recording before I forget. So my name is Katie Cunningham. I'm the technology transfer specialist with the Opioid Response Network in New York. The Opioid Response Network, or the ORN, is a SAMHSA-funded organization. We provide free training and technical assistance to communities and organizations related to opioid and stimulant drug use, but also other substances, as we'll hear about alcohol today, and just substance use-related topics in general, which seems to be everything related to life in general. And what we mean by technical assistance is that we offer educational resources, training, guidance on implementation of evidence-based programs, free of charge, with the goal of strengthening local organizations and community responses to the overall overdose epidemic. So we accept requests from organizations of various sizes and backgrounds, and I'm part of the team that handles requests specifically for New York State, but there's a version of me all over the country that's responsible for their respective regions. So I will put a link to the ORN website if you're interested in learning more in the chat, and also my contact information if you want to reach out directly for any questions. But other than that, you are in for a treat with Dr. Martinez, and I will hand it over to her. Great, thank you. Thank you. So I'll start just by explaining, I am a psychiatrist. I've done neuroscience research since finishing residency, and I finished residency in the last century. So I've been doing neuroscience research for a very long time in substance use disorders. And to be honest, it was a very interesting intellectual puzzle, like how do drugs interact with brain systems? And then I had two sons, and as they grew up and became teenagers, I was suddenly like, wow, I have all this intellectual knowledge and it's not really applicable to the real world, and I better change that quickly. And so I started giving a lot of talks to high schools and high school students and educators and parents, not only because I was sort of like learning how to take what I had learned and make it useful in the real world, but also because what I would like in my life, and which I think most of my colleagues would like, is fewer patients. At this point, there are about 3,000 physicians who are trained to treat substance use disorders in the United States, and 20 million people with a substance use disorder. So we are overwhelmed, and what we really need is fewer patients, and that has a lot to do with prevention. And that's where folks like you really hold the key to making this desire come to fruition. So what I'm gonna be talking to you today about is a lot about prevention, acute risks and prevention. So I'll go ahead and get started. And... Mm-hmm. You should be able to... We see the screen, it's just, yeah, okay. You see the slideshow now? Mm-hmm. Yep, thank you. Great. So we, Katie mentioned the ORN, so I'll go over these quickly, and then I'll just start here. So I'm gonna start with some data, some information. So accidents are the top cause of death in the United States among teenagers. Mostly motor vehicle accidents, although swimming deaths also count into this as well. And half of these include alcohol. In fact, half of all swimming deaths do also include alcohol. This has been the case since I was in high school. It's probably been the case since most of us were in high school, and it hasn't changed. So part of the talk that I give is how can we address this? Overdose is a major cause of death among young adults, although teenagers are now the fastest growing group to die of an overdose. This is mostly opioids, but it also includes alcohol. When I'm talking to teenagers, I often talk about overdose on alcohol, which we often call poisoning, but it is an overdose, and it is a significant risk. And then when it comes to assault, about half of all sexual assaults on college campuses involve alcohol. We don't know the data when it comes to high school. I haven't been able to find it. I assume it's gonna be probably about the same. And when it comes to physical assaults, alcohol is often involved as well. So when I talk to teenagers, and when I talk to parents, I often mention these three risks repeatedly, accidents, overdose, and assault. I repeat it over and over and over, and I'll talk more about it here. And then we have the risk of addiction. At this point, about 30 million people in the United States have an alcohol use disorder, which is a tremendously high number. It's 13% of males ages 12 and older, and 9% of females, although females are catching up with males with each year that goes by. And alcohol use disorder almost always begins in the teenage years. So what can we do about it? How can we address this problem? And how can we do more when it comes to prevention? Well, we know it doesn't work. I can tell you having done this research and having done this work for 20 plus years, punishment often doesn't stop drug use. And the other thing that doesn't stop drug use is avoiding the issue altogether, which I think most parents do tend to engage in, and a number of us adults, we don't have a great solution. So we often, at least as parents, I can tell you, try to ignore the problem and hope for the best. However, we do know it works for sex. I did residency in the 90s when the AIDS epidemic was destroying the country, and it was thought to be unstoppable until we really invested heavily in prevention. And part of this prevention was using science to talk about sex, and talked about how to make rational decisions and how to reduce risk. And now we have data showing that it works. We know that science-based sex education works. It reduces the risk of a sexually transmitted infection. It reduces the risk of unplanned pregnancy, sexual assault. It actually even delays the initiation of sex. So kids who understand the science and understand the science behind sex and risk are likely to have sex at a later age. So the question is, can we do the same when it comes to drug use in teenagers? Can we reduce the risk and reduce the harms and improve prevention by using science to talk about drug use? So this includes knowing how to recognize dangerous situation. It includes knowing the risks and how to mitigate those risks. And it includes talking about addiction and recognizing the risks of addiction, especially when it's early on, when it's starting early on. So what I'm going to be talking about today is I'm going to start with the acute risks of alcohol, again, accidents, overdose, and assault. And then I'm going to talk about the risks beyond the acute risks of intoxication, the risks of health, the development of an alcohol use disorder and self-medication. And what's interesting is this, I talked to teenagers, what I've learned is that they're very interested in the science of substances of alcohol and other drugs. They get a lot of information on all of this from social media. And really do sort of soak it up. And they know, they know that some of it is true and they know that some of it is not true. And they are interested in knowing like what's real and what's not. So when I talk to adolescents, when I talk to teenagers, I really stick to the facts and the science. So let's start with alcohol. So the risks of intoxication when it comes to alcohol, as all of us know as adults, but it's often not known to adolescents, is that the risk depends on the dose. And the dose is often miscalculated. So when we're talking about the science of alcohol, we often measure things in standard drinks, which I've shown one here. So just, you know, in general, a standard drink is one 12 ounce, 5% beer. And so one drink in an hour makes people feel more social, more relaxed, which is why alcohol is probably among the most used of drugs, especially in social situations, but it also impairs coordination. As drinking goes up, number of drinks, two to three drinks an hour, impulsivity increases, there's a loss of fear. And there's a worse thing of physical coordination, which increases risk of an accident. Around three to four drinks in an hour, although more drinks and more time, people can have a blackout where there's no memory, they make bad decisions. They may be walking and talking and seeming normal, but are really at a high risk of accidents and death, frankly. And with more drinks, as people increase their alcohol use over time, there is a risk of shutting down the brain and dying of an alcohol overdose. As I mentioned, this is often referred to as alcohol poisoning, but it really is an overdose. And it happens in the United States to about six people every day. Some of the biggest risks when I always, I always dread early fall and spring break because that's when we hear reports, especially on college campuses, of kids over drinking and dying of alcohol overdoses. But it can also and does also happen in the high school years. And certainly one of the risks is that people tend to drink alcohol in large containers. So the Red Solo cup can have a lot of alcohol, especially if it's got a mixed drink in it. And then of course we have the gallon, with the gallon jugs, which was a trend for a while. I hope it's dying down where people are just simply drinking alcohol out of jugs. So again, the risks of, the acute risks of intoxication are accidents. And when it comes to accidents, we always think of motor vehicle accidents, but it's not just motor vehicle accidents that we need to be mindful of. As I mentioned, half of all swimming deaths involve alcohol. There's also things like riding a bicycle, skateboarding, skiing, climbing, even just walking out in the freezing cold, if it's winter and it's upstate New York and you're over intoxicated, that can be a risk of a death by accident. When it comes to assault, as I mentioned, about half of all assaults involve alcohol. And this often involves alcohol use on the part of the victim. Simply having an impaired level of consciousness, sort of not really thinking clearly, puts you at bigger risk of being the victim of an assault, either sexual or physical. And then overdose, as I mentioned, this happens in about six people every day in the United States, with alcohol specifically. So when it comes to the risks, when I talk to teenagers and parents, as I said, I focus on accidents, overdose and assault. And I also talk about it with cannabis. The risks are also there. There's not really a risk of overdose per se, but over intoxication is a risk. And alcohol combined with cannabis actually increases the risk of an alcohol overdose. And then with opioids, obviously there's a risk of overdose. And so I'm not gonna go over these here today because we're really focused on alcohol, but it's important to talk about these risks. I always start with alcohol because it is the most commonly used drug and most people are familiar with it. And then I move on to the other drugs to sort of explain these risks. So when I talk to teenagers, I talk to people about how can we reduce risk? What can we do about this? Clearly not drinking is top of the list, but we also need to rely on teenagers to take care of each other. And when I talk to kids, I talk about like the importance of taking care of a friend who gets into trouble with alcohol or any other drug, it resonates deeply. And they actually remember what I say and they try and like keep this in mind because what I point out is that you can be responsible for preventing your friend from experiencing something like an accident, an assault, or an overdose. So everybody knows friends don't let friends drive drunk, but as I mentioned, it's also swimming and other things. Assault, if someone is intoxicated and they're at risk of an assault, it's important to get that person to safety. Usually contacting parents, contacting somebody who can be reached, but it's important to not just let it happen is to know that risk is there and to intervene. And then an overdose, over-intoxication, it was very common for people to take too much of a drug. This is what's happening a lot on college campuses when it comes to early fall, there's a lot of alcohol use. And when somebody has too much of a drug to use, whether it's alcohol or anything else, people often feel scared and embarrassed and they wanna get home alone. And that's probably the most risky thing that they can do. What they really need is they need help, they need help from a friend. And if they're teenagers, they need help from a parent because this is when they're at the highest risk of an accident, an assault or an overdose is when they're trying to get home alone after accidentally taking too much. When it comes to an overdose, it's important that everybody knows what an overdose looks like. Usually if somebody is sort of unresponsive or is becoming unable to respond due to drug use, everybody sort of freaks out and tries to figure out like what drug was taken. And that's not the thing to do. The important thing to do is to focus on the person. The symptoms of an overdose to any drug, it doesn't matter which drug it is, are fear, confusion, dizziness, drowsiness, it can have some called chest pain and nausea. The important thing when I'm talking to teenagers is if somebody can't, I keep it simple, if they can't walk, talk or stay awake, that's when you have to get help. That's when you urgently have to get help. You should get help before that stage if anyone's at risk, but if they can't walk, talk or stay awake, that's when 911 has to be called. You have to get intervention for somebody because sometimes, especially with alcohol, if somebody's had too much to drink, kids think that if somebody's had too much to drink, if you put them on their side so that they don't vomit, that they're going to be safe. But the real truth is that sometimes people die of an alcohol overdose without vomiting. So 911 has to be called. They do need to be put in the recovery position, which is putting someone on their side so that they do vomit, they don't breathe it in, but you need to make sure that first responders can find the person and the person needs to get to a hospital. And again, it doesn't matter if it's opioids, alcohol, even cannabis. Sometimes people have too much cannabis and they feel very like they're passed out and their blood pressure goes really low and can't sit up. That's what emergency departments are for. They're to manage these types of situations. And the important thing is to not let somebody try and manage this alone, but to get them help. And then when I talk to parents, I'm like, well, what can parents do? First thing is to discuss alcohol use, discuss family expectations, discuss the rules, but it's important to have a family emergency plan. I did this with my own kids. It's some like, if there's a problem at a party or a problem at some social situating that you're at, whether you or someone else and you contact me, our primary priority is safety. The primary thing is to get you to safety or your friend to safety. We will discuss the issues later, but I'm not gonna scream at you for using alcohol. I'm not gonna scream at you for doing something. My first thing is to get you home and to get you safe. And I think that it's important for parents to have this conversation with their kids so that they have someone that they know that they can contact. And I extend this to my children's friends when they're in high school, is you'll call me and I will help. Or even in college, when my oldest son was in college, he did call me when there was an issue at a party. And then when it comes to parents, there is an impression that teenagers exposed to alcohol at home somehow learn to drink more responsibly. I hear this a lot. There's this idea that perhaps in France, kids learn to drink wine at home or in other settings if you have alcohol at home, it sort of improves safety. But the data actually shows that that's not the case. It shows it doesn't improve safety and it can actually backfire where teenagers drink more and they're more likely to drink heavily. Also, it's illegal. You can't do this. Providing alcohol at a teenage party is illegal in practically every state. It also increases the risk of harm to others. And that's simply also problematic. So I sort of harp on this when I do talk to parents because there is this sort of perception, well, at least if they're home, they're safe, but the data doesn't support that at all. So I'm gonna now talk beyond intoxication. And let's just talk about patterns of drug use in the past few years. So this is the data from 12th graders who've reported drinking from 1991 to 2003. And this is data from the Monitoring the Future study. So this is about 50,000 students who've been interviewed for a couple of decades, 30 years or so. And the good news is that alcohol use is definitely down from the early 90s. It was about half of people were drinking in the past month, half of high school seniors. And now it's sort of in the range of like 25 to 30%. That's the good news. The bad news is that it hasn't really changed. We've seemed to have sort of hit this sort of plateau or the ceiling, if you will, between about 2017, 2018, and now with the bump in 2020. And we haven't really continued to decrease this. And so we kind of, you know, we need to have a mission to kind of continue to bring this down. The other news that I found very interesting, this is data from 2019, is that the decrease in boys has been greater than the decrease in girls. So this is alcohol use. This is past month alcohol use, and this is past month binge drinking in boys and girls. So this is children 12 to 13, 14 to 15, and 16 to 17, any alcohol use in the past month, and this is binge drinking. And interestingly, girls are actually reporting more alcohol use and more binge drinking compared to boys, which had not happened in the past. Boys always drink more than girls, and now we're starting to see this change. So we really need to be mindful of the fact that girls are at risk here and not really decreasing as quickly as boys. And then over here, if we look at the amount of college students who are reporting getting drunk in the past month. So this is not just drinking alcohol, this is getting drunk in the past month. And the good news is, is again, this has decreased by about 23% from 1991. But once again, if we look here in about the past five years, we've really hit a plateau. It hasn't really continued to decrease that much. So we can also do more by talking more about alcohol use in high school. We need to continue that into college because we need to bring these levels down as well. And then I wanna focus on this data over here. This is again, monitoring the future data. And this is looking at kids who have had any alcohol in the past 30 days. So I'll start with the 12th graders. So about 33%, any alcohol in the past 30 days. That's about 34% of high school seniors, 20% got drunk. So out of that 34%, 20% actually got drunk, which is a pretty significant proportion. And then of those, 17% were binge drinking. And if we look at the 10th grade data, it's similar, more people using alcohol, but the number goes up in 12th grade between just simply alcohol use and binging or getting drunk. And then unfortunately we have children back here in the very early ages, in eighth grade, who report binge drinking and getting drunk in the past 30 days. So the question to me comes like, how can we figure out who these kids are? Can we figure out like who are the children who are not only using alcohol, but are also getting intoxicated or binge drinking? So this is just the same data here to remind us of it. And I just wanna remind you that the risk of binge drinking is tremendously high. It's not just the risks that I mentioned of accidents, overdose, assault. It's definitely a risk of having an alcohol use disorder. And the data is shown here. This is people who have, sorry, I need to move the slide a little bit. These are people who have an alcohol use disorder, harmful drinking, and alcohol dependence. And we don't use these anymore. We use alcohol use disorder, but we can think of this as a severe alcohol use disorder. Essentially what this data shows is that children or adolescents who are binge drinking are much more likely to go on to have an alcohol use disorder, harmful drinking, or a serious alcohol use disorder as time goes on. So binge drinking, we're talking about these kids here, their risk of developing a substance use disorder, an alcohol use disorder, as they become adults is remarkably high. And this is just data looking at age of first use and the risk of alcohol use disorder. So this is just people who already have an alcohol use disorder and how old were they when they started drinking any alcohol. And as you can see, a small percentage started drinking after the age of 21, significant number started drinking at 13, 14, 15, and 16, and even all the way up. So what we have is, you know, we need to sort of have a good sense of not only who's drinking alcohol, we need for teenagers and adolescents to have a good sense of what the risks are of that, not only the acute risks, but the long-term risks. And how can we do more for these children who are already in trouble starting in eighth, 10th, and 12th grade? So this was an interesting study that came out very recently. This is from the ABCD study. So the ABCD study is this huge study that's being done across multiple sites across the country. And it's looking at substance use in early adolescents and teenagers, and it's using a lot of imaging data. So this was a study that included children who were nine to 10 years old, about 6,000 kids, and it followed them for three years to try and figure out like who would end up using alcohol among those who were only nine and 10 years old. And it included a bunch of different measures, and there's a huge list over here, and I won't go into them individually, but they are sort of lumped together here by different colors. And the first thing that they found, actually interestingly, because it is a brain imaging study, was that the structural MRI wasn't that great at predicting who is going to use drugs and who wasn't. It was okay, but it wasn't nearly as good as demographic factors and other factors, things that we can actually measure a lot more easily than we can brain structure. So, whoa. So one of the things they found was peer use and intent to use, which is shown here in the sort of purple-y colors. And what this means is, are you around other people, your peers, who are already using substances, especially alcohol? And intent to use was a questionnaire that they had that just simply asked people about like how familiar they felt with it, how much they were fearful of using drugs, and risk of harm. It assessed the risk of harm. So what this data shows is that children who were around other people using alcohol or other drugs and didn't think that it was harmful were at risk, were more likely to be using drugs. And here in blue, we have prenatal exposure to any substance use was a large predictor. So any prenatal exposure to any substance, not just alcohol, was predictive of substance use. Over here in the blue, the light blue, we have community risk and protective factors. This was how available are drugs. You know, can you walk into a store and walk out with a six pack or not in your neighborhood? What are the perceived norms? How many people around you are using alcohol? What is the sort of like attitudes or opinions of drug use in the neighborhood? And then down here in the green, we have mental health. And these were all measures of impulsivity, urgency, different measures of impulsivity, which are urgency, premeditation, and cognition. So it looked at things like cognitive testing with respect to reading, vocabulary, and then a lot of measures impulsivity, sensation seeking, lack of planning, perseverance, and inhibitory control. As we go down the list, we have being Jewish being a large risk factor. I don't know how to explain that, although being Muslim or Mormon was not. And then age, the older the person was more likely. And then down here, I'm gonna focus at this as we get to the end. Having detention or suspension was a significant risk factor. It was actually almost as big as prenatal exposure. And I'll talk to this sort of at the end is like, you know, we sort of have right now, I could do a very fancy imaging study, which I have done to predict who's gonna use alcohol, or I can look and see who was in detention or suspended. And that's gonna give me a very, very high likelihood that this kid, so these are children nine to 10 years old, that this child is at a very high risk for not only substance use as they go on, but probably a substance use disorder over time. So I just wanna go back to, this is a study I showed you before. This is looking at binge drinkers and the risk of having an alcohol use disorder, harmful drinking, or dependence. And again, showing that having binge drinking was associated with these risks of alcohol use disorder over time. But I also wanna point out the data here. This is from that same study, and it looked at the risk factors. So being 17 or 18 was a risk factor for alcohol use, for either alcohol use disorder or for binge drinking. Smoking, so anyone who is using tobacco, smoking cigarettes was more likely to be using alcohol, binge drinking, or have an alcohol use disorder. Using any other drugs, mostly cannabis. So if somebody was using cannabis or marijuana, they were also more likely to not only be drinking alcohol as teenagers. This is adolescents, 13 to 20 year old individuals. So they're not only more likely to be using alcohol, they're more likely to be binge drinking, and they're more likely to have an alcohol use disorder. These are two measures. This is the STAI and the Zung score. These are measures of anxiety and depression. And what this data showed is that if you were more likely, if you had a higher ratings of anxiety, so they broke it down by less than 40 and over 40. This is just a scale that people fill out. Again, you had a higher risk of binge drinking and an alcohol use disorder as time went on, not necessarily alcohol use, but binge drinking and alcohol use disorder. And the same was seen with depression, that depression was highly correlated with having an alcohol use disorder. And these are people who have an alcohol use disorder by the time that they're 20 years old. So we have to be mindful of the fact that anxiety and depression are tightly correlated with the development of an alcohol use disorder pretty early on in life. And now I just wanna talk a little bit about trauma. We certainly have a lot of evidence showing that childhood trauma is associated with mental health problems and alcohol use disorder. This was an interesting study that came out in 2020. This is again, a data set, an imaging data set as from the National Consortium on Alcohol and Neurodevelopment in Adolescents. And they did FMRI, so they did imaging scans at baseline and then, I have like a hair trigger on this thing. And then they looked at cognition. So they did a bunch of cognitive testing and then they looked at follow-up for four years. These were young children when they started imaging who had a history of trauma. They looked at cognitive testing and then they looked at alcohol use down the road. And essentially what they saw was that childhood trauma, the level of severity of childhood trauma was associated with impaired executive functioning. So the more childhood trauma somebody had as a child, the more cognitive impairment they had, the decrease they saw, the changes they saw in the dorsal anterior cingulate insula. I can read off all these regions, but I can tell you these are the brain regions that are involved in sort of taking in outside information, combining it with your emotional state and making a decision, making a plan. These are the brain regions that were mostly affected. And from this, they saw that those children were at high risk of future drinking. So again, childhood trauma led to cognitive dysfunction, changes in the brain, and then increased risk of future high-risk drinking as they followed them over the four years. And this is a recent review paper that came out. I think it's a very nicely done review paper that tries to look at what is the changes that happened in the brain? What are the changes that happened in the brain that makes somebody more likely to use alcohol? And what are the changes that happened in the brain that changed the brain? Because it's really hard to say, like we have changes that happen in the brain. Some of them predate alcohol exposure and some of them come after the alcohol exposure. So what they saw when it came to what predates, what are the risk factors for alcohol use? They had impaired cognitive inhibition, impulsivity, and deficits in executive function. So kids who are having impulsive disorders and cognitive dysfunction are more likely to use alcohol as they're followed over time. And they looked at the changes of the brain. Right here in blue, these are the changes that predate alcohol use. So we have here the cingulate and we have the dorsolateral prefrontal cortex. The cingulate is the part of the brain that's sort of deep in the brain, deep in the midline. And what it does is it takes sort of like your internal state, like for example, how hungry somebody is, and compares it to the environment, which is, okay, right now I'm supposed to be in this training, and then makes a plan. Do I stay in the training and put off my hunger because I'm going to be able to eat in about an hour and a half? Or do I turn off my camera and go eat? So it sort of takes the internal environment and the external demands and helps make decisions. So the cingulate is clearly involved in practically every psychiatric disorder. Then they also saw changes in the dorsolateral prefrontal cortex. This is sort of involved in planning and working memory. This is the part of the brain, if I give you a phone number and you can remember it, that involves this part of the brain. And then the orbital frontal cortex, which is really involved in sort of determining the value of a reward. And then when they looked at changes that happened after alcohol use, these are the things that were a result of alcohol use. We start here with the temporal lobe, sort of in the lateral temporal lobe. This is the amygdala and hippocampus. This is clearly involved in memory. The hippocampus is all the memories in and all the memories out. It's sort of like the door that opens up and lets memories in and lets memories out. And the amygdala is involved in fear and anxiety. So these were the changes that they saw after alcohol use. And then they also saw changes in the prefrontal cortex, sort of shown here in pink. This is the medial prefrontal cortex, also involved in learning memory. The green changes here were changes that were involved in functional MRI changes, sort of like connectivity. And the ones I was showing you, the blue and the red, these are changes in gray matter. This is actually changes in brain tissue. So some of the functional changes were overlapping and they saw a lot of changes in the parietal cortex, which is sort of the part of the brain that sort of keeps track of where you are in space and keeps track of the external environment. So to put this in context, what can we say? What we can say is that if we have changes in the cingulate and the prefrontal cortex, so if we have changes in impulsivity, changes in cognitive function, or let me say that differently, impaired cognitive function. So kids who are struggling with impaired cognitive function are at a high risk of using alcohol. And then after they use that alcohol, they're at high risk of having that impairment worsen across different tasks. So on that note, goodness gracious, on that note, I'm going to talk about ADHD. Because when we think about impulsivity and cognitive control in adolescence, one of the top of the things that comes to the list is ADHD. And I feel very passionate about ADHD because I can tell you after doing this research, doing this work for 30 years, the number of people who come in to see me who either had ADHD that was unrecognized and untreated as children or have it now is about half of people, depending on the substance I'm looking at. When it comes to cannabis, it's about half of people. When it comes to cocaine, probably about half as well. And this is the data, this is shown by the data. So this is data from 2011, but it has been replicated many times. And what it shows is that kids with ADHD are much more likely to be using drugs and they're much more likely to develop a drug problem over time. So one here is an odds ratio. This is the likelihood of alcohol use or dependence to a drug if you don't have ADHD and above this is with ADHD. So kids with ADHD are much more likely to be using alcohol. They're much more likely to have an alcohol use disorder. They're more likely to use cocaine. They're more likely to use nicotine. They're more likely to use cannabis and they're much more likely to have an addiction to those disorders. And it's really actually remarkably profound that we know how to intervene. I'll talk more about this. And that I know that a child with ADHD who's struggling and who's not being treated is more likely to see me down their roads versus kids who aren't. And this is data looking at ADHD in kids who have conduct problems and those who don't. So I'll talk a little bit more about this in a minute, but kids with ADHD, some of them are much more likely to have conduct problems. So ADHD isn't just sort of like, you're not paying attention in class and needing extra time on a test or the problems that happen in the classroom with the test scores. Kids with ADHD tend to have, some kids with ADHD a significant proportion have a lot of social problems as well. A lot of difficulty getting along, not only with their peers, but also with their parents and with school personnel. And what this data shows is that, if you've ever used alcohol as ADHD alone, and this is ADHD combined with conduct disorder. And as you can see, the risk is not, the risk with ADHD is pretty high, but if you add on conduct disorder, the likelihood that these children are drinking or have been drunk is remarkably high. But this is sort of the good news. The good news about ADHD is that we can treat it. And this is just some data looking at treatment of ADHD with stimulants. And sometimes I like to go back in history. I'm a big history fan. And this was a study that was published in the 1930s. It was published by a physician named Charles Bradley who was at a hospital in Rhode Island. And this hospital in Rhode Island was for children who had behavioral problems. They had to be cognitively normal to get into the hospital, but they had behavior problems and they were sent to live there because of their issues with getting along with other people. And at the time in the 30s, benzidrine, which is amphetamine was very, it was being used a lot. People using it for allergies and sinuses and headache. And he gave it to children with headaches. And what he saw and what he reported was an improvement in children's performance at school in about half the kids. But in practically all of the children, he reported a behavioral improvement. And I just point this out because I wanna, you know, I always point this out, especially to parents. And when we talk about ADHD, we always focus on the academic function. And actually the data with stimulants and ADHD, treating with stimulants and ADHD and academic function is a little plus minus. There's an improvement in classwork. There's an improvement in grades, but it's not that profound. What is remarkably profound is the improvement in social function. So kids with ADHD, when they're treated with stimulants, they have improved social functioning with peers, educators, and parents. And there's even studies that show they have improvement in theory of mind and empathy. Just sort of giving, it was sort of like reducing that impulsivity, actually makes them more adept at social cognition. And this is the data, this is a meta-analysis looking across a lot of studies. And it's looking at the effect of stimulants versus placebo in kids with ADHD, but who also have aggression, oppositional behavior, and conduct disorder. And what it shows is a significant improvement. All of the studies show an improvement with stimulants versus placebo. And so I do talk to parents a lot about the importance of treating ADHD, and I can go into that more. The data definitely shows that treating ADHD with stimulants is protective. There's issues with stimulants. A lot of people have side effects, and that's a whole nother discussion. But the first message is that treating ADHD with medication is protective. And this is the data showing this. So this is data with kids with ADHD who are treated with medication. And what this shows, I know this is kind of a busy slide, but all the kids had ADHD, and they look to see who is using alcohol. This is two-week binge drinking, cigarette smoking, cannabis use, cocaine use, and any substance use. And essentially what this data shows is if you have a child with ADHD, and they're treated with medication, stimulant medication, at age nine or younger, and if it's consistent, meaning not stopping and started, stopping and started, the likelihood that they were drinking, binge drinking as a high school senior is 22%. And that's the same as population control. So if you treat a kid with ADHD with stimulants, you can make the likelihood that they're binge drinking in high school the same as kids who don't have ADHD. The data isn't as good as if you start treating later, especially if you start treating around age 15 or older, about 40% of kids are binge drinking versus those without ADHD is only 20%. So we really need to do a better job of getting parents to understand that we have to start protecting kids earlier with ADHD. And I know it's difficult to get the prescriptions and the shortages and all this type of stuff, but it is really incredibly protective. And then I just wanna talk a little bit about oppositional defiant disorder and conduct disorder. These are disorders that are often viewed as, I can tell you people don't wanna treat them, psychiatrists don't wanna treat them. It's a little tough, but they really are psychiatric disorders. Oppositional defiant disorders characterized by defiance, vindictiveness, threatening behaviors, spitefulness, and disruptions at work and school affects about five to 7% of kids. Conduct disorders, aggression towards others, destruction of property, violation of rights and norms, and it's about five to 7% of kids. It's important to realize there's a lot of overlap between ADHD, oppositional defiant disorder, and conduct disorder. About half of kids with ADHD have these disorders. About half of kids with oppositional defiant disorder or conduct disorder have ADHD. Impulsivity is a key feature of both of these, but so is impaired social functioning. And so if you look at the data, this is kids with, blue is data with no disorder, red is ADHD alone, and green is ADHD with conduct disorder. And as you can imagine, they have a lot of trouble with keeping, making friends, trouble with police or being suspended, being held back in school. And as you can imagine, a kid who's experiencing social problems, which comes along with social isolation, discovers something like alcohol, it can definitely make them feel like a lot, A, feel a lot better, and B, often find a group of people who are more accommodating. And if you have difficulties with social skills, alcohol is very popular because it makes people feel more social. It makes you less aware of any social inhibitions you have. So you can imagine if you're having a hard time getting along with other people, alcohol is sort of very welcoming because it makes you feel less obvious about it. It doesn't make it better, but it makes you less aware of the problem. And then this is just an interesting study that I wanted to point out. It's actually a study from 1997. It's largely been forgotten, I think, by clinicians and neuroscientists, but it was a study that looked at conduct disorders. So these are kids who really are having, who's struggling a lot. And essentially all it showed was that kids who had conduct disorder, who were treated with methylphenidate had an improvement in their antisocial behavior versus those with placebo. So it just, again, sort of shows that we're talking about kids who have conduct disorder, a lot of disruptiveness at school, that treating with stimulants can be helpful. So I'm going to sum up this section and then move on to the next section. So what do we know so far? Well, first thing, alcohol use has declined among adolescents, but there are still significant risks. A lot of those risks, as I mentioned, we've kind of hit a plateau in the decrease in alcohol use. We don't see it continuing to decrease. And so we need to do more to keep that going and to try and keep that decrease going down a little bit lower. Alcohol use at a young age is very hazardous, not only associated with greater risk of harm, but a greater risk of alcohol use disorder. Binge drinking is a warning sign for a future alcohol use disorder. And then what were the predictors that we saw of early use in binge drinking? There was peer use, if you're around a community that's using, and intent to use, meaning sort of translating into a familiarity, for example, with alcohol, sort of not risking it as being harmful or risky, but sort of viewing it as sort of just a part of life. That's sort of the intent to use here. Prenatal drug exposure, community risk and protective factors. This was sort of like, you know, in your community, is there access to alcohol and other drugs? Are there resources? Are there neighborhood cohesiveness? You know, does your neighbor notice if you're not coming out of your house? Does your school notice that if you're missing school? And then mental health. You know, the risk factors for early alcohol use and binge drinking include ADHD, oppositional defined disorder, conduct disorder, depression, anxiety, and PTSD. And then I just want to return to the detention suspension question. As I mentioned, when we're looking at kids who are at a high risk of misusing alcohol, of using alcohol at all to begin with, and developing an alcohol use disorder, we have kids who have a history of detention suspension. And I know that we often, you know, these children are often sort of viewed as being, you know, the bad kids. Other parents don't want their kids to play with them. But the data also shows that kids with a mental health problem are more likely those who are going to be suspended. So when we're talking about children who have detention or suspension, it's really worth doing a mental health evaluation on these children. Because the likelihood is that they may have ADHD, even depression, PTSD. The only mental health problem here that I listed here that's not associated with an increased risk of detention or suspension is actually anxiety. All the other ones are much more likely, kids who have these disorders are much more likely to have a history of detention or suspension. And so we have, you know, as I mentioned, we can do a big expensive imaging study, or we can look and see who has been suspended or has detention in terms of looking at risk factors. So I just want to switch a little bit and talk about what does self-medication look like. This was an interesting study. This was a large study looking to see when do psychiatric disorders develop? At what age do psychiatric disorders develop? So over here, it was many studies combined together in this meta-analysis. And what this shows is that this is any psychiatric disorder, any mental health disorder. And what it shows is at age 14, between ages 14 and 30 is when the most likelihood is of developing of a psychiatric disorder. And actually this has been shown in other studies. It's like if you're going to develop a psychiatric disorder, whether it's depression, anxiety, or anything else, the likelihood that you develop before the age of 25 is pretty high. So this is the average age for mood disorders is 20, shown here. And over here, anxiety disorders, there's a peak at age five, and then another one at age 15. And this is a likelihood. This is substance use disorders. The most common age to have a substance use disorder develop is 19. And I can tell you is that I don't see very many 19-year-olds. People don't come to see me until they're usually in their 30s and 40s. And so this disorder developed at 19, and I'm trying to do something about it 20 and 30 years later. So we need to do more, as I mentioned, for prevention. And we need to think about what a self-medication looks like, because what this data is saying to me is that children are developing these different psychiatric disorders. I should have included ADHD and ODD on here. And what's easier to get is a substance. Alcohol is a lot easier to get than mental health treatment. And the same applies to cannabis and nicotine. So a lot of kids who are using drugs, especially alcohol, and especially in a way that is regular or hazardous, are probably self-medicating. And what a self-medication looks like, drug use alone, a child using drugs alone is probably self-medicating, meaning that they're using drugs to address a mental health problem. Missing school, drug use at school or missing school, drug use that interferes with academic performance, drug use that's triggered by stress, drug use that is used to make somebody feel more socially comfortable, and drug use that increases over time. Because one of the things about self-medication is it tends to increase over time. And the important thing to realize about self-medication, whether you're an adolescent or not, is that most people don't recognize it. So let's say somebody has ADHD and they're using alcohol to sort of feel less stressed and to feel sort of that less sort of underlying anxiety that often comes with ADHD, sort of this underlying agitation. They might not even put together that alcohol is helping that feel better. They might know that alcohol is having an effect. They might know that they're feeling distracted and all this type of stuff, but oftentimes people don't recognize self-medication in themselves. They might know it's relieving stress, but they might not see it as self-medicating. And that's why it's important for outside people who can see these things going on to have these open discussions. And so I often get this question mostly from teenagers, what's the problem with self-medication? Usually, well, why can't we use cannabis to treat anxiety disorders? And there's a few reasons. The first reason why we can't use alcohol or any other drug as self-medication is because when the effects wear off, the symptoms come back. So let's say somebody is using alcohol because they have a social anxiety disorder and they feel less socially anxious. They will feel less anxious at the time that they're intoxicated. But once that intoxication wears off, the anxiety is gonna come right back. So this is why alcohol or other drugs don't work as self-medication because they only have that self-medicating effect when the person is intoxicated. So when the intoxication's gone, the next day, the symptoms are right back. Self-medication can definitely make disorders worse, especially depression, anxiety, and ADHD over time. I should say it can make disorders worse. This is probably most shown with alcohol. Alcohol use definitely over time will not improve ADHD, anxiety, depression, or any other disorder. And then of course, there's a risk of developing an alcohol use disorder. So if you're using alcohol to feel less anxious, the likelihood of an alcohol use disorder is much higher. And that's because psychiatric symptoms can't be controlled. I can't just say, oh, I'm only gonna feel anxious after work on a Friday. They happen all the time, day, night at school. And so self-medication tends to lead to increased drug use because psychiatric symptoms are happening at all these different times. And then I just wanna point out, among teenagers and adolescents, as I showed you with that data, like the average age of developing a substance use disorder is 19, which means there's a significant number of people who are in the 16, 17, 18 year old range who already have a substance use disorder. And these are the DSM-5 criteria for substance use disorder. And I'm not gonna go over all of them in detail, but I just wanna point out that a mild, there's these 11 questions, a mild is yes to any two or three of the 11, moderate four or five, six or more is a severe. There are a number of children in our schools, teenagers who will meet criteria for mild substance use disorder, and they don't know it. So one of the things that when I talk to kids is I talk about what does a substance use disorder look like, I go over the different symptoms, any drug use interferes with schoolwork, missing or skipping school, giving up on a passion. Lots of times kids don't think about it, but like somebody used to be on the yearbook club or on a soccer team, and now they're not. And if they're not because of their drug use, that's the warning sign for a substance use disorder. Any drug use is triggered by craving is a warning sign or a symptom of a substance use disorder. Drug use increases risk of an accident. So if somebody has been drunk driving, that's already a symptom of having a substance use disorder. That's one, and you only need one or two more to have a substance use disorder. So this is a big one. Anyone who's used alcohol under the influence of driving or any of these other things already has a warning sign of a substance use disorder. And then, you know, tolerance is a big one. Like people don't realize how quickly tolerance develops. Tolerance to alcohol develops really quickly and people don't think that they have tolerance, but they often do. So you can ask, how does your current use compare to one month ago or six months ago? Are you spending more than before? Anyone who's using daily or near daily has tolerance to any drug. That's sort of just a given. And then if anyone's ever taken a drug holiday, which sometimes people will decrease their use so that they can get more of an effect down the road. Of course, the issue with drug holidays is usually when people take a drug holiday, let's say they try and drink less so that they don't have to drink as much to get intoxicated down the road, is they usually replace that drug holiday with another drug. And then withdrawal. You know, we often think about withdrawal, drug withdrawal as being like on movies and stuff where people are sort of extremely ill and sick, but withdrawal can be very subtle. Sometimes people just feel like irritable and fatigue and a lack of sleep. Oh, I thought I had one more slide, but I do not. And I just want to leave time for questions. I just wanted to add, this is my lab. If you want to find me, I'm sure you can find my email address, but if you look up Tiana Martinez Columbia, it will pull up my website and my email is there. And again, I just wanted to thank SAMHSA and ORN for funding me. And a couple of other websites I'd like to point out. One is the Trevor Project. I didn't talk at all actually about LGBTQ plus youth. I think that this is a very important special population. Trevor Project has remarkable resources for this group. And then when it comes to ADHD, there's two resources online. One is Attitude Magazine, ADT Attitude Magazine, and the other one is Chad. Attitude Magazine has phenomenal resources for parents and educators when it comes to ADHD. And with that, we just have our QR code for our survey and I am happy to take any questions. I know I talked a lot. I mean, I'll start off, as you correctly said, many parents are reluctant to put their children on ADD medication, even when they know the research, because they're worried about the side effects. There's a myth that if they start on medication, they're gonna be more likely, and you can show them the stats, but no parent likes their kids to be on medication unless it's life-saving. What do you say, besides the research, are there any really simple analogies that you can think of to convince people to start early? That's a real, I can tell you, I give talks to schools. I've given talks to schools, private schools on the East side, and I've given talks around the corner where I am in Washington Heights, and I hear the same thing from parents. And it's just amazing to me that we are sort of battling against this. And there's a few things that I say. The first thing that I say is that, I've been doing this for 30 years, and I can tell you when somebody walks into my office and they have a substance use disorder, I can bet it's 50-50 that they had ADHD as a kid. Now, let's say that I could do that for breast cancer or Alzheimer's disease. Like, let's say I knew a risk factor that reduced your risk of breast cancer or Alzheimer's disease. Would you do something about it? And everybody says, yes. So sometimes I'm very blunt about it in that way. Like when it comes to the health of a parent, we are all very wary of these sort of like major disorders. So I kind of put in that context sometimes if I'm being very blunt. And I say to them, I understand the reluctance. And I also tend to point out that most of the data shows that it's not so much the schoolwork that improves, that does improve. But if you can improve your kid's ability to get along with other people, if you can improve their social function, you are giving them the gift of a lifetime. Because that's what the teenage years are about, right? That's what high school is really about. High school is about figuring out how to negotiate the world outside of home. And by treating them, you are giving them the ability to do that better because that's where the data is strongest. I also sometimes add that if you have a kid with ADHD and you treat with stimulants, you decrease the risk of suicide and you decrease the risk of obesity and you decrease the risk of depression. So I hit that hard when I talk to parents. So risk of suicide, obesity, what was the third? Stimulants decrease the risk of suicide, obesity and depression. Okay, thank you. And also you explained that the combination of alcohol and marijuana together increase the risk of overdose. Could you just explain exactly how that happens? So I don't think we know exactly how that happens as from epidemiological data. Like when I talk to teenagers, I always hear, you can't overdose on marijuana. I'm like, well, that is true. We have no reported overdoses on cannabis alone. But combined with alcohol, there are, you're more likely to overdose on alcohol. And I think part of it is simply, I don't know that it's a physiological measure, it may be. I honestly think that the likelihood is just losing track of how much alcohol you've had, not sort of like being aware of how intoxicated you may be feeling and taking in more. I think it's more of a perception problem and an ability to sort of like view yourself from the outside and realize that you're getting into trouble. But I may be wrong. I don't think we know yet if it's something, if it's a physiological interaction, or if it's more of a sort of loss of control issue. Okay, we've been told by some physicians that because marijuana reduces nausea, that it may inhibit the vomit reflex that would normally occur when you're drinking too much. Do you agree with that? That to me is physiological plausible, makes sense. I haven't seen any data to support it, but it certainly makes sense. Okay, thank you. Any other questions? I have a question back to the alcohol, I'm sorry, the ADHD discussion previous. So isn't it true that anxiety tends to be a comorbidity of ADHD among adolescents and children? And hypothetically in this discussion, would that play into the medic recommending medication? Like what does that look like? And if you're talking to parents and this comes up. So you have the issue, certainly, you know, as I mentioned, stimulants for ADHD is lifesaving, but it does come with, it's not easy. First of all, you're getting the prescription, it's a controlled substance, getting it every month is difficult, but there's also a lot of side effects. Kids often have side effects. And among them is sort of like this nervousness and agitation and insomnia and an appetite loss. That's the bad news. The good news though, is that there are a lot of preparations now of stimulants. Like there's one, I forgot, I think it's called Journey. It's like a jawbreaker, it's really hard. You take the night before, so it releases very slowly. There's now an amphetamine patch. So there are ways to get around those side effects. It does take a lot of work. It's not easy. And it takes parents sort of like being like, you're going back to the doctor a lot and making changes. There is also data with guanfacin. So guanfacin is not a stimulant and it's used at nighttime. I think it's underused, frankly. It really helps a lot with sleep. And there's some data, especially in children showing that it can reduce anxiety. So some psychiatrists use it just for anxiety disorders on its own, not even for ADHD, even though it's FDA approved for ADHD. So I would definitely consider guanfacin at night for kids who have ADHD with anxiety. And then if a kid really can't take stimulants and, or the shortage is profound or whatever, there's adamoxetine, which is not a stimulant, but related to those, that could also be used as well. So there's lots of different preparations of stimulants to try and get around side effects and there's guanfacin and adamoxetine. And clearly adding behavioral treatment to stimulant makes stimulant treatment even better. But the data is pretty clear that we need to have stimulants on board. Will you be making your slides available? Absolutely. Oh, wonderful. Okay, so we can request those. Thank you so much. Yeah, I will send the slides and I'm stopping there.

substance abuse

alcohol

ADHD

self-medication

early intervention

psychiatric disorders

social functioning

overdose

proactive intervention