Alcoholism, Substance Abuse and Dependency > Chapter 8 - Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Continuing with the theme of providing treatment, the following article from the NIDA addresses principles of treatment for Adolescent drug use.

Treatment of Adolescents

NIDA wishes to thank the following individuals for their helpful comments during the review of this publication:

Tina Burrell, M.A., Washington State Department of Social and Health Services Connie Cahalan, Missouri Department of Mental Health Barbara Cimaglio, Vermont Department of Health Michael L. Dennis, Ph.D., Chestnut Health Systems

Rochelle Head-Dunham, M.D., Louisiana Department of Health and Hospitals Scott W. Henggeler, Ph.D., Medical University of South Carolina

Sharon Levy, M.D., M.P.H., Children’s Hospital Boston

Kenneth J. Martz, Psy.D., CAS, Pennsylvania Department of Drug and Alcohol Programs Kathy Paxton, M.S., West Virginia Bureau for Behavioral Health and Health Facilities Paula D. Riggs, M.D., University of Colorado School of Medicine


From the Director

Since its first edition in 1999, NIDA’s Principles of Drug Addiction Treatment has been a widely used resource for health care providers, families, and others needing information on addiction and treatment for people of all ages. But recent research has greatly advanced our understanding of the particular treatment needs of adolescents, which are often different from those of adults. I thus am very pleased to present this new guide, Principles of Adolescent Substance Use Disorder Treatment, focused exclusively on the unique realities of adolescent substance use—which includes abuse of illicit and prescription drugs, alcohol, and tobacco—and the special treatment needs for people aged 12 to 17.

The adolescent years are a key window for both substance use and the development of substance use disorders. Brain systems governing emotion and reward-seeking are fully developed by this time, but circuits governing judgment and self-inhibition are still maturing, causing teenagers to act on impulse, seek new sensations, and be easily swayed by their peers—all of which may draw them to take risks such as trying drugs of abuse. What is more, because critical neural circuits are still actively forming, teens’ brains are particularly susceptible to being modified by those substances in a lasting way—making the development of a substance use disorder much more likely.

Addiction is not the only danger. Abusing drugs during adolescence can interfere with meeting crucial social and developmental milestones and also compromise cognitive development. For example, heavy marijuana use in the teen years may cause a loss of several IQ points that are not regained even if users later quit in adulthood. Unfortunately, that drug’s popularity among teens is growing—possibly due in part to legalization advocates touting marijuana as a “safe” drug. Nor do most young people appreciate the grave safety risks posed by abuse of other substances like prescription opioids and stimulants or newly popular synthetic cannabinoids (“Spice”)—and even scientists still do not know much about how abusing these drugs may affect the developing brain.

These unknowns only add to the urgency of identifying and intervening in substance use as early as possible. Unfortunately, this urgency is matched by the difficulty of reaching adolescents who need help. Only 10 percent of adolescents who need treatment for a substance use disorder actually get treatment. Most teens with drug problems don’t want or think they need help, and parents are frequently blind to indications their teenage kids may be using drugs—or they may dismiss drug use as just a normal part of growing up.

Historically the focus with adolescents has tended to be on steering young people clear of drugs before problems arise. But the reality is that different interventions are needed for adolescents at different places along the substance use spectrum, and some require treatment, not just prevention. Fortunately, scientific research has now established the efficacy of a number of treatment approaches that can address substance use during the teenyears. This guide describes those approaches,as well as presents a set of guiding principles and frequently asked questions about substance abuse and treatment in this age group. I hope this guide will be of great use to parents, health care providers, and treatment specialists as they strive to help adolescents with substance use problems get the help they need.

Nora D.
Volkow, M.D.
Director
National Institute on Drug Abuse

I. Introduction

People are most likely to begin abusing drugs*—including tobacco, alcohol, and illegal and prescription drugs— during adolescence and young adulthood. By the time they are seniors, almost 70 percent of high school students will have tried alcohol, half will have taken an illegal drug, nearly 40 percent will have smoked a cigarette, and more than 20 percent will have used a prescription drug for a nonmedical purpose.1 There are many reasons adolescents use these substances, including the desire for new experiences, an attempt to deal with problems or perform better in school, and simple peer pressure. Adolescents are “biologically wired” to seek new experiences and take risks, as well as to carve out their own identity. Trying drugs may fulfill all of these normal developmental drives, but in an unhealthy way that can have very serious long-term consequences.

Many factors influence whether an adolescent tries drugs, including the availability of drugs within the neighborhood, community, and school and whether the adolescent’s friends are using them. The family environment is also important: Violence, physical or emotional abuse, mental illness, or drug use in the household increase the likelihood an adolescent will use drugs.

Finally, an adolescent’s inherited genetic vulnerability; personality traits like poor impulse control or a high need for excitement; mental health conditions such as depression, anxiety, or ADHD; and beliefs such as that drugs are “cool” or harmless make it more likely that an adolescent will use drugs.2


The adolescent brain is often likened to a car with a fully functioning gas pedal (the reward system) but weak brakes (the prefrontal cortex).

The brain continues to develop through early adulthood. Mature brain regions at each developmental stage are indicated in blue. The prefrontal cortex (red circles), which governs judgment and self-control, is the last part of the brain to mature.
Source: PNAS 101:8174–8179, 2004.

The teenage years are a critical window of vulnerability to substance use disorders, because the brain is still developing and malleable (a property known as neuroplasticity), and some brain areas are less mature than others. The parts of the brain that process feelings of reward and pain—crucial drivers of drug use—are thefirst to mature during childhood. What remains incompletely developed during the teen years are the prefrontal cortex and its connections to other brain regions. The prefrontal cortex is responsible for assessing situations, making sound decisions, and controlling our emotions and impulses; typically this circuitry is not mature until a person is in his or her mid-20s (see figure,above).

The adolescent brain is often likened to a car with a fully functioning gas pedal (the reward system) but weak brakes (the prefrontal cortex). Teenagers are highly motivated to pursue pleasurable rewards and avoid pain,but their judgment and decision-making skills are still limited. This affects theirability to weigh risks accurately and make sound decisions, including decisions about using drugs. For these reasons, adolescents are a major target for prevention messages promoting healthy, drug-free behavior and giving young people encouragement andskills to avoid the temptations of experimenting with drugs.3

Most teens do not escalate from trying drugs to developing an addiction or other substance use disorder;* however, even experimenting with drugs is a problem. Drug use can be part of a pattern of risky behavior including unsafe sex, driving while intoxicated, or other hazardous, unsupervised activities. And in cases when a teen does develop a pattern of repeated use, it can pose serious social and health risks, including:

  • schoolfailure
  • problems with family and otherrelationships
  • loss of interest in normal healthyactivities
  • impairedmemory
  • increased risk of contracting an infectious disease (like HIV or hepatitis C) via risky sexual behavior or sharing contaminated injection equipment
  • mental health problems—including substance use disorders of varyingseverity the very real risk of overdosedeath

 

How drug use can progress to addiction

Different drugs affect the brain differently, but a common factor is that they all raise the level of the chemical dopamine in brain circuits that control reward and pleasure.

The brain is wired to encourage life-sustaining and healthy activities through the release of dopamine. Everyday rewards during adolescence—such as hanging out with friends, listening to music, playing sports,and all the other highly motivating experiences for teenagers—cause the release of this chemical in moderate amounts. This reinforces behaviors that contribute to learning, health, well-being, and the strengthening of social bonds.

Drugs, unfortunately, are able to hijack this process. The “high” produced by drugs represents a flooding of the brain’s reward circuits with much more dopamine than natural rewards generate. This creates an especially strong drive to repeat the experience. The immature brain, already struggling with balancing impulse and self-control, is more likely to take drugs again without adequately considering the consequences.4 If the experience is repeated, the brain reinforces the neural links between pleasure and drug-taking, making the association stronger and stronger. Soon, taking the drug may assume an importance in the adolescent’s life out of proportion to otherrewards.

The development of addiction is like a vicious cycle: Chronic drug use not only realigns aperson’s priorities but also may alter key brain areas necessary for judgment and self-control, further reducing the individual’s ability to control or stop their drug use. This is why, despite popular belief, willpower alone is often insufficient to overcome an addiction. Drug use has compromised the very parts of the brain that make it possible to “say no.”

Not all young people are equally at risk for developing an addiction. Various factors including inherited genetic predispositions and adverse experiences in early life make trying drugs and developing a substance use disorder more likely. Exposure to stress (such as emotional or physical abuse) in childhood primes the brain to be sensitive to stress and seek relief from it throughout life; this greatly increases the likelihood of subsequent drug abuse and of starting drug use early.5 In fact, certain traits that put a person at risk for drug use, such as being impulsive or aggressive, manifest well before the first episode of drug use and may be addressed by prevention interventions during childhood.6 By the same token, a range of factors, such as parenting that is nurturing or a healthy school environment, may encourage healthy development and thereby lessen the risk oflater druguse.

*For purposes of this guide, the term addiction refers to compulsive drug seeking and use that persists even in the face of devastating consequences; it may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, 2013). The spectrum of substance use disorders in the DSM-5 includes the criteria for the DSM-4 diagnostic categories of abuse and dependence.


Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.

Drug use at an early age is an important predictor of development of a substance use disorder later. The majority of those who have a substance use disorder started using before age 18 and developed their disorder by age 20.7 The likelihood of developing a substance use disorder is greatest for those who begin use in their early teens. For example, 15.2 percent of people who start drinking by age 14 eventually develop alcohol abuse or dependence (as compared to just 2.1 percent of those who wait until they are 21 or older), 8 and 25 percent of those who begin abusing prescription drugs at age 13 or younger develop a substance use disorder at some time in their lives.9 Tobacco, alcohol, and marijuana are the first addictive substances most people try. Data collected in 2012 found that nearly 13 percent of those with a substance use disorder began using marijuana by the time they were 14.

When substance use disorders occur in adolescence, they affect key developmental and social transitions, and they can interfere with normal brain maturation. These potentially lifelong consequences make addressing adolescent drug use an urgent matter. Chronic marijuana use in adolescence, for example,has been shown to lead to a loss of IQ that is not recovered even if the individual quits using in adulthood.11 Impaired memory or thinking ability and other problems caused by drug use can derail a young person’s social and educational development and hold him or her back in life.

The serious health risks of drugs compound the need to get an adolescent who is abusing drugs into treatment as quickly as possible.

Also, adolescents who are abusing drugs are likely to have other issues such as mental health problems accompanying and possibly contributing to their substance use, and these also need to be addressed.Unfortunately, less than one third of adolescents admitted to substance abuse treatment who have other mental health issues receive any care for their conditions.

Adolescents’ drug use and treatment
needs differ from those of adults

Adolescents in treatment report abusing different substances than adult patients do. For example, many more people aged 12–17 received treatment for marijuana use than for alcohol use in 2011 (65.5 percent versus 42.9 percent), whereas it was the reverse for adults (see figure, page 5). When adolescents do drink alcohol, they are more likely than adults to binge drink (defined as five or more drinks in a row on a single occasion).14 Adolescents are less likely than adults to report withdrawal symptoms when not using a drug, being unable to stop using a drug, or continued use of a drug in spite of physical or mental health problems; but they are more likely than adults to report hiding their substance use, getting complaints from others about their substance use, and continuing to use in spite of fights or legal trouble.

Adolescents also may be less likely than adults to feel they need help or to seek treatment on their own. Given their shorter histories of using drugs (as well as parental protection), adolescents may have experienced relatively few adverse consequences from their drug use; their incentive to change or engage in treatment may correspond to the number of such consequences they have experienced.15 Also, adolescents may have more difficulty than adults seeing their own behavior patterns (including causes and consequences of their actions) with enough detachment to tell they need help.

Only 10 percent of 12- to 17-year-olds needing substance abuse treatment actually receive any services.16 When they do get treatment, it is often for different reasons than adults. By far, the largest proportion of adolescents who receive treatment are referred by the juvenile justice system (see figure, page 7). Given that adolescents with substance use problems often feel they do not need help, engaging young patients in treatment often requires special skills and patience.

Many treatment approaches are available
to address the unique needs of adolescents.

The focus of this guide is on evidence-based treatment approaches those that have been scientifically tested and found to be effective in the treatment of adolescent substance abuse. Whether delivered in residential or inpatient settings or offered on an outpatient basis, effective treatments for adolescents primarily consist of some form of behavioral therapy. Addiction medications, while effective and widely prescribed for adults, are not generally approved by the U.S. Food and Drug Administration (FDA) for adolescents.

However, preliminary evidence from controlled trials suggest that some medications may assist adolescents in achieving abstinence,so providers may view their young patients’ needs on a case-by-case basis in developing a personalized treatment plan.

Whatever a person’s age, treatment is not “one size fits all.” It requires taking into account the needs of the whole person—including his or her developmental stage and cognitive abilities and the influence of family, friends, and others in the person’s life, as well as any additional mental or physical health conditions. Such issues should be addressed at the same time as the substance use treatment. When treating adolescents, clinicians must also be ready and able to manage complications related to their young patients’ confidentiality and their dependence on family members who may or may not be supportive of recovery.

Supporting Ongoing Recovery-Sustaining
Treatment Gains and Preventing Relapse

Enlisting and engaging the adolescent in treatment is only part of a sometimes long and complex recovery process.17 Indeed, treatment is often seen as part of a continuum of care. When an adolescent requires substance abuse treatment, follow-up care and recovery support (e.g., mutual-help groups like 12-step programs) may be important for helping teens stay off drugs and improving their quality of life.

Number of Adolescents Aged 12–17 Admitted to Publicly Funded Substance Abuse Treatment Facilities on an Average Day,by Principal Source of Referral:Treatment Episode Data Set 2008

When substance use disorders are identified and treated in adolescence—especially if they are mild or moderate—they frequently give way to abstinence from drugs with no further problems. Relapse is a possibility, however, as it is with other chronic diseases like diabetes or asthma. Relapse should not be seen as a sign that treatment failed but as an occasion to engage in additional or different treatment. Averting and detecting relapse involves monitoring by the adolescent, parents, and teachers, as well as follow-up by treatment providers. Although recovery support programs are not a substitute for formal evidence-based treatment, they may help some adolescents maintain a positive and productive drug-free lifestyle that promotes meaningful and beneficial relationships and connections to family, peers, and the community both during treatment and after treatment ends. Whatever services or programs are used, an adolescent’s path to recovery will be strengthened by support from family members, non-drug-using peers, the school, and others in his or her life.

*“Treatment providers” in this chart refers to “alcohol/drug abuse care providers.” Treatment providers can and do refer people to treatment if, for example, a person is transferring from one level of treatment to another and the original facility does not provide the level of treatment that the person needs, or if a person changes facilities for some other reason. “Other health care professionals” refers to physicians, psychiatrists, or other licensed health care professionals or general hospitals, psychiatric hospitals, mental health programs, or nursing homes.

II. Principles of Adolescent Substance Use Disorder Treatment

  • 1. Adolescent substance use needs to be identified and addressed as soon as possible. Drugs can have long-lasting effects on the developing brain and may interfere with family, positive peer relationships, and school performance. Most adults who develop a substance use disorder report having started drug use in adolescence or young adulthood, so it is important to identify and intervene in drug use early.

  • 2. Adolescents can benefit from a drug abuse intervention even if they are not addicted to a drug.18 Substance use disorders range from problematic useto addiction and can be treated successfully at any stage, and at any age. For young people, any drug use (even if it seems like only “experimentation”), is cause for concern, as it exposes them to dangers from the drug and associated risky behaviors and may lead to more drug use in the future. Parents and other adults should monitor young people andnot underestimate the significance of what may appear as isolated instances of drug taking.

  • 3. Routine annual medical visits are an opportunity to askadolescents about drug use. Standardized screening tools are available to help pediatricians, dentists, emergency room doctors, psychiatrists, and other clinicians determine an adolescent’s level of involvement (if any) in tobacco, alcohol, and illicit and nonmedical prescription drug use.19 When an adolescent reports substance use, the health care provider can assess its severity and either provide an onsite brief intervention or refer the teen to a substance abuse treatment program.20, 21

  • 4. Legal interventions and sanctions or family pressure may play an important role in getting adolescents to enter, stay in, and complete treatment. Adolescents with substance use disorders rarely feel they need treatment and almost never seek it on their own. Research shows that treatment can work even if it is mandated or ente

  • 5. Substance use disorder treatment should be tailored to the unique needs of the adolescent. Treatment planning begins with acomprehensive assessment to identify the person’s strengths and weaknesses to be addressed. Appropriate treatment considers an adolescent’s level of psychological development, gender, relations with family and peers, how well he or she is doing in school, the larger community, cultural and ethnic factors, and any special physical or behavioral issues.

The best treatment programs provide a combination of therapies and other services to meet the needs of the individual patient.
  • 6. Treatment should address the needs of the whole person, ratherthan just focusing on his or her drug use. The best approach to treatment includes supporting the adolescent’s larger life needs, such as thoserelated to medical, psychological, and social well-being, as well as housing, school, transportation, and legalservices. Failing to address such needs simultaneously could sabotage the adolescent’s treatment success.

  • Many adolescents who abuse drugs have a history of physical,
    emotional, and/or sexual abuse or other trauma.


  • 7. Behavioral therapies are effective in addressing adolescent druguse. Behavioral therapies, delivered by trained clinicians, help an adolescent stay off drugs by strengthening his or her motivation to change. This can be done by providing incentives for abstinence, building skills to resist and refuse substances and deal with triggers or craving, replacing drug use with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships.

  • 8. Families and the community are important aspects of treatment. The support of family members is important for an adolescent’s recovery.Several evidence-based interventions for adolescent drug abuse seek to strengthen family relationships by improving communication and improving family members’ ability to support abstinence from drugs. In addition, members of the community (such as school counselors, parents, peers, and mentors) can encourage young people who need help to get into treatment—and support them along the way.

  • 9. Effectively treating substance use disorders in adolescents requires also identifying and treating any other mental health conditions they may have. Adolescents who abuse drugs frequently also suffer from other conditions including depression, anxiety disorders, attention- deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct problems.23 Adolescents who abuse drugs, particularly those involved in the juvenile justice system, should be screened for other psychiatric disorders. Treatment for these problems should be integrated with the treatment for a substance use disorder.

  • 10. Sensitive issues such as violence and child abuse or riskof suicide should be identified and addressed. Many adolescents who abuse drugs have a history of physical, emotional, and/or sexual abuse or other trauma.24 If abuse is suspected, referrals should be made to social and protective services, following local regulations and reporting requirements.

  • 11. It is important to monitor drug use during treatment. Adolescents recovering from substance use disorders may experience relapse, or a return to drug use. Triggers associated withrelapse vary and can include mental stressand social situations linked with prior drug use. It is important to identify a return to drug use early before an undetected relapse progresses to moreserious consequences. A relapse signals the need for more treatment or a need to adjust the individual’s current treatment plan tobetter meet his or herneeds.

  • 12. Staying in treatment for an adequate period of time and continuity of care afterward are important. The minimal length of drug treatment depends on the type and extent of theadolescent’s problems, but studies show outcomes are better when a person stays in treatment for 3 months or more.25 Because relapses often occur, more than one episode of treatment may be necessary. Many adolescents also benefit from continuing care following treatment,26 including drug use monitoring, follow-up visits at home,27 and linking the family to other needed services.

  • A relapse signals the need for more treatment or
    a need to adjust the individual’s current treatment plan.


  • 13. Testing adolescents for sexually transmitted diseases like HIV, as well as hepatitis B and C, is an important part of drug treatment. Adolescents who use drugs—whether injecting or non-injecting—are at an increasedrisk for diseases that are transmitted sexually as well as through the blood, including HIV and hepatitis B and C. All drugs of abuse alter judgment and decision making, increasing the likelihood that an adolescent will engage in unprotected sex and other high-risk behaviors including sharing contaminated drug injection equipment and unsafe tattooing and body piercing practices––potential routes of virus transmission. Substance use treatment can reduce this risk both by reducing adolescents’ drug use (and thus keeping them out of situations in which they are not thinking clearly) and by providing risk-reduction counseling to help them modify or change their high- risk behaviors.28,29

III. FREQUENTLY ASKED QUESTIONS

1. Why do adolescents take drugs?
Adolescents experiment with drugs or continue taking them for several reasons, including:
  • To fit in: Many teens use drugs “because others are doing it”—or they think others are doing it—and they fear not being accepted in a social circle that includes drug-using peers.
  • To feel good: Abused drugs interact with the neurochemistry of the brain to produce feelings of pleasure. The intensity of this euphoria differs by the type of drug andhow it is used.
  • To feel better: Some adolescents suffer from depression, social anxiety, stress- related disorders, and physical pain. Using drugs may be an attempt to lessen these feelings of distress. Stress especially plays a significant role in starting and continuing drug use as well as returning to drug use (relapsing) for those recovering from an addiction.
  • To do better: Ours is a very competitive society, in which the pressure to perform athletically and academically can be intense. Some adolescents may turn to certain drugs like illegal or prescription stimulants because they think those substances will enhance or improve their performance.
  • To experiment: Adolescents are often motivated to seek new experiences, particularly those they perceive as thrilling or daring.
2. What drugs are most frequently used by adolescents?

Alcohol and tobacco are the drugs most commonly abused by adolescents, followed by marijuana. The next most popular substances differ between age groups. Young adolescents tend to favor inhalant substances (such as breathing fumes of household cleaners,glues, or pens; see “The Dangers of Inhalants,” page 15), whereas older teens are more likely to use synthetic marijuana (“K2” or “Spice”) and prescription medications—particularly opioid pain relievers like Vicodin® and stimulants like Adderall®. In fact, the Monitoring the Future survey of adolescent drug use and attitudes shows that prescription and over-the-counter medications account for a majority of the drugs most commonly abused by high-school seniors.


Most Commonly Abused Drugs by High School Seniors (Other than Tobacco and Alcohol)

The top drug used in this category is Adderall (7.4%) *The top drugs used in this category are Vicodin (5.3%) and OxyContin (3.6%) Source: Monitoring the Future National Results on Adolescent Drug Use: Summary of Key Findings, 2013.

3. How do adolescents become addicted to drugs,and which factors increase risk?

Addiction occurs when repeated use of drugs changes how a person’s brain functions over time. The transition from voluntary to compulsive drug use reflects changes in the brain’s natural inhibition and reward centers that keep a person from exerting control over the impulse to use drugs even when there are negative consequences—the defining characteristic of addiction.

Some people are more vulnerable to this process than others, due to a range of possible risk factors. Stressful early life experiences such as being abused or suffering other forms of trauma are one important risk factor.Adolescents with a history of physical and/or sexual abuse are more likely to be diagnosed with substance use disorders.30 Many other risk factors, including genetic vulnerability, prenatal exposure to alcohol or other drugs, lack of parental supervision or monitoring, and association with drug-using peers also play an important role.31

At the same time, a wide range of genetic and environmental influences that promote strong psychosocial development and resilience may work to balance or counteract risk factors, making it ultimately hard to predict which individuals will develop substance use disorders and which won’t.

4. Is it possible for teens to become addicted to marijuana?

Yes. Contrary to common belief, marijuana is addictive. Estimates from research suggest that about 9 percent of users become addicted to marijuana; this number increases among those who start young (to about 17 percent, or 1 in 6) and among daily users (to 25–50 percent).32Thus, many of the nearly 7 percent of high- school seniors who (according to annual survey data)33report smoking marijuana daily or almost daily are well on their way to addiction, if not already addicted, and may be functioning at a sub-optimal level in their schoolwork and in other areas of their lives.

Long-term marijuana users who try to quit report withdrawal symptoms including irritability, sleeplessness, decreased appetite, anxiety, and drug craving, all of which can make it difficult to stay off the drug. Behavioral interventions, including Cognitive-Behavioral Therapy and Contingency Management (providing tangible incentives to patients who remain drug-free) have proven to be effective in treating marijuana addiction (see Page 24 for deblockedions of these treatments). Although no medications are currently available to treat marijuana addiction, it is possible that medications to ease marijuana withdrawal, block its in toxicating effects, and prevent relapse may emerge from recent discoveries about the workings of the endocannabinoid system, a signaling system in the body and brain that uses chemicals related to the active ingredients in marijuana.

Legalization of marijuana for adult recreational use and for medicinal purposes is currently the subject of much public debate. Whatever the outcome, public health experts are worried about use increasing among adolescents, since marijuana use as a teen may harm the developing brain, lower IQ, and seriously impair the ability to drive safely, especially when combined with alcohol.

Parents seeking more information about the effects of marijuana on teens are encouraged to see information offered on NIDA’s Web site: http://www.drugabuse.gov/drugs-abuse/marijuana.

The Dangers of Inhalants

Various household products, including cleaning fluids, glues, lighter fluid, aerosol sprays, and office supplies like markers and correction fluid, have fumes that are sometimes breathed to obtain a brief, typically alcohol-like high. Because of their ready availability, these are frequently among the earliest substances youth abuse; they are generally less popular among older teens, who have greater access to other substances like alcohol or marijuana.

Although the high from inhalants typically wears off quickly, immediate health consequences of inhalant abuse may be severe: In addition to nausea or vomiting, users risk suffocation and heart failure— called “sudden sniffing death.” Serious long-term consequences include liver and kidney damage, hearing loss, bone marrow damage, and brain damage. Although addiction to inhalants is not very common, it can occur with repeated abuse.

Early abuse of inhalants may also be a warning sign for later abuse of other drugs. One study found that youth who used inhalants before age 14 were twice as likely to later use opiate drugs.34 So it is important for parents to safeguard household products and be alert to signs that their younger teens may be abusing these substances.

In the case of opioid pain relievers such as Vicodin® or OxyContin®, there is a great risk of addiction and death from overdose associated with such abuse. Especially when pills are crushed and injected or snorted, these medications affect the brain and body very much like heroin, including euphoric effects and a hazardous suppression of breathing (the reason for death in cases of fatal opioid overdose).

In fact, some young people who develop prescription opioid addictions shift to heroin because it may be cheaper to obtain.35 ADHD medications such as Adderall® (which contains the stimulant amphetamine) are increasingly popular among young people who take them believing it will improve their school performance. This too is a dangerous trend. prescription stimulants act in the brain similarly to cocaine or illegal amphetamines, raisingheart rate and blood pressure, as well as producing an addictive euphoria. Other than promoting wakefulness, it is unclear that such medications actually provide much or any cognitive benefit, however, beyond the benefits they provide when taken as prescribed to those withADHD.36

5. Is abuse of prescription medications as dangerous as other forms of illegal druguse?

Psychoactive prescription drugs, which include opioid pain relievers, stimulants prescribed for ADHD, and central nervous system depressants prescribed to treat anxiety or sleep disorders,are all effective and safe when taken as prescribed by a doctor for the conditions they are intended to treat. However, they are frequently abused— that is, taken in other ways, in other quantities, or by people for whom they weren’t prescribed— and this can have devastating consequences.

6. Are steroids addictive andcansteroidabusebe treated?

Some adolescents—mostly male—abuse anabolic-androgenic steroids in order to improve their athletic performance and/or improve their appearance by helping build muscles. Steroid abuse may lead to serious, even irreversible, health problems including kidney impairment, liver damage, and cardiovascular problems that raise the risk of stroke and heart attack (even in young people). An undetermined percentage of steroid abusers may also become addicted to the drugs—that is, continuing to use them despite physical problems and negative effects on social relations—but the mechanisms causing this addiction are more complex than those for other drugs of abuse.

Steroids are not generally considered intoxicating, but animal studies have shown that chronic steroid use alters the same dopamine reward pathways in the brain that are affected by other substances. Other factors such as underlying body image problems also contribute to steroid abuse.37 Moreover, when people stop using steroids, they can experience withdrawal symptoms such as hormonal changes that produce fatigue, loss of muscle mass and sex drive, and other unpleasant physical changes. One of the more dangerous withdrawal symptoms is depression, which has led to suicide in some people discontinuing steroids. Steroid abuse is also frequently complicated by abuse of other substances taken either as part of a performance-enhancing regimen (such as stimulants) or to help manage pain-, sleep-, or mood-related side effects (such as opioids, cannabis, and alcohol).38 Because of this complicated mix of issues, treatment for steroid abuse necessarily involves addressing all related mental and physical health issues and substance use disorders simultaneously. This may involve behavioral treatments as well as medications to help normalize the hormonal system and treat any depression or pain issues that may be present. If symptoms are severe or prolonged, hospitalization may be needed.

7. How do other mental health conditions relate to substance use in adolescents?

Drug use in adolescents frequently overlapswith other mental health problems. For example, a teen with a substance use disorder is morelikely to have a mood, anxiety, learning, or behavioral disorder too. Sometimes drugs can make accurately diagnosing these other problems complicated. Adolescents may begin taking drugs to deal with depression or anxiety, for example; on the other hand, frequent drug use may also cause or precipitate those disorders. Adolescents entering drug abuse treatment should be given a comprehensive mental health screening to determine if other disorders are present. Effectively treating a substance use disorder requires addressing drug abuse and other mental health problems simultaneously.

8. Does treatment of ADHDwithstimulant medications like Ritalin® and Adderall® increase risk of substance abuse later in life?

prescription stimulants are effective at treating attention disorders in children and adolescents, but concerns have been raised that they could make a young person more vulnerable to developing later substance use disorders. On balance, the studies conducted so far have found no differences in later substance use for ADHD-affected children who received treatment versus those that did not. This suggests that treatment with ADHD medication does not affect (either negatively or positively) an individual’s risk for developing a substance use disorder.39

8. Does treatment of ADHD with stimulant medications like Ritalin® and Adderall® increase risk of substance abuse later in life?

prescription stimulants are effective at treating attention disorders in children and adolescents, but concerns have been raised that they could make a young person more vulnerable to developing later substance use disorders. On balance, the studies conducted so far have found no differences in later substance use for ADHD-affected children who received treatment versus those that did not. This suggests that treatment with ADHD medication does not affect (either negatively or positively) an individual’s risk for developing a substance use disorder.

9. What are signs of drug use in adolescents, and what role can parents play ingetting treatment?

If an adolescent starts behaving differently for no apparent reason––such as acting withdrawn, frequently tired or depressed, or hostile–it could be a sign he or she is developing a drug-related problem. Parents and others may overlook such signs, believing them to be a normal part of puberty.

Other signs include:
  • a change in peergroup
  • carelessness withgrooming
  • decline in academicperformance
  • missing classes or skippingschool
  • loss of interest in favoriteactivities
  • changes in eating or sleepinghabits
  • deteriorating relationships withfamily members andfriends

Parents tend to underestimate the risks or seriousness of drug use. The symptoms listed here suggest a problem that may already have become serious and should be evaluated to determine the underlying cause—which could be a substance abuse problem or another mental health or medical disorder. Parents who are unsure whether their child is abusing drugs can enlist the help of a primary care physician, school guidance counselor, or drug abuse treatment provider. Parents seeking treatment for an adolescent child are encouraged to see NIDA’s booklet, Seeking Drug Abuse Treatment: Know What to Ask (http://www.drugabuse.gov/publications/ seeking-drug-abuse-treatment) and see the Treatment Referral Resources section of this guide.

 

10. How can parents participate in their adolescent child’s treatment?

Parents can actively support their child and engage with him or her during the treatmentand recovery process. Apart from providing moral and emotional support, parents can also play a crucial role in supporting the practical aspects of treatment, such as scheduling and making appointments, as well as providing needed structure and supervision through household rules and monitoring. Also, several evidence- based treatments for adolescents specifically address drug abuse within the family context. Family-based drug abuse treatment can help improve communication, problem-solving, and conflict resolution within the household. Treatment professionals can help parents and other family members identify ways they can support the changes the adolescent achieves through treatment (see “Family-Based Approaches,” pages 25–26).

11. What role can medical professionals play in addressing substance abuse (including abuse of prescription drugs)among adolescents?

Medical professionals have an important role to play in screening their adolescent patients for drug use, providing brief interventions, referring them to substance abuse treatment if necessary, and providing ongoing monitoring and follow-up. Screening and brief interventions do not have to be time-consuming and can be integrated into general medical settings.

  • Screening. Screening and brief assessment tools administered during annual routine medical checkups can detect drug use before it becomes a serious problem. The purpose of screening is to look for evidence of anyuse of alcohol, tobacco, or illicit drugs or abuse of prescription drugs and assess how severe the problem is. Results from such screens can indicate whether a more extensive assessment and possible treatment are necessary (see “Screening Tools and Brief Assessments Used with Adolescents,” below).40 Screening as a part of routine care also helps to reduce the stigma associated with being identified as having a drug problem.
  • Brief Intervention. Adolescents who report using drugs can be given a brief intervention to reduce their drug use and other risky behaviors. Specifically, they should be advised how continued drug use may harm their brains, general health, and other areas of their life, including family relationships and education. Adolescents reporting no substance use can be praised for staying away from drugs and rescreened during their next physical.
  • Referral. Adolescents with substance use disorders or those that appear to be developing a substance use disorder may need a referral to substance abuse treatment for more extensive assessment and care.
  • Follow-up. For patients in treatment, medical professionals can offer ongoing support of treatment participation and abstinence from drugs during follow-up visits. Adolescent patients who relapse or show signs of continuing to use drugs may need to be referred back to treatment.
  • Before prescribing medications that can potentially be abused, clinicians can assess patients for risk factors such as mental illness or a family history of substance abuse, consider an alternative medication with less abuse potential, more closely monitor patients at high risk, reduce the length of timebetween visits for refills so fewer pills are on hand,and educate both patients and their parents about appropriate use and potential risks of prescription medications, including the dangers of sharing them with others.

 

12. Is adolescent tobacco use treated similarly to other druguse?

Yes. People often don’t think of tobacco use as a kind of “drug abuse” that requires treatment, and motives for quitting smoking may be somewhat different than motives for quitting other drugs. But tobacco use has well-known health risks–– especially when begun in the teen years––and the highly addictive nicotine in tobacco can make treatment a necessity to help an adolescent quit. Laboratory research also suggests that nicotine may increase the rewarding and addictive effects of other drugs, making it a potential contributor to other substance use disorders.

Common treatment approaches like Cognitive-Behavioral Therapy are now being used to help adolescents quit smoking (and quit using other drugs) by helping them “train their brains” so they learn to recognize and control their cravings and better deal with life stress. Other therapies like Contingency Management and Motivational Enhancement use incentives and motivation techniques to help teens reduce or stop smoking.44 (See page 24 for deblockedions of these treatments.)Tobacco use often accompanies other drug use and needs to be addressed as part of other substance use disorder treatment. In a recent survey, nearly 55 percent of current adolescent cigarette smokers (ages 12 to 17) were also illicit drug users (by comparison, only about 6 percent of those who did smoke used any illicit drugs).45 Also, cigarette smoking can be an indicator of other psychiatric disorders, which can be identified through comprehensive screening by a treatment provider.

13. Are there medications to treat adolescent substance abuse?

Several medications are approved by the FDA to treat addiction to opioids, alcohol,and nicotine in individuals 18 and older. In most cases, little research has been conducted to evaluate the safety and efficacy of these medications for adolescents; however, some health care providers do use these medications “off-label,” especially in older adolescents (see “Addiction Medications,” pages 26–28).

14. Do girls and boys have different treatment needs?

Adolescent girls and boys may have different developmental and social issues that may call for different treatment strategies or emphases. For example, girls with substance use disorders may be more likely to also have mood disorders such as depression or to have experienced physical or sexual abuse. Boys with substance use disorders are more likely to also have conduct, behavioral, and learning problems, which may be very disruptive to their school, family, or community. Treatments should take into account the higher rate of internalizing and traumatic stress disorders among adolescent girls, the higher rate of externalizing disruptive disorders and juvenile justice problems among adolescent boys, and other gender differences that may play into adolescent substance use disorders.

15. What are the unique treatment needs of adolescents from different racial/ethnic backgrounds?

Treatment providers are urged to consider the unique social and environmental characteristics that may influence drug abuse and treatment for racial/ethnic minority adolescents, such as stigma, discrimination, and sparse community resources. With the growing number of immigrant children living in the United States, issues of culture of origin, language, and acculturation are important considerations for treatment. The demand for bilingual treatment providers to work with adolescents and their families will also be increasing as the diversity of the U.S. population increases.

16. What role can the juvenile justice system play in addressing adolescent drugabuse?

Involvement in the juvenile justice system is unfortunately a reality for many substance- abusing adolescents, but it presents a valuable opportunity for intervention. Substance use treatment can be incorporated into the juvenile justice system in several ways. These include:

  • screening and assessment for drug abuse upon arrest
  • initiation of treatment while awaiting trial
  • access to treatment programs in the community in lieu of incarceration (e.g., juvenile treatment drugcourts)46,47
  • treatment during incarceration followed by community-based treatment after release

Coordination and collaboration between juvenile justice professionals, drug abuse treatment providers, and other social service agencies are essential in getting needed treatment to adolescent offenders, about one half of whom have substance use disorders.48

17. What role do 12-step groupsorotherrecovery support services play in addiction treatment for adolescents?

Adolescents may benefit from participation in self- or mutual-help groups like 12-step programs or other recovery support services,which can reinforce abstinence from drug use and other changes made during treatment, as well as support progress made toward important goals like succeeding in school and reuniting with family. Peer recovery support services and recovery high schools provide a community setting where fellow recovering adolescents can share their experiences and support each other in living a drug-free life.

It is important to note that recovery support services are not a substitute for drug abuse treatment. Also, there is sometimes a risk in support-group settings that conversation among adolescents can turn to talk extolling drug use; group leaders need to be aware of such a possibility and be ready to direct the discussion in more positive directions if necessary.

IV. TREATMENT SETTINGS

Treatment for substance use disorders is delivered at varying levels of care in many different settings. Because no single treatment is appropriate for every adolescent, treatments must be tailored for the individual. Based on the consensus of drug treatment experts, the American Society of Addiction Medicine (ASAM) has developed guidelines for determining the appropriate intensity and length of treatment for adolescents with substance abuse problems, based on an assessment involving six areas:

  • (1) Level of intoxication and potentialfor withdrawal
  • (2) Presence of other medicalconditions
  • (3) Presence of other emotional, behavioral,or cognitive conditions
  • (4) Readiness or motivation to change
  • (5) Risk of relapse or continued druguse
  • (6) Recovery environment (e.g., family, peers, school, legal system)

With a substance use disorder—as with any other medical condition—treatment must be long enough and strong enough to be effective. Just as an antibiotic must be taken for sufficient time to kill a bacterial infection, even though symptoms may already have subsided, substance abuse treatment must continue for a sufficient length of time to treat the disease. Undertreating a substance use disorder— providing lower than the recommended level of care or a shorter length of treatment than recommended—will increase the risk of relapse and could cause the patient, his or her family members, or the referring juvenile justicesystem to lose hope in the treatment because they will see it as ineffective.

This section will review the settings in which adolescent drug abuse treatment most often occurs. Outpatient/Intensive Outpatient Adolescent drug abuse treatment is most commonly offered in outpatient settings. When delivered by well-trained clinicians, this can be highly effective. Outpatient treatment is traditionally recommended for adolescents with less severe addictions, few additional mental health problems, and a supportive living environment, although evidence suggests that more severe cases can be treated in outpatient settings as well. Outpatient treatment varies in the type and intensity of services offered and may be delivered on an individual basis or in a group format (although research suggests group therapy can carry certain risks; see “Group Therapy for Adolescents,” page 23). Low- or moderate-intensity outpatient care is generally delivered once or twice a week.

Intensive outpatient services are delivered more frequently, typically more than twice a week for at least 3 hours per day. Outpatient programs may offer drug abuse prevention programming (focused on deterring further drug use) or other behavioral and family interventions.50,51

Partial Hospitalization

Adolescents with more severe substance use disorders but who can still be safely managed in their home living environment may be referred to a higher level of care called partial hospitalization or “day treatment.” This setting offers adolescents the opportunity to participate in treatment 4–6 hours a day at least 5 days a week while living at home.52

Residential/Inpatient Treatment

Residential treatment is a resource-intense high level of care, generally for adolescents with severe levels of addiction whose mental health and medical needs and addictive behaviors require a 24-hour structured environment to make recovery possible. These adolescents may have complex psychiatric or medical problems or family issues that interfere with their ability to avoid substance use. One well- known long-term residential treatment model is the therapeutic community (TC). TCs use a combination of techniques to “resocialize” the adolescent and enlist all the members of the community, including residents and staff, as active participants in treatment.Treatment focuses on building personal and social responsibility and developing new coping skills. Such programs offer a range of family services and may require family participation if the TC is sufficiently close to where the family lives. Short- term residential programs also exist.53

V. EVIDENCE-BASED APPROACHES TO TREATING ADOLESCENT SUBSTANCE USE DISORDERS

Research evidence supports the effectiveness of various substance abuse treatment approaches for adolescents. Examples of specific evidence-based approaches are described below, including behavioral and family-based interventions as well as medications. Each approach is designed to address specific aspects of adolescent drug use and its consequences for the individual, family, and society. In order for any intervention to be effective, the clinician providing it needs to be trained and well- supervised to ensure that he or she adheres to the instructions and guidance described in treatment manuals. Most of these treatments have been tested over short periods of 12–16 weeks, but for some adolescents, longer treatments may be warranted; such a decision is made on a case-by-casebasis.The provider should use clinical judgment to select the evidence-based approach that seems best suited to the patient and his or her family.*

BEHAVIORAL APPROACHES

Behavioral interventions help adolescents to actively participate in their recovery from drug abuse and addiction and enhance their ability to resist drug use. In such approaches, therapists may provide incentives to remain abstinent, modify attitudes and behaviors related to drug abuse, assist families in improving their communication and overall interactions, and increase life skills to handle stressful circumstances and deal with environmental cues that may trigger intense craving for drugs. Below are some behavioral treatments shown to be effectivein addressing substance abuse in adolescents (listed in alphabeticalorder).

Group Therapy for Adolescents

Adolescents can participate in group therapy and other peer support programs during and following treatment to help them achieve abstinence. When led by well- trained clinicians following well-validated Cognitive-Behavioral Therapy (CBT) protocols (see page 24), groups can provide positive social reinforcement through peer discussion and help enforceincentives to staying off drugs and living a drug-free lifestyle. However, group treatment for adolescents carries a risk of unintended adverse effects: Group may steer conversation toward talk that glorifies or extols drug use, thereby undermining recovery goals. Trained counselors need to be aware of that possibility and direct group activities and discussions in a positive direction.

Adolescent Community Reinforcement Approach (A-CRA)S

A-CRA is an intervention that seeks to help adolescents achieve and maintain abstinence from drugs by replacing influences in their lives that had reinforced substance use with healthier family, social, and educational or vocational reinforcers. After assessing the adolescent’s needs and levels of functioning, the therapist chooses from among 17 A-CRA procedures to address problem-solving, coping, and communication skills and to encourage active participation in constructive social and recreational activities.54

Cognitive-Behavioral Therapy (CBT)

CBT strategies are based on the theory that learning processes play a critical role in the development of problem behaviors like drug abuse. A core element of CBT is teaching participants how to anticipate problems and helping them develop effective copingstrategies. In CBT, adolescents explore the positive and negative consequences of using drugs. They learn to monitor their feelings and thoughts and recognize distorted thinking patterns and cues that trigger their substance abuse; identify and anticipate high-risk situations; and apply an array of self-control skills, including emotional regulation and anger management, practical problem solving, and substance refusal. CBT may be offered in outpatient settings in either individual or group sessions (see “Group Therapy for Adolescents,” page 23) or in residentialsettings.55

Contingency Management (CM)

Research has demonstrated the effectiveness of treatment using immediate and tangible reinforcements for positive behaviors to modify problem behaviors like substance abuse. This approach, known as Contingency Management (CM), provides adolescents an opportunity to earn low-cost incentives such as prizes or cash vouchers (for food items, movie passes, and other personal goods) in exchange for participating in drug treatment, achieving important goals of treatment, and not using drugs. The goal of CM is to weaken the influence of reinforcement derived from using drugsand to substitute it with reinforcement derived from healthier activities and drug abstinence. For adolescents, CM has been offered in a variety of settings, and parents can be trained to apply this method at home. CM is typically combined either with a psychosocial treatment or a medication (where available). Recent evidence also supports the use of Web-based CM to help adolescents stop smoking.56

Motivational Enhancement Therapy (MET)

MET is a counseling approach that helps adolescents resolve their ambivalenceabout engaging in treatment and quitting their drug use. This approach, which is based on a technique called motivational interviewing, typically includes an initial assessment of the adolescent’s motivation to participate in treatment, followed by one to three individual sessions in which a therapist helps the patient develop a desire to participate in treatment by providing non-confrontational feedback. Being empathic yet directive, the therapistdiscusses the need for treatment and tries to elicit self- motivational statements from the adolescent to strengthen his or her motivation and build a plan for change. If the adolescent resists, the therapist responds neutrally rather than by contradicting or correcting the patient. MET, while better than no treatment, is typically not used as a stand-alone treatment for adolescents with substance use disorders but is used to motivate them to participate in other types of treatment.57

Twelve-Step Facilitation Therapy

Twelve-Step Facilitation Therapy is designed to increase the likelihood that an adolescent with a drug abuse problem will become affiliated and actively involved in a 12-step program like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Such programs stress the participant’s acceptance that life has become unmanageable, that abstinence from drug use is needed, and that willpower alone cannot overcome the problem. The benefits of 12- step participation for adults in extending the benefits of addiction treatment appear to apply to adolescent outpatients as well, according to recent research. Research also suggests adolescent-specific 12-step facilitation strategies may help enhance outpatient attendance rates.58

Behavioral interventions help adolescents to actively participate in their recovery from drug abuse and addiction and enhance their ability to resist drug use.

FAMILY-BASED APPROACHES

Family-based approaches to treating adolescent substance abuse highlight the need to engage the family, including parents, siblings, and sometimes peers, in the adolescent’s treatment. Involving the family can be particularly important, as the adolescent will often be living with at least one parent and be subject to the parent’s controls, rules, and/or supports.

Family-based approaches generally address a wide array of problems in addition to the young person’s substance problems,including family communication and conflict; other co- occurring behavioral, mental health, and learning disorders; problems with schoolor work attendance; and peer networks. Research shows that family-based treatments are highly efficacious; some studies even suggest they are superior to other individual and group treatment approaches.59 Typically offered in outpatient settings, family treatments have also been tested successfully in higher-intensity settings such as residential and intensive outpatient programs. Below are specific types of family-based treatments shown to be effective in treating adolescent substance abuse.

Brief StrategicFamily Therapy (BSFT)

BSFT is based on a family systems approach to treatment, in which one member’s problem behaviors are seen to stem from unhealthy family interactions. Over the course of 12–16 sessions, the BSFT counselor establishes a relationship with each family member,observes how the members behave with one another, and assists the family in changing negative interaction patterns. BSFT can be adapted to a broad range of family situations in various settings (mental health clinics, drug abuse treatment programs, social service settings, families’ homes) and treatment modalities (as a primary outpatient intervention, in combination with residential or day treatment, or as an aftercare/continuing-care service following residential treatment).60

Involving the family can be particularly important in adolescent substance abuse treatment.

Family Behavior Therapy (FBT)

FBT, which has demonstrated positive results in both adults and adolescents, combines behavioral contracting with contingency management to address not only substance abuse but other behavioral problems as well. The adolescent and at least one parent participate in treatment planning and choose specific interventions from a menu of evidence- based treatment options. Therapists encourage family members to use behavioral strategies taught in sessions and apply their new skills to improve the home environment. They set behavioral goals for preventing substance use and reducing risk behaviors for sexually transmitted diseases like HIV, which are reinforced through a contingency management (CM) system (see deblockedion on page 24). Goals are reviewed and rewards provided at each session.61

Functional Family Therapy (FFT)

FFT combines a family systems view of family functioning (which asserts that unhealthy family interactions underlie problembehaviors) with behavioral techniques to improve communication, problem-solving, conflict resolution, and parenting skills. Principal treatment strategies include (1)engaging families in the treatment process and enhancing their motivation for change and (2) modifying family members’ behavior using CMtechniques, communication and problem solving, behavioral contracts, and other methods.62

Multidimensional Family Therapy (MDFT)

MDFT is a comprehensive family- and community-based treatment for substance- abusing adolescents and those at high risk for behavior problems such as conduct disorder and delinquency. The aim is to foster family competency and collaboration with other systems like school or juvenile justice. Sessions may take place in a variety of locations, including in the home, at a clinic, at school, at family court, or in other community locations. MDFT has been shown to be effective even with more severe substance use disorders and can facilitate the reintegration of substance abusing juvenile detainees into the community.63

Multisystemic Therapy (MST)

MST is a comprehensive and intensive family- and community-based treatment that has been shown to be effective even with adolescents whose substance abuse problems are severe and with those who engage in delinquent and/ or violent behavior. In MST, the adolescent’s substance abuse is viewed in terms of characteristics of the adolescent (e.g., favorable attitudes toward drug use) and those of his or her family (e.g., poor discipline, conflict, parental drug abuse), peers (e.g., positive attitudes toward drug use), school (e.g., dropout, poor performance), and neighborhood (e.g., criminal subculture). The therapist may work with the family as a whole but will also conduct sessions with just the caregivers or the adolescent alone.64

ADDICTION MEDICATIONS

Several medications have been found to be effective in treating addiction to opioids,alcohol, or nicotine in adults, although none of these medications have been approved by the FDA to treat adolescents. In most cases, only preliminary evidence exists for theeffectiveness and safety of these medications in people under 18, and there is no evidence on the neurobiological impact of these medications on the developing brain. However, despite the relative lack of evidence, some health care providers do use medications “off-label” when treating adolescents (especially older adolescents) who are addicted to opioids, nicotine, or (less commonly) alcohol. Newer compounds continue to be studied for possibly treating substance use disorders in adults and adolescents, but none other than those listed here have shown conclusive results.

Note that there are currently no FDA-approved medications to treat addiction to cannabis, cocaine, or methamphetamine in any age group.

Opioid Use Disorders

Buprenorphine reduces or eliminates opioid withdrawal symptoms, including drug cravings, without producing the “high” or dangerous side effects of heroin and other opioids. It does this by both activating and blocking opioidreceptors in the brain (i.e., it is what is known as a partial opioid agonist). It is available for sublingual (under-the-tongue) administration both in a stand-alone formulation (calledSubutex®) and in combination with another agent called naloxone. The naloxone in the combined formulation (marketed as Suboxone®) is included to deter diversion or abuse of the medication by causing a withdrawal reaction if it is intravenously injected.65 Physicians with special certification may provide office-based buprenorphine treatment for detoxification and/ormaintenancetherapy.66Itissometimes prescribed to older adolescents on the basis of two research studies indicating its efficacy for this population,67,68 even though it is not approved by the FDA for pediatricuse.*

Methadone also prevents withdrawal symptoms and reduces craving in opioid- addicted individuals by activating opioid receptors in the brain (i.e., a full opioidagonist). It has a long history of use in treatment of opioid dependence in adults, and is available in specially licensed methadone treatment programs. In select cases and in some States, opioid-dependent adolescents between the ages of 16 and 18 may be eligible for methadone treatment, provided they have two documented failed treatments of opioid detoxification or drug-free treatment and have a written consent for methadone signed by a parent or legal guardian.69

It has a long history of use in treatment of opioid dependence in adults, and is available in specially licensed methadone treatment programs. In select cases and in some States,opioid-dependent adolescents between the ages of 16 and 18 may be eligible for methadone treatment, provided they have two documented failed treatments of opioid detoxification or drug-free treatment and have a written consent for methadone signed by a parent or legal guardian.69

Naltrexone is approved for the prevention of relapse in adult patients following complete detoxification from opioids. It acts by blocking the brain’s opioid receptors (i.e., an opioid antagonist), preventing opioid drugs from acting on them and thus blocking the high the user would normally feel and/or causing withdrawal if recent opioid use has occurred. It can be taken orally in tablets or as a once-monthly injection given in a doctor’s office (a preparation called Vivitrol®).70

Alcohol Use Disorders

Acamprosate (Campral®) reduces withdrawal symptoms by normalizing brain systems disrupted by chronic alcohol consumption in adults.
Disulfiram (Antabuse®) inhibits an enzyme involved in the metabolism of alcohol, causing an unpleasant reaction if alcohol is consumed after taking the medication.71

* According to the FDA label, “SUBOXONE and SUBUTEX are not recommended for use in pediatric patients. The safety and effectiveness of SUBOXONE and SUBUTEX in patients below the age of 16 have not been established.”
‡ Medication-assisted therapies are rarely used to treat adolescent alcohol use disorders.

Naltrexone decreases alcohol-inducedeuphoria and is available in both oral tablets and long- acting injectable preparations (as in its use for the treatment of opioid addiction,above).

Nicotine Use Disorders

Bupropion, commonly prescribed for depression, also reduces nicotine cravings and withdrawal symptoms in adult smokers.72
Nicotine Replacement Therapies (NRTs) help smokers wean off cigarettes by activating nicotine receptors in the brain. They are available in the form of a patch, gum, lozenge, nasal spray, or inhaler.73

Varenicline reduces nicotine cravings and withdrawal in adult smokers by mildly stimulating nicotine receptors in thebrain.74

RECOVERY SUPPORT SERVICES

To reinforce gains made in treatment and to improve their quality of life more generally, recovering adolescents may benefit from recovery support services, which include continuing care, mutual help groups (such as 12-step programs), peer recovery support services, and recovery high schools. Such programs provide a community setting where fellow recovering persons can share their experiences, provide mutual support to each other’s struggles with drug or alcohol problems, and in other ways support a substance-free lifestyle. Note that recovery support servicesare not substitutes for treatment. Also, the existing research evidence for these approaches (with the exception of Assertive Continuing Care) is preliminary; anecdotal evidence supports the effectiveness of peer recovery support services and recovery high schools, for example, but their efficacy has not been established through controlled trials.

Assertive Continuing Care (ACC)

ACC is a home-based continuing-care approach delivered by trained clinicians to prevent relapse, and is typically used after an adolescent completes therapy utilizing the Adolescent Community Reinforcement Approach (A-CRA, see page 23). Using positive and negative reinforcement to shape behaviors, along with training in problem-solving and communication skills, ACC combines A-CRA and assertive case management services (e.g., use of a multidisciplinary team of professionals, round-the-clock coverage, assertive outreach) to help adolescents and their caregivers acquire the skills to engage in positive social activities.75

Mutual Help Groups

Mutual help groups such as the 12-step programs Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) provide ongoing support for people with addictions to alcohol or drugs, respectively, free of charge and in a community setting. Participants meet in a group with others in recovery, once a week or more, sharing their experiences and offering mutual encouragement. Twelve-step groups are guided by a set of fundamental principles that participants are encouraged to adopt––including acknowledging that willpower alone cannot achieve sustainedsobriety,that surrender to the group conscience must replace self-centeredness, and that long- term recovery involves a process of spiritual renewal.76

Peer Recovery Support Services

Peer recovery support services, such as recovery community centers, help individuals remain engaged in treatment and/or the recovery process by linking them together both in groups and in one-on-onerelationships with peer leaders who have direct experience with addiction and recovery. Depending on the needs of the adolescent, peer leaders may provide mentorship and coaching and help connect individuals to treatment, 12- step groups, or other resources. Peer leaders may also facilitate or leadcommunity-building activities, helping recovering adolescents build alternative social networks and have drug- and alcohol-free social options.77

Recovery High Schools

Recovery high schools are schools specifically designed for students recovering from substance abuse issues. They are typically part of another school or set of alternative school programs within the public school system,but recovery school students are generally separated from other students by means of scheduling and physical barriers.Such programs allow adolescents newly in recovery to be surrounded by a peer group supportive of recovery efforts and attitudes. Recoveryschools can serve as an adjunct to formal substance abuse treatment, with students often referred by treatment providers and enrolled in concurrent treatment for other mental health problems.78

TREATMENT REFERRAL RESOURCES

Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Locator: 1-800-662-HELP or search www.findtreatment.samhsa.gov

The “Find A Physician” feature on the American Society of Addiction Medicine (ASAM) Web site: http://community.asam.org/search/default.asp?m=basic

The Patient Referral Program on the American Academy of Addiction Psychiatry Web site: http://www.aaap.org/patient-referral-program

The Child and Adolescent Psychiatrist Finder on the American Academy of Child and Adolescent Psychiatry Web site: http://www.aacap.org/cs/root/child_and_adolescent_psychiatrist_finder/child_and_adolescent_psychiatrist_finder

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Group Therapy in Substance Abuse Treatment

We finish up the treatment protocols with the following excerpt regarding the stage of group therapy from the following publication by SAMHSA: Center for Substance Abuse Treatment.Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series, No. 41.HHS Publication No. (SMA) 15-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

This chapter describes the characteristics of the early, middle, and latest ages of treatment.Each stage differs in the condition of clients, effective the rapeutic strategies,and optimal leadership characteristics.For example, in early treatment, clients can be emotionally fragile, ambivalent about relinquishing chemicals, and resistant to treatment. Thus,treatment strategies focus on immediate concerns:achieving abstinence, preventing relapse, and managing cravings. Also, to establish a stable working group, a relatively active leader emphasizes therapeutic factors like hope,group cohesion,and universality.Emotionally charged factors,such as catharsis and re enactment of family of origin issues,are deferred until later in treatment.In the middle, or action, stage of treatment, clients need the group’s assistance in recognizing that their substance abuse causes many of their problems and blocks them from getting things they want. As clients reluctantly sever their ties with substances, they need help managing their loss and finding healthy substitutes. Often, they need guidance in understanding and managing their emotional lives.

Late­stage treatment spends less time on substance abuse per se and turns toward identifying the treatment gain stobe maintained and risks that remain.During this stage,members may focus on the issues of living,resolving guilt,reducing shame,and adopting a more introspective, relational view of themselves.

Adjustments To Make Treatment Appropriate

As clients move through different stages of recovery, treatment must move with them, changing therapeutic strategies and leadership roles with the condition of the clients. These changes are vital since interventions that work well early in treatment may be ineffective, and even harmful, if applied in the same way later in treatment (Flores 2001).

Any discussion of intervention adjustments to make treatment appropriate at each stage, however, necessarily must be oversimplified for three reasons. First, the stages of recovery and stages of treatment will not correspond perfectly for all people. Clients move in and out of recovery stages in a nonlinear process. A client may fall back, but not necessarily back to the beginning. “After a return to substance use,clients usually revert to an earlier change stage not always to maintenance or action, but more often to some level of contemplation.

They may even become precontemplators again,temporarily unwilling or unable to try to change . . . [but] a recurrence of symptoms does not necessarily mean that a client has abandoned a commitment to change” (Center for Substance Abuse Treatment 1999b, p. 19). See chapters 2 and 3 for a discussion of the stages of change.

A return to drug use, properly handled, can evenbe instructive. With guidance, clients can learn to recognize the events and situations that trigger renewed substance use and regression to earlier stages of recovery. This knowledge becomes helpful in subsequent attempts leading to eventual recovery. Client progress­regress­ progress waves, however, require the counselor to constantly reevaluate where the client is in the recovery process, irrespective of the stage of treatment.

Second, adjustments in treatment are needed because progress throught hestages of recovery is not time bound.There is no way to calculate how long any individual should require to resolvethe issues that arise at any stage of recovery. The result is that different group members may achieve and beat different stages of recovery at the same time in the life cycle of the group. The group leader, therefore, should use interventions that take the group as a whole into account.Third, therapeutic interventions, meaningthe acts of a clinician intended to promote healing, may not account for all (or any) of the change in a particular individual. Some people give up drugs or alcohol without undergoing treatment. Thus, it is an error to assume that an individu­ al is moving through stages of treatment because of assistance at every point from insti­ tutions and self­help groups. To stand the best chance for meaningful intervention, a leader should determine where the individual best fits in his level of function, stance toward absti­ nence, and motivation to change. In short, generalizations about stages of treatment may not apply to every client in every group.

The Early Stage of Treatment
Condition of Clients in Early Treatment

In the early stage of treatment, clients may be in the precontemplation, contemplation, preparation, or early action stage of change, depend­ ing on the nature of the group. Regardless of their stage in early recovery, clients tend to be ambivalent about ending substance use. Even those who sincerely intend to remain abstinent may have a tenuous commitment to recovery.Further, cognitive impairment from substances is at its most severe in these early stages of recovery, so clients tend to be rigid in their thinking and limited in their ability to solve problems. To some scientists, it appears that the “addicted brain is abnormally conditioned, so that environmental cues surrounding drug use have become part of the addiction” (Leshner 1996, p. 47).

Typically,people who abuse substances do not enter treatment on their own.Some enter treatment due to health problems, others because they are referred or mandated by the legal system, employers, or family members (Milgram and Rubin 1992). Group members commonly are in extreme emotional turmoil, grappling with intense emotions such as guilt, shame, depression,and anger about entering treatment.

Even if clients have entered treatment volun­ tarily, they often harbor a desire for substances and a belief that they can return to recreation­ al use once the present crisis subsides. At first, most clients comply with treatment expectations more from fear of consequences than froma sincere desire to stop drinking or using illicit drugs (Flores 1997; Johnson1973).

Consequently, the group leader faces the challenge of treating resistant clients. In general, resistance presents in one of two ways. Some clients actively resist treatment.Otherspassive­ ly resist. They are outwardly cooperative and go to great lengths to give the impression of willing engagement in the treatment process, but their primary motivation is a desire to be free from external pressure. The group leader has the delicate task of exposing the motives behind the outward compliance.

The art of treating addiction in early treatment is in the defeat of denial and resistance, which almost all clients with addictions carry into treatment. Group therapy is considered an effective modality for…overcoming the resistance that characterizes addicts.Ask illed group leader can facilitate members’ confronting each other about their resistance. Such confrontation is useful because it is difficult for one addict to deceive another. Because addicts usually have a history of adversarial relationships with authority figures, they are more likely to accept information from their peers than a group leader. A group can also provide addicts with the opportunity for mutual aid and support; addicts who present for treatmen tare usually well connected to a dysfunctional subculture but socially isolated from healthy contacts (Milgram and Rubin 1992, p. 96). Emphasis therefore is laced on acculturating clients into a new culture,the culture of recovery(Kemkeretal.1993).

Therapeutic Strategies in Early Treatment

In 1975, Irvin Yalom elaborated on earlier work and distinguished 11 therapeutic factors that contribute to healing as group therapy unfolds:

  • Instilling hope some group members exemplify progress toward recovery and support others in their efforts, thereby helping to retain clients in therapy.
  • Universality groups enable clients to see that they are not alone, that others have similar problems.
  • Imparting information leadersshed light on the nature of addiction via direct instruction.
  • Altruism—group members gain greater self esteem by helping each other.
  • Corrective recapitulation of the primary familygroup—groups provide a family­like context in which long­standing unresolved conflicts can be revisited and constructively resolved.
  • Developing socializing techniques—groups give feedback;others’impressions reveal how a client’s ineffective social habits might under mine relationships.
  • Imitative behavior—groups permit clients to tryout new behavior of others.
  • Interpersonal learning—groups correct the distorted perceptions of others.
  • Group cohesiveness—groups provide a safe holding environment within which people feel free to be honest and open with each other.
  • Catharsis—groups liberate clients as they learn how to express feelings and reveal what is bothering them.
  • Existential factors—groups aid clients in coming to terms with hard truths,such as (1) life can be unfair; (2) life can be painful and death is inevitable; (3) no matter how close one is to others, life is faced alone; (4) it is important to live honestly and not get caught up in trivial matters; (5) each of us is responsible for the ways in which we live.

In different stages of treatment,some of these therapeutic factors receive more attention than others. For example, in the beginning of the recovery process,it is extremely important for group members to experience the therapeutic factor of universality. Group members should come to recognize that although they differ in some ways, they also share profound connections and similarities,and they are not alone in their struggles.

The therapeutic factor of hope also is particu­ larly important in this stage. For instance, a new member facing the first day without drugs may come into a revolving membership group that includes people who have been abstinent for 2 or 3 weeks. The mere presence of people able to sustain abstinence for days––even weeks––provides the new member with hope that life can be lived without alcohol or illicit drugs. It becomes possible to believe that abstinence is feasible because others are obviously succeeding.

Imparting information often is needed to help clients learn what needs to be done to get through a day without chemicals. Psychoeducation also allows group members to learn about addiction, to judge their practices against this factual information, and to postpone intense interaction with other group members until they are ready for such highly charged work. Attention to group cohesiveness is important early in treatment because only when group members feel safety and belonging within the group will they be able to for man attachment to the group and fully experience the effects of new knowledge,universality,and hope.

Therapeutic factors such as catharsis, existen­ tial factors, or recapitulation of family groups generally receive little attention in early treat­ ment. These factors often are highly charged with emotional energy and are better left until the group is well established.

During the initial stage of treatment,the therapist helps clients acknowledge and understand how substance abuse has dominated and dam­ aged their lives. Drugs or alcohol, in various ways,can provide as ubstitute for the give­and­take of relationships and a means of surviving without a healthy adjustment to life. As substances are withdrawn or abandoned, clients give up a major source of support without having anything to put in its place (Brown 1985; Straussner1997).

In this frightening time, counselors need to ensure that the client has a sense of safety. The group leader’s task is to help group members recognize that while alcohol or illicit drugs may have provided a temporary way to cope with problems in the past, the consequences were not worth the price, and new, healthier ways canbe found to handle life’s problems.

In early stage treatment,strong challenges to a client’s fragilemental and emotional condition can be very harmful.Outof touch with unmedicated feelings, clients already are susceptible to wild emotional fluctuations and a reprone to unpredictable responses. Interpersonal relationships are disturbed, and the effects of substances leave the client prone to use“primitive defensive operations such as denial, splitting, projective identification, and grandiosity” (Straussner 1997, p.68).

This vulnerable time, however, is also one of opportunity. In times of crisis, “an individual’s attachment system opens up” and the therapist has a chance to change the client’s internal dynamics (Flores 2001, p. 72). Support networks that can provide feedback and structure are especially helpful at this stage.Clients also need reliable information to strengthen their motivation.At this time, clients are solidifying their “new identity as an alcoholic with the corresponding belief in loss of control.”They develop“a new logical structure” with which to assail their “former logic and behavior.” They also can develop a “new story . . . the Alcoholics Anonymous drunkalogue,”which recalls their experiences and compares previous events with what life is like now(Brown1985).

Whether information is offered through skills groups, psychoeducational groups, supportive therapy groups, spiritually oriented support groups, or process groups, clients are most likely to use the information and tools provided in an environment alive with supportive human connections. All possible sources of positive forces in a client’s life should be marshaled to help the client manage life’s challenges instead of turning to substances or other addictive behaviors.

Painful feelings, which clients are not yet prepared to face, can sometimes trig­ ger relapse. If relapses occur in an outpatient setting––as they often do, because relapses occur in all chronic illnesses, including addic­ tion––the group member should be guided through the regression.Thelead­ er encourages the client to attend self­ help groups, explores the sequence of events leading to relapse,determines what cues led to relapse, and suggests changes that might enable the client to manage cravings better or avoid exposure to strong cues.

For some clients, chiefly those mandated into treatment by courts or employers,grave consequences in evitablyensue as a result of relapse. AsVannicelli(1992)pointsout,however,clinicians should view relapse not as failure,but as a clinical opportunity for both group leader and clients to learn from the event, integrate the new knowledge, and strengthen levels of motivation.Discussion of the relapse in group not only helps the individual who relapsed learnhowtoavoidfutureuse,butitalsogives other group members a chance to learn from the mistakes of others and to avoid making the same mistakes themselves.

A Note on Attachment Theory and Substance Abuse Treatment

Attachment theory provides a comprehensive meta­theory of addiction that not only integrates diverse mental health models with the disease­concept, but also furnishes guidelines for clinical practice that are compatible with existing addiction treatment strategies including anabstinence basis and alignment with 12­Step treatment philosophy.

Attachment theory (Bowlby 1979) and self psychology (Kohut 1977b) provided the first compelling theories that offered a practical alternative rationale for the addiction cycle that is not only compatible with the disease concept, but expands it by providing a more complete and intellectually satisfying theoretical explanation why Alcoholic Anonymous(AA)works as it does.

According to the theory, attachment is recognized as a primary motivational force with its own dynamics,and these dynamics have far reaching and complex consequences(Bowlby1979).Inclients with substance use disorders there is an inverse relation between their substance abuse and healthy interpersonal attachments. A person who is actively abusing substances can rarely negotiate the demands of healthy inter personal relationships successfully.

Using this theoretical model, substance abuse can be viewed as an attachment disorder. Individuals who have difficulty establishing intimate attachments will be more inclined to substitute substances for their deficiency in intimacy.Because of their difficulty maintaining emotional closeness with others,they are more likely to substitute various behaviors(including substance abuse)to distract them from their lackof intimate inter personal relations.

The use of substances may initially serve a compensatory function, helping those who feel uncomfortable in social situations because of inadequate interpersonal skills. However, substances of abuse will gradually compromise neurophysiologi­ cal functioning and erode existing interpersonal skills. Managing relationships tends to become increasingly difficult, leading to a heightened reliance on sub­ stances, which accelerates deterioration and increases abuse and dependence.Eventually,the individual’s relationship with substances of abuse becomes both an obstacle to and a substitute for interpersonal attachments. If problems in attachment are a primary cause of substance abuse, then a therapeutic process that addresses the client’s interpersonal relations will be effective for long­term recovery (Flores 2001; Straussner 1993). Treatment concentrates on removing stress­inducing stimuli,teaching ways to recognize and quell environmental cues that trigger in appropriate behaviors, providing positive reinforcement and support,cultivating positive habits that endure, and developing secure and positive attachments.

Leadership in Early Treatment

Clients usually come to the first session of group in an anxious, apprehensive state of mind, which is intensified by the knowledge that they will soon be revealing personal information and secrets about themselves. The ther­ apist begins by making it clear that clients have some things in common. All have met with the therapist, have acceded to identical agreements, and have set out to resolve important personal issues. Usually, the therapist then suggests that members get to know each other. One technique is to allow the members to decide exactly how they will introduce themselves. The therapist observes silently—but not impassivelywatching how interaction develops (Rutan and Stone2001). During early treatment,a relatively active leader seeks to engage clients in the treatment process. Clients early on “usually respond more favorably to the group leader who is sponta­ neous,‘alive,’ and engaging than they do to the group leader who adopts the more reserved stance of technical neutrality associated with the more classic approaches to group therapy” (Flores 2001, p. 72). The leader should not be overly charismatic, but should be a strong enough presence to meet clients’ dependency needs during the early stage of treatment.

During early treatment, the effective leader will focus on immediate, primary concerns: achieving abstinence, preventing relapse, and learning ways to manage cravings. The leader should create an environment that enables clients to acknowledge that (1) their use of addictive sub stances was harmful and (2) some things they want cannot be obtained while their pattern of substance use continues. As clients take their first steps toward a life centered on healthy sources of satisfaction, they need strong sup­ port, ahigh degree of structure, positive human connections, and active leadership. In process groups, the leader pays particular attention to feelings in the early stage of treatment. Many people with addiction histories are not sure what they feel and have great difficul­ ty communicating their feelings to others. Leaders begin to help group members move toward affect regulation by labeling and mirroring feelings as they arise in group work.Theleader’s subtle instruction and empathy enables clients to begin to recognize and own their feelings.This essential step toward managing feelings also leads clients toward empathy with the feelings of others.

The Middle Stage of Treatment
Condition of Clients in Middle Stage Treatment

Often,in as little as a few months,institutional and reimbursement constraints limit access to ongoingcare.Peoplewithaddictionhistories, however, remain vulnerable for much longer and continue to struggle with dependency.They need vigorous assistance maintaining behavioral changes throughout the middle, or action, stage of treatment. Several studies(Committee on Opportunities in Drug Abuse Research 1996;Londonetal. 1999; Majewska 1996; Paulus et al. 2002; Strickland et al. 1993; Volkow et al. 1988, 1992) have observed decreased blood flow and metabolic changes rates in the brains ofsubjects who abused stimulants (cocaine and methaphetamine). The studies also found that deficits persisted for at least 3 to 6 months after cessation of drug use. Whether these deficits predated substance abuse or not, treatment personnel should expect to see clients with impaired decision­ making and impulse control manifested by difficulties in attending, concentrating,learning new material, remembering things heard or seen, producing words, and integrating visual and motor cues. For the clinician, this finding means that clients may not have the mental structures in place to enable them to make the difficult decisions faced during the action stage of treatment. If clients draw and use support from the group, however, the client’s affect will re-emerge,combine with new behaviors and beliefs, and produce an increasingly stable and internalized structure (Brown 1985).

Cognitive capacity usually begin store turn to normal in the middle stage of treatment. The frontal lobe activity in a person addicted to cocaine,forexample,is dramatically different after approximately 4–6 months of non use. Still,the mind can play tricks.Clients distinctly may remember the comfort of their substance past, yet forget just how bad the rest of their lives were and the seriousness of the consequences that loomed before they came into treatment. As a result, the temptation to relapse remains a concern.

Therapeutic Strategies in Middle­Stage Treatment

In middle-stage recovery, as the client experiences some stability, the therapeutic factors of self-knowledge and altruism can be emphasized. Universality, identification, cohesion, and hope remain important as well.Practitioners have stressed the need to workin alliance with the client’s motivation for change. The therapist uses whatever leverage exists such as current job or marriage concerns––to power movement toward change.The goal is to help clients perceive the causal relationship between substance abuse and current problems in their lives. Counselors should recognize and respect the client’s position and the difficulty of change. The leader who leaves group members feeling that they are understood is more likely to be in a position to influence change, while sharp confrontations that arouse strong emotions and appear judgmental may trigger relapse (Flores1997).

Therapeutic strategies also should take into account the important role substance abuse has played in the lives of people with addictions. Often, from the client’s perspective, drugs of abuse have become their best friends.They fill hours of boredom and help them cope with difficulties and disappointments. Asclientsmove away from their relationship with their best friend,they may feel vulnerable or emotionally naked, because they have not yet developed coping mechanisms to negotiate life’s inevitable problems. It is crucial that clients recognize these feelings as transient and understand that the feeling that something vital is missing can have a positive effect. It may be the impetus that clients need to adopt new behaviors that are adaptive, safe, legal, and rewarding.

As the recovering client’s mental, physical, and emotional capacities grow stronger, anger, sad­ ness, terror, and grief may be expressed more appropriately. Clients need to use the group as a means of exploring their emotional and inter­ personal world. They learn to differentiate, identify, name, tolerate, and communicate fee ings. Cognitive–behavioral interventions can provide clients with specific tools to help modulate feelings and to become more confident in expressing and exploring them. Interpersonal process groups are particularly helpful in the middle stage of treatment, because the authentic relationships within the group enable clients to experience and integrate a wide range of emotions in a safe environment.

When strong emotions are expressed and dis­ cussed in group, the leader needs to modulate the expression of emerging feelings, delicately balancing a tolerable degree of expression and alevel so overwhelming that it inhibits positive change or leads to a desire to return to sub­ stance use to manage the intensity. It also is very important for the group leader to “sew the client up” by the end of the session. Clients should not leave feeling as if they are “bleeding” emotions that they cannot cope with or dispel. A plan for the rest of the day should be developed, and the increased likelihood of relapse should be acknowledged so group members see the importance of following theplan.

Leadership in Middle­Stage Treatment

Historically,denial has been the target of most treatment concepts. The role of the leader was primarily to confront the client in denial, thereby presumably provoking change. More recently, clinicians have stressed the fact that “confrontation,if done too punitively or if motivated by a group leader’s counter transference issues, can severely damage the therapeutic alliance” (Flores 1997, p. 340). Inappropriate confrontation may even strengthen the client’s resistance to change, thereby increasing the rigidity of defenses.

When it is necessary to pointout contradictions in clients’ statements and interpretations of reality, such confrontations should be well­ timed, specific, and indisputably true. For example, author Wojciech Falkowski had a client whose medical records distinctly showed abnormal liver functions. When the client maintained that he had no drinking problem, Falkowski gently suggested that he “convince his liver of this fact.” The reply created a ripple of amusement in the group,and“theclient immediately changed his attitude in the desired direction”(Falkowski1996,p.212).Suchcar­ ing confrontations made at the right time and in the right way are helpful,whether they come from group members or the leader. Another way of understanding confrontation is to see it as an outcome rather than as a style.

From this point of view,the leader helps group members see how their continued use of drugs or alcohol interferes with what they want to get out of life. This recognition, supported by the group, motivates individuals to change. It seems that people who abuse substances need someone to tell it like it is“in are a listic fashion without adopting a punitive, moralistic, or superior attitude”(Flores1997,p.340).

In the middle stage of treatment, the leader helps clients join a culture of recovery in which they grow and learn. The leader’s task is to engage members actively in the treatment and recovery process. To prevent relapse, clients need to learn to monitor their thoughts and feelings, paying special attention to internal cues. Both negative and positive dimensions may be motivational. New or relapsed group members can remind others of how bad their former lives really were, while the group’s vision of improvements in the quality of life isa distinct and immediate beam ofhope. The leader can support the process of change bydrawing attention to new and positive devel­ opments, pointing out how far clients have traveled, and affirming the possibility of increased connection and new sources of satis­ faction. Leaders should bear in mind, however, that people with addictions typically choose immediate gratification over long-range goals, so benefits achieved and sought after should be real, tangible, and quickly attainable.

The benefits of recovery yield little satisfaction to some clients,and for them,the task of staying on course can be difficult. Their lives in recovery seem worse,not better.Many experience depression, lassitude, agitation, or anhedonia (that is, a condition in which formerly satisfying activities are no longer pleasurable). Eventually, their lives seem devoid of any meaningful purpose, and they stop caring aboutrecovery.

These clients may move quickly from “I don’t care” to relapse, so the group leader should be vigilant and prepared to intervene when a client is doing all that should be done in the recovery process, yet continues to feel bleak. Such clients need attention and accurate diagnosis. Do they have an undiagnosed co­ occurring disorder? Do they need antidepressants? Do they need more intensive, frequent, adjuncts to therapy, such as more Alcoholics Anonymous or Narcotics Anonymous meetings and additional contactswith asponsor? Leaders need to help group members under­ stand and accept that many forms of therapy outside the group can promote recovery. Group members should beencouraged to sup­ port each other’s efforts to recover, however much their needs and treatment options may differ.

The leader helps individuals assess the degree of tructure and connection they need as recovery progresses. Some group members find that participation in religious or faith groups meets their needs for affiliation and support. Forlong­term, chronically impaired people with addictive histories, highly intensive participation in 12­Step groups is usually essential for an extended period of time.

The Late Stage of Treatment
Condition of Clients in Late­Stage Treatment

During the late (also referred to as ongoing or maintenance) stage of treatment, clients work to sustain the attainments of the action stage, but also learn to anticipate and avoid tempting situations and triggers that set off renewed sub­ stance use. To deter relapse, the systems that once promoted drinking and drug use are soughtout and severed. Despite efforts to forestall relapse, many clients, even those who have reached the late stage of treatment, do return to substance use and an earlier stage of change. In these cases, the efforts to guard against relapse were not all invain.Clients who return to substance abuse do so with new information.With it,they may be able to discover and acknowledge that some of the goals they set are unrealistic,certain strategies attempted are ineffective, and environments deemed safe are not at all conducive to successfulrecovery. With greater insight into the dynamics of their substance abuse, clients are better equipped to make another attempt at recovery, and ultimately, to succeed.As the substance abuse problem fades into the background, significant underlying issues often emerge, such as poor self­ image,relationship problems,the experience of shame, or past trauma. For example, an unusually high percentage of substance and alcohol abuse occurs among men and women who have survived sexual or emotional abuse. Many such cases warrant an exploration of dissociative defenses and evaluation by a knowledgeable mental health professional. When the internalized pain of the past is resolved, the client will begin to understand andexperience healthy mutuality, resolving conflicts without the maladaptive influence of alcohol or drugs. If the underlying conflicts are left unresolved, however, clients are at increased risk of other compulsive behavior, such as excessive exercise, overeating, gam­ bling, or excessive sexualactivity.

Therapeutic Strategies in Late­ Stage Treatment

In the early and middle stages of treatment, clients necessarily are so focused on maintain­ ing abstinence that they have little or no capacity to notice or solve other kinds of problems. In late­stage treatment, however, the focus of group interaction broadens. It attends less to the symptoms of drug and alcohol abuse and more to the psychology of relational interaction. Inlate­stagetreatment,clientsbegintolearnto engage in life. As they begin to manage their emotional states and cognitive processes more effectively,they can face situations that involve conflict or cause emotion. A process­oriented group may become appropriate for some clients who are finally able to confront painful realities, such as being an abused child or abusive parent. Other clients may need groups to help them build a healthier marriage, communicate more effectively,or become a better parent. Some may want to develop new job skills to increase employability. Some clients may need to explore existential concernsor issues stemming from their family of origin.These emphases donot deny the continued importance of universality,hope,group cohesion sand other therapeutic factors.Instead it implies that as group members become more and more stable,they can begin to probe deeper into the relational past. The group can be used in the here and now to settle difficult and painful old business.

Leadership in Late­Stage Treatment

The leader plays a very different role in late­ stage treatment, which refocuses on helping group members expose and eliminate personal deficits that endanger recovery. Gradually, the leader shifts toward interventions that call upon people who are chemically dependent to take a cold, hard look at their inner world and system of defenses,which have prevented them from accurately perceiving their self­defeating behavioral patterns. To become adequately resistant to substance abuse, clients should learn to cope with conflict without using chemicals to escape reality, self­soothe, or regulate emotions (Flores1997).

As in the early and middle stages, the leader helps group members sustain abstinence and makes sure the group provides enough support and gratification to prevent acting out and premature termination. While early­ and middle­stage interventions strive to reduce or modulate affect, late­stage interventions permit more intense exchanges.

Thus, in late treatment, clients no longer are cautioned against feeling too much. The leader no longer urges them to apply slogans like “Turn it over” and “One day at a time.” Clients finally should manage the conflicts that dominate their lives, predisposethemto maladaptive behaviors, and endanger their hard­wonabstinence.Theleaderallowsclients to experience enough anxiety and frustration to bring out destructive and maladaptive characterological patterns and coping styles. These characteristics provide abundant grist for the groupmill.

Final Chapter: Course Conclusion

Alcohol and substance abuse is a wide ranging and complicated area of treatment for health professionals. It is important for Nurses, Social Workers and Counselors to understand the prevalence of such use as they work with clients that come into their care. Such knowledge is significant in how they assess and treat patients and clients that come under their care, whether medically or in counseling. Depression can often impact the origins of a person’s use and the severity of their abuse of alcohol and drugs. When used to self-medicate, it becomes difficult for the user to quit. While they may understand the ill-effects, it is more psychologically painful to face the feelings that come from withdrawals.

This course has provided the licensed professional information regarding the prevalence of alcohol and substance abuse in the United States. In addition, multiple assessment approaches and tools have been provided. Different treatment approaches have been provided which can be implemented in treatment.

A fundamental part of each of these programs, and for any treatment intervention to work or have long term affects, is that the client must have a desire to change. Some have argued that this is not only necessary, but for some, it is all that is needed. One thing is clear: Although incarceration, or residential treatment rehabilitation centers or regular testing can “mess” with the client using for a period of time, unless they have decided it is time to stop, they will not. In treatment, it is vital to find out the level of desire the client has to stop using. Cognitive interventions can help the client see the need to stop using drugs, and obtain the desire to stop, by showing them how their life can change for the better. Behavioral interventions can help them gain confidence in their ability to control their behaviors and their life.

In any case, something so difficult will not be overcome with out a lot of will on the part of the client. The relationship with you, the healthcare professional, is a vital part of helping the client develop the will to follow through with successful treatment.

This course utilized extensively the use of resources from the NIDA and SAMHSA, who provide ongoing research in this field. We hope that you have enjoyed the course.

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