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force.
      ).
      The SAMHSA has a wealth of online resources that provide information about promoting mental and behavioral health, identifying risk and protective factors, and implementing evidence-based prevention strategies. There is also a resource guide for SBIRT training and implementation (http://www.samhsa.gov/sbirt/resources). The publication “Identifying and Responding to Substance Use Among Adolescents and Young Adults: A Compendium of Resources for Medical Practice” is a valuable resource both for practitioners and faculty (
      National Center for Physician Training in Addiction Medicine
      Identifying and responding to substance use among adolescents and young Adults: A compendium of resources for medical practice.
      ).
      Let's all resolve in 2017 to educate ourselves, our teens, and their families about addiction; screen universally for mental, behavioral, and substance abuse disorders; refer appropriately to treatment; and participate in evidenced-based prevention activities in our communities. I truly believe that the health and safety of our teens and communities depends on our actions.

      References

      1. American Academy of Pediatrics. (2016). Blueprint for Children: How the Next President Can Build a Foundation for a Healthy Future. Retrieved from https://www.aap.org/en-us/transitions/Pages/blueprint-for-children.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token

        • American Association for Cancer Research
        Cancer in 2014.
        Author, Philadelphia, PA2014 (Retrieved from)
        • American Diabetes Association
        The cost of diabetes.
        Author, Alexandria, VA2013 (Retrieved from)
      2. American Heart Association. (2016). Heart and stroke statistics. Retrieved from https://www.heart.org/HEARTORG/General/Heart-and-Stroke-Association-Statistics_UCM_319064_SubHomePage.jsp

        • American Society of Addiction Medicine
        Public policy statement: Definition of addiction.
        Author, Chevy Chase, MD2011 (Retrieved from)
        • Chambers R.A.
        • Taylor J.R.
        • Potenza M.N.
        Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability.
        The American Journal of Psychiatry. 2003; 160: 1041-1052
        • Denisco R.C.
        • Kenna G.A.
        • O'Neil M.G.
        • Kulich R.J.
        • Moore P.A.
        • Mehta N.P.
        Screening and brief intervention in primary care settings.
        Alcohol Research & Health. 2011; 28: 57-62
        • Merikangas K.R.
        • He J.P.
        • Burstein M.
        • Swanson S.
        • Avenevoli S.
        • Cui L.
        • Swendsen J.S.
        Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
        Journal of the American Academy of Child & Adolescent Psychiatry. 2010; 49: 980-989
        • National Center on Addiction and Substance Abuse at Columbia University
        Adolescent substance use: America's #1 public health problem.
        Author, New York, NY2011 (Retrieved from)
        • National Center for Physician Training in Addiction Medicine
        Identifying and responding to substance use among adolescents and young Adults: A compendium of resources for medical practice.
        Author, Bethesda, MD2015 (Retrieved from)
        • National Institute on Drug Abuse
        Dramatic increases in maternal opioid use and neonatal abstinence syndrome.
        National Institutes of Health, Bethesda, MD2015 (Retrieved from)
        • Substance Abuse and Mental Health Services Administration
        Adverse childhood experiences.
        Author, Rockville, MD2016 (Retrieved from)
      3. Substance Abuse and Mental Health Services Administration. (2016b). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm

        • Substance Abuse and Mental Health Services Administration
        Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT).
        Author, Rockville, MD2015 (Retrieved from)
        • Squeglia L.M.
        • Jacobus J.
        • Tapert S.F.
        The Influence of substance use on adolescent brain development.
        Clinical EEG and Neuroscience. 2009; 40: 31-38
        • Whitlock E.P.
        • Polen M.R.
        • Green C.A.
        • Orleans T.
        • Klein J.
        • U.S. Preventive Services Task Force
        Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force.
        Annals of Internal Medicine. 2004; 140: 557-568