Assessment and Treatment of Assessment and Treatment of Adolescent Substance Use Adolescent Substance Use Disorders: Practical Tips for Disorders: Practical Tips for

Primary Care Providers in WYPrimary Care Providers in WY

Ray C. Hsiao, MDRay C. Hsiao, MD

Assistant Professor of Psychiatry, University of Washington Assistant Professor of Psychiatry, University of Washington

Co-Director, Adolescent Substance Abuse ProgramCo-Director, Adolescent Substance Abuse Program

Seattle Children’s HospitalSeattle Children’s Hospital

PAL Conference, Laramie, WY; 3/24/12 PAL Conference, Laramie, WY; 3/24/12

ObjectivesObjectives

Participants will learn about the prevalence and Participants will learn about the prevalence and patterns of substance use and substance use patterns of substance use and substance use disorders (SUDs) in adolescentsdisorders (SUDs) in adolescents

Participants will become familiar with common Participants will become familiar with common screening and assessment tools of SUDs in screening and assessment tools of SUDs in adolescentsadolescents

Participants will be able to describe and utilize Participants will be able to describe and utilize common treatment options for SUDs in common treatment options for SUDs in adolescentsadolescents

DisclosureDisclosure

No conflict of interest to reportNo conflict of interest to report

Off-label discussion of medications Off-label discussion of medications

OverviewOverview

DefinitionsDefinitionsPrevalencePrevalenceScreening: the Adolescent Perspective and Risk Screening: the Adolescent Perspective and Risk and Protective Factorsand Protective FactorsAssessmentAssessmentTreatmentTreatmentCo-Occurring DisordersCo-Occurring DisordersQuestions and AnswersQuestions and Answers

Substance-Related DisordersSubstance-Related Disorders

Substances covered in DSM IV-TR: Alcohol, Substances covered in DSM IV-TR: Alcohol, Amphetamine, Caffeine, Cannabis, Cocaine, Amphetamine, Caffeine, Cannabis, Cocaine, Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine, Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine, Sedative/Hypnotic/Anxiolytic, Other/UnknownSedative/Hypnotic/Anxiolytic, Other/Unknown

Substance Use Disorders (SUDs) = Substance Abuse or Substance Use Disorders (SUDs) = Substance Abuse or Dependence Dependence

Substance-Induced Disorders = Substance Intoxication Substance-Induced Disorders = Substance Intoxication or Withdrawalor Withdrawal

Nicotine & Polysubstance: No AbuseNicotine & Polysubstance: No Abuse

Caffeine: No Abuse or DependenceCaffeine: No Abuse or Dependence

Substance AbuseSubstance Abuse

A maladaptive pattern of substance use leading to A maladaptive pattern of substance use leading to clinically significant impairment or distress, as clinically significant impairment or distress, as manifested by one (or more) of the following occurring at manifested by one (or more) of the following occurring at anytime within a 12-month period:anytime within a 12-month period:

Recurrent use resulting in a failure to fulfill major role Recurrent use resulting in a failure to fulfill major role obligations at work, school or homeobligations at work, school or homeRecurrent substance use in situations in which it is Recurrent substance use in situations in which it is physically hazardousphysically hazardousRecurrent substance-related legal problemsRecurrent substance-related legal problemsContinued substance use despite having persistent or Continued substance use despite having persistent or recurrent social or interpersonal problems caused or recurrent social or interpersonal problems caused or exacerbated by the effects of the substanceexacerbated by the effects of the substance

Never met criteria for dependenceNever met criteria for dependence

Substance DependenceSubstance Dependence

A maladaptive pattern of substance use, leading to A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as clinically significant impairment or distress, as manifested by three (or more) of the following, manifested by three (or more) of the following, occurring at any time in the same 12-month period:occurring at any time in the same 12-month period:

Tolerance: “a need for markedly increased amounts Tolerance: “a need for markedly increased amounts of the substance to achieve intoxication or desired of the substance to achieve intoxication or desired effect” or “markedly diminished effect with continued effect” or “markedly diminished effect with continued use of the same amount of the substance”use of the same amount of the substance”Withdrawal: “the characteristic withdrawal syndrome Withdrawal: “the characteristic withdrawal syndrome for the substance” or “the same (or a closely related) for the substance” or “the same (or a closely related) substance is taken to relieve or avoid withdrawal substance is taken to relieve or avoid withdrawal symptomssymptoms

Substance DependenceSubstance DependenceSubstance is often taken in larger amounts or over Substance is often taken in larger amounts or over a longer period than intendeda longer period than intended

Persistent desire or unsuccessful efforts to cut Persistent desire or unsuccessful efforts to cut down or control substance usedown or control substance use

Great deal of time is spent in activities necessary to Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recoverobtain the substance, use the substance, or recover

Important social, occupational, or recreational Important social, occupational, or recreational activities are given up or reducedactivities are given up or reduced

Substance use is continued despite knowledge of Substance use is continued despite knowledge of persistent or recurrent physical or psychological persistent or recurrent physical or psychological problem caused or exacerbated by substanceproblem caused or exacerbated by substance

Dependence SpecifiersDependence Specifiers

With Physiological DependenceWith Physiological DependenceWithout Physiological DependenceWithout Physiological Dependence

Course SpecifiersCourse SpecifiersEarly Full RemissionEarly Full RemissionEarly Partial RemissionEarly Partial RemissionSustained Full RemissionSustained Full RemissionSustained Partial RemissionSustained Partial RemissionOn Agonist TherapyOn Agonist TherapyIn a Controlled EnvironmentIn a Controlled Environment

Polysubstance DependencePolysubstance Dependence

Repeatedly using at least 3 groups of Repeatedly using at least 3 groups of substances (not including caffeine or nicotine)substances (not including caffeine or nicotine)

Dependence criteria were met as a group but Dependence criteria were met as a group but not for any specific substancenot for any specific substance

Most commonly in individuals where the Most commonly in individuals where the substance use is highly prevalent but the drugs substance use is highly prevalent but the drugs of choice frequently changedof choice frequently changed

DSM 5: Substance Use DisordersDSM 5: Substance Use Disorders

11 criteria: replaced “legal problem” with 11 criteria: replaced “legal problem” with “craving or a strong desire or urge to use a “craving or a strong desire or urge to use a specific substance”specific substance”

New Severity SpecifiersNew Severity SpecifiersModerate: 2-3 criteria positiveModerate: 2-3 criteria positive

Severe: 4 or more criteria positiveSevere: 4 or more criteria positive

Same Course Specifiers as DSM IV-TRSame Course Specifiers as DSM IV-TR

Potentially identify problematic use earlier and Potentially identify problematic use earlier and lead to proper interventionlead to proper intervention

Frequently Asked Question # 1Frequently Asked Question # 1

How common is substance How common is substance use in adolescents?use in adolescents?

Who is using?Who is using?

What are they using?What are they using?

Quiz #1Quiz #1

How common is substance use? In a class of How common is substance use? In a class of 100 high school seniors, how many have tried 100 high school seniors, how many have tried the following during their lifetime:the following during their lifetime:

Cigarettes?Cigarettes?

Alcohol?Alcohol?

Illicit Drugs?Illicit Drugs?

Illicit Drugs other than Cannabis?Illicit Drugs other than Cannabis?

Prevalence of Substance UsePrevalence of Substance Use

Monitoring The Future (MTF) StudyMonitoring The Future (MTF) Studywww.monitoringthefuture.org

NIDA funded national studyNIDA funded national study

Middle/high school, college, young adultsMiddle/high school, college, young adults

40,000+ adolescents from 300+ sites40,000+ adolescents from 300+ sites

Survey behaviors/attitudes on substance useSurvey behaviors/attitudes on substance use

Annual follow-up survey to graduating classAnnual follow-up survey to graduating class

MTF Lifetime Prevalence: 2011MTF Lifetime Prevalence: 20118th8th 10th10th 12th12th

Any Any CigarettesCigarettes 18.4%18.4% 30.4%30.4% 40.0%40.0%

Any AlcoholAny Alcohol33.1%33.1% 56.0%56.0% 70.0%70.0%

Any Illicit Any Illicit DrugDrug 20.1%20.1% 37.7%37.7% 49.9%49.9%

Any Illicit Any Illicit Drug other Drug other than MJthan MJ

9.8%9.8% 15.6%15.6% 24.9%24.9%

MTF Lifetime Prevalence: 2011MTF Lifetime Prevalence: 2011

88thth 1010thth 12th12thMarijuanaMarijuana 16.4%16.4% 34.5%34.5% 45.5%45.5%InhalantsInhalants 13.1%13.1% 10.1%10.1% 8.1%8.1%AmphetaminesAmphetamines 5.2%5.2% 9.0%9.0% 12.2%12.2%HeroinHeroin 1.2%1.2% 1.2%1.2% 1.4%1.4%HallucinogenHallucinogen 3.3%3.3% 6.0%6.0% 8.3%8.3%CocaineCocaine 2.2%2.2% 3.3%3.3% 5.2%5.2%MethamphetamineMethamphetamine 1.3%1.3% 2.1%2.1% 2.1%2.1%Ecstasy/MDMAEcstasy/MDMA 2.6%2.6% 6.6%6.6% 8.6%8.6%TranquilizersTranquilizers 3.4%3.4% 6.8%6.8% 8.7%8.7%Other NarcoticsOther Narcotics N/AN/A N/AN/A 13.0%13.0%

Summary of MTF Trend FindingsSummary of MTF Trend Findings

Male generally more drug useMale generally more drug use

College-bound adolescents use lessCollege-bound adolescents use less

Regional variation is quite complex & changingRegional variation is quite complex & changing

Population density is not a predictor of usePopulation density is not a predictor of use

Socioeconomic class difference mostly smallSocioeconomic class difference mostly small

Whites ≥ Hispanics > African Americans: Whites ≥ Hispanics > African Americans: Hispanics in 8Hispanics in 8thth grade higher in most categories grade higher in most categories but may have higher drop-out rate and earlier but may have higher drop-out rate and earlier initiation to account for lower numbers in 12initiation to account for lower numbers in 12thth gradegrade

Quiz #2Quiz #2

In adolescents ages 12-17:In adolescents ages 12-17:How common is Substance Abuse?How common is Substance Abuse?

How common is Substance How common is Substance Dependence?Dependence?

Prevalence of SUDsPrevalence of SUDs

National Household Survey on Drug Use and National Household Survey on Drug Use and Health (NHSDUH)Health (NHSDUH)

http://oas.samhsa.gov/nsduh.htmFormerly NHSDA(buse) Formerly NHSDA(buse) Youth 12-17 years old: survey use and abuseYouth 12-17 years old: survey use and abuse8% classified with SUDs in 2005 (3.1% 8% classified with SUDs in 2005 (3.1% Abuse, 4.9% Dependence): 8.3% for males, Abuse, 4.9% Dependence): 8.3% for males, 7.8% for females7.8% for females7.3% classified with SUDs in 2010 (4.5% 7.3% classified with SUDs in 2010 (4.5% Alcohol, 4.7% Illicit drugs): 6.9% for males, Alcohol, 4.7% Illicit drugs): 6.9% for males, 7.7% for females7.7% for females

Prevalence of SUDsPrevalence of SUDs

National Comorbidity Survey-Adolescent National Comorbidity Survey-Adolescent Supplement ( NCS-A): Supplement ( NCS-A): Merikangas et al, JAACAP 2010Merikangas et al, JAACAP 2010

Youth 13-18 years old: diagnostic surveyYouth 13-18 years old: diagnostic survey11.4 classified with SUDs: (6.4% Alcohol, 11.4 classified with SUDs: (6.4% Alcohol, 8.9% Illicit drugs): 12.5% for males, 10.2% for 8.9% Illicit drugs): 12.5% for males, 10.2% for femalesfemalesSUDs rates by age group:SUDs rates by age group:

13-14: 3.7%13-14: 3.7%15-16: 12.2%15-16: 12.2%17-18: 22.3%17-18: 22.3%

NHSDUH 2010: SUDs PatternNHSDUH 2010: SUDs Pattern

Most Common Types of Substance Used: Most Common Types of Substance Used: Alcohol > Marijuana > Pain Relievers > Alcohol > Marijuana > Pain Relievers > Cocaine > Others (methamphetamine, Cocaine > Others (methamphetamine, heroin, hallucinogen)heroin, hallucinogen)

Polysubstance use is commonPolysubstance use is common

Reflected in most treatment studies and Reflected in most treatment studies and clinical trials clinical trials (O’Brien et al 2005)(O’Brien et al 2005)

Summary: Epidemiological Studies Summary: Epidemiological Studies

Experimentation is normative but Experimentation is normative but consequences can be severe and far-consequences can be severe and far-rangingranging

Abuse is the exception: look for early Abuse is the exception: look for early initiation and heavy useinitiation and heavy use

““Gateway Theory”: CigarettesGateway Theory”: Cigarettes Alcohol Alcohol Cannabis Cannabis Other illicit drugs Other illicit drugs

Frequently Asked Question #2Frequently Asked Question #2

How do I know whether my How do I know whether my patient is using too much or not? patient is using too much or not? (i.e., Is he/she just a typical (i.e., Is he/she just a typical teenager or someone who needs teenager or someone who needs an intervention or assessment)an intervention or assessment)

Tasks of AdolescenceTasks of Adolescence

Emancipation/surrender of childhoodEmancipation/surrender of childhood

Identity formationIdentity formationSexual Sexual

IntellectualIntellectual

MoralMoral

SpiritualSpiritual

EthnicEthnic

Functional role in societyFunctional role in society

Risk Factors for SUDsRisk Factors for SUDs

Newcomb 1997Newcomb 1997

Four generic domainsFour generic domains

Cultural/SocietalCultural/Societal

Interpersonal: family and peers Interpersonal: family and peers

PsychobehavioralPsychobehavioral

BiogeneticBiogenetic

Relevance modified by age, gender, and Relevance modified by age, gender, and ethnicityethnicity

Mediating FactorsMediating Factors

Early experimentationEarly experimentation

Substance-Dependent parentsSubstance-Dependent parents

Substance-Abusing siblingsSubstance-Abusing siblings

Conduct disturbancesConduct disturbances

Deviant and substance-abusing peersDeviant and substance-abusing peers

Sensation-seeking temperamentSensation-seeking temperament

Impulse and self-control problemsImpulse and self-control problems

Mediating FactorsMediating Factors

Poor parental supervisionPoor parental supervision

Heavy drug-use neighborhoodsHeavy drug-use neighborhoods

School problemsSchool problems

Social skills deficitsSocial skills deficits

Parents with poor parenting skillsParents with poor parenting skills

Victims of trauma, abuse and neglectVictims of trauma, abuse and neglect

ADHD

Depression

ODD CD ASP

Substance Use Abuse Dependence

FamilyFamily0 10 205 15

PEERS PEERS

Resilience Resilience

SUD, abuse, neglectSUD, abuse, neglect

SchoolSchool Truancy, failure, HS dropout Truancy, failure, HS dropout

Antisocial; drug-usingAntisocial; drug-using

Riggs’ Developmental Pathways to Adolescent Mental Health, Substance Problems

Genetics Attachment

Individual Individual

Fetal Exposure Fetal Exposure Drugs/AlcoholDrugs/Alcohol

IMPEDES DEVELOPMENT

Coping skills

Social /interpersonal skills

Communication skills

Identity, values consolidation

Affect identification/regulation

Self-Efficacy/external locus control

Cognitive development

Pro-social network

IQ; academic performance; femalehobby; empathic gatekeeper

Quiz #3Quiz #3

What is the screening instrument What is the screening instrument recommended by the American recommended by the American Academy of Pediatrics for Academy of Pediatrics for adolescents with substance use adolescents with substance use disorders?disorders?

Screening/TestingScreening/Testing

CRAFFT (Knight 2002): screening; 2 or more of the CRAFFT (Knight 2002): screening; 2 or more of the following indicate significant problemfollowing indicate significant problem

CarCar

RelaxRelax

AloneAlone

Family/friendsFamily/friends

ForgetForget

TroubleTrouble

Drug testing: urine or other modalitiesDrug testing: urine or other modalities

Frequently Asked Question #3Frequently Asked Question #3

What do I do if my patient is in What do I do if my patient is in need of an assessment or need of an assessment or intervention?intervention?

What happens at a chemical What happens at a chemical dependency assessment? Who dependency assessment? Who performs the assessment?performs the assessment?

Chemical Dependency AssessmentChemical Dependency Assessment

Usually performed by Substance Abuse Usually performed by Substance Abuse Counselors/Chemical Dependency Counselors/Chemical Dependency Professionals (CDPs)Professionals (CDPs)

Assessment usually consists of a clinical Assessment usually consists of a clinical interview that addresses the 6 dimensions of interview that addresses the 6 dimensions of American Society of Addiction Medicine (ASAM) American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC)Patient Placement Criteria (PPC)

Quiz # 4Quiz # 4

How many dimensions of the How many dimensions of the ASAM PPC can you name?ASAM PPC can you name?

ASAM PPC DimensionsASAM PPC Dimensions

I: Acute intoxication and/or withdrawal potentialI: Acute intoxication and/or withdrawal potential

II: Biomedical conditions and complicationsII: Biomedical conditions and complications

III: Emotional, behavioral, or cognitive conditions III: Emotional, behavioral, or cognitive conditions and complicationsand complications

IV: Readiness to ChangeIV: Readiness to Change

V: Relapse, continued use, or continued V: Relapse, continued use, or continued problem potentialproblem potential

VI: Recovery environmentVI: Recovery environment

Quiz # 5Quiz # 5

Can you name the 4 different Can you name the 4 different levels of chemical dependency levels of chemical dependency treatment identified in the treatment identified in the ASAM PPC?ASAM PPC?

ASAM PPC LevelsASAM PPC Levels

Level 0.5: Early InterventionLevel 0.5: Early Intervention

Level I: Outpatient Services: <9hours/weekLevel I: Outpatient Services: <9hours/week

Level II: Intensive outpatient (9-19 hours/week)/ Level II: Intensive outpatient (9-19 hours/week)/ Partial hospitalization (>20 hours/week)Partial hospitalization (>20 hours/week)

Level III: residential/inpatient services (e.g., Level III: residential/inpatient services (e.g., imminent risk in relapse, continued use or imminent risk in relapse, continued use or recovery environment)recovery environment)

Level IV: medically managed intensive inpatient Level IV: medically managed intensive inpatient services (e.g., imminent risk in D1, D2, or D3)services (e.g., imminent risk in D1, D2, or D3)

Psychiatric AssessmentPsychiatric Assessment

Multiple domains: Timeline approachMultiple domains: Timeline approach

Psychiatric/behavioralPsychiatric/behavioral

FamilyFamily

School/VocationalSchool/Vocational

Recreational/LeisureRecreational/Leisure

MedicalMedical

Collateral, collateral, collateral!!!Collateral, collateral, collateral!!!

ToxicologyToxicology

Pre-natalAttachment School-age

AdolescentCollege-age

Adult

Longitudinal Developmental History Pre-natal; attachment

Onset and Progression of Psychiatric Symptoms ODD/CD ADHD Depression Mania /hypomania Anxiety (SAD, PTSD, GAD, OCD) Psychosis

Peers Deviancy Substance Use Gang

Substance Use Onset, experimentation For all substances used >5x

Progression to regular use Peak use Current use (last month) Last use

School LD; special education Behavior problems Academic performance

Riggs’ Lifetime TimelineRiggs’ Lifetime Timeline

FamilyAbuse, neglect, conflict, SUDFamily managementParental monitoring

Frequently Asked Question #4Frequently Asked Question #4

How do I get my patient into How do I get my patient into treatment?treatment?

What happens when my What happens when my patient is in treatment in patient is in treatment in Washington State?Washington State?

Outpatient/Intensive Outpatient Outpatient/Intensive Outpatient ServicesServices

Non-residential programs providing Non-residential programs providing chemical dependency assessments, chemical dependency assessments, alcohol/drug free counseling services and alcohol/drug free counseling services and education for youth age 10 to 20education for youth age 10 to 20

Designed to screen, assess, diagnose, Designed to screen, assess, diagnose, and treat misuse, abuse, and addiction to and treat misuse, abuse, and addiction to alcohol and other drugsalcohol and other drugs

Detox/Stabilization ServicesDetox/Stabilization Services

Services providing at-risk, runaway, Services providing at-risk, runaway, homeless youth age 13-17 a safe, homeless youth age 13-17 a safe, temporary, and protective environmenttemporary, and protective environmentCriteria: experiencing crisis related to the Criteria: experiencing crisis related to the harmful effects of intoxication and/or harmful effects of intoxication and/or withdrawal from alcohol and other drugs, withdrawal from alcohol and other drugs, in conjunction with an emotional or in conjunction with an emotional or behavioral crisisbehavioral crisisTypical length of stay: 1-5 daysTypical length of stay: 1-5 days

Inpatient TreatmentInpatient Treatment

Programs designed for “chemically Programs designed for “chemically dependent” youth age 13-17dependent” youth age 13-17

Services include intensive individual, Services include intensive individual, group, and family counseling, education, group, and family counseling, education, school activities, recreation, recovery school activities, recreation, recovery support groups, and connection to support groups, and connection to continuing treatment in the home continuing treatment in the home communitycommunity

Levels of Inpatient ServicesLevels of Inpatient Services

Level 1Level 1

Primary addiction problems requiring less clinical Primary addiction problems requiring less clinical intervention and behavior managementintervention and behavior management

Level 2Level 2

Co-occurring emotional and mental health Co-occurring emotional and mental health problems, youth resistant to treatment, or high problems, youth resistant to treatment, or high probability to run from treatmentprobability to run from treatment

Recovery House Recovery House

Continued residential stay after completing Continued residential stay after completing primary inpatient treatmentprimary inpatient treatment

NHSDUH 2010: Treatment NeedsNHSDUH 2010: Treatment Needs

Overall: 1.8 million youths aged 12-17 Overall: 1.8 million youths aged 12-17 (7.5% of sample population) needed (7.5% of sample population) needed treatment -> 138,000 youths received treatment -> 138,000 youths received treatment at a specialty facility (7.6% of treatment at a specialty facility (7.6% of youths who needed treatment)youths who needed treatment)Most treatment occurred in outpatient Most treatment occurred in outpatient settingssettings

Barriers to TreatmentBarriers to Treatment

Five most often reported reasons for not Five most often reported reasons for not receiving treatment receiving treatment (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)(NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)

Not ready to stop using (40.2%)Not ready to stop using (40.2%)

Cost or insurance barriers (32.9%)Cost or insurance barriers (32.9%)

Stigma (e.g., negative opinions from neighbors Stigma (e.g., negative opinions from neighbors and community, negative effect on job) (22.8%)and community, negative effect on job) (22.8%)

Can handle the problem without treatment (9.9%)Can handle the problem without treatment (9.9%)

Did not know where to go (9.3%)Did not know where to go (9.3%)

Barriers to TreatmentBarriers to Treatment

Five most often reported reasons for not Five most often reported reasons for not receiving treatment despite seeking receiving treatment despite seeking treatment: treatment: (NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)(NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)

Cost or insurance barriers (45.2%)Cost or insurance barriers (45.2%)

Not ready to stop using (30.3%)Not ready to stop using (30.3%)

Treatment not needed (15.5%)Treatment not needed (15.5%)

Stigma (15.0%)Stigma (15.0%)

No Transportation/Inconvenient (8.4%)No Transportation/Inconvenient (8.4%)

Additional Complications in Adolescent Additional Complications in Adolescent SUD TreatmentSUD Treatment

Polysubstance use: typically alcohol and Polysubstance use: typically alcohol and marijuana, occasional cocaine or opiates marijuana, occasional cocaine or opiates (Winters (Winters et al 2000; Kaminer et al 2002; Henggeler et al 1996)et al 2000; Kaminer et al 2002; Henggeler et al 1996)

High rates of comorbid psychiatric disorders High rates of comorbid psychiatric disorders (Armstrong et al 2002)(Armstrong et al 2002)

High rates of substance abuse in immediate High rates of substance abuse in immediate families families (Henggeler et al 1996; Winters et al 2000)(Henggeler et al 1996; Winters et al 2000)

Developmental vulnerabilityDevelopmental vulnerabilityInvolvement in multiple systems: legal, school, Involvement in multiple systems: legal, school, and medical problems may present firstand medical problems may present firstHigh attrition rate: 50-80% High attrition rate: 50-80% (Henggeler et al 1996)(Henggeler et al 1996)

Frequently Asked Questions #5Frequently Asked Questions #5

Does treatment work? (e.g., Does treatment work? (e.g., “I’ve known people who have “I’ve known people who have been through rehab many been through rehab many times but they are still times but they are still addicted”)addicted”)

Why TreatmentWhy Treatment

Inconsistent outcomes after treatment Inconsistent outcomes after treatment prior to 1990’sprior to 1990’s (Catalano et al. 1992)(Catalano et al. 1992)

Treatment might escalate problemsTreatment might escalate problems (Kaminer (Kaminer 2005; Dishion et al 1999)2005; Dishion et al 1999)

Recent reviews show psychosocial Recent reviews show psychosocial treatment is better than no treatmenttreatment is better than no treatment (Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006)(Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006)

Effective early intervention is critical and Effective early intervention is critical and can be preventive in later yearscan be preventive in later years (Grant & Dawson (Grant & Dawson 1997; Santisteban et al. 2003; NHSDUH series)1997; Santisteban et al. 2003; NHSDUH series)

Treatment Evaluation Studies: Older Treatment Evaluation Studies: Older StudiesStudies

Older studies tend to be evaluations of four Older studies tend to be evaluations of four types of programs types of programs

““Minnesota Model”: comprehensive 4-6 week Minnesota Model”: comprehensive 4-6 week inpatient program using 12-Stepinpatient program using 12-Step

Outpatient drug-free programs: individual and group Outpatient drug-free programs: individual and group with some family counselingwith some family counseling

““Therapeutic Community”: 6-12 months residential Therapeutic Community”: 6-12 months residential program using 12-Stepprogram using 12-Step

Outward Bound or life skills training programs: 3-4 Outward Bound or life skills training programs: 3-4 weeks wilderness program focusing on challenges of weeks wilderness program focusing on challenges of survival and group interdependencysurvival and group interdependency

Treatment Evaluation Studies: Older Treatment Evaluation Studies: Older StudiesStudies

On average 50% reported they had reduced On average 50% reported they had reduced use measured in days and 38% followed use measured in days and 38% followed had complete abstinence at 6 monthshad complete abstinence at 6 months (Williams (Williams et al 2000)et al 2000)

Limited by methodological problems: tend to be Limited by methodological problems: tend to be evaluations of inpatient programsevaluations of inpatient programs (Dennis & White 2003)(Dennis & White 2003)

Uncontrolled evaluation of single programUncontrolled evaluation of single programFew control groupsFew control groupsVaried primary outcome measuresVaried primary outcome measuresReliance on self-report or clinical recordsReliance on self-report or clinical recordsLack of standardized or validated measuresLack of standardized or validated measuresLimited follow-upLimited follow-up

Frequently Asked Question #6Frequently Asked Question #6

What kind of treatment should What kind of treatment should my patient be getting?my patient be getting?

Quiz # 6Quiz # 6

How many “evidence-based” How many “evidence-based” treatment can you name for treatment can you name for adolescents with substance adolescents with substance use disorders?use disorders?

Emerging Evidence for Psychosocial Emerging Evidence for Psychosocial TreatmentsTreatments

Emerging evidence for interventions in Emerging evidence for interventions in individual or group settings and in individual or group settings and in combinationcombination

Family-based approachesFamily-based approachesBehavioral TherapiesBehavioral TherapiesCognitive Behavioral Therapy (CBT)Cognitive Behavioral Therapy (CBT)12-Step Programs12-Step ProgramsHarm ReductionHarm ReductionMotivational approachesMotivational approaches

Emerging Evidence for Psychosocial Emerging Evidence for Psychosocial TreatmentsTreatments

Studies often had limitationsStudies often had limitations (O’Brien et al 2005)(O’Brien et al 2005)

Differential attritionDifferential attrition

No validated independent outcome measures No validated independent outcome measures with objective evaluation of drug usewith objective evaluation of drug use

Small sample sizesSmall sample sizes

No specification and evaluation of treatment No specification and evaluation of treatment fidelity and qualityfidelity and quality

Dilution of interventionsDilution of interventions

Limited follow-upLimited follow-up

Multisystemic TherapyMultisystemic Therapy

Manualized approach addressing multiple Manualized approach addressing multiple determinants of substance use and determinants of substance use and antisocial behaviorsantisocial behaviors

Engage family members as collaboratorsEngage family members as collaboratorsStressing the strength of youth and familiesStressing the strength of youth and familiesAddressing barriers to treatment goalsAddressing barriers to treatment goalsTherapists familiar with several therapies Therapists familiar with several therapies including CBT and structural family therapyincluding CBT and structural family therapyFrequent home visits and on-call full timeFrequent home visits and on-call full time

Brief Strategic Family Therapy (BSFT)Brief Strategic Family Therapy (BSFT)

Less intensive than MST: fewer systems Less intensive than MST: fewer systems and less frequent (weekly office visits)and less frequent (weekly office visits)

Target patterns of interactionsTarget patterns of interactionsEngaging all family members in treatmentEngaging all family members in treatment

Identify family strengths and roles and Identify family strengths and roles and relationships linked to problemrelationships linked to problem

Develop new family interactions to protect the Develop new family interactions to protect the adolescent (e.g. parenting skills; conflict adolescent (e.g. parenting skills; conflict resolution) resolution)

Multidimensional Family Therapy Multidimensional Family Therapy (MDFT)(MDFT)

Multicomponent, staged, family therapyMulticomponent, staged, family therapy

Liddle et al 2001: 182 SUD adolescentsLiddle et al 2001: 182 SUD adolescentsMDFT vs Group (CBT) vs Multifamily educationMDFT vs Group (CBT) vs Multifamily education

6 months of weekly sessions: 70% completed6 months of weekly sessions: 70% completed

MDFT superior at 6 and 12 monthsMDFT superior at 6 and 12 months

42% vs 32% vs 26% 42% vs 32% vs 26%

Other promising family interventions include Other promising family interventions include family system therapy (FST) and functional family family system therapy (FST) and functional family therapy (FFT)therapy (FFT)

Behavioral TherapyBehavioral Therapy

Operant conditioning principles to address Operant conditioning principles to address reinforcing properties of substancesreinforcing properties of substances

Azrin et al 1994: 26 substance-using Azrin et al 1994: 26 substance-using youthsyouths

Behavior therapy vs supportive counselingBehavior therapy vs supportive counseling

Modeling, rehearsal, self-monitoring, homeworkModeling, rehearsal, self-monitoring, homework

Behavior therapy had better school and family Behavior therapy had better school and family functioning and less substance use on urine toxicology functioning and less substance use on urine toxicology screens and self-reportsscreens and self-reports

Behavioral TherapyBehavioral Therapy

Contingency management: utilize reward Contingency management: utilize reward systemssystems

Vouchers (Higgins et al 1994) or Fishbowl Vouchers (Higgins et al 1994) or Fishbowl (Petry et al 2000)(Petry et al 2000)

Cash incentives reduced smoking (Corby et al Cash incentives reduced smoking (Corby et al 2000)2000)

Vouchers improved treatment retention (Sinha Vouchers improved treatment retention (Sinha et al 2003) et al 2003)

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Based on social learning theoryBased on social learning theoryFunctional analysis of substance useFunctional analysis of substance useSkills training and self-regulation strategiesSkills training and self-regulation strategies

Waldron et al 2001: 129 SUD adolescentsWaldron et al 2001: 129 SUD adolescentsFFT(12hrs) vs Individual CBT(10+2 MET) vs FFT(12hrs) vs Individual CBT(10+2 MET) vs CBT+FFT(24) vs Psychoed/CBT group (12)CBT+FFT(24) vs Psychoed/CBT group (12)70-80% completion: follow-up at 4, 7, 19 months 70-80% completion: follow-up at 4, 7, 19 months Significant reduction for all: FFT & CBT+FFT better Significant reduction for all: FFT & CBT+FFT better and effects persisted at 7-month follow-upand effects persisted at 7-month follow-up

Waldron et al 2003: 31 SUD treatment refusersWaldron et al 2003: 31 SUD treatment refusersInd. CBT reduced use but use was still heavyInd. CBT reduced use but use was still heavy

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Kaminer et al 2002: 88 SUD adolescentsKaminer et al 2002: 88 SUD adolescents8 weeks of Group CBT vs Psychoed group 8 weeks of Group CBT vs Psychoed group 86% completion; 65% available for 9-month 86% completion; 65% available for 9-month follow-upfollow-upCBT>Psychoed for males; same for femalesCBT>Psychoed for males; same for femalesSame at follow-up with high relapse rate 52%Same at follow-up with high relapse rate 52%high drop out rate with Conduct Disordershigh drop out rate with Conduct Disorders

Emerging support in comparison studiesEmerging support in comparison studies ((Liddle 2002; Liddle et al 2001)Liddle 2002; Liddle et al 2001)

Twelve-Step ProgramsTwelve-Step Programs

Alcoholics Anonymous (AA), Narcotics Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and many other Anonymous (NA), and many other substance specific programssubstance specific programs

Focus on building support networkFocus on building support networkSpiritually based and abstinence onlySpiritually based and abstinence onlyMost common but no RCT: TSF effective in Most common but no RCT: TSF effective in adult studiesadult studies (Project Match 1997; Carroll et al 1998)(Project Match 1997; Carroll et al 1998)

““Minnesota Model” studyMinnesota Model” study (Winters et al 2000)(Winters et al 2000)

Better substance & psychosocial outcomeBetter substance & psychosocial outcome

Harm ReductionHarm Reduction

Client centered approach applying Client centered approach applying readiness to change conceptreadiness to change concept

Precontemplation, contemplation, preparation, Precontemplation, contemplation, preparation, action, maintenance, relapseaction, maintenance, relapseFocus on reducing consequences of useFocus on reducing consequences of useDevelop strategies and skillsDevelop strategies and skillsEmerging adolescent dataEmerging adolescent data (Toumbourou et al 2007)(Toumbourou et al 2007)

Controversial but valuable as intermediate Controversial but valuable as intermediate treatment goaltreatment goal (AACAP 2005)(AACAP 2005)

Motivational approachesMotivational approaches

Motivational interviewing (MI)Motivational interviewing (MI)Client-centered approach focusing on ambivalenceClient-centered approach focusing on ambivalenceExpress EmpathyExpress EmpathyDevelop DiscrepancyDevelop DiscrepancyRoll with ResistanceRoll with ResistanceSupport Self-EfficacySupport Self-Efficacy

Motivational Enhancement Therapy (MET)Motivational Enhancement Therapy (MET)Assessment interview + personal feedback Assessment interview + personal feedback using MI techniquesusing MI techniquesCommonly used in combination with othersCommonly used in combination with others

Motivational approachesMotivational approaches

MI TechniquesMI Techniques (Miller & Rollnick 2002)(Miller & Rollnick 2002)

Open-ended questionsOpen-ended questionsListen ReflectivelyListen ReflectivelyAffirmAffirmSummarizeSummarizeElicit self-motivational statementsElicit self-motivational statements

Monti et al 1999: MI vs TAUMonti et al 1999: MI vs TAU94 adolescent in ER: alcohol related problem94 adolescent in ER: alcohol related problemMI decreased problems at 6-monthsMI decreased problems at 6-months

Cannabis Youth Treatment (CYT)Cannabis Youth Treatment (CYT)

600 adolescents from 4 sites600 adolescents from 4 sites

MET/CBT5 vs MET/CBT12 vs Family MET/CBT5 vs MET/CBT12 vs Family Support Network vs MDFT vs Adolescent Support Network vs MDFT vs Adolescent Community Reinforcement Approach Community Reinforcement Approach (ARCA): 6-21 sessions over 5-12 weeks (ARCA): 6-21 sessions over 5-12 weeks

95% follow-up rate up to 30-months95% follow-up rate up to 30-months

All performed equally well: 50% reductionAll performed equally well: 50% reduction

Effects maintained at follow-upEffects maintained at follow-up

Pharmacological TreatmentPharmacological Treatment

Limited research with few controlled studies and Limited research with few controlled studies and very small samplesvery small samples (Waxmonsky & Wilens 2005)(Waxmonsky & Wilens 2005)

NicotineNicotineBupropion (Wellbutrin) (Upadhyaya et al 2005)Bupropion (Wellbutrin) (Upadhyaya et al 2005)Nicotine Replacement TherapyNicotine Replacement Therapy

AlcoholAlcoholDisulfiram (Antabuse)Disulfiram (Antabuse)Naltrexone Naltrexone (Deas et al 2005)(Deas et al 2005)

AcamprosateAcamprosate

OpiateOpiateMethadoneMethadoneBuprenorphineBuprenorphineNaltrexoneNaltrexone

SUD Treatment factorsSUD Treatment factors

Treatment > none & Longer better Treatment > none & Longer better Pretreatment Pretreatment

Non-white, high severity, criminality, lower educational status = poorer Non-white, high severity, criminality, lower educational status = poorer outcomeoutcome

Intreatment Intreatment Time, family, skills, scope of servicesTime, family, skills, scope of services

PosttreatmentPosttreatmentPeers, activitiesPeers, activities

Positive factorsPositive factorsTreatment completion, low pretreatment use, peer & parent social Treatment completion, low pretreatment use, peer & parent social support support

SummarySummary

Treatment is better than no treatmentTreatment is better than no treatmentWell-defined structured approaches targeting Well-defined structured approaches targeting broad dimensions work bestbroad dimensions work bestTreatment completion-> better outcomeTreatment completion-> better outcomeMost support for family-based txMost support for family-based txGrowing support for CBT, Contingency Growing support for CBT, Contingency Management, Motivational approachesManagement, Motivational approachesDifference in effect may be time and person Difference in effect may be time and person dependent dependent

Co-Occurring Disorders Co-Occurring Disorders

SUDs + Mental Disorders: evolvingSUDs + Mental Disorders: evolving

COD is the rule, not the exceptionCOD is the rule, not the exception60% (Armstrong & Costello, 2002)60% (Armstrong & Costello, 2002)

Disruptive Behavior Disorders (DBDs)Disruptive Behavior Disorders (DBDs)

Depression & other mood disordersDepression & other mood disorders

Anxiety disordersAnxiety disorders

Attention-Deficit Hyperactivity Disorder (ADHD)Attention-Deficit Hyperactivity Disorder (ADHD)

Learning disabilities & sensory problemsLearning disabilities & sensory problems

Others: Bulimia, Psychosis, Personality DisordersOthers: Bulimia, Psychosis, Personality Disorders

Co-Occurring DisordersCo-Occurring Disorders

Presence of psychiatric disorders leads to increased risk Presence of psychiatric disorders leads to increased risk of SUDsof SUDs

Especially Conduct and Depressive DisordersEspecially Conduct and Depressive Disorders

COD vs. SUD alone:COD vs. SUD alone:More alcohol or drug dependenceMore alcohol or drug dependenceMore family, school, criminal problemsMore family, school, criminal problemsMore likely to engage in delinquent behaviors and use More likely to engage in delinquent behaviors and use hallucinogens & cannabis in the 12 months after treatment hallucinogens & cannabis in the 12 months after treatment

Treatment needs to target both SUD and Treatment needs to target both SUD and psychiatric problemspsychiatric problems (Pumariega et al 2004)(Pumariega et al 2004)

Medications have increased roleMedications have increased roleTackle comorbid problem aggressivelyTackle comorbid problem aggressively

ADHD

Depression

ODD CD ASP

Substance Use Abuse Dependence

FamilyFamily0 10 205 15

PEERS PEERS

Resilience Resilience IQ; academic performance; femalehobby; empathic gatekeeper

SUD, abuse, neglectSUD, abuse, neglect

SchoolSchool Truancy, failure, HS dropout Truancy, failure, HS dropout

Antisocial; drug-usingAntisocial; drug-using

Evidence-Based Treatment of Adolescent SUDEvidence-Based Treatment of Adolescent SUD

Genetics Attachment

Individual Individual Angold et al., 99; Capaldi et a 1992l., 199 Ingoldsby et al 2006; Fergusson et al., 1998; Lewinsohn,Rohde et al.,1995

Fetal Exposure Fetal Exposure Drugs/AlcoholDrugs/Alcohol Adolescent Brain Development

Family-based interventionsFamily-based interventionsMultidimensional; MST; BSFT; Multidimensional; MST; BSFT; Functional Family Therapy (FFT)Functional Family Therapy (FFT)

Behavioral interventionsBehavioral interventionsOperant PrinciplesOperant PrinciplesContingency ManagementContingency ManagementMotivational IncentivesMotivational Incentives

Motivational Enhancement TherapyMotivational Enhancement TherapyCognitive-behavioral therapy (CBT)Cognitive-behavioral therapy (CBT)PharmacotherapyPharmacotherapy (adult trials)(adult trials)

Aversive (disulfram)Aversive (disulfram)

Antagonists (naltrexone)Antagonists (naltrexone)

Agonists (methadone, buprenorphine)Agonists (methadone, buprenorphine)

Detoxification protocolsDetoxification protocols

Integrated TreatmentIntegrated Treatment

Riggs et al., 2007: Landmark studyRiggs et al., 2007: Landmark study126 adolescents 13-19126 adolescents 13-1916-week individual CBT+Fluoxetine vs. CBT+Placebo for 16-week individual CBT+Fluoxetine vs. CBT+Placebo for SUD+MDD+CDSUD+MDD+CDMDD remission: Fluox > Placebo on CDRS-RMDD remission: Fluox > Placebo on CDRS-RSUD: reduce use in both groupsSUD: reduce use in both groups

Remitters > non-remitRemitters > non-remitConduct: reduced in both groupsConduct: reduced in both groups

Remitters > non-remitRemitters > non-remit

Riggs et al., 2007: Follow-upRiggs et al., 2007: Follow-upCBT retained gains at one year follow-upCBT retained gains at one year follow-up

Overall Summary Overall Summary

SUDs are complex disordersSUDs are complex disorders

Uniqueness of adolescents: Problems with Uniqueness of adolescents: Problems with classification/nomenclatureclassification/nomenclature

Epidemiological data to enhance understandingEpidemiological data to enhance understanding

Prevention effortsPrevention efforts

Treatment developmentTreatment development

Suggestions for Primary Care Suggestions for Primary Care ProvidersProviders

Remember the “1 in 10” ruleRemember the “1 in 10” rule

Use screening tools: when in doubt -> REFER!Use screening tools: when in doubt -> REFER!

Gather collateral information (including drug Gather collateral information (including drug testing) and educate parents on warning signstesting) and educate parents on warning signs

Know your local resources and assemble your Know your local resources and assemble your own referral/treatment networkown referral/treatment network

Inquire about training, modality of treatment, Inquire about training, modality of treatment, treatment philosophy, scope of servicestreatment philosophy, scope of services

Support groups for patients/familiesSupport groups for patients/families

Suggestions for Primary Care Suggestions for Primary Care ProvidersProviders

Know your state law: age of consent for treatment, Know your state law: age of consent for treatment, confidentialityconfidentiality

Encourage adolescents to engage in pro-social activities Encourage adolescents to engage in pro-social activities and recovery supportand recovery support

Treat Co-Occurring Disorders: consider medications for Treat Co-Occurring Disorders: consider medications for primary psychiatric disordersprimary psychiatric disorders

Consider training in Motivational Interviewing and Consider training in Motivational Interviewing and Twelve Step FacilitationTwelve Step Facilitation

Consider training in BuprenorphineConsider training in Buprenorphine

Judicious use of medications with addictive potentials Judicious use of medications with addictive potentials when indicated when indicated

Additional Useful ResourcesAdditional Useful Resources

http://www.nida.nih.govNIDA for TeensNIDA for TeensResources for Parents/TeachersResources for Parents/TeachersResources for ProvidersResources for Providers

http://www.aacap.orgFacts for Families Facts for Families Practice ParametersPractice Parameters

Wikipedia: common slang terms for illicit Wikipedia: common slang terms for illicit substances and current trends but need to verify substances and current trends but need to verify original sourceoriginal sourceFree training opportunities: Hazelden Free training opportunities: Hazelden