A vulnerable population
As defined by Erik Erikson’s psychosocial stages of development, adolescents struggle between establishing their own identity vs role confusion.13 In an attempt to relate to peers or give in to peer pressure, some adolescents start by experimenting with nicotine, alcohol, and/or marijuana; however, some may move on to using other illicit drugs.14 Risk factors for the development of SUDs include early onset of substance use and a rapid progression through stages of substance use from experimentation to regular use, risky use, and dependence.15 In our case study, Ms. L’s substance use followed a similar pattern. Further, the comorbidity of SUDs and other psychiatric disorders may add a layer of complexity when caring for adolescents. Box 116-20 describes the relationship between comorbid psychiatric disorders and SUDs in adolescents.
Disruptive behavior disorders are the most common coexisting psychiatric disorders in an adolescent with a substance use disorder (SUD), including opioid use disorder. These individuals typically present with aggression and other conduct disorder symptoms, and have early involvement with the legal system. Conversely, patients with conduct disorder are at high risk of early initiation of illicit substance use, including opioids. Early onset of substance use is a strong risk factor for developing an SUD.16
Mood disorders, particularly depression, can either precede or occur as a result of heavy and prolonged substance use.17 The estimated prevalence of major depressive disorder in individuals with an SUD is 24% to 50%. Among adolescents, an SUD is also a risk factor for suicidal ideation, suicide attempts, and completed suicide.18-20
Anxiety disorders, especially social phobia, and posttraumatic stress disorder are common in individuals with SUD.
Adolescents with SUD should be carefully evaluated for comorbid psychiatric disorders and treated accordingly.
Common clinical manifestations of opioid use vary depending on when the patient is seen. An individual with OUD may appear acutely intoxicated, be in withdrawal, or show no effects. Chronic/prolonged use can lead to tolerance, such that a user needs to ingest larger amounts of the opioid to produce the same effects.
Acute intoxication can cause sedation, slurring of speech, and pinpoint pupils. Fresh injection sites may be visible on physical examination of IV users. The effects of acute intoxication usually depend on the half-life of the specific opioid and the individual’s tolerance.10 Tolerance to heroin can occur in 10 days and withdrawal can manifest in 3 to 7 hours after last use, depending on dose and purity.3 Tolerance can lead to unintentional overdose and death.
Withdrawal. Individuals experiencing withdrawal from opioids present with flu-like physical symptoms, including generalized body ache, rhinorrhea, diarrhea, goose bumps, lacrimation, and vomiting. Individuals also may experience irritability, restlessness, insomnia, anxiety, and depression during withdrawal.
Other manifestations. Excessive and chronic/prolonged opioid use can adversely impact socio-occupational functioning and cause academic decline in adolescents and youth. Personal relationships are significantly affected. Opioid users may have legal difficulties as a result of committing crimes such as theft, prostitution, or robbery in order to obtain opioids.
Continue to: Screening for OUD