Overview of Adolescent
Substance Abuse & Treatment
Joan E. Zweben, Ph.D.
Executive Director, EBCRP
Clinical Professor of Psychiatry, UCSF
PREP Program Training
June 23, 2011
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)
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
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)
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)
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)
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
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
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
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)
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
BASIC ISSUES (AOD)
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.
BUT
Any amount of alcohol/drug use is
undesirable in persons with cooccurring disorders, and should be
recognized and addressed
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)
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”
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
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)
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
What About the
Therapeutic Alliance?



Studies outside substance abuse show this
accounts for a greater % of the variance than
specific techniques
Different “specific” therapies yield similar
outcomes, but there is wide variability across
sites and therapists
More therapist education/experience does not
improve efficacy
(Adapted from W.R. Miller, Oct 06)
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
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
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
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
Pitfalls of Abstinence-Oriented
Treatment






Failure to assess motivation level before
pushing abstinence commitment
Failure to understand factors promoting
continued use
Unrealistic timetables
Power struggle vs clinical approach
Failure to recognize fluctuating motivation
Inappropriate termination of treatment
Pitfalls of Harm Reduction
Approach





Inappropriately low expectations for
what client can achieve
Difficulty setting clear goals
Reluctance to ask client to abstain
completely
Underestimate risks/lethality
Clinician alcohol and/or illicit drug use
Abstinence & Harm Reduction



It’s a continuum, not a polarity
Clients choose goals; professionals give
clear recommendations and feedback
Considerations differ for individuals and
groups, and especially for residential
treatment
Self-Medication Theory
Two versions:
 etiological - psychiatric disorder
“causes” the person to develop
substance abuse
 coping method - substances are used to
cope with the psychiatric disorder
VS:
 many factors initiate; those and others
perpetuate
Addressing the Client’s SelfMedication Perspective


Acknowledge that drugs may work in
the short run
Use journal to get long term view



“On balance, is your life getting better or
worse since you started drinking/using?
Interference with prescribed
medications
Offer alternatives to deal with social
situations, emotional distress, etc.
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.
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)
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
Post Treatment Recovery
Environment





Mutual aid system (aka self help)
Family
Social network
Living environment
Recovery homes, schools, support
centers, churches, etc.
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
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)
www.ebcrp.org