Significant progress has been made in conceptualizing, testing, and implementing treatment strategies and programs for adolescents with SUD. One of the challenges in the treatment of adolescent SUD has been the attempt to match the individual needs of the adolescent to appropriate treatment services and levels of care. There is a growing consensus that SUD is not an acute disorder with a potentially chronic, relapsing course. A common view of addiction treatment is that it is a linear process requiring a continuum of case management and case monitoring akin to that in chronic disease management.
Systems of Care for Adolescents with Sud
Eighty percent of adolescents with SUD are treated in outpatient settings. Outpatient services usually deliver episodic care utilizing group therapy without coordination or continuity of care. While many adolescents with mild to moderate severity respond to some degree to brief interventions, some do not. Moreover, the higher the severity, the less likely this is. More characteristic is a relapsing/remitting course over a prolonged period of time across several episodes of care and levels of care, with different services and interventions. Since SUD is usually a part of a dysfunction in school, family, legal, and behavioral domains, the need for service coordination and multidisciplinary teamwork is clear. There is a growing utilization of the American Society for Addiction medicine Placement Criteria for both youth and adults.
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Libby AM,Riggs PD: Integrated services for substance abuse and mental health: Challenges and opportunities. In: Kaminer Y,Oscar OG (eds).Adolescent Substance Abuse: Psychiatric Comorbidity & High Risk Behaviors. New York: Haworth Press, 2007.
Psychosocial treatments that have shown promise for adolescent SUD include the following: Multi-systemic Therapy (MST); Multi-dimensional Family Therapy (MDFT); Cognitive–Behavioral Therapy (CBT), conducted either in groups or individually; Motivational Enhancement Therapy (MET); Contingency Management Reinforcement; the Minnesota 12-Step model; and other integrative models of treatment. Twelve-step programs are often recommended. However, little is known regarding the effectiveness of this approach for adolescents.
There is little evidence to suggest that one therapy is more effective than another.
Family therapy is the most researched treatment modality for adolescent substance abuse. MST is an intensive home-based family intervention that addresses schools, peer groups, parenting skills, family communication skills, and family relations. MST combines structural and strategic family therapy with cognitive behavioral therapy. While prior reviews conclude that MST is the most promising empirically-based treatment for children with substance abuse, the conclusion was that available evidence does not support the claim that MST is more effective than usual services or other interventions for youth with social, emotional or behavioral problems. There is no evidence of harmful effects compared to alternative services. MST has several advantages in that it is comprehensive, based upon current knowledge of youth and family problems, well documented, and empirical.
MDFT is recognized as one of the most promising interventions for adolescent drug abuse. MDFT combines drug counseling with multiple systems assessment and intervention both inside and outside the family. The approach is developmentally and ecologically oriented, to the environmental and individual systems in which the adolescent resides. MDFT is manualized and delivered in 16–25 sessions over 4–6 months at home or in the office.
CBT views substance use and related problems as learned behaviors initiated and maintained by environmental factors. Most CBT approaches integrate classical conditioning, operant conditioning, and social learning theory. Recent studies involve rigorous designs, larger samples, random assignment, direct comparisons of two or more active treatments, improved measures, manualization, and longer-term outcome assessment. The focus in treatment has been on improved drug refusal skills and managing of high-risk situations. Improved self-efficacy is associated with better outcome. CBT can also be applied in group settings. Different adolescents are manageable in a group once a clearly communicated, behavioral contract for ground rules is established. Experienced therapists can address inappropriate behavior and employ “trouble shooting” techniques.
MI and MET are based on research on the process of change. MI pertains both to a style of relating and a set of techniques to facilitate that process. Five main strategies are used in applying this approach: (1) express empathy; (2) develop discrepancy; (3) avoid argumentation; (4) roll with resistance; and (5) support self-efficacy. Ever since treatment results for adolescent substance abuse have been reported, clinicians and researchers have noted the difficulty of keeping adolescents in treatment. Retention can be regarded as one successful treatment outcome. Brief motivational interventions have not been investigated until recently. A single session of MI, designed to reduce illicit drugs among young people between 16–20 years of age, produced significant decrease in cannabis use at 12-week follow-up compared with nonintervention. Several studies have successfully employed MI following a negative event (e.g., a motor vehicle accident with referral to the emergency room), an intervention exploiting a “teachable moment.” MET may be suitable for adolescents because they do not have to admit to having a substance use problem in order to benefit from it. MI alone may not be sufficient for adolescents with severe AOSUD or psychiatric comorbidity. However, it may be an effective preliminary to such treatments as CBT.
The Cannabis Youth Treatment study is most probably the most important study yet conducted. This randomized prospective field experiment compared five interventions, in various combinations, across the four US implementation sites, for 600 adolescents. The study addressed the comparative efficacy of five treatments. Two group CBT interventions were offered. Both began with individual MET sessions, followed by either 3 or 10 sessions of group administered CBT. A third intervention was MET/CBT plus a 6-week family psycho-educational intervention. A 12-session individual Adolescent Community Reinforcement Approach, and a 12-week course of MDFT were also tested. The effectiveness of five treatment models was evaluated in a community-based program and an academic medical center. Although all five models were not implemented within each treatment site, the MET plus three sessions of group CBT was replicated across all four sites, making it possible to study site differences and conduct quasi-experimental comparisons of the interventions across the study arms. All five interventions produced a significant reduction in cannabis use and negative consequences of use, from pretreatment to the 3-month follow-up. These reductions were sustained through the 12-month follow-up. Changes in marijuana use were accompanied by amelioration of behavioral problems, family problems, school problems, school absences, argumentativeness, violence, and illegal activity. Despite considerable support for family intervention in the literature, the individual Adolescent Community Reinforcement Approach and individual MET plus three sessions of group CBT produced better outcomes than the family approach in terms of days of substance use at 3 months. However, these initial differences were not sustained. The best predictor of long-term outcome was initial level of change. In terms of cost effectiveness, MDFT was better than the other interventions. One of the important contributions of the Cannabis Youth Treatment to the knowledge base is the emphasis on community effectiveness and ecological validity compared to a demonstration of efficacy in specialized research setting.
Treatment of adolescents with substance-related problems often incorporate the 12-step philosophy advocated by Alcoholics Anonymous (AA), and Narcotics Anonymous (NA). A national survey of adolescent programs found that more than two-thirds (67%) involved “12-step” concepts. Many of these programs encourage attendance at community AA and NA groups following treatment. Four studies have examined the predictors of participation in AA/NA. A retrospective study found that youth who were more hopeless, had friends who did not use drugs, and who had less parental involvement during treatment were more likely to become involved in AA. Two studies found that more severely alcohol and drug-involved youth, and those more motivated for abstinence and not by coping skills or self-efficacy, were more likely to both attend and become actively involved in AA/NA in the first 3 months posttreatment. An 8-year follow-up study found that, following inpatient treatment, more severe substance dependence, measured by the number of DSM-IV-TR dependence symptoms at the time of treatment, predicted AA/NA attendance throughout a 6-year follow-up period, but not at 8-years following treatment, after controlling for age, gender and intake substance use indices.
Developmentally-related differences between adolescents and adults suggest that 12-step programs may not be appropriate for youth. For instance, when adolescents are compared to older adult counterparts for whom AA was originally devised, adolescents on average have less addiction severity and related sequelae, and lower substance-related problem recognition and motivation for abstinence. They are significantly younger relative to the majority of other AA/NA members. Some youth are uncomfortable with the spiritual/religious emphasis of AA/NA. AA/NA may be suitable for youth whose addiction is more severe.
Treatment of substance in the context of co-occurring psychiatric disorders: the National Institute of Drug Abuse recommends integrated treatment of co-occurring psychiatric disorders as a core treatment principle. However, systemic and economic barriers impede the implementation of integrated care: Not enough treatment providers; the resistance by gatekeepers to specialty care; and financing streams. Combined treatment of psychiatric disorder and SUD may produce a better outcome than mental health or SUD treatment alone. The optimal design of integrated treatment (e.g., simultaneous or sequential), and the treatment components and dosage have yet to be determined. Psychopharmacological treatment for psychiatric comorbidity usually addresses only the psychiatric disorder.
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Medications are sometimes used to prevent relapse once an initial remission is secured. Pharmacotherapy is only useful when combined with counseling. Examples include naltrexone for opioid or alcohol abuse/dependence, and drugs such as disulfiram for alcohol abuse and dependence. These agents are rarely used in adolescent populations.
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Relapse rates are over 60% 12 months after treatment. However, little has been done to link patients with aftercare. Often, there is no coordinated continuing care. The lack of posttreatment support and monitoring leaves patients vulnerable to relapse. The literature provides little guidance for aftercare programs. It is not clear who is a candidate for aftercare. Few programs describe the means of linking completers or non-completers with aftercare. Adolescents referred to residential treatment have severe SUD and are at risk both for relapse and poor linkage to aftercare. Adolescents referred from residential treatment to continuing care services are more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 months postdischarge and to reduce 3-month postdischarge days of alcohol use provided they are assigned to an assertive continuing-care protocol providing case management, home visits, and a community reinforcement approach. Aftercare reduced the likelihood of suicidal ideations.
Many communities lack aftercare services. Even if referrals are made, many adolescents do not enter, or only participate minimally in, aftercare interventions. Godley and colleagues found that only 36% of adolescents discharged from residential treatment attended one or more aftercare sessions at community clinics. It is imperative to provide aftercare unplanned discharged adolescents because they are at the highest risk for bad outcome. At a minimum, providers should track linkage rates by type of discharge and determine whether the adolescent is referred to their own organization or another service provider to inform their linkage practice. Finally, new interventions and modalities should be tested. Telepsychiatry should be used when distance from service providers and cost effectiveness are barriers for the provision of aftercare.
Godley MD,Godley SH,Dennis ML: Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. J Subst Abuse Treat
Kaminer Y,Burleson J,Goldston D,Haberek R: Suicidal ideation in adolescents with alcohol use disorders during treatment and aftercare. Am J Addict 2006;15(Suppl 1):43–49.