Overview of Adolescent Substance Abuse & Treatment

Overview of Adolescent Substance Abuse & Treatment

Joan E. Zweben, Ph.D.Executive Director, EBCRP

Clinical Professor of Psychiatry, UCSF

PREP Program TrainingJune 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 AbuseAdolescent 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 FactorsProtective 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)

MarijuanaMarijuana 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)

TobaccoTobacco 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)

RelapseRelapse 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 PreventionAdolescent 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 SUDSPharmacotherapy 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 SUDSAdolescent 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)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)BASIC ISSUES (AOD)

Capsule Definition of AddictionCapsule 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.

BUTBUTAny amount of alcohol/drug use

is undesirable in persons with co-occurring disorders, and should be recognized and addressed

Compulsive Drug Seeking is Initiated Outside Consciousness

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 HeritageRole 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

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 DisorderAddiction 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 OutcomesDifferent 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?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 EnhancementMotivational 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

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-OrientedTreatment Philosophies: Abstinence-Oriented

abstain from drug of choice abstain from other intoxicants

drug substitutionrole in precipitating relapse

dependable control not possible; hence detach

widest margin of safety

Treatment Philosophies:Harm ReductionTreatment 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 TreatmentPitfalls 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 ApproachPitfalls 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 ReductionAbstinence & 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 TheorySelf-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 Self-Medication Perspective

Addressing the Client’s Self-Medication 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 AwakeningRole 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)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 ModelKey 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 EnvironmentPost Treatment Recovery Environment

Mutual aid system (aka self help) Family Social network Living environment Recovery homes, schools, support

centers, churches, etc.

Essential Elements of TreatmentEssential 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?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)

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