11 S
Depressant Adolescent Robert
Substances Medicine
L. DuPont,
FOCUS
MD* and Keith
QUESTIONS
1. What is the epidemiology of depressant use in adolescents? 2. What is the current trend in selection of depressants by adolescents? 3. What are the differences in effect and risk between benzodiazepines and other depressants? 4. How can one differentiate among substance abuse, substance dependence, and addiction in adolescents? 5. What interventions are helpful in the treatment of depressant abuse in adolescents? 6. Is there a causal relationship between maternal use of benzodiazepines and fetal abnormalities?
Central nervous system (CNS) depressants, including alcohol, barbiturates, and benzodiazepines, reduce CNS activity. This class of drugs is
S
used treat other
in medical epilepsy, practice to insomnia, and conditions associated with excessive CNS excitability. Although there is potential for abuse, prescribed depressant medicines are not among the most popular of abused drugs, particularly for adolescents. Alcoholic beverages, however, despite their universal illegality for adolescents in the United States, are commonly used by teenagers. The benzodiazepines largely have replaced other depressants in medical practice because their therapeutic effects are achieved with relatively low risks of sedation, death from overdose, or abuse. The nonbenzodiazepine sedatives and hypnotics, in contrast, commonly produce unwanted drowsiness at therapeutic doses.
routinely anxiety,
Also,
the
therapeutic
dose
for
other sedatives and hypnotics is much closer to a lethal dose, contributing to a high risk of accidental and deliberate overdose. Before the introduction of benzodiazepines, barbiturates were a major cause of accidental poisonings and suicide. *president
and
tOirector
Institute for Behavior Executive Boulevard, 301-231-9010.
Pediatrics
in Review
No.
PhDt
It is important for pediatricians to have a basic understanding of the epidemiology of depressant use by adolescents, the medical and nonmedical uses of depressants, the physiologic and behavioral consequences of their use, the long-term dosage and abuse of depressants, and the management of and association between maternal depressant use and fetal abnormalities. The emphasis of this article is on the benzodiazepines because they are the safest, most effective, and most widely prescribed members of this class of medicines. The discussion focuses on use and abuse by adolescents, which generally does not differ dramatically from the pattern of use and abuse by adults. Some medical practitioners avoid prescribing antianxiety medications to adolescents; this is a misguided practice, especially if an adolescent’s quality of life could be enhanced substantially by the appropriate medical treatment of a diagnosed illness, most often an anxiety disorder.
Epidemiology The majority of initial use of all nonmedical drugs occurs during the teenage years. Nonmedical drug use is rare in those younger than 10 y. Initiation of nonmedical use of a drug is uncommon among those 25 y of age or older, except among people who previously have used drugs nonmedically.’ Nonmedical drug use by adolescents may be transitory or prolonged. In general, the earlier nonmedical drug use begins, the greater the likelihood of progression to serious adverse consequences. Psychosocial and biological factors contribute to onset of drug use during adolescence, a period of physical and emotional transition during which the individual tests limits and becomes more independent in the context of lowered parental and societal control The drug categories used in epidemiologic surveys are not entirely consistent across studies. In general,
and Health, mc, 6191 Rockville, MD 20852;
/3
E. Saylor,
over behavior.
of Research,
Vol.
in
10
October
“psychotherapeutics” are all prescribed substances, whether taken under a valid prescription or not. Thus, these substances may be used “medically” (as intended under a valid prescription for the user) or “nonmedically” (outside the boundaries of medical practice). Among the psychotherapeutics are the stimulants, depressants, and analgesics. Depressants are further categorized as sedatives (for daytime use) and hypnotics (for treatment of insomnia). Depressants also include “tranquilizers,” a term generally indicating the benzodiazepines, which can be used as either sedatives or hypnotics. The term “tranquilizer” largely has been replaced by the term “antianxiety medicine.” Alcohol is not a prescribed medicine and, therefore, not a psychotherapeutic, but it is a depressant substance. During 1990, approximately 16% of youth 12 to 17 y of age reported having used an illicit drug during the past year, and 8. 1% used within the past month.2 An estimated 2.7% of youth 12 to 17 y of age reported nonmedical use, excluding alcohol, of any psychotherapeutic drugs (including sedatives, stimulants, tranquilizers, and analgesics) during 1990. For the same year, approximately 1.5% of 12- to 17-y-old respondents reported nonmedical use of tranquilizers (primarily benzodiazepines), and 2% used sedatives nonmedically (primarily barbiturates). In contrast, alcohol is by far the most commonly used psychoactive substance in all age groups. Fifty percent of youth ages 12 to 17 y tried alcohol at some time, and approximately 25% were current users during 1990. By the senior year of high school, 57% of youth reported use of alcohol.3 Alcohol produces CNS depressant effects similar to the effects produced by prescribed depressant medicines, such as barbiturates, through the gamma-aminobutyric acid (GABA) system. In terms of abuse, sedatives and hypnotics can be thought of as “booze in a pill.” The sedatives and
1992
Downloaded from http://pedsinreview.aappublications.org/ at Pennsylvania State University on May 24, 2015
381
SUBSTANCE
ABUSE
Depressants hypnotics are not used as widely as alcohol because they are harder for adolescents to obtain and their use is less socially accepted. However, the street market and family medicine cabinet remain ready sources of depressant drugs for many adolescents, especially those already actively using other nonmedical substances. A steady decline in nonmedical depressant use other than alcohol has occurred since 1975, when approximately 20% of high school seniors reported ever using a depressant nonmedically.3 During 1990,
Depressant Adolescent Robert
Substances Medicine
L. DuPont,
FOCUS
MD* and Keith
QUESTIONS
1. What is the epidemiology of depressant use in adolescents? 2. What is the current trend in selection of depressants by adolescents? 3. What are the differences in effect and risk between benzodiazepines and other depressants? 4. How can one differentiate among substance abuse, substance dependence, and addiction in adolescents? 5. What interventions are helpful in the treatment of depressant abuse in adolescents? 6. Is there a causal relationship between maternal use of benzodiazepines and fetal abnormalities?
Central nervous system (CNS) depressants, including alcohol, barbiturates, and benzodiazepines, reduce CNS activity. This class of drugs is
S
used treat other
in medical epilepsy, practice to insomnia, and conditions associated with excessive CNS excitability. Although there is potential for abuse, prescribed depressant medicines are not among the most popular of abused drugs, particularly for adolescents. Alcoholic beverages, however, despite their universal illegality for adolescents in the United States, are commonly used by teenagers. The benzodiazepines largely have replaced other depressants in medical practice because their therapeutic effects are achieved with relatively low risks of sedation, death from overdose, or abuse. The nonbenzodiazepine sedatives and hypnotics, in contrast, commonly produce unwanted drowsiness at therapeutic doses.
routinely anxiety,
Also,
the
therapeutic
dose
for
other sedatives and hypnotics is much closer to a lethal dose, contributing to a high risk of accidental and deliberate overdose. Before the introduction of benzodiazepines, barbiturates were a major cause of accidental poisonings and suicide. *president
and
tOirector
Institute for Behavior Executive Boulevard, 301-231-9010.
Pediatrics
in Review
No.
PhDt
It is important for pediatricians to have a basic understanding of the epidemiology of depressant use by adolescents, the medical and nonmedical uses of depressants, the physiologic and behavioral consequences of their use, the long-term dosage and abuse of depressants, and the management of and association between maternal depressant use and fetal abnormalities. The emphasis of this article is on the benzodiazepines because they are the safest, most effective, and most widely prescribed members of this class of medicines. The discussion focuses on use and abuse by adolescents, which generally does not differ dramatically from the pattern of use and abuse by adults. Some medical practitioners avoid prescribing antianxiety medications to adolescents; this is a misguided practice, especially if an adolescent’s quality of life could be enhanced substantially by the appropriate medical treatment of a diagnosed illness, most often an anxiety disorder.
Epidemiology The majority of initial use of all nonmedical drugs occurs during the teenage years. Nonmedical drug use is rare in those younger than 10 y. Initiation of nonmedical use of a drug is uncommon among those 25 y of age or older, except among people who previously have used drugs nonmedically.’ Nonmedical drug use by adolescents may be transitory or prolonged. In general, the earlier nonmedical drug use begins, the greater the likelihood of progression to serious adverse consequences. Psychosocial and biological factors contribute to onset of drug use during adolescence, a period of physical and emotional transition during which the individual tests limits and becomes more independent in the context of lowered parental and societal control The drug categories used in epidemiologic surveys are not entirely consistent across studies. In general,
and Health, mc, 6191 Rockville, MD 20852;
/3
E. Saylor,
over behavior.
of Research,
Vol.
in
10
October
“psychotherapeutics” are all prescribed substances, whether taken under a valid prescription or not. Thus, these substances may be used “medically” (as intended under a valid prescription for the user) or “nonmedically” (outside the boundaries of medical practice). Among the psychotherapeutics are the stimulants, depressants, and analgesics. Depressants are further categorized as sedatives (for daytime use) and hypnotics (for treatment of insomnia). Depressants also include “tranquilizers,” a term generally indicating the benzodiazepines, which can be used as either sedatives or hypnotics. The term “tranquilizer” largely has been replaced by the term “antianxiety medicine.” Alcohol is not a prescribed medicine and, therefore, not a psychotherapeutic, but it is a depressant substance. During 1990, approximately 16% of youth 12 to 17 y of age reported having used an illicit drug during the past year, and 8. 1% used within the past month.2 An estimated 2.7% of youth 12 to 17 y of age reported nonmedical use, excluding alcohol, of any psychotherapeutic drugs (including sedatives, stimulants, tranquilizers, and analgesics) during 1990. For the same year, approximately 1.5% of 12- to 17-y-old respondents reported nonmedical use of tranquilizers (primarily benzodiazepines), and 2% used sedatives nonmedically (primarily barbiturates). In contrast, alcohol is by far the most commonly used psychoactive substance in all age groups. Fifty percent of youth ages 12 to 17 y tried alcohol at some time, and approximately 25% were current users during 1990. By the senior year of high school, 57% of youth reported use of alcohol.3 Alcohol produces CNS depressant effects similar to the effects produced by prescribed depressant medicines, such as barbiturates, through the gamma-aminobutyric acid (GABA) system. In terms of abuse, sedatives and hypnotics can be thought of as “booze in a pill.” The sedatives and
1992
Downloaded from http://pedsinreview.aappublications.org/ at Pennsylvania State University on May 24, 2015
381
SUBSTANCE
ABUSE
Depressants hypnotics are not used as widely as alcohol because they are harder for adolescents to obtain and their use is less socially accepted. However, the street market and family medicine cabinet remain ready sources of depressant drugs for many adolescents, especially those already actively using other nonmedical substances. A steady decline in nonmedical depressant use other than alcohol has occurred since 1975, when approximately 20% of high school seniors reported ever using a depressant nonmedically.3 During 1990,
