The effectiveness of interventions for young people with illicit drug
problems.
Claire MacLeod & Catriona Matheson, September 2011
Key Points:
1. Two Cochrane reviews and nine trials were found. Most of the trials were
conducted in the USA thus generalisability of findings is limited. One UK
trial was found.
2. The evidence base was predominantly focussed on mixed drug problems,
but trials focussing on heroin and cannabis usage were also found.
3. No trials of interventions specifically focussed on cocaine, LSD or
psychostimulant abuse were found.
4. The evidence from the single UK trial indicated some benefit of one-hour
single-session face-to-face motivational interviews for generic drug use in
adolescents.
5. There is insufficient evidence around the effectiveness of treatment in
opiate dependence and further research is warranted.
Background
Drug misuse in adolescents is recognised as a growing problem worldwide. This
brief topic review looked at the published literature on randomised controlled
trials (RCTs), trials and comparative studies of various pharmacological,
psychosocial and family interventions for young people with illicit drug problems.
Cannabis is often cited as the most commonly used drug by young people, but
cocaine, ecstasy, amphetamines, LSD, inhalants, and heroin are also used. Drug
misuse often occurs in conjunction with alcohol abuse and is also linked with
mental health. Many individuals are also polydrug or multidrug users, consuming
more than one illicit substance. Hence, this topic is complex and multifaceted,
but of increasing importance in today’s world.
Methods
PubMed/MEDLINE, Scopus, the CRD, and the Cochrane database were searched
from inception to August 2011. Search terms used were ‘substance misuse’ and
‘adolescents’, with various combinations of drug names and limitations to trials
and comparative studies to focus the search on comparative studies and reduce
the volume of non-relevant literature.
The reference lists of relevant articles
were also hand searched. Only RCTs, controlled trials and comparative studies
were included, and the majority of participants had to be less than 18 years old.
Results
Two Cochrane reviews and nine trials were identified by the search strategy.
Most of the trial literature was undertaken in the USA. One UK trial was found.
The included evidence is briefly discussed below, grouped according to drug type.
Opiate usage
Two Cochrane reviews and three USA trials were found (all of the trials were
already included in the Cochrane reviews).
Minozzi S, Amato L, Davoli M.
Maintenance treatments for opiate
dependent adolescents (Review). The Cochrane Library 2009, Issue 2.
This Cochrane review searched the literature for published trials of any opioid
agonist treatment alone or in combination with psychosocial treatment versus
control in opiate dependent adolescents (up to 18 years old). Two USA trials
were identified (Lehmann, 1973 and Woody, 2008) that enrolled 187 outpatient
heroin addicts aged between 14 and 21 years. Lehmann 1973 studied LAAM
maintenance versus methadone maintenance, and Woody 2008 studied shortterm
buprenorphine-naloxone
(14-day
detox)
versus
maintenance
buprenorphine-naloxone (14 weeks). The trial by Lehmann was considered at
high risk of bias whilst the Woody trial was considered at low risk of bias.
The Lehmann trial reported no difference between interventions. The Woody trial
reported statistically significantly lower rates of self-reported use at 12 months
(RR 0.73, 95% CI 0.57 to 0.95) and self-reported cocaine use (RR 0.12, 95% CI
0.02 to 0.90) with buprenorphine-naloxone maintenance but no statistically
significant differences in the rates of positive urine at the end of treatment, selfreported alcohol use, or self-reported marijuana use. There were no side-effects
reported with Lehmann, but the Woody trial reported that head-ache was
common (16-21%) with buprenorphine. The review authors concluded that there
was a lack of evidence, which could be due to the difficulties in conducting trials
in young people. The systematic review was well conducted and the authors’
conclusions appear appropriate.
Minozzi S, Amato L, Davoli M.
Detoxification treatments for opiate
dependent adolescents (Review). The Cochrane Library 2009, Issue 4.
This Cochrane review searched the literature for published trials of any
pharmacological treatment alone or in combination with psychosocial treatment
versus control in opiate dependent adolescents (up to 18 years old). Two USA
trials were identified (Marsch, 2005 and Woody, 2008) that enrolled 190
outpatient opiate addicts aged between 13 and 21 years. Marsch 2005 studied
buprenorphine sublingual tablets versus clonidine patches and Woody 2008
studied buprenorphine-naloxone maintenance (14 weeks) versus buprenorphine
naloxone short-term (14-day detox). Both trials were considered quite good
quality.
The Marsch trial reported that buprenorphine was associated with a statistically
significantly greater likelihood of initiating naltrexone to maintain abstinence
compared with clonidine (RR 11.00, 95% CI 1.58 to 76.55). The Woody trial
reported statistically significantly higher rates of self-reported use at 12 months
(RR 1.36, 95% CI 1.05 to 1.76) and self-reported cocaine use (RR 8.54, 95% CI
1.11 to 65.75) with buprenorphine detox (compared with maintenance) but no
statistically significant differences in the rates of positive urine at the end of
treatment, self-reported alcohol use, or self-reported marijuana use. The Marsch
trial did not report adverse events. There were no serious adverse events
reported with the Woody trial, but headache was commonly reported (16-21%)
with buprenorphine. The review authors concluded that there was a lack of
evidence, especially for methadone, which could be due to the difficulties in
conducting trials in young people. The systematic review was well conducted and
the authors’ conclusions appear appropriate.
Marsch LA, Bickel WK, Basger GJ, et al. Comparison of pharmacological
treatments for opioid-dependent adolescents.
Archives of General
Psychiatry 2005;62:1157-64.
This trial was included in the Cochrane detoxification review and is already
discussed above.
Lehmann WX. The use of 1-alpha-acetyl-methadol (LAAM) as compared
to methadone
In the maintenance and detoxification of young heroin addicts. NIDA
monograph 1973;8:82-3.
This trial was included in the Cochrane maintenance review and is already
discussed above.
Woody GE, Poole SA, Subramanian G, et al. Extended versus short-term
buprenorphine-naloxone for treatment of opiate-addicted youth. JAMA
2008; 300(17):2003-11.
This trial was included in both the Cochrane reviews and is already discussed
above.
Cannabis usage
One publication was found that that reported on two trials conducted in the USA.
Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment
(CYT) Study: Main findings from two randomised trials. J Substance
Abuse Treatment 2004; 27:197-213.
The first trial studied Motivational Enhancement Treatment/Cognitive Behaviour
Therapy
5
sessions
(MET/CBT5),
versus
Motivational
Enhancement
Treatment/Cognitive Behaviour Therapy 12 sessions (MET/CBT12), versus Family
Support Network (FSN) in 300 adolescents aged between 13 and 18 years. The
majority of participants had weekly or daily marijuana use, but some participants
also reported alcohol use and other drug use.
There was no significant difference between interventions in terms of days of
abstinence, but there was a trend favouring MET/CBT5 in terms of per cent in
recovery. The trial also reported that MET/CBT5 was the least costly programme
and thus the most cost-effective programme overall. The trial was reasonably
well conducted, using a randomised design, reporting loss to follow-up and
patient characteristics, and the trial results seem reliable.
The second trial studied MET/CBT5, versus Adolescent Community Reinforcement
Approach (ACRA) versus Multidisciplinary Family Therapy (MDFT) in 300
adolescents aged between 13 and 18 years. The majority of participants had
weekly or daily marijuana use, but some participants also reported alcohol use
and other drug use.
There was no significant difference between interventions in terms of days of
abstinence or per cent recovery. The trial reported that ACRA was the least
costly programme and thus the most cost-effective programme overall. The trial
was reasonably well conducted, using a randomised design, reporting loss to
follow-up and patient characteristics, and the trial results seem reliable.
Non-specific drug misuse and multi-drug misuse
Four trials were found, three were conducted in the USA and one was conducted
in the UK (McCambridge, 2004).
Baer JS, Garrer SB, Beadnell B, et al. Brief motivational interventions
with homeless adolescents: evaluating effects on substance use and
service utilisation. Psychology of Addictive Behaviours 2007; 21(4):5826.
This randomised trial studied 117 homeless adolescents (aged 13-19 years) with
drug and/or alcohol abuse problems. The intervention was a brief motivational
intervention (BMI) which was compared with usual care in an outpatient setting.
Randomisation was unbalanced during the study, which may have introduced bias
into the trial. There was no difference in drug use outcomes but participants in
the BMI group had an increase in service utilisation during the trial which
returned to baseline during follow-up. Participants reported overall reductions in
drug use over time. The authors concluded that BMI for homeless people is not
robust and further research is needed, which appears appropriate.
Liddle HA, Dakof GA, Parker K, et al. Multidimensional family therapy for
adolescent drug abuse: results of a randomised clinical trial. American
Journal of Drug and Alcohol Abuse 2001;27(4):651-88.
This trial randomly assigned 182 marijuana and alcohol abusing adolescents
(mean age =15.9 years) to one of three treatments: multidimensional family
therapy (MDFT), adolescent group therapy (AGT), or multidimensional education
intervention (MEI). Interventions were delivered on an out-patient basis by
community therapists, and follow-up was 12 months. The results indicated that
all of the interventions were beneficial, but MDFT was superior in terms of
prosocial school/academic performance, family functioning and drug use. The
authors noted limitations in terms of a lack of data on co-morbid conditions,
differences in the sample in terms of gender and ethnicity, and potential
generalizability problems due to a lack of diagnostic criteria.
The authors
concluded that family based interventions are most effective.
Given the small
sample sizes in the intervention groups, together with the limitations identified by
the authors, the reliability of results is uncertain. The generalizability to UK
clinical practice is also questionable.
McCambridge J and Strang J. The efficacy of single session motivational
interviewing in reducing drug consumption and perceptions of drug
related risk and harm among young people: results from a multi-cluster
randomised trial. Addiction 2004;99:39-52.
This was the only UK trial identified. It was a cluster randomised trial that
enrolled 200 adolescents from further education colleges (aged 16-20 years) to
either motivational interviewing or non-intervention education as usual. The
included participants were nearly all cannabis users (ranging from daily to
monthly), but many were also users of stimulants and some were users of other
illicit drugs. Many participants were also users of alcohol and tobacco. The
motivational intervention was a one-hour single-session face-to-face structured
interview. Data on drug use was collected through interview at recruitment and
three months later.
The follow up rate was good at 89%. Compared to baseline, the motivational
intervention had a 66% reduction in cannabis usage (control arm had a 27%
increase in usage), a 39% decrease in alcohol consumption (12% increase in
control group), and a 21% decrease in cigarette smoking (12% increase in
control group). For both alcohol and cannabis users the effect was greatest in the
heavier users. There was no difference in the use of other drugs. The trial also
reported other behavioural outcomes such as decisions to cut-down and stop, and
selling of drugs. The authors concluded that the trial supports the use of
targeting multi-drug use in a generic fashion among adolescents. The trial was
generally well conducted but the authors noted the potential for a Hawthorn
effect, the lack of statistical powering and the fact that results were self-reported.
Overall, the trial provides promising results in a UK setting with a complex
population of adolescents with multi-drug use.
Morral AR, McCaffrey DF and Ridgeway G. Effectiveness of communitybased treatments for substance abusing adolescents: 12-month
outcomes of youths entering Phoenix Academy or alternative probation
dispositions. Psychology of Addictive Behaviour 2004;18(3):257-68.
This trial studied 449 adolescent participants (aged 13-17 years) recruited to
either Phoenix Academy (a specialist drug abuse programme) or control facilities.
All participants were detainees, and were followed-up for 12 months. The trial
found that Phoenix Academy was associated with superior substance use and
psychological functional outcomes. No difference in crime was detected. The
authors noted several limitations such as the use of case-mix approach in place of
randomisation, the use of self-reported outcomes, and the uncertainty that the
programme is specifically better than other programmes. The authors concluded
that further research is needed, which seems appropriate.
Methodological Points
Most of the trials were conducted in the USA so the generalizability of finding to a
UK setting is questionable. The single UK trial was generally well conducted and
provides evidence that is directly transferable to UK practice. The UK trial was
cluster randomised, reported good follow-up rates (89.5%), and had similar
baseline participant characteristics.
Intervention Features
The type of intervention varied from pharmacological to psychosocial and family
interventions. Delivery of interventions was generally by trained personnel, and
most interventions were provided on an outpatient basis. The UK trial was based
on a single-session one-hour face-to-face motivational interview, which will likely
be reproducible in clinical practice, albeit with some training requirements for
staff providing the interview.
Gaps in Knowledge
There are a number of unknown factors in treating adolescents with substance
misuse problems:
 Most of the trial literature came from the USA; hence, the applicability of
results to UK practice is uncertain.
 No evidence was found for interventions specifically targeted at adolescent
users of cocaine, psychostimulants, or LSD.
 Most outcomes were self-reported, which are prone to bias and may
overestimate benefits of treatments.
 The components and factors of the interventions which are most effective
are not clear.
 Many of the interventions were delivered in very controlled conditions with
trained personnel, which may not reflect the reality of drug intervention
services in practice.
 There are likely to be subgroups of adolescent drug users that are liable to
derive the greatest benefit from interventions, but currently the available
literature does not identify these groups.
Conclusion
The evidence base for interventions targeted at adolescent drug users is sparse;
most of the trials were conducted in the USA, only one UK trial was found. The
trials were predominantly focussed on mixed drug using populations, but some
trials included participants with specific heroin or cannabis usage problems. No
trials of interventions exclusively focussed on cocaine, LSD or psychostimulant
abuse were found. The evidence from the single UK trial is the most transferable
to UK clinical practice and indicates the benefits of a one-hour single-session
face-to-face motivational interview for generic drug use in adolescents. There are
a number of evidence gaps and further research is warranted.
References
Baer JS, Garrer SB, Beadnell B, et al. Brief motivational interventions with
homeless adolescents: evaluating effects on substance use and service utilisation.
Psychology of Addictive Behaviours 2007; 21(4):582-6.
Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment (CYT)
Study: Main findings from two randomised trials. J Substance Abuse Treatment
2004; 27:197-213.
Lehmann WX. The use of 1-alpha-acetyl-methadol (LAAM) as compared to
methadone
In the maintenance and detoxification of young heroin addicts. NIDA monograph
1973;8:82-3.
Liddle HA, Dakof GA, Parker K, et al. Multidimensional family therapy for
adolescent drug abuse: results of a randomised clinical trial. American Journal of
Drug and Alcohol Abuse 2001;27(4):651-88.
Marsch LA, Bickel WK, Basger GJ, et al.
Comparison of pharmacological
treatments for opioid-dependent adolescents. Archives of General Psychiatry
2005;62:1157-64.
McCambridge J and Strang J.
The efficacy of single session motivational
interviewing in reducing drug consumption and perceptions of drug related risk
and harm among young people: results from a multi-cluster randomised trial.
Addiction 2004;99:39-52.
Minozzi S, Amato L, Davoli M. Maintenance treatments for opiate dependent
adolescents (Review). The Cochrane Library 2009, Issue 2.
Minozzi S, Amato L, Davoli M. Detoxification treatments for opiate dependent
adolescents (Review). The Cochrane Library 2009, Issue 4.
Morral AR, McCaffrey DF and Ridgeway G. Effectiveness of community-based
treatments for substance abusing adolescents: 12-month outcomes of youths
entering Phoenix Academy or alternative probation dispositions. Psychology of
Addictive Behaviour 2004;18(3):257-68.
Woody GE, Poole SA, Subramanian G, et al.
Extended versus short-term
buprenorphine-naloxone for treatment of opiate-addicted youth. JAMA 2008;
300(17):2003-11.
Key contact for further information: Dr Catriona Matheson, Centre of Academic
Primary Care, University of Aberdeen. e mail: c.i.math@abdn.ac.uk