Adolescent Health Care: A Practical Guide

Chapter 74

Intensive Drug Treatment

Brigid L. Vaughan

John R. Knight

Principles of Drug Treatment in Adolescents

Primary health care providers, and indeed all health care providers who work with adolescents, have a clear responsibility to screen adolescents for substance use disorders, as described in Chapter 73. Adolescents with low-risk substance use may be amenable to office-based brief interventions. However, adolescents with more severe difficulties, or with substance use disorders, often require more specific or intensive treatment.

The American Academy of Child and Adolescent Psychiatry's (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders (American Academy of Child and Adolescent Psychiatry, 2005) sets forth evidence-based recommendations regarding the assessment and care of adolescents with substance use disorders (Table 74.1).

A primary requirement in working with adolescents is an explicit review of the limits of confidentiality (American Academy of Child and Adolescent Psychiatry, 2005). Youths are more likely to be honest in discussing their substance use when assured of confidentiality. However, they must also be informed of when and why information will be shared with others, for instance when there is concern of possible harm to the teen or others. Although the adolescent is certainly entitled to confidentiality, the health care provider should not encourage secrets in families. Family involvement is a necessary component in any substance abuse treatment program, but especially with the care of adolescents.

Matching Patients to Appropriate Treatment

No single treatment is appropriate for all individuals. Matching of treatment settings, interventions, and services to each patient's problems and needs is critical (Drug Strategies, 2003). Treatment for adolescents must be adolescent-specific, not simply an adult program that tries to accommodate younger patients (American Society of Addiction Medicine, 2001). Adolescents who use substances may have a more rapid progression from casual use to dependence; they are more likely to use multiple substances, and often are at higher risk of co-occurring psychopathology. They must have a comprehensive, multidimensional assessment to adequately formulate an appropriate treatment plan. The American Society of Addiction Medicine (ASAM) and Drug Strategies, a nonprofit research institute, have published documents to help with this process, the ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders (American Society of Addiction Medicine, 2001) and Treating Teens: A Guide to Adolescent Drug Programs (Drug Strategies, 2003), respectively. Treating Teens includes questions (Table 74.2) to help families and providers in assessing the appropriateness of potential programs.

Overview of Available Treatments

Inpatient Care

It is important for the health care provider to have a general understanding of the range and types of treatments available, to best counsel patients and families. Treatment should be provided in the least restrictive setting possible (American Academy of Child and Adolescent Psychiatry, 2005). Safety issues, patient or family motivation, medical or psychiatric complications, treatment availability, and failure of treatment in a less-intensive setting, all may lead to the need for an intensive treatment setting.

1. Detoxification: Adolescents usually do not experience physical withdrawal symptoms from the most commonly used substances (e.g., cannabis). However, those who are dependent on alcohol, other sedative-hypnotics, and opioids often experience withdrawal symptoms that require medical management. Detoxificationis a term used to describe the medical monitoring and treatment of withdrawal symptoms. It can be done on an outpatient basis, but detoxification often requires a 3- to 5-day inpatient medical hospitalization. Detoxification should be considered for all patients who have symptoms of physical dependence on alcohol or benzodiazepines. Opioid withdrawal is not life threatening, as alcohol withdrawal can be, but it is very uncomfortable and can be relieved with detoxification.
2. Psychiatric hospitalization or acute residential treatment: For adolescents whose substance use disorder has caused or has been accompanied by severe

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behavioral or even frank psychiatric symptoms, inpatient psychiatric hospitalization or acute residential treatment may be needed (American Academy of Child and Adolescent Psychiatry, 2005). In these settings, patients are stabilized in a safe, structured setting. The initial work of stopping substance use, assessing readiness to change and motivation, and crisis intervention with the teen and family are carried out in these settings over a 1- to 2-week stay. More specific psychiatric assessment and treatment are also initiated when indicated.

TABLE 74.1 Recommendations for the Assessment and Care of Adolescents with Substance Use Disorders (American Academy of Child and Adolescent Psychiatry, 2005)

The adolescent must be assured of an appropriate level of confidentiality. Assessment must include developmentally appropriate screening questions regarding the use of alcohol and drugs. A positive screen necessitates a more formal evaluation. Toxicology, that is, drug testing, is to be a routine part of assessment and ongoing treatment. Adolescents who have substance use disorders need specific treatment. Treatment of substance use disorders should be in the least restrictive setting. Family therapy and/or substantial family involvement should be included in treatment of adolescents with substance use disorders. Treatment programs should strive to fully engage adolescents and maximize treatment completion. Medication to manage craving or withdrawal, or for aversion therapy can be used as indicated. Treatment of adolescents with substance use disorders must help develop peer support. Involvement with 12-step groups, like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), should be encouraged. Programs should provide comprehensive services, including vocational, recreational, medical services as indicated. Adolescents with substance use disorders require comprehensive psychiatric assessment, in order to check for comorbid disorders. Co-occurring psychiatric disorders require treatment. Programs must provide or arrange for aftercare.

Outpatient Care

For medically and behaviorally stable patients, outpatient treatment is the mainstay of substance abuse treatment. This can consist of individual, group, or family therapy, or any combination of these. Day treatment programs also may be used when an adolescent is transitioning from a more-intensive level of care, or needs greater supervision than provided by outpatient visits. There are multiple treatment modalities that can be used in caring for adolescents with substance use disorders; some of these will be summarized in the subsequent text.

TABLE 74.2 Ten Important Questions to Ask of a Treatment Program

From (Drug Strategies, 2003). 1. How does your program address the needs of adolescents? 2. What kind of assessment does the program conduct of the adolescent's problems? 3. How often does the program review and update the treatment plan in light of the adolescent's progress? 4. How is the family involved in the treatment process? 5. How do you engage adolescents so that they stay in treatment? 6. What are the qualifications of program staff and what kind of clinical supervision is provided? 7. Does the program offer separate single sex groups as well as male and female counselors for girls and boys? 8. How does the program follow-up with the adolescent and provide continuing care after treatment is completed? 9. What evidence do you have that your program is effective? 10. What is the cost of the program?

1. Cognitive behavioral therapy: Cognitive behavioral therapy (CBT) is a structured, goal-oriented counseling style (Reinecke et al., 1996) that has been found effective (Azrin et al., 2001; Dennis et al., 2004; Waldron et al., 2001). It is designed to teach patients specific skills that will help them remain abstinent. Cognitive behavioral training teaches patients to identify thoughts and feelings that precede drug use. Once the patient can recognize these situations, she/he can then learn either

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to avoid the situation or to substitute with behaviors other than drug use. CBT is most effective when the patient is willing to practice newly acquired skills. CBT can be used in individual, family, or group therapy settings. It may be used alone or in combination with motivational interviewing, which has been described in Chapter 73.

2. Group therapy: Group treatment for adolescents with substance use disorders is appealing in several ways. Meeting with a group of adolescents who share similar difficulties may be easier for a teen, as she/he will be assured that she/he is not “the only one” with such troubles. Congregating with peers, even if for treatment, coincides with a developmentally normal preference of adolescents. Additionally, in the context of limited resources, being able to provide care for multiple patients simultaneously is cost-effective and allows care for more people. However, studies have yielded mixed reviews (American Academy of Child and Adolescent Psychiatry, 2005). Including youths with more severe conduct disorders in groups may lead to poor outcomes (Dishion et al., 2001). In view of this, careful evaluation of potential group members' appropriateness is warranted.
3. 12-Step fellowships: Another form of peer-based support may be found in 12-step fellowships, namely Alcoholics Anonymous (AA) and/or Narcotics Anonymous (NA). Ideally, adolescents should attend young people's meetings (Jaffe, 2001), or be accompanied to AA/NA meetings by a trusted adult. As is generally recommended for people early in recovery, adolescents would benefit from getting a sponsor. Twelve-step meetings are often an integral part of substance abuse treatment programs (Drug Strategies, 2003). It is imperative that the individual adolescent's developmental level be considered when progressing through the 12 steps (Simkin, 1996).
4. Family therapy: Family therapy has been studied more than any other treatments for adolescent substance use disorders. Limited studies comparing different outpatient studies have found family therapy to be superior (Stanton and Shadish, 1997; Williams and Chang, 2000). There are multiple forms of family therapy that have been studied using randomized clinical studies. These include functional family therapy (Alexander et al., 1990), brief strategic family therapy (Szapocznik et al., 1983, 1988), family systems therapy (Joanning et al., 1992), multidimensional family therapy (MDFT) (Dennis et al., 2002; Liddle et al., 2001), and multisystemic therapy (MST) (Henggeler et al., 1991, 2002).

MDFT was developed at the University of Miami School of Medicine, and is intended to treat adolescents with substance abuse and behavioral problems. MDFT includes individual and family sessions, with and without the teen, as well as intensive advocacy with social systems, like schools and courts. There are one to four family meetings per week, with frequent interim phone contact. Treatment continues for 4 to 8 months. There are detailed treatment manuals to ensure accurate replication of MDFT; the program has been implemented in 16 other sites in the United States (Drug Strategies, 2003).

MST is an intensive 4-month program, and was developed to address the needs of adolescents at high risk of incarceration or foster care. Not only are the sessions held in the family's home, but therapists are also always available to assist and provide intervention to families. Parents identify the goals for treatment, and therapists help them identify the causes and then implement solutions. MST includes comprehensive psychiatric and substance abuse services. The Medical University of South Carolina, where MST was developed, continues to conduct clinical studies of its efficacy and to provide training to outside agencies nation- and world-wide (Drug Strategies, 2003).

5. Drug court: The success of adult drug courts and the increasing prevalence of substance abuse in the adjudicated adolescent population have resulted in the institution of >100 juvenile drug court programs in close to 50 states (American University, 2001). A successful juvenile drug court will use the case management system, which provides a more “user-friendly” interface with the adolescent and family (Drug Strategies, 2003). There should be positive reinforcement for compliance as well as clearly outlined consequences that are swiftly enforced for violation of court-ordered program guidelines. Limited studies indicate that juvenile drug court does reduce recidivism and substance use while the adolescent is participating in the program (Belenko, 2001). Efforts are underway to better utilize juvenile drug courts in delivering research-based treatment interventions to adolescents and families (Belenko and Logan, 2003).
6. Contingency management: Another outpatient treatment model that relies heavily on reinforcement of desirable behaviors is contingency management (Budney et al., 2001). With this treatment model, urine testing is used to detect substance use, and substance abstinence (as detected by a negative drug test result) is reinforced while substance use results in a loss of reinforcement. The reinforcement may be gift certificates, movie tickets, or small amounts of money. Contingency management has been found to be effective in treating adult substance use (Higgins et al., 2002); studies with adolescent patients are promising (Azrin et al., 1994; Corby et al., 2000; Kamon et al., 2005), but additional research is needed (Kaminer, 2000).

Long-term Residential Treatment

For youths who have “failed” outpatient treatment for substance use disorders, longer-term treatment may be in order. As with outpatient treatment, there is a wide range of long-term treatment options. Residential treatment is usually long-term treatment for 6 to 12 months, but may be as brief as 1 month (Drug Strategies, 2003). Residential programs provide a variety of therapeutic sessions daily, including individual, group, and family therapy, as well as an educational component. These programs can accommodate adolescents who may have both psychiatric and substance use disorders. The adolescents who are placed in residential programs have not been able to stop using substances and may well have other concerning behaviors like self-injury or a history of suicide attempts. Some residential programs are “locked” for the most at-risk youths.

1. Therapeutic communities: Therapeutic communities also provide treatment for adolescents with severe substance and behavioral difficulties who have failed less-intensive treatments (Drug Strategies, 2003; Pumariega et al., 2005). These youths are not able to live at home and are not at risk of violent behaviors (Drug Strategies,

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2003). This treatment modality is generally of longer duration, 18 to 24 months. Half-way houses, or reentry facilities, provide supervised living for patients recovering from drug dependence (Drug Strategies, 2003). They may serve as a step-down for adolescents who have completed a more-intensive treatment.

2. Therapeutic schools: Therapeutic schools are designed to meet the academic and therapeutic needs of adolescents with a variety of mental health and behavioral problems. Though not designed solely for substance abuse treatment, many schools will have substance abuse services. Therapeutic schools may be residential, include a boarding component, or function solely as a day school with adolescents living at home.
3. Wilderness therapy: For many youths, outpatient treatment is insufficient but inpatient services are too restrictive (Tuma, 1989). For this population, wilderness therapy programs are used at times as an alternative (Russell et al., 1999). Limited studies have been promising (Davis-Berman and Berman, 1989). However, despite the increasing use of wilderness therapy programs they have not been adequately studied (Mulvey et al., 1993); wilderness therapy programs typically serve adolescents having a variety of behavior problems (Drug Strategies, 2003). Adolescents who go for wilderness therapy have generally been resistant to making changes in their behaviors and may have had multiple past treatment experiences (Drug Strategies, 2003; Russell et al., 1999). The treatment involves individual and group therapy, educational curricula, and group living with peers in an unfamiliar environment with application of outdoor-living skills and physical challenges (Russell et al., 1999). The programs are meant to boost responsibility—personal and social—and to encourage emotional growth. Though not specifically designed to treat drug problems, drug use is common among teens in these programs, and most programs will have some specific drug treatment component. Wilderness therapy programs generally last 3 to 8 weeks (Drug Strategies, 2003).

Pharmacotherapy

Developing medication treatments for substance use disorders is an active area of research at this time. This work has even included efforts to develop vaccines to treat drug dependence (Haney and Kosten, 2004; Kosten and Biegel, 2002; Martell et al., 2005; Sofuoglu and Kosten, 2005). However, currently there are few substances of abuse for which there are any corresponding pharmacotherapies (Vocci et al., 2005; Wilkins, 2005). Following is a brief summary of medications currently available to treat problems due to alcohol and opioids.

1. Alcohol: Disulfiram, naltrexone, and acamprosate are the only medications approved for the treatment of alcohol dependence in adults (Mann, 2004); none of them are approved for use in adolescents. Disulfiram was the first medication used for treating alcoholism, and is an aversive therapy that causes an unpleasant reaction if the patient uses alcohol while taking it. The disulfiram–alcohol reaction can result in nausea, vomiting, flushing, headache, diaphoresis, dyspnea, palpitations, chest pain, blurred vision, or confusion (Banys, 1988). Disulfiram is not recommended for use in adolescents. Naltrexone, an opioid antagonist, helps to support abstinence in heavy drinkers by limiting the rewarding effects of alcohol. Acamprosate is the most recent U.S. Food and Drug Administration (FDA)-approved medication for treating alcohol dependence, and acts by alleviating cravings; therefore, is useful as a maintenance medication (Mann, 2004; Schaffer and Naranjo, 1998; Wilkins, 2005). Specific serotoninergic reuptake inhibitors (SSRIs) can be of help to patients with alcohol dependence by treating underlying psychiatric disorders, like depression or anxiety, which may be present (Mann, 2004).
2. Opioids: The treatment of opioid dependence in adults has utilized pharmacotherapy since the mid-1960s when methadone as agonist therapy began (Dole and Nyswander, 1976). The federal government strictly regulates the use of methadone (Rettig and Yarmolinsky, 1995). Patients who have been dependent on heroin for >1 year, and are at least 18-years-old, are eligible for methadone maintenance (Leshner, 2003). This clearly restricts access for adolescents, particularly since they may have a shorter history of opioid dependence.

Although methadone has been the major medication used for opioid maintenance, newer medications, such as levomethadyl acetate (LAAM) and buprenorphine are similarly effective (Johnson et al., 2000). Concern regarding cardiotoxicity with LAAM has limited its use in treating drug dependence (Joseph, 2005). Buprenorphine is a partial opioid agonist and therefore may have some advantages, including fewer withdrawal symptoms and a lower risk of overdose (O'Connor, 2000). The buprenorphine-naloxone preparation lessens risk of abuse (Fudala et al., 1998; Strain et al., 2000; Weinhold et al., 1992).

Treatment of Co-Occurring Disorders

Individuals who are struggling with both psychiatric and substance use disorders, have been called dually diagnosed; however, more recently they have been thought of as having “co-occurring disorders” because they rarely have difficulties in only two arenas (Drake et al., 2000). Treatment models for patients with co-occurring disorders have included sequential (Weiss and Najavits, 1998), parallel, and integrated care of the psychiatric and substance use disorders (Dennison, 2005). The integrated model for treating co-occurring psychiatric and substance use disorders in adolescents is supported by research (Drug Strategies, 2003; National Institute on Drug Abuse, 1999). Treatment for patients with co-occurring disorders may include psychosocial interventions as well as psychopharmacology.

Mood Disorders

It can be difficult to discern whether a mood disorder preceded or is the result of substance use. Nonetheless depression in adolescents has been correlated with an earlier age at onset of substance use disorders (Deykin et al., 1987). The presence of chronic depression and dysthymia has been found to precede substance use difficulties (Hovens et al., 1994), while major depression has been found to follow it (Bukstein et al., 1992; Hovens et al., 1994). Those participants with primary depression were more likely to be female; additionally, they tended

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to have a parent with psychiatric difficulties and to have a history of victimization (Deykin et al., 1987). Although studies in adolescents are limited as compared to studies in adults, the use of SSRIs to treat depression in youths with substance use disorders appears to be safe and likely effective (Deas and Thomas, 2001; Lohman, 2002; Riggs, 1997). Bipolar disorder in adolescents may also be associated with substance use disorders, but this has been less well studied (Clark and Neighbors, 1996). Nonetheless, a controlled study by Geller et al. (1998) found that lithium had a good safety profile in treating adolescents with co-occurring bipolar and substance use disorders. Although the study results included greater decline in substance use for teens treated with lithium than those given placebo, pharmacotherapy for the mood disorder did not adequately address the substance use disorder in the absence of specific substance abuse treatment.

Anxiety Disorders

As noted earlier for mood disorders, it can be difficult to determine whether anxiety led to or was caused by substance abuse. Although CBT, often combined with SSRI medication, is an established regimen for treating adolescents with anxiety disorders (March and Wells, 2002), the treatment of teens with anxiety and substance use disorders has not been adequately studied (Riggs, 2003). However, preliminary data suggests that adolescents with substance use disorders and anxiety may be helped by CBT (Najavits, 2003). Additionally, as previously noted, SSRI medications have been found to be safe in adolescents who continue to use alcohol (Lohman, 2002), and so may be used to treat anxiety as well as depression. It is recommended that benzodiazepines not be used to treat co-occurring anxiety in teens with substance use disorders because of their abuse potential (Riggs, 2003).

Attention-Deficit Hyperactivity Disorder

Longitudinal studies have shown that attention-deficit hyperactivity disorder (ADHD) is associated with an increased risk of substance use disorders (Katusic et al., 2003; Molina and Pelham, 2003). Adolescents with ADHD have earlier onset of substance dependence (Biederman et al., 1997). Additionally, a meta-analysis conducted by Wilens et al. (2003) found that stimulant treatment of ADHD is associated with lower risk of substance use disorders. This is especially important because stimulants are the first-line medication for treating ADHD, and are very effective (American Academy of Child and Adolescent Psychiatry, 1997). Health care providers are at times reluctant to prescribe stimulants to patients with ADHD and substance use disorders because the medication can be abused if ground up and used intravenously or intranasally (Wilens, 2004). Longer-acting stimulant medications, particularly osmotic release oral system (OROS) methylphenidate (Concerta), have much less abuse potential (Jaffe, 2002; Wilens, 2004). Nonstimulant medications, like bupropion and atomoxetine, are also effective in treating ADHD (Michelson et al., 2002; Wilens et al., 2001). Bupropion, which does not have a formal indication for treating ADHD, may be helpful for adolescents with comorbid ADHD and depression (Daviss et al., 2001), and so could be considered as an option for teens with co-occurring ADHD and substance use disorders (Riggs, 2003). Additional research is needed in this area.

Acute and Chronic Pain

The topic of pain control in patients with and without history of substance use disorders is quite broad; following is a discussion of salient issues to be considered. The current concerns, in society and the medical community, about undertreatment of pain and opiate abuse/dependence make this a particularly important topic (Ling et al., 2005). Historically, experts in managing pain have underestimated the risk and prevalence of addiction, while substance abuse experts have shown great reluctance to use opioids to treat pain (Passik, 2001). Greater communication and collaboration between professionals is clearly needed in order to adequately treat patients with chronic pain and substance use disorders (Ling et al., 2005).

Pseudoaddiction refers to drug-seeking behavior generated by inadequate pain management (Weissman and Haddox, 1989). The patient's quest for opiate medication is generated by the desire for relief of pain, not by mood-altering effects of the drug (Portenoy et al., 2005; Weissman and Haddox, 1989). Patients with pseudoaddiction may hoard medication, request specific drugs, or escalate medication dose without informing/asking the treating physician (Portenoy et al., 2005). Adequate pain treatment can prevent pseudoaddiction (Ling et al., 2005). If a patient in pain who is complaining of needing more medication becomes involved with illicit drugs or illegal acts (e.g., injecting oral medications, prescription forgery, stealing drugs from others) or exhibits a decline in functioning, then a substance use disorder must be considered (Portenoy et al., 2005).

Patients with a history of past or recent substance abuse or dependence are not immune to pain-related conditions. It has even been suggested that people with opioid dependence are less tolerant to pain (Compton et al., 2000). Patients with both substance use disorders and a pain syndrome, for example, related to cancer or an injury, require comprehensive assessment. This is to include a detailed history of current and past substance use; review of all medical records; permission to contact other current and past health care providers, pharmacies, and family; and urine drug testing as indicated (Portenoy et al., 2005). Ongoing care necessitates continued open communication between all involved providers.

In summary, intensive treatment of substance use disorders in adolescents may occur in a variety of settings and utilize a wide range of services. Common themes, however, include the need for thorough assessment, comprehensive care which involves the family, as well as thoughtful continuing care. The primary care clinician caring for adolescents can serve an important role by educating teens and their families about treatment needs and options, guiding families through various stages of care, and supporting them during difficulties that may arise.

Web Sites

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www.drugstrategies.org. Drug Strategies is a nonprofit research foundation that promotes more effective ways of dealing with the nation's drug and alcohol problems. Drug Strategies also sponsors www.bubblemonkey.com a confidential Web site dedicated to answering teens' questions about drugs and alcohol.

www.reclaimingfutures.org. This Web site provides information about Reclaiming Futures sites which provide research-based interventions for teens with substance use disorders.

www.dea.gov/pubs/abuse. This site provides text of Drugs of Abuse, which provides straightforward information about drugs.

www.buprenorphine.samhsa.gov. This Web site provides information about the use of buprenorphine in treating opioid dependence, as well as a “physician locator” to help patients and families find treatment.

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