Overview of Adolescent Substance Abuse & Treatment

1. 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

2. 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)

3. 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

4. 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)

5. 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)

6. 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)

7. 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

8. 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

9. 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

10. 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)

11. 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

12. BASIC ISSUES (AOD)

13. 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. Capsule Definition of Addiction

14. BUT Any amount of alcohol/drug use is undesirable in persons with co-occurring disorders, and should be recognized and addressed

15. 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)

16. 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”

17. 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

18. 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)

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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.

31. 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)

32. 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

33. Post Treatment Recovery Environment • Mutual aid system (aka self help) • Family • Social network • Living environment • Recovery homes, schools, support centers, churches, etc.

34. 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

35. 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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