The authors present a clinically focused introduction to treatment principles for adolescent substance abuse disorders and reviews evidence-based approaches.
Substance use and substance use disorders (SUDs) that emerge during adolescence are associated with increased morbidity and mortality, along with a number of short- and long-term negative health consequences. Many adolescents experiment with alcohol or other drugs, and a significant minority will develop problems with substance use. Recent national surveys indicate that 18% and 21% of US high school students report binge drinking and smoking marijuana, respectively, in the past 30 days.1
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
Of the 1.3 million adolescents who met criteria for an SUD in 2014, fewer than 10% received treatment.2 Early screening, diagnosis, and treatment of adolescents with SUDs have the potential to reduce morbidity and mortality. This is particularly important for child and adolescent mental health providers because approximately 40% of adolescents who present for mental health treatment may have a comorbid SUD.3
Core principles for the clinical management of adolescents
SUDs in adolescents have multifactorial etiologies and are treated using developmentally informed approaches that apply integrated and concurrent treatment for both substance use and any co-occurring psychiatric disorders. Table 1 presents 8 core principles for the clinical management of adolescents with SUDs.
Common risk factors for youths with an SUD fall into larger domain-level factors:
• Individual: genetic, early childhood temperament, psychiatric symptoms and disorders, history of trauma exposure
• Family and parent: family dysfunction, parent-teen relationship, parental substance use, parental psychiatric disorders, parental involvement, monitoring, permissibility relating to adolescent drug use, sibling drug use
• Environment/community: involvement with substance-using or antisocial peers, peer pressure, media promotion, access to alcohol and other drugs, poverty, exposure to community violence
A comprehensive diagnostic evaluation that includes the patient and his or her parents is used to characterize developmental history, risk and protective factors, current and lifetime psychiatric symptoms and disorders, and substance use and related disorders.
These sessions would provide psychoeducation on the negative consequences of marijuana use and the benefits of a drug-free household as well as parental skills training. Furthermore, screening the parent(s) for substance use and psychiatric disorders and referring them for treatment may improve family functioning.
In another example, a teen who presents with binge drinking 2 or 3 days per week and a history of recent sexual assault may benefit from a trauma-informed approach (eg, trauma-focused cognitive behavioral therapy [CBT]).
Treatment strategies for adolescent SUDs
There is strong evidence for the efficacy of psychosocial or behavioral interventions in the treatment of adolescent SUDs. As such, evidence-based behavioral interventions should be used as the backbone or platform for treating adolescents with SUDs. Working with parents and families can also improve treatment outcomes.
All adolescents who present with substance use or SUDs need to be carefully assessed for co-occurring psychiatric disorders. Evidence-based psychosocial and pharmacotherapy approaches are used concurrently to treat psychiatric disorders when present. There also may be a role for adjunctive addiction pharmacotherapy for treating adolescents with SUDs who do not respond to behavioral intervention.
Addressing co-occurring/comorbid psychiatric disorders
For adolescents with SUDs, comorbidity is the rule rather than the exception. Over 70% of adolescents who meet diagnostic criteria for an SUD also meet criteria for one or more psychiatric disorders.4 The most common co-occurring psychiatric disorders with SUDs include conduct disorder, ADHD, depression, and stress-related disorders (eg, PTSD).
The relationship between psychiatric symptoms and substance use is bidirectional. Co-occurrence of substance use and psychiatric disorders during adolescence is associated with poorer outcomes, including lower treatment retention, increased risk of relapse, worse psychosocial and family functioning, and a higher likelihood of persistence of substance use problems into adulthood. Integrated and concurrent treatment of co-occurring disorders in the same clinical space with the same providers is associated with better outcomes.
Psychosocial or behavioral interventions
The principal goal of treatment of SUDs in adolescents is achieving and maintaining abstinence and improving functioning. Psychosocial or behavioral interventions are the primary treatment modality for adolescents with SUDs. (For comprehensive reviews of behavioral interventions, see Hogue et al5 and Waldron and Turner.6) A number of behavioral interventions are effective for the treatment of adolescent SUDs (Table 2):
• Motivational interviewing (MI)
• Family-based therapies (FBT)
• Integrated interventions that combine MI, CBT, and/or FBTs
Most comparative analyses have shown similar effect sizes across interventions, but findings from a meta-analysis by Tripodi and colleagues7 suggest that CBT is associated with higher rates of abstinence at follow-up and thus may have more enduring effects than other interventions. With regard to treatment matching, preliminary evidence suggests that age and comorbidity may guide treatment selection.
Hendricks and colleagues8 compared multidimensional family therapy (MDFT) with CBT in adolescents with SUDs. No differences were seen between interventions in rates of cannabis use at 1-year follow-up, but age and comorbidity moderated treatment outcome. Younger adolescents (ages 13 to 16) and those with co-occurring psychiatric disorders responded better to MDFT, while older adolescents (ages 17 to 18) and those without co-occurring disorders responded better to CBT. Additional studies are needed in this area.
Psychosocial or behavioral intervention is the primary treatment modality for youths with substance use problems. Pharmacotherapy should be reserved for patients who have not been able to achieve abstinence or improvements in functioning with primary behavioral interventions.
The current scientific literature on pharmacotherapy for the treatment of adolescent SUDs is inconsistent. (For comprehensive reviews, see Hammond9 and Hammond and Gray.10) Preliminary findings suggest that certain medications when administered in combination with behavioral interventions may improve outcomes. The strongest data are for tobacco, cannabis, and opioid use disorders. These medication-assisted approaches include nicotine replacement therapy and bupropion for tobacco, N-acetylcysteine for cannabis, and buprenorphine-naloxone for opioid use disorders.
For alcohol use disorders, the literature is scarce; however, small randomized controlled trials (RCTs) and open-label studies indicate that alcohol maintenance medications commonly used in adults (eg, naltrexone, disulfiram) are well-tolerated in adolescents and may be helpful in reducing heavy drinking and alcohol-related cravings. Clinicians who provide SUD treatment to adolescents who do not respond to behavioral intervention may consider adding adjunctive pharmacotherapy, but should monitor closely for adverse effects.
In addition, pharmacotherapy for the treatment of comorbid/co-occurring psychiatric disorders may improve treatment outcomes and should be considered if an adolescent’s psychiatric symptoms don’t respond to behavioral interventions. While most RCTs for pharmacotherapy targeting co-occurring disorders in youth have had negative results, co-occurring depression and ADHD symptoms track with substance use during treatment.
Across RCTs, treatment responders showed reductions in depression and ADHD symptoms along with substance use, while non-responders showed no changes in substance use or psychiatric symptoms.11-13 In light of this, clinicians should aggressively target co-occurring depression and ADHD during treatment because improvements in these domains may provide better outcomes.
For co-occurring substance use and affective disorders in adolescents, fluoxetine, sertraline, and bupropion may be useful for depression and lithium for bipolar disorder.11,13-15 Atomoxetine, bupropion, and osmotic-release methylphenidate may be effective for co-occurring substance use and ADHD.10,12,14
Acknowledgment. Dr. Hammond is supported by a National Institute on Drug Abuse/American Academy of Child & Adolescent Psychiatry (NIDA/AACAP) career development award (K12DA000357).
Dr. Hammond is Assistant Professor of Psychiatry, Division of Child & Adolescent Psychiatry, Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, Baltimore, MD. Dr. Sharma is a Child and Adolescent Psychiatry Fellow, Division of Child & Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine.The authors report no conflicts of interest concerning the subject matter of this article.
1. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance: United States, 2015. MMWR Surveill Summ. 2016;65:1-174.
2. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
3. Aarons GA, Brown SA, Hough RL, et al. Prevalence of adolescent substance use disorders across five sectors of care. J Am Acad Child Adolesc Psychiatry. 2001;40:419-426.
4. Kaminer Y, Bukstein O, eds. Adolescent Substance Abuse: Dual Diagnosis and High Risk Behaviors. Binghamton, NY: Routledge, Francis & Taylor Group; 2008.
5. Hogue A, Henderson CE, Ozechowski TJ, Robbins MS. Evidence base on outpatient behavioral treatments for adolescent substance use: updates and recommendations 2007-2013. J Child Adolesc Psychol. 2014;43:695-720.
6. Waldron HB, Turner CW. Evidence-based psychosocial treatments for adolescent substance abuse. J Clin Child Adolesc Psychol. 2008;37:238-261.
7. Tripodi SJ, Bender K, Litschge C, Vaughn MG. Meta-analysis of controlled studies 1960-2010. Arch Pediatr Adolesc Med. 2010;164:85-91.
8. Hendricks V, Van der Schee E, Blanken P. Matching adolescents with a cannabis use disorder to multidimensional family therapy or cognitive behavioral therapy: treatment effect moderators in a randomized controlled trial. Drug Alcohol Depend. 2012;125:119-126.
9. Hammond CJ. The role of pharmacotherapy in the treatment of adolescent substance use disorders. Child Adolesc Psychiatr Clin N Am. 2016;25:685-711.
10. Hammond CJ, Gray KM. Pharmacotherapy for substance use disorders in youths. J Child Adolesc Subst Abuse. 2016;25:292-316.
11. Riggs PD, Mikulich-Gilbertson SK, Davies RD, et al. A randomized controlled trial of fluoxetine and cognitive behavioral therapy in adolescents with major depression, behavior problems, and substance use disorders. Arch Pediatr Adolesc Med. 2007;161:1026-1034.
12. Riggs PD, Winhusen T, Davies RD, et al. Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders. J Am Acad Child Adolesc Psychiatry. 2011;50:903-914.
13. Deas D, Randall CL, Roberts JS, Anton RF. A double-blind placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study. Hum Psychopharmacol. 2000;15:462-469.
14. Solhkhah R, Wilens TE. Bupropion SR for the treatment of substance-abusing outpatient adolescents with attention-deficit/hyperactivity disorder and mood disorders. J Child Adolesc Psychopharmacol. 2015;15:777-786.
15. Geller B1, Cooper TB, Sun K, et al. Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. J Am Acad Child Adolesc Psychiatry. 1998;37:171-178.