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exception of the latter 2 rates of extreme binge drinking, these estimates range between 6% and 9% higher in col- lege students. While in high school, the college-bound students were less likely to consume alcohol; thus, these rates indicate a substantial increase in alcohol consump- tion in the transition between high school and college.
In contrast, the annual prevalence of illicit drug use was lower among college students compared with their non- college peers: at 39% and 44%, respectively. In the college population, the highest annual prevalence was for mari- juana use (34%), followed by medically unsupervised amphetamines (10%), medically unsupervised sedatives/ tranquilizers (6.6%), and ecstasy/3,4-methylenedioxy- methamphetamine (5%). Prescription opioid narcotics, cocaine, and hallucinogen misuse was slightly under 5%, while use of inhalants, gamma hydroxybutyrate, ket- amine, and heroin was much rarer. It is worth noting that, like alcohol use, past-year amphetamine salts misuse was higher among college students compared with their non- college peers. Annual prevalence of marijuana use was 5% greater in college men than in women, and amphet- amine misuse was 2.5% greater in men.
While these rates may seem trivial, the consequences are clear. Excessive college drinking has a profound effect on the individual and the community, with yearly estimates of 1825 deaths; 599,000 injuries; 696,000 as- saults; and 97,000 sexual assaults or date rapes.2 More than 80% of all apprehensions by campus police in- volve alcohol. And a quarter of students report academ- ic problems related to alcohol consumption.3 It is abun-
dantly clear that college substance abuse poses a significant community health risk. Furthermore, the increased risk to the individual may be long-lasting and have lifelong consequences.
by Derek Blevins, MD and Surbhi Khanna, MBBS
T he transition from high school to college often sparks excitement and fear in the new high school graduate. There are many things to con- sider as he or she plans for this transition, and these considerations are influenced by the ex-
periences of parents and older siblings and friends; ad- vice from teachers and guidance counselors; and—last but not least—popular media, including movies, televi- sion, and music.
These sources play a major role in shaping the idea of what college might be like. Some nights will be spent in the library writing term papers, while others may be spent socializing at fraternity parties playing beer pong and drinking a mysterious “jungle juice.” Along with the sense of newfound freedom from the “hall pass,” high school truancy laws, and the umbrella of parental oversight comes increased access to alcohol, illicit sub- stances, and pharmaceutical drugs.
As clinicians, we may find it difficult to address this developmental period. We understand how important it is for youth to develop an individualized sense of self outside the context of previous constraints, but we also want to limit risk to young persons and to the community, which makes it difficult to determine when and how to intervene.
Prevalence Alcohol use among college students far exceeds that of any other psychoac- tive substance. The most recent data from the Monitoring the Future Na- tional Survey estimate that 63% of college students in 2014 consumed alco- hol within the past 30 days and 35% had occasions of heavy drinking (5 or more drinks in a row) in the past 2 weeks.1 In addition, 43% reported being drunk in the past 30 days; 13% reported having 10 or more drinks in a row in the past 2 weeks, and 5% reported having 15 or more in a row. With the
YOUNG ADULT PSYCHIATRY: PART 2 Clinical Implications of Substance
Abuse in Young Adults
18 Transition Issues for Patients With Eating Disorders Jennifer Derenne, MD
20 Cyberbullying, Who Hurts, and Why Michelle C. Ramos, PhD and Diana C. Bennett, MS
25 Growing Up With ADHD: Clinical Care Issues Thomas E. Brown, PhD
Special Report Chairperson Jerald Kay, MD
ALSO IN THIS SPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORTSPECIAL REPORT
J A N UA RY 2 0 1 6
Neurobiology of substance use and development At the biological level, various regions of the brain continue to develop and mature at different intervals throughout young adulthood. These active pro- cesses make the individual more likely to engage in novelty-seeking behav- iors while simultaneously making the brain more susceptible to neurotoxic processes that can result from substance use. For substance abusers, increased neuroplasticity during development comes with a cost.
Imaging studies have confirmed various neural structural and physiologi- cal changes associated with adolescent and young adult alcohol use.4,5 These changes include reduced hippocampal volumes and accelerated gray matter reduction in the frontal and temporal cortices with attenuated white matter growth in the corpus callosum and pons. These effects translate into problems with executive function, learning and memory, impulse control, and affective regulation. In addition, neurobiological changes alter cognition and increase the risk of substance use disorders and other neuropsychiatric processes.
Impact on psychopathology Drug use among college students puts them at increased risk for adverse health, behavioral, and social consequences. Among adults aged 18 or older with serious mental illness in 2014, the percentage of those who had past-year substance use disorder was highest among 18- to 25-year-olds (35%), fol- lowed by 26- to 49-year-olds (25%).6 Evidence suggests that heavy drinking
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during adolescence and young adult- hood is associated with poor neuro- cognitive functioning and is particu- l a r l y a s s o c i a t e d w i t h p o o r visuospatial skills and attention.7
Students who regularly used mar- ijuana and those who increased their use mid-college utilized health care services more often and had higher levels of depressive and anxiety-re- lated symptoms up to 7 years after college.8 Substance use may also be an independent risk factor for sui- cide, and it is important to recognize this during risk assessments, espe- cially in adolescents and young adults. In college students, the co- occurrence of substance use behav- iors and mental health problems (eg, major depression, panic disorder, generalized anxiety disorder) was as- sociated with higher odds of ciga- rette smoking. Among the 67% with co-occurring frequent binge drinking and mental health problems, only 38% received mental health services in the past year.9
The most recent data from the Na- tional College Health Assessment survey reported that 35% of under- graduates felt so depressed it was dif- ficult to function in the past year, 58% felt overwhelming anxiety, and a staggering 10% seriously contem- plated suicide.10 This contrasts with low reports of college students who received treatment for depression (13%), anxiety (15.8%), and sub- stance abuse (1%). Given the estab- lished bidirectional relationship be- t w e e n s u b s t a n c e a bu s e a n d depression and anxiety, as well as the clear increased risk of suicide with substance abuse, this information is alarming for families, college cam- puses, and mental health providers alike.
Among the 20.2 million adults aged 18 or older in 2014 who had a past substance use disorder, 2.3 mil- lion (11.3%) also had a serious mental illness.6 It is clear that substance abuse during the early college years is sig- nificant and that the potential conse- quences are not only imminent but may be lasting. However, this also presents an opportunity to make a change early because a large number of youths transitioning to adulthood on college campuses can be reached during this vulnerable period.
Primary prevention on college campuses Colleges and universities are espe- cially critical for early intervention, given that they are the gateway to adulthood for nearly half of the US population and that the college years are the period during which young adults initiate or increase drug use.1
P S Y C H I AT R I C T I M E S
(Please see Substance Abuse in Young Adults, page 16)
In terms of comorbidities, ap- proximately 1% of adults in the gen- eral population met criteria for both mental illness and substance use dis- order in the past year.6 Delivering interventions in settings where stu- dents who have problems with alco- hol are most likely to be seen, such as in health or counseling centers, may be most effective. Research shows
that several carefully conducted community initiatives aimed at re- ducing alcohol problems among college-age youths have been effec- tive, leading to reductions in under- age drinking, alcohol-related as- saults, emergency department visits, and alcohol-related crashes.11
One strategy to increase participa- tion in these interventions is to make screening routine in university health centers and to use new technology to reach a larger percentage of stu- dents.12 A review of computerized and web-based brief interventions for college students suggested that personalized feedback may be the
key component in this strategy’s suc- cess, both in motivating students and in helping them learn the skills they need to successfully change their behavior.13
Anonymous mandatory surveys during new and returning student ori- entation could dually serve to in- crease college administrators’ awareness of the prevalence of sub-
stance use and allow the student to reflect on his or her substance use patterns. However, using universal screenings as a means of mandating treatment referrals may result in un- der-reporting and thus limit their utility to both administrators and stu- dents. New college students, in par- ticular, are only beginning to appre- ciate that honest information does not always result in restriction or punishment. This allows an opportu- nity to establish a relationship that is more likely to result in a partnership with college administrators and po- tentially with clinicians in the future.
Another strategy to improve pre-
vention and increase participation of students is to develop a system of referral and financial penalties for students who are disciplined for sub- stance-related infractions, such as a mandated intervention at campus student health. These types of prac- tices may prevent the escalation of alcohol or drug use in students who are just beginning to experiment with substances.
Screening considerations The most critical skill for clinicians is to recognize problem drinking or substance use behaviors. Keep in mind that most college students have only recently been released from pa- rental oversight; thus, the most effec- tive approach is likely to be non-con- frontational and nonjudgmental and to lack paternalism. The AUDIT (Al- cohol Use Disorders Identification Test) is a commonly used 10-item alcohol screening tool.14 It has been shown to be effective in the college population, with a sensitivity of 91% when compared with a more com- prehensive diagnostic interview. Findings indicate that the AUDIT-C, which consists of the first 3 items from the AUDIT, is effective at de- tecting at-risk drinking in the college population (Figure 1).15
Screening college students for substance use other than alcohol may be more complicated for a number of reasons. Simply asking about drug use may result in a nega- tive screening because the college student may consider only sub- stances such as cocaine, heroin, or methamphetamine in this category (the prevalence of abuse of these substances in the college population is low). Asking specifically about
marijuana use and the use of their friends’ prescription medications, especially stimulants, is likely to re- sult in more clinically useful infor- mation. The Drug Abuse Screening Test (DAST) is a 28-item instru- ment that has been validated as a clinical screening tool for past-year substance use.16 The brief 10-item version, DAST-10, has been shown to be effective in college-age stu- dents (Figure 2).17
An additional complication of substance use screening is the ever- growing list of new illicit drugs and
1. How often do you have a drink containing alcohol?
0 = Never
1 = Monthly or less often
2 = 2 to 4 times monthly
3 = 2 to 3 times weekly
4 = ≥ 4 times weekly
2. How many standard drinks containing alcohol do you have on a typical day?
0 = 1 or 2
1 = 3 or 4
2 = 5 or 6
3 = 7 to 9
4 = ≥ 10
3. How often do you have 6 or more drinks on one occasion?
0 = Never
1 = Less than monthly
2 = Monthly
3 = Weekly
4 = Daily or almost daily
AUDIT, Alcohol Use Disorders Identification Test.
Copyright © 1990 World Health Organization.
Figure 1. AUDIT-C is a 3-item screening test that can be used in college students using a cut-off score of 7 in men and 5 in women; in the general population, scores of 4 or more in men and 3 or more in women are considered positive.14
It is clear that substance abuse during the early college years is significant and that the potential consequences are not only imminent but may be lasting.
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cally showing a reduction in early- onset (before age 25) alcoholism.18
Agonist therapies, including methadone and buprenorphine, re- main the mainstay of opioid depen- dence treatment. In the college stu- dent population, treatment with buprenorphine is likely a more ac- ceptable alternative to methadone maintenance, which requires daily visits to a methadone clinic. Anoth- er option for opioid dependence is antagonist therapy with oral or monthly injections of naltrexone.
Unfortunately, current evidence for cannabis dependence, the most widely abused substance in this population, is limited to a handful of open-label studies; more research on pharmacotherapy is needed.
Nonpharmacological interven- tions. A study involving students mandated to substance abuse treat- ment showed a reduction in high- risk drinking with either a brief mo- tivational intervention (MI) or an alcohol education session, but stu-
YOUNG ADULT PSYCHIATRY: PART 2 dents who received a brief MI re- ported fewer alcohol-related prob- lems. 19 A follow-up study of high-risk college students who re- ceived a single brief MI continued to show a significant reduction in negative alcohol-related conse- quences at 4 years.20 These positive results for a brief MI have also been shown to generalize to drug use in a college student health clinic.21
No published study has exam- ined the utility of pharmacotherapy with a brief intervention for alcohol dependence specifically in youth transitioning to adulthood. A brief MI, such as the BASICS (Brief Al- cohol Screening and Intervention for College Students) program, con- tinues to be the most validated ther- apeutic option in this population. A recent review focused on different modalities for adolescent substance use, including 12-step–based thera- py, cognitive behavioral therapy (CBT), motivation-based therapy, family-based intervention, and mixed or other approaches.22 A con- sistent pattern emerged that showed overall positive effects for all treat- ment modalities; however, family- based intervention, CBT, and moti- vational enhancement therapy had the best outcomes.
Although pharmacotherapy may play some role for college students with substance abuse problems, ef- fective psychotherapies remain the mainstay of treatment. Furthermore, as is true for all age groups, the im- portance of treating comorbid mood and anxiety disorders cannot be overemphasized.
Conclusion College substance use is clearly a prevalent and controversial issue. Many who engage in binge drinking, experiment with illicit drugs, and/or misuse pharmaceuticals will go through this rite of passage relative- ly unscathed. However, others will not. Identifying and treating prob- lematic substance use behaviors in college students may prevent injury, sexual assault, academic difficulties, and legal complications during col- lege, and may reduce the risk of fu- ture substance dependency or men- tal health complications.
Dr Blevins and Dr Khanna are third-year psychiatry residents in the department of psychiatry and neurobehavioral sciences at the University of Virginia Medical School in Charlottesville, VA. The authors report no conflicts of interest concerning the subject matter of this article.
1. Johnston LD, O’Malley PM, Bachman JG, et al.
Substance Abuse in Young Adults Continued from page 15
DAST-10 No Yes
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you always able to stop using drugs when you want to? (If never used drugs, answer Yes)
4. Have you had blackouts or flashbacks as a result of drug use?
5. Do you ever feel bad or guilty about your drug use? (If never used drugs, answer No)
6. Does your spouse (or parents) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your drug use (eg, memory loss, hepatitis, convulsions, bleeding)?
DAST, Drug Abuse Screening Test.
Copyright © 1982 Addiction Research Foundation.
Figure 2. DAST-10 is a modified version of the DAST developed by Harvey A. Skinner: scores of 0 (no problems reported) suggest no action; 1-2 (low level problems) sug- gest monitoring and reassessment; 3-5 (moderate level problems) suggest further investigation; and 6-8 (substantial level problems) or 9-10 (severe level problems) suggest intensive assessment.17
variations of old ones, which limits the use of a list of commonly abused drugs with yes or no checkboxes. Re- gardless of the tool that is used, maintaining a nonjudgmental stance, asking the right questions, and re- minding college students that their parents and college deans cannot ac- cess their medical records are likely to result in a more clinically mean- ingful substance use history.
Treatment options Pharmacotherapy. There have been no FDA approvals for medications for alcohol dependence in over 10 years, which leaves disulfiram, nal- trexone, and acamprosate as the only FDA-approved options. Other medications including gabapentin, topiramate, and ondansetron have been shown to improve drinking outcomes, with the latter specifi-
Monitoring the Future National Survey Results on Drug Use, 1975-2014: Volume II, College Students and Adults Ages 19-55. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2015. 2. Hingson RW, Wenxing Z, Weitzman ER. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24, 1998-2005. J Stud Alcohol Drugs. 2009;16:12-20. 3. Presley CA, Meilman PW, Lyerla R, Cashin JR. Alcohol and Drugs on American College Campuses. Use, Consequences, and Perceptions of the Cam- pus Environment. Volume I: 1989-1991; 1996. http://eric.ed.gov/?id=ED358766. Accessed De- cember 1, 2015. 4. De Bellis MD, Clark DB, Beers SR, et al. Hippo- campal volume in adolescent-onset alcohol use disorders. Am J Psychiatry. 2000;157:737-744. 5. Squeglia LM, Tapert SF, Sullivan EV, et al. Brain development in heavy-drinking adolescents. Am J Psychiatry. 2015;172:531-542. 6. Center for Behavioral Health Statistics and Qual- ity. Behavioral health trends in the United States: results from the 2014 National Health Survey on Drug Use and Health; 2015. http://www.samhsa. gov/data/sites/default/files/NSDUH-FRR1-2014/ NSDUH-FRR1-2014.pdf. Accessed December 1, 2015. 7. Tapert SF, Caldwell L, Burke C. Alcohol and the adolescent brain: human studies. Alcohol Res Health. 2004;28:205-212. 8. Caldeira KM, O’Grady KE, Vincent KB, et al. Mari- juana use trajectories during the post-college tran- sition: health outcomes in young adulthood. Drug Alcohol Depend. 2012;125:267-275. 9. Cranford JA, Eisenberg D, Serras AM. Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students. Addict Behav. 2009;34:134-145. 10. American College Health Association. ACHA— National Health Assessment II: Undergraduate Stu- dents Reference Group Data Report, Spring 2015. Hanover, MD: American College Health Association; 2015. 11. Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbid- ity among US college students ages 18-24: chang- es from 1998 to 2001. Annu Rev Public Health. 2005;26:259-279. 12. National Institute on Alcohol Abuse and Alcohol- ism. What colleges need to know now: an update on college drinking research; 2007. http://www.col- legedrinkingprevention.gov/1college_bulletin- 508_361C4E.pdf. Accessed December 1, 2015. 13. Walters ST, Neighbors C. Feedback interven- tions for college alcohol misuse: what, why and for whom? Addict Behav. 2005;30:1168-1182. 14. Kokotailo PK, Gangnon R, Brown D, et al. Valid- ity of the alcohol use disorders identification test in college students. Alcohol Clin Exp Res. 2004;28: 914-920. 15. DeMartini KS, Carey KB. Optimizing the use of the AUDIT for alcohol screening in college students. Psychol Assess. 2012;24:954-963. 16. Skinner HA. The Drug Abuse Screening Test. Ad- dict Behav. 1982;7:363-371. 17. McCabe SE, Boyd CJ, Cranford JA, et al. A mod- ified version of the Drug Abuse Screening Test among undergraduate students. J Subst Abuse Treat. 2006;31:297-303. 18. Johnson BA. Medication treatment of different types of alcoholism. Am J Psychiatry. 2010;167: 630-639. 19. Borsari B, Carey KB. Descriptive and injunctive norms in college drinking: a meta-analytic integra- tion. J Stud Alcohol. 2003;64:331-341. 20. Baer JS, Kivlahan DR, Blume AW, et al. Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. Am J Public Health. 2001;91:1310-1316. 21. Amaro HA, Reed E, Rowe E, et al. Brief screen- ing and intervention for alcohol and drug use in a college student health clinic: feasibility, implemen- tation, and outcomes. J Am Coll Health. 2010;58: 357-364. 22. Tanner-Smith EE, Wilson SJ, Lipsey MW. A com- parative effectiveness of outpatient treatment for adolescent substance abuse: a meta-analysis. J Subst Abuse Treat. 2013;44:145-158. ❒
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