|CLINICAL CASE CONFERENCE
|Year : 2016 | Volume
| Issue : 2 | Page : 129-133
Early-onset heroin use and its link to conduct disorder: Clinical and management challenges
Shobhit Jain1, Raman Deep Pattanayak2, Rachna Bhargava2, Anju Dhawan3
1 Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
3 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Nov-2016|
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Childhood substance abuse and delinquency often progress to harder substances and antisocial personality disorder and carries deleterious consequences for self, family and community at large. Early management of such cases poses several clinical and management challenges, as highlighted in the present case. The treatment seeking for this sub-population is very low in spite of community surveys showing a worrisome pattern of substance use among younger population. Further, very few specialty clinics and trained manpower exist in the country to manage early onset substance use. Whether conduct disorder be cause or consequence for drug use is debatable, in view of shared risk factors. The present case helps to understand need for comprehensive assessment for identifying risk factors and comorbid conditions. Only pharmacological management does not help, psychosocial management must be delivered. Several prevention strategies may also help if these risk factors are identified before progression to illicit substance use disorder.
Keywords: Adolescent, conduct disorder, management, opioid-related disorders, substance abuse
|How to cite this article:|
Jain S, Pattanayak RD, Bhargava R, Dhawan A. Early-onset heroin use and its link to conduct disorder: Clinical and management challenges. J Mental Health Hum Behav 2016;21:129-33
|How to cite this URL:|
Jain S, Pattanayak RD, Bhargava R, Dhawan A. Early-onset heroin use and its link to conduct disorder: Clinical and management challenges. J Mental Health Hum Behav [serial online] 2016 [cited 2019 Mar 21];21:129-33. Available from: http://www.jmhhb.org/text.asp?2016/21/2/129/193434
| Introduction|| |
Children and adolescents constitute only a small percentage of treatment-seekers in drug dependence treatment settings (≤15 years: 0.4% and 16-20 years: 4.6%).  Community surveys in India suggest that tobacco, alcohol, and cannabis are prevalent substances of abuse among adolescents, but opioid use is relatively rare (about 1 in 1000). Heroin use was seen in 3.3% of drug-using adolescents in contact with Nehru Yuva Kendras across the country. ,
The presence of certain risk factors may increase the likelihood of early-onset illicit drug use in some individuals. The odds of developing drug dependence increases 5-fold in the presence of conduct disorder and 10-14-fold if both conduct disorder and antisocial behavior are present. 
Adolescents who began using drugs at earlier ages have greater drug use and other problems.  Studies have described the progression of patients with conduct disorder and substance use disorder to antisocial personality disorder. ,
We discuss the case of an adolescent patient with early-onset heroin dependence occurring in the presence of conduct disorder, with an early-onset and rapid progression from licit to illicit drug use.
| Case Report|| |
Patient, Master K, is a 15-year-old, school drop-out, from the nuclear family of lower socioeconomic status from New Delhi. He presented to the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi, along with his mother. The chief complaints revealed an initiation of beedi use at 6 years, ganja (marijuana) use at 9 years, inhalant use at 11 years, and smack (heroin) use at 12 years of age. In addition, the patient was involved in antisocial activities since childhood.
The patient initiated beedi while studying in Class I (at 6 years of age) in the company of older boys. He did not have much interest in studies, found cheating in the examination, and was not promoted to next class. In the coming year, he started to run away during school hours to spend time with older boys involved in pickpocketing and stealing. The patient, being the youngest, was trained to pick out purses and mobiles from bus passenger's pockets and he would do it mostly for enjoyment. He would hand over the stolen money to older boys, who would reward him with good food or movie show. He was using 10-12 beedis/day by this time. The patient would often get in a verbal and physical fight with his classmates, at times hitting with stick or stone. After nearly 2 years, family members came to know of his tobacco use and school truancy, following which he was scolded/beaten. At the age of 9 years, he experimented with ganja along with his friends. He enjoyed its pleasurable effects and started smoking 1-2 ganja-filled cigarettes daily. With time, the dose and frequency of use increased and, eventually, he started purchasing it directly from drug sellers in the area. Due to lack of interest in studies, he left the school after Class V and continued pickpocketing with his drug-using peers. His ganja use increased up to about 7-8 cigarettes per day.
At the age of 11 years, he tried huffing inhalants (diluent fluid) on being offered by a friend. He would use one bottle/day in divided doses, which increased to two bottles/day over 6 months to get the same effects as previous. After starting of inhalants, his beedi and ganja use continued in the same pattern as previous. His daily drug expenditure was about Rs. 100/day, easily available from pickpocketing. He would often come home late and skip dinner with family. He was regularly beaten up by his father, and his mother would occasionally hide the incidents related to drug use from his father. As father perceived the mother to be overprotective, parents began to have frequent conflicts with each other. His younger siblings started to blame the patient for parent's conflicts and often comment on his drug use, which would lead to fight among them. This led to familial dysfunction. There were several incidents of running away from home for a period between 2 and 6 days after a fight. His parent tried to send him to ancestral home at village, but each time he would return back to Delhi on his own.
At the age of 12 years, he chased smack (street heroin) out of curiosity with a friend. He felt dizziness and vomiting immediately after chasing but liked its pleasurable effects immensely. He started chasing a small packet worth Rs. 50 on a daily basis, purchasing it from a peddler in their locality. Gradually, he started using smack worth Rs. 300/day after a year and Rs 600-800/day after 2 years of starting it. Whenever his parents would lock him at home, he would develop severe withdrawals which resolved only after smack use. Due to his drug use and other behavioral problems, his mother left her job and father had to miss days from wage work. After initiating smack, the inhalant use decreased to 2-3 times/month only, but beedi and ganja use continued as previously. His pickpocketing also continued and, a few times, police arrested him though no case was filed. Father's drinking increased to almost daily evening (about a quarter of country liquor) over these 2-3 years, which he attributed to stress/conflicts due to patient's behavior.
Due to his uninterrupted drug use, family members forcefully admitted him twice in a private deaddiction center for a month's time each. He relapsed soon after discharge both times. Thereafter, parents would often cry and show their disappointment to the patient. Sometimes, they would express their wish to end their lives if patient's drug use continued. Furthermore, during this time, the patient had three seizure episodes (not investigated/treated) over 3 months. Around this time, the patient agreed to make another effort to remain drug-free but was unable to control his craving and discomfort. His mother would bring him some unidentified medications from a local pharmacist to get relief, after which he was able to reduce the dose of various substances (current pattern at presentation: 5-6 beedis, 4 ganja-filled cigarettes, and 2 small packets of smack). Thereafter, his parents brought him to the Adolescent Specialty Clinic, NDDTC.
There is no other family history of substance abuse (except father's alcohol dependence) or psychiatric illness. The patient's birth and developmental history was unremarkable.
In childhood history, beginning from the age of 6 years, the patient had school truancy, initiated frequent fights with classmates, including serious injuries to others, disobedience of family members, several incidents of running away from home, stealing money, association with drug-using friends, involvement in antisocial activities, and involvement in gang activities to take revenge from people considered to be his enemies. There is no history of cruelty to animals or fire-setting. No history of sexual contact or high-risk sexual behavior is reported by the patient.
General physical and systemic examination revealed no abnormality. The patient was cooperative for interview but was noticed to be fidgety, restless, and staring toward the floor. Eye contact was made but ill-sustained. Affect was euthymic. Ideas of guilt and remorse were expressed in thought content sample. Higher mental functions were intact. Assessment of motivation indicated action phase.
An ICD-10 diagnosis  of mental and behavioral disorders due to the use of opioids dependence syndrome (F11.22), tobacco dependence syndrome (F17.22), cannabinoids dependence syndrome (F12.21), volatile solvent dependence syndrome (F10.21), and Socialized Conduct Disorder (F91.2) was made.
The patient was admitted for further assessment and management. Hemogram, liver, and kidney function tests were within normal limits. Urine drug screen revealed cannabis use but was negative for opioids and benzodiazepine.
The patient was initiated on tablet buprenorphine 1.2 mg/day in divided doses, tablet diazepam 5 mg/day nighttime and nicotine gum replacement. The patient was physically comfortable with no withdrawals. On the 2 nd day of admission, he had a generalized seizure episode witnessed by mother and nursing staff. Neurology consultation was sought and both contrast-enhanced computed tomography brain and electroencephalogram came to be normal. Tablet valproate 600 mg per day was started as advised by neurologist. The seizure did not recur and the patient could be slowly tapered off the buprenorphine tablets in the next 10 days. In long-term pharmacological intervention, the antagonist therapy was discussed with patient and family members. Tablet naltrexone 50 mg/day was started after 3-day opioid-free interval, and parents were advised to supervise compliance and regularity of follow-ups. Nonpharmacological interventions were initiated during the ward stay, with a plan to continue them long term, as follows [Table 1]:
|Table 1: Early-onset substance use disorders in patients with conduct disorder: Psychosocial interventions |
Click here to view
I. Psychoeducation sessions were taken regarding substance use and its long-term consequences, nature of addictive disorders, physical and psychosocial complications, etc
II. Motivation enhancement sessions: Patient was encouraged to identify some negative events in his life such as loss of reputation, conflict within the family, punishment, arrest, and helped him to relate those with his substance use. An attempt was made to develop discrepancy between what the patient desires/wishes and what his substance use is leading to. The patient was able to understand and agreed with the treatment team but attributed his drug use to unavoidable peer pressure. The patient was initially of the opinion that he would be able to abstain only by staying in his ancestral village, away from the current environment. Care was taken to avoid direct argumentation with the patient, and this point was noted to further discuss it in future if required. The patient requested for ways to help make him abstinent. He was reassured and affirmed so as to support his self-efficacy. The need for staying in treatment was explained to him. His self-efficacy was also enhanced by giving examples of other patients who sought treatment and were able to abstain, conveying that staying abstinent was possible with treatment contact. All the sessions were conducted in an empathic manner without being judgmental about the patient's substance use or lifestyle
III. Relapse prevention sessions: Initial sessions were held for identifying high-risk situations such as people, places, paraphernalia, time of day, unstructured time, and peer pressure which facilitate drug use. Most of the situations were identified from the history, of which peer pressure and internal urges figured prominently. Further sessions focused on equipping him with requisite coping skills to handle these situations. For craving management, repeated sessions were taken to rehearse him to delay, distract, deep breathing exercises when the urge occurs. The patient was educated about relapse being a process as opposed to an event and to identify the early warning signs of relapse. Separate sessions focused on understanding and developing skills to deal with craving and skills to handle with social or peer pressure to use substance
IV. Family sessions: involving both parents focused on psychoeducation, parenting style modification (from punishment to differential reinforcement, avoid criticism, functional optimism), change of home environment, with a view to improving the relationship with siblings and addressing parental conflicts
V. Structuring of daily routine after discharge and vocational skill development plan was discussed.
Apart from two minor incidents, the patient was largely cooperative for treatment and followed staff instructions during ward stay. The patient was discharged within a month, with a plan to continue antagonist medication and psychosocial intervention sessions on an outpatient basis.
| Discussion|| |
Several issues need to be highlighted in this case, which are relevant for management. These include a very early onset of licit substances, rapid progression to illicit drugs, diagnosable conduct disorder, deviant peer group, absence of an alternate, nondeviant peer group, school drop-out status, low socioeconomic status, inadequate supervision by parents due to their involvement in daily wage work, conflict between parents, regular alcohol use by father, high accessibility for drugs in his surrounding, and comorbid seizures.
At times, it is difficult to say whether conduct symptoms are a cause or a consequence of drug use. In a study by Morihisa et al.,  the onset of tobacco, alcohol, and marijuana use was generally earlier than the first robbery and/or theft. Conversely, crack and hallucinogen use usually happened after the onset of illegal activities. As for inhalants, the number of youths who used it first, having robbed/stolen later, and the number of those who first robbed/stole, having consumed it later, were approximately the same. Many studies have mentioned drug use as a consequence of conduct disorder. , There appears to be no consensus in the international studies, whether engagement in illegal activities is the cause or consequence of drug use. However, there is a general consensus among almost all studies that patients with conduct disorder had an earlier onset of drug use. ,,, Similar findings have been observed in this case with conduct disorder whose age of onset of tobacco, cannabis, and heroin was much earlier than findings in the national survey on pattern and profile of child substance use.  Studies have also positively associated between severity of conduct disorder with severity of drug use and related problem. ,
The evidence from several familial, genetic, and electrophysiological ,,,, studies has found an association between conduct disorder and substance use disorder. Genes related to chromosome 2p14-2q14.3 have been identified in common to drug use disorder and conduct disorder. Further, it has been demonstrated that GABRA2, a gene associated with alcohol dependence, is associated with conduct disorder symptoms and externalizing behavior in adolescent, providing evidence that variations in one gene can manifest as different conditions at different stages of the life cycle. ,
The first large-scale nationwide survey (NDDTC, AIIMS, New Delhi, and NCPCR) for pattern, profile, and correlates of substance use among Indian children (n = 4024 children, including school-going, out-of-school, and street children across 135 sites, 25 states), found that the mean age of onset was lowest for tobacco (12.3 years), inhalants (12.4 years), cannabis (13.4 years), and alcohol (13.6 years).  The use of harder substances (e.g., opium, pharmaceutical opioids, heroin) was later in the course of progression (14.3-14.9 years) and then, finally, use of substances through injecting route was reported at 15.1 years. These findings support the progression of substance use consistent with the gateway hypothesis.  Similar pattern was noted in this patient, albeit with an early onset and much rapid progression.
Involvement with substance-using peers represents a strong risk factor associated with increased substance use among young people. Three major theories have been proposed to explain the relationship between adolescents' own substance use and peer substance use, which include peer socialization model, , peer selection model, ,, and bidirectional model.  In the present case too, the patient got engaged in a deviant peer group before the onset of illicit drugs.
There were several reasons why antagonist medication trial was preferred as the first trial in this patient. Agonist medication is often dispensed only to adults as a general policy, due to concerns about starting youth on treatment that is often long term and reluctance to bring young patients into daily contact with adult patients with extensive addiction histories and antisocial behaviors. As per guidelines by Handford et al.,  agonist medication may be considered for adolescent patients with early onset of opioid dependence, severe dysfunction, engagement in high-risk and antisocial behaviors, and poor motivation to quit. Agonist maintenance may be considered for adolescents whose age is at least 16 years or above, opioid use ≥1 year, and two documented failed attempts.  Very few reports or studies are available till date on long-term buprenorphine maintenance for adolescent opioid users  and only one prior study till date has described the use of naltrexone (antagonist) in adolescent opioid dependence.  Naltrexone dose of 50 mg/day has been found safe in 16-18-year-aged adolescents with alcohol use disorders.  A Cochrane Review on databases from 1966 to 2008 for randomized or controlled trials for the effectiveness of any maintenance agent in adolescents found it to be inconclusive. 
In this case, considering factors such as early onset of drug use, rapid progression to dependence and illicit substance use, conduct disorder, and living in slums with high availability of illicit drugs, long-term plan of opioid agonist maintenance may have been an option. However, considering other factors such as young age, good family support, short-duration use of opioids, motivation for quitting drug, and first self-motivated treatment attempt, a long-term plan of opioid antagonist treatment was considered first.
The management of such cases includes a strong focus on the psychosocial interventions. Failure to address psychosocial issues will reduce the chance of successful treatment and increase the risk of relapse.  Many interventions have been suggested in previous studies on drug using conduct disorder patients, namely CBT, family therapy, behavior therapy as contingency management.
Family therapy should definitely be a component of any treatment program for the youth based on its superior efficacy. , The evidence favors family and parenting interventions for adolescents with conduct disorder. Multisystemic therapy is one of the most extensively validated and widely transported evidence-based psychosocial treatments which address various factors which are associated with substance use and conduct disorder. Contingency management has been shown effective treatment of adolescent substance abuse in an integrated study of evidence-based practices. 
The outcome of such cases is variable. The presence of multitude of poor prognostic factors such as conduct disorder, substance use, deviant peer group, low education, and poverty, makes the prognosis guarded in the long term though treatment retention would be a crucial factor. The onset of deviant behavior at or before age 10, a greater diversity of deviant behavior, and more extensive pretreatment drug use best-predicted progression to antisocial personality disorder.  Preventive studies have focused on effective interventions that can nip the budding risk behaviors in the early years of life (at or before 8 years of age), before the development of substance abuse, delinquency, and violence. 
| Conclusion|| |
From both a preventive and management point of view, it is important to pay attention to the link between conduct disorder and early-onset substance use.
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Conflicts of interest
There are no conflicts of interest.
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