1. Overview of Adolescent Substance Abuse & Treatment
Overview of Adolescent Substance Abuse (PREP)
Overview of Adolescent Substance Abuse & Treatment
Stuart Tiegel, MSW
Assistant Professor and Director Family Clinic
Department of Psychiatry, JHU
Private Practice
October 2011
Joan E. Zweben, Ph.D.

2. Adolescent Substance Use
Critical time for onset of SUDS
Experimentation is prevalent; most do not develop SUDS
Prevalence rates in higher risk samples is approx 24% or higher
Social factors, esp peer influence, are strongest determinants of initiation of use.
Psychological factors and effects of the substances more closely linked to abuse.
(Millin & Walker, 2011)

3. Adolescent Substance Abuse
Overview of Adolescent Substance Abuse (PREP)
Adolescent Substance Abuse
Marijuana is the most prevalent, then alcohol. Polydrug use is the norm
Tobacco: most smokers initiate during adolescence
Prescription drug abuse is rising
Adolescent brain more is susceptible to alcohol and other drugs
Prevention efforts target salient risk and protective factors
Joan E. Zweben, Ph.D.

4. Protective Factors Positive temperament/self-acceptance
Intellectual ability/academic performance
Supportive family/home environment
Caring relationship with at least one adult
External support system that encourages prosocial values
Law abidance/avoidance of delinquent peer friendships
(Millin & Walker, 2011)

5. Marijuana Impact on developing brain
Distortions of self-concept due to disturbances of attention and concentration
Conclude they are not intelligent, don’t like school; seek peer group with negative attitudes and behaviors
Increased risk of psychotic illness
Possible interference with medications
(Zweben & Martin, 2009)

6. Tobacco
Most smokers initiate in adolescence; 1/3 are current smokers (Randall & Upadhyaya 2009)
Early onset smokers more like to develop SUDS
Approx 50% of the risk for nicotine dependence is genetic
Effective pharmacological tx – little is known
Adolescent smokers at significantly greater risk for relapse following tx
(de Dios et al, 2009; Meyers & Prochaska, 2008)

7. Relapse
Low rates (50%) of continuous abstinence at 3 months following tx
Common context: social situation, peer influence. (Adults: negative intra- or interpersonal states)
PREP clients seen long term; this is an advantage

8. Adolescent Treatment and Relapse Prevention
Tailor to biopsychosocial level of development
Family involvement necessary; improves outcomes
Integrated treatment of comorbid conditions is crucial; prevalence of COD is higher than in other age group populations
Comprehensive services, longer time in tx

9. Pharmacotherapy for SUDS
Overview of Adolescent Substance Abuse (PREP)
Pharmacotherapy for SUDS
Usually used only for comorbid conditions, not SUDS
Barriers
Lack of safety and efficacy info
Reluctance to use medications to treat SUD
Recent RCTs using buprenorphine (for opiate dependence) show greater retention and abstinence
Joan E. Zweben, Ph.D.

10. Adolescent Treatment Approaches for SUDS
Family therapy
Multidimensional family therapy (MDFT)
Brief strategic family therapy (BSFT)
Multisystemic therapy (MST)
Functional family therapy
Behavioral family therapy
Cognitive behavioral therapy
Twelve-step approaches
Therapeutic communities
Community reinforcement/contingency management
(Jaffe et al, 2009)

11. Treatment Outcome Parameters (Adolescents)
Attrition rates 20%-50% across program types
Low motivation
Don’t perceive AOD use as a problem
Early therapeutic alliance increases retention and predicts better outcomes on drug use, internalizing and externalizing behaviors

12. BASIC ISSUES (AOD)

13. Capsule Definition of Addiction
Addiction is behavior that is compulsive, not under dependable control, and persists despite adverse consequences
Behavior is voluntary during the initiation stage, but becomes compulsive over time
Importance of physical dependence has evolved to concepts of dyscontrol, salience, and neuroadaptation.

14. BUT
Any amount of alcohol/drug use is undesirable in persons with co-occurring disorders, and should be recognized and addressed

15. Compulsive Drug Seeking is Initiated Outside Consciousness
“cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs”
Set in motion by nucleus accumbens (limbic structure, “animal brain”)
Sets in motion a pattern of learned compulsive behavior
Difficult to override even when negative consequences are recognized
(Sellman 2009)

16. Role of Genetic Heritage
Heritability estimates range from 40% - 60%. Varies with different drugs.
No single gene, or even a handful of genes
Complex interaction between genes, especially those that influence temperament, and environmental factors
Current model is interactive, “nature via nurture”

17. Co-occurring Disorders (COD) are the Norm, not the Exception
We still design our treatment systems around our own limitations
Addiction treatment system is the default for almost everyone except those with SMI
Attitudes towards medications have changed in the addiction treatment system
Clinicians endorse the idea of integrated treatment, but research lags behind
Criteria for many addiction research studies exclude people with COD, particularly SMI
And, criteria for SMI studies exclude COD

18. Addiction is a Chronic Relapsing Disorder
Similar to diabetes, asthma, hypertension
Key factors for all four:
Adherence to treatment recommendations
Family and social support
Poverty factors
Stigma influential in determining attitudes towards addiction (e.g, re-occurrence vs relapse)
Research often based on acute care model
(McLellan et al, JAMA, 2000)

19. Different Treatments Produce Similar Outcomes
Main Models:
Motivational enhancement
Cognitive-behavioral (CBT)
Twelve-step facilitation
Community reinforcement
Modest effect sizes
Therapeutic alliance not well studied in addiction treatment research; many studies elsewhere
Inadequate understanding of key implementation factors

20. Motivational Enhancement
Motivation is amenable to clinical intervention (vs “come back when you are ready”)
Assess stage of motivation and select intervention accordingly
Remember that motivation is a variable state, not a fixed trait
Combination of internal motivation and external pressure is helpful

21. Treatment Should be Individualized and Comprehensive
Addiction is a biopsychosocial disorder
Emphasis on evidence-based treatments can lead to another version of cookie-cutter treatment
Practical problems (legal, vocational) are important in addition to medical, psychiatric and family issues
The community context is relevant

22. Treatment Philosophies: Abstinence-Oriented
abstain from drug of choice
abstain from other intoxicants
drug substitution
role in precipitating relapse
dependable control not possible; hence detach
widest margin of safety

23. Treatment Philosophies: Harm Reduction
“Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.”
The Harm Reduction Working Group & Coalition, 1995

24. Role of the Spiritual Awakening
Many recover without a dramatic spiritual awakening
Must reorient to a healthy sense of purpose and meaning
Higher power comes in many forms; can reframe to inner wisdom, higher consciousness, etc.

25. Recovery-Oriented Systems of Care (ROSC)
System must address a chronic (not acute) disorder
Treatment plays an important role, but cannot meet all needs
Communities of recovery play a key role in long term success; must have assertive linkages
(William White, 2008)

26. Key Ingredients of the Community Model
Co-occurring disorders arise in a community context
Identification of problems must include the community context
Plans for recovery include building a healthy level of community support
Successful treatment isn’t just clinical

27. Post Treatment Recovery Environment
Mutual aid system (aka self help)
Family
Social network
Living environment
Recovery homes, schools, support centers, churches, etc.

28. Essential Elements of Treatment
Start where pt is willing to begin
Involve family members
Structure, structure, structure
Appropriate integration with treatment of psychiatric disorder(s)
Participation in a community that supports the recovery process

29. What is Recovery? Resolution of AOD problems
Progressive achievement of physical, emotional and relational health
Citizenship: life meaning and purpose, self-development, social stability, social contribution, elimination of threats to public safety
(William White, 2009)

30. Overview of Adolescent Substance Abuse (PREP)
Credits
Joan E. Zweben, Ph.D.
Clinical Professor of Psychiatry, UCSF
Joan E. Zweben, Ph.D.