Assessment and Treatment of
Adolescent Substance Use
Disorders: Practical Tips for
Primary Care Providers in WY
Ray C. Hsiao, MD
Assistant Professor of Psychiatry, University of Washington
Co-Director, Adolescent Substance Abuse Program
Seattle Children’s Hospital
PAL Conference, Laramie, WY; 3/24/12
Objectives
Participants will learn about the prevalence and
patterns of substance use and substance use
disorders (SUDs) in adolescents
Participants will become familiar with common
screening and assessment tools of SUDs in
adolescents
Participants will be able to describe and utilize
common treatment options for SUDs in
adolescents
Disclosure
No conflict of interest to report
Off-label discussion of medications
Overview
Definitions
Prevalence
Screening: the Adolescent Perspective and Risk
and Protective Factors
Assessment
Treatment
Co-Occurring Disorders
Questions and Answers
Substance-Related Disorders
Substances covered in DSM IV-TR: Alcohol,
Amphetamine, Caffeine, Cannabis, Cocaine,
Hallucinogen, Inhalant, Nicotine, Opioid, Phencyclidine,
Sedative/Hypnotic/Anxiolytic, Other/Unknown
Substance Use Disorders (SUDs) = Substance Abuse or
Dependence
Substance-Induced Disorders = Substance Intoxication
or Withdrawal
Nicotine & Polysubstance: No Abuse
Caffeine: No Abuse or Dependence
Substance Abuse
A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by one (or more) of the following occurring at
anytime within a 12-month period:
Recurrent use resulting in a failure to fulfill major role
obligations at work, school or home
Recurrent substance use in situations in which it is
physically hazardous
Recurrent substance-related legal problems
Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance
Never met criteria for dependence
Substance Dependence
A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as
manifested by three (or more) of the following,
occurring at any time in the same 12-month period:
Tolerance: “a need for markedly increased
amounts of the substance to achieve intoxication
or desired effect” or “markedly diminished effect
with continued use of the same amount of the
substance”
Withdrawal: “the characteristic withdrawal
syndrome for the substance” or “the same (or a
closely related) substance is taken to relieve or
avoid withdrawal symptoms
Substance Dependence
Substance is often taken in larger amounts or
over a longer period than intended
Persistent desire or unsuccessful efforts to cut
down or control substance use
Great deal of time is spent in activities necessary
to obtain the substance, use the substance, or
recover
Important social, occupational, or recreational
activities are given up or reduced
Substance use is continued despite knowledge of
persistent or recurrent physical or psychological
problem caused or exacerbated by substance
Dependence Specifiers
With Physiological Dependence
Without Physiological Dependence
Course Specifiers
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Polysubstance Dependence
Repeatedly using at least 3 groups of
substances (not including caffeine or nicotine)
Dependence criteria were met as a group but
not for any specific substance
Most commonly in individuals where the
substance use is highly prevalent but the drugs
of choice frequently changed
DSM 5: Substance Use Disorders
11 criteria: replaced “legal problem” with
“craving or a strong desire or urge to use a
specific substance”
New Severity Specifiers
Moderate: 2-3 criteria positive
Severe: 4 or more criteria positive
Same Course Specifiers as DSM IV-TR
Potentially identify problematic use earlier and
lead to proper intervention
Frequently Asked Question # 1
How common is substance
use in adolescents?
Who is using?
What are they using?
Quiz #1
How common is substance use? In a class of
100 high school seniors, how many have tried
the following during their lifetime:
Cigarettes?
Alcohol?
Illicit Drugs?
Illicit Drugs other than Cannabis?
Prevalence of Substance Use
Monitoring The Future (MTF) Study
www.monitoringthefuture.org
NIDA funded national study
Middle/high school, college, young adults
40,000+ adolescents from 300+ sites
Survey behaviors/attitudes on substance use
Annual follow-up survey to graduating class
MTF Lifetime Prevalence: 2011
8th
10th
12th
18.4%
30.4%
40.0%
33.1%
56.0%
70.0%
Any Illicit
Drug
20.1%
37.7%
49.9%
Any Illicit
Drug other
than MJ
9.8%
15.6%
24.9%
Any
Cigarettes
Any Alcohol
MTF Lifetime Prevalence: 2011
Marijuana
Inhalants
Amphetamines
Heroin
Hallucinogen
Cocaine
Methamphetamine
Ecstasy/MDMA
Tranquilizers
Other Narcotics
8th
16.4%
10th
34.5%
12th
45.5%
13.1%
5.2%
1.2%
3.3%
10.1%
9.0%
1.2%
6.0%
8.1%
12.2%
1.4%
8.3%
2.2%
1.3%
2.6%
3.3%
2.1%
6.6%
5.2%
2.1%
8.6%
3.4%
N/A
6.8%
N/A
8.7%
13.0%
Summary of MTF Trend Findings
Male generally more drug use
College-bound adolescents use less
Regional variation is quite complex & changing
Population density is not a predictor of use
Socioeconomic class difference mostly small
Whites ≥ Hispanics > African Americans:
Hispanics in 8th grade higher in most categories
but may have higher drop-out rate and earlier
initiation to account for lower numbers in 12th
grade
Quiz #2
In adolescents ages 12-17:
How common is Substance Abuse?
How common is Substance
Dependence?
Prevalence of SUDs
National Household Survey on Drug Use and
Health (NHSDUH)
http://oas.samhsa.gov/nsduh.htm
Formerly NHSDA(buse)
Youth 12-17 years old: survey use and abuse
8% classified with SUDs in 2005 (3.1% Abuse,
4.9% Dependence): 8.3% for males, 7.8% for
females
7.3% classified with SUDs in 2010 (4.5%
Alcohol, 4.7% Illicit drugs): 6.9% for males,
7.7% for females
Prevalence of SUDs
National Comorbidity Survey-Adolescent
Supplement ( NCS-A): Merikangas et al, JAACAP 2010
Youth 13-18 years old: diagnostic survey
11.4 classified with SUDs: (6.4% Alcohol,
8.9% Illicit drugs): 12.5% for males, 10.2% for
females
SUDs rates by age group:
13-14: 3.7%
15-16: 12.2%
17-18: 22.3%
NHSDUH 2010: SUDs Pattern
Most Common Types of Substance Used:
Alcohol > Marijuana > Pain Relievers >
Cocaine > Others (methamphetamine,
heroin, hallucinogen)
Polysubstance use is common
Reflected in most treatment studies and
clinical trials (O’Brien et al 2005)
Summary: Epidemiological Studies
Experimentation is normative but
consequences can be severe and farranging
Abuse is the exception: look for early
initiation and heavy use
“Gateway Theory”: Cigarettes Alcohol
 Cannabis  Other illicit drugs
Frequently Asked Question #2
How do I know whether my
patient is using too much or not?
(i.e., Is he/she just a typical
teenager or someone who needs
an intervention or assessment)
Tasks of Adolescence
Emancipation/surrender of childhood
Identity formation
Sexual
Intellectual
Moral
Spiritual
Ethnic
Functional role in society
Risk Factors for SUDs
Newcomb 1997
Four generic domains
Cultural/Societal
Interpersonal: family and peers
Psychobehavioral
Biogenetic
Relevance modified by age, gender, and
ethnicity
Mediating Factors
Early experimentation
Substance-Dependent parents
Substance-Abusing siblings
Conduct disturbances
Deviant and substance-abusing peers
Sensation-seeking temperament
Impulse and self-control problems
Mediating Factors
Poor parental supervision
Heavy drug-use neighborhoods
School problems
Social skills deficits
Parents with poor parenting skills
Victims of trauma, abuse and neglect
Riggs’ Developmental Pathways to Adolescent Mental Health, Substance Problems
IQ; academic performance; female
Resilience
hobby; empathic gatekeeper
Substance
Use
Abuse
Dependence
PEERS
IMPEDES DEVELOPMENT
Antisocial; drug-using
Coping skills
School Truancy, failure, HS dropout
SUD, abuse, neglect
Genetics
Attachment
 Communication
skills
Family
 Social /interpersonal skills
 Identity, values consolidation
10
5
Fetal Exposure
 Affect identification/regulation
0
15
20
Drugs/Alcohol
ADHD locus control
 Self-Efficacy/external
 Cognitive development
Pro-social network
ODD
Individual
CD
ASP
Depression
Quiz #3
What is the screening instrument
recommended by the American
Academy of Pediatrics for
adolescents with substance use
disorders?
Screening/Testing
CRAFFT (Knight 2002): screening; 2 or more of
the following indicate significant problem
Car
Relax
Alone
Family/friends
Forget
Trouble
Drug testing: urine or other modalities
Frequently Asked Question #3
What do I do if my patient is in
need of an assessment or
intervention?
What happens at a chemical
dependency assessment? Who
performs the assessment?
Chemical Dependency Assessment
Usually performed by Substance Abuse
Counselors/Chemical Dependency
Professionals (CDPs)
Assessment usually consists of a clinical
interview that addresses the 6 dimensions of
American Society of Addiction Medicine (ASAM)
Patient Placement Criteria (PPC)
Quiz # 4
How many dimensions of the
ASAM PPC can you name?
ASAM PPC Dimensions
I: Acute intoxication and/or withdrawal potential
II: Biomedical conditions and complications
III: Emotional, behavioral, or cognitive conditions
and complications
IV: Readiness to Change
V: Relapse, continued use, or continued
problem potential
VI: Recovery environment
Quiz # 5
Can you name the 4 different
levels of chemical dependency
treatment identified in the
ASAM PPC?
ASAM PPC Levels
Level 0.5: Early Intervention
Level I: Outpatient Services: <9hours/week
Level II: Intensive outpatient (9-19 hours/week)/
Partial hospitalization (>20 hours/week)
Level III: residential/inpatient services (e.g.,
imminent risk in relapse, continued use or
recovery environment)
Level IV: medically managed intensive inpatient
services (e.g., imminent risk in D1, D2, or D3)
Psychiatric Assessment
Multiple domains: Timeline approach
Psychiatric/behavioral
Family
School/Vocational
Recreational/Leisure
Medical
Collateral, collateral, collateral!!!
Toxicology
Riggs’ Lifetime Timeline
Longitudinal Developmental History
 Pre-natal; attachment
Family
Abuse, neglect, conflict, SUD
Family management
Parental monitoring
Pre-natal
Attachment
School
 LD; special education
 Behavior problems
 Academic performance
Adolescent
School-age
Onset and Progression of Psychiatric Symptoms
 ODD/CD
 ADHD
 Depression
 Mania /hypomania
 Anxiety (SAD, PTSD, GAD, OCD)
 Psychosis
Peers
 Deviancy
 Substance Use
 Gang
Adult
College-age
Substance Use
 Onset, experimentation
 For all substances used >5x
 Progression to regular use
 Peak use
 Current use (last month)
 Last use
Frequently Asked Question #4
How do I get my patient into
treatment?
What happens when my
patient is in treatment in
Washington State?
Outpatient/Intensive Outpatient
Services
Non-residential programs providing
chemical dependency assessments,
alcohol/drug free counseling services and
education for youth age 10 to 20
Designed to screen, assess, diagnose,
and treat misuse, abuse, and addiction to
alcohol and other drugs
Detox/Stabilization Services
Services providing at-risk, runaway,
homeless youth age 13-17 a safe,
temporary, and protective environment
Criteria: experiencing crisis related to the
harmful effects of intoxication and/or
withdrawal from alcohol and other drugs,
in conjunction with an emotional or
behavioral crisis
Typical length of stay: 1-5 days
Inpatient Treatment
Programs designed for “chemically
dependent” youth age 13-17
Services include intensive individual,
group, and family counseling, education,
school activities, recreation, recovery
support groups, and connection to
continuing treatment in the home
community
Levels of Inpatient Services
Level 1
Primary addiction problems requiring less
clinical intervention and behavior management
Level 2
Co-occurring emotional and mental health
problems, youth resistant to treatment, or high
probability to run from treatment
Recovery House
Continued residential stay after completing
primary inpatient treatment
NHSDUH 2010: Treatment Needs
Overall: 1.8 million youths aged 12-17
(7.5% of sample population) needed
treatment -> 138,000 youths received
treatment at a specialty facility (7.6% of
youths who needed treatment)
Most treatment occurred in outpatient
settings
Barriers to Treatment
Five most often reported reasons for not
receiving treatment
(NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)
Not ready to stop using (40.2%)
Cost or insurance barriers (32.9%)
Stigma (e.g., negative opinions from neighbors
and community, negative effect on job) (22.8%)
Can handle the problem without treatment (9.9%)
Did not know where to go (9.3%)
Barriers to Treatment
Five most often reported reasons for not
receiving treatment despite seeking
treatment:
(NHSDUH 2007-10 Combined Data: Treatment in Aged 12 or older)
Cost or insurance barriers (45.2%)
Not ready to stop using (30.3%)
Treatment not needed (15.5%)
Stigma (15.0%)
No Transportation/Inconvenient (8.4%)
Additional Complications in Adolescent
SUD Treatment
Polysubstance use: typically alcohol and
marijuana, occasional cocaine or opiates (Winters
et al 2000; Kaminer et al 2002; Henggeler et al 1996)
High rates of comorbid psychiatric disorders
(Armstrong et al 2002)
High rates of substance abuse in immediate
families (Henggeler et al 1996; Winters et al 2000)
Developmental vulnerability
Involvement in multiple systems: legal, school,
and medical problems may present first
High attrition rate: 50-80% (Henggeler et al 1996)
Frequently Asked Questions #5
Does treatment work? (e.g.,
“I’ve known people who have
been through rehab many
times but they are still
addicted”)
Why Treatment
Inconsistent outcomes after treatment
prior to 1990’s (Catalano et al. 1992)
Treatment might escalate problems (Kaminer
2005; Dishion et al 1999)
Recent reviews show psychosocial
treatment is better than no treatment
(Pumariega et al 2004; O’Brien et al 2005; Liddle & Rowe 2006)
Effective early intervention is critical and
can be preventive in later years (Grant & Dawson
1997; Santisteban et al. 2003; NHSDUH series)
Treatment Evaluation Studies: Older
Studies
Older studies tend to be evaluations of four
types of programs
“Minnesota Model”: comprehensive 4-6 week
inpatient program using 12-Step
Outpatient drug-free programs: individual and group
with some family counseling
“Therapeutic Community”: 6-12 months residential
program using 12-Step
Outward Bound or life skills training programs: 3-4
weeks wilderness program focusing on challenges of
survival and group interdependency
Treatment Evaluation Studies: Older
Studies
On average 50% reported they had
reduced use measured in days and 38%
followed had complete abstinence at 6
months (Williams et al 2000)
Limited by methodological problems: tend to be
evaluations of inpatient programs (Dennis & White 2003)
Uncontrolled evaluation of single program
Few control groups
Varied primary outcome measures
Reliance on self-report or clinical records
Lack of standardized or validated measures
Limited follow-up
Frequently Asked Question #6
What kind of treatment should
my patient be getting?
Quiz # 6
How many “evidence-based”
treatment can you name for
adolescents with substance
use disorders?
Emerging Evidence for Psychosocial
Treatments
Emerging evidence for interventions
in individual or group settings and in
combination
Family-based approaches
Behavioral Therapies
Cognitive Behavioral Therapy (CBT)
12-Step Programs
Harm Reduction
Motivational approaches
Emerging Evidence for Psychosocial
Treatments
Studies often had limitations (O’Brien et al 2005)
Differential attrition
No validated independent outcome measures
with objective evaluation of drug use
Small sample sizes
No specification and evaluation of treatment
fidelity and quality
Dilution of interventions
Limited follow-up
Multisystemic Therapy
Manualized approach addressing multiple
determinants of substance use and
antisocial behaviors
Engage family members as collaborators
Stressing the strength of youth and families
Addressing barriers to treatment goals
Therapists familiar with several therapies
including CBT and structural family therapy
Frequent home visits and on-call full time
Brief Strategic Family Therapy (BSFT)
Less intensive than MST: fewer systems
and less frequent (weekly office visits)
Target patterns of interactions
Engaging all family members in treatment
Identify family strengths and roles and
relationships linked to problem
Develop new family interactions to protect the
adolescent (e.g. parenting skills; conflict
resolution)
Multidimensional Family Therapy
(MDFT)
Multicomponent, staged, family therapy
Liddle et al 2001: 182 SUD adolescents
MDFT vs Group (CBT) vs Multifamily
education
6 months of weekly sessions: 70% completed
MDFT superior at 6 and 12 months
42% vs 32% vs 26%
Other promising family interventions include
family system therapy (FST) and functional
family therapy (FFT)
Behavioral Therapy
Operant conditioning principles to address
reinforcing properties of substances
Azrin et al 1994: 26 substance-using
youths
Behavior therapy vs supportive counseling
Modeling, rehearsal, self-monitoring, homework
Behavior therapy had better school and family
functioning and less substance use on urine
toxicology screens and self-reports
Behavioral Therapy
Contingency management: utilize reward
systems
Vouchers (Higgins et al 1994) or Fishbowl
(Petry et al 2000)
Cash incentives reduced smoking (Corby et al
2000)
Vouchers improved treatment retention (Sinha
et al 2003)
Cognitive Behavioral Therapy
Based on social learning theory
Functional analysis of substance use
Skills training and self-regulation strategies
Waldron et al 2001: 129 SUD adolescents
FFT(12hrs) vs Individual CBT(10+2 MET) vs
CBT+FFT(24) vs Psychoed/CBT group (12)
70-80% completion: follow-up at 4, 7, 19 months
Significant reduction for all: FFT & CBT+FFT better
and effects persisted at 7-month follow-up
Waldron et al 2003: 31 SUD treatment refusers
Ind. CBT reduced use but use was still heavy
Cognitive Behavioral Therapy
Kaminer et al 2002: 88 SUD adolescents
8 weeks of Group CBT vs Psychoed group
86% completion; 65% available for 9-month
follow-up
CBT>Psychoed for males; same for females
Same at follow-up with high relapse rate 52%
high drop out rate with Conduct Disorders
Emerging support in comparison studies
(Liddle 2002; Liddle et al 2001)
Twelve-Step Programs
Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), and many other
substance specific programs
Focus on building support network
Spiritually based and abstinence only
Most common but no RCT: TSF effective in
adult studies (Project Match 1997; Carroll et al 1998)
“Minnesota Model” study (Winters et al 2000)
Better substance & psychosocial outcome
Harm Reduction
Client centered approach applying
readiness to change concept
Precontemplation, contemplation, preparation,
action, maintenance, relapse
Focus on reducing consequences of use
Develop strategies and skills
Emerging adolescent data (Toumbourou et al 2007)
Controversial but valuable as intermediate
treatment goal (AACAP 2005)
Motivational approaches
Motivational interviewing (MI)
Client-centered approach focusing on ambivalence
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
Motivational Enhancement Therapy (MET)
Assessment interview + personal feedback
using MI techniques
Commonly used in combination with others
Motivational approaches
MI Techniques (Miller & Rollnick 2002)
Open-ended questions
Listen Reflectively
Affirm
Summarize
Elicit self-motivational statements
Monti et al 1999: MI vs TAU
94 adolescent in ER: alcohol related problem
MI decreased problems at 6-months
Cannabis Youth Treatment (CYT)
600 adolescents from 4 sites
MET/CBT5 vs MET/CBT12 vs Family
Support Network vs MDFT vs Adolescent
Community Reinforcement Approach
(ARCA): 6-21 sessions over 5-12 weeks
95% follow-up rate up to 30-months
All performed equally well: 50% reduction
Effects maintained at follow-up
Pharmacological Treatment
Limited research with few controlled studies and
very small samples (Waxmonsky & Wilens 2005)
Nicotine
Bupropion (Wellbutrin) (Upadhyaya et al 2005)
Nicotine Replacement Therapy
Alcohol
Disulfiram (Antabuse)
Naltrexone (Deas et al 2005)
Acamprosate
Opiate
Methadone
Buprenorphine
Naltrexone
SUD Treatment factors
Treatment > none & Longer better
Pretreatment
Non-white, high severity, criminality, lower educational status = poorer
outcome
Intreatment
Time, family, skills, scope of services
Posttreatment
Peers, activities
Positive factors
Treatment completion, low pretreatment use, peer & parent social
support
Summary
Treatment is better than no treatment
Well-defined structured approaches targeting
broad dimensions work best
Treatment completion-> better outcome
Most support for family-based tx
Growing support for CBT, Contingency
Management, Motivational approaches
Difference in effect may be time and person
dependent
Co-Occurring Disorders
SUDs + Mental Disorders: evolving
COD is the rule, not the exception
60% (Armstrong & Costello, 2002)
Disruptive Behavior Disorders (DBDs)
Depression & other mood disorders
Anxiety disorders
Attention-Deficit Hyperactivity Disorder (ADHD)
Learning disabilities & sensory problems
Others: Bulimia, Psychosis, Personality Disorders
Co-Occurring Disorders
Presence of psychiatric disorders leads to increased risk
of SUDs
Especially Conduct and Depressive Disorders
COD vs. SUD alone:
More alcohol or drug dependence
More family, school, criminal problems
More likely to engage in delinquent behaviors and use
hallucinogens & cannabis in the 12 months after treatment
Treatment needs to target both SUD and
psychiatric problems (Pumariega et al 2004)
Medications have increased role
Tackle comorbid problem aggressively
Evidence-Based Treatment of Adolescent SUD
academic performance; female Resilience
IQ;
hobby; empathic gatekeeper
Family-based interventions
Multidimensional; MST; BSFT;
Functional Family Therapy (FFT)
Substance
Use
Abuse
Dependence
Behavioral interventionsPEERS
Antisocial; drug-using
Operant Principles
Contingency Management
Motivational
Incentives
Genetics Attachment
School Truancy, failure, HS dropout
SUD, abuse, neglect
Family
Motivational Enhancement Therapy
0
10
5 therapy (CBT)
Cognitive-behavioral
Fetal Exposure
15
20
Adolescent Brain Development
Drugs/Alcohol
Pharmacotherapy
(adult
trials)
ADHD
Aversive (disulfram)
 Antagonists (naltrexone)
ODD
Agonists (methadone, buprenorphine)
Detoxification protocols
Individual
CD
ASP
Depression
Angold et al., 99; Capaldi et a 1992l., 199 Ingoldsby et al 2006; Fergusson et al., 1998; Lewinsohn,Rohde et al.,1995
Integrated Treatment
Riggs et al., 2007: Landmark study
126 adolescents 13-19
16-week individual CBT+Fluoxetine vs. CBT+Placebo for
SUD+MDD+CD
MDD remission: Fluox > Placebo on CDRS-R
SUD: reduce use in both groups
Remitters > non-remit
Conduct: reduced in both groups
Remitters > non-remit
Riggs et al., 2007: Follow-up
CBT retained gains at one year follow-up
Overall Summary
SUDs are complex disorders
Uniqueness of adolescents: Problems with
classification/nomenclature
Epidemiological data to enhance understanding
Prevention efforts
Treatment development
Suggestions for Primary Care
Providers
Remember the “1 in 10” rule
Use screening tools: when in doubt -> REFER!
Gather collateral information (including drug
testing) and educate parents on warning signs
Know your local resources and assemble your
own referral/treatment network
Inquire about training, modality of treatment,
treatment philosophy, scope of services
Support groups for patients/families
Suggestions for Primary Care
Providers
Know your state law: age of consent for treatment,
confidentiality
Encourage adolescents to engage in pro-social activities
and recovery support
Treat Co-Occurring Disorders: consider medications for
primary psychiatric disorders
Consider training in Motivational Interviewing and
Twelve Step Facilitation
Consider training in Buprenorphine
Judicious use of medications with addictive potentials
when indicated
Additional Useful Resources
http://www.nida.nih.gov
NIDA for Teens
Resources for Parents/Teachers
Resources for Providers
http://www.aacap.org
Facts for Families
Practice Parameters
Wikipedia: common slang terms for illicit
substances and current trends but need to verify
original source
Free training opportunities: Hazelden