Commentary
Helping patients with addictions get, stay clean
Advise patients to consider programs affiliated with major medical centers or established treatment centers, an expert says.
‘Adolescents indeed care about their health’
During a separate presentation, Peter Jackson, MD, a psychiatrist at the University of Vermont Medical Center, Burlington, noted that an estimated 3.4 million adolescents in the United States meet criteria for an SUD, but fewer than 10% enter treatment each year. Of those who do enter treatment, 50% relapse within 6 months.
Dr. Peter Jackson
“It’s not the same story for illicit drugs, unfortunately, and that’s largely due to marijuana,” Dr. Jackson said. He noted that adolescent cannabis use is inversely proportional to how dangerous they perceive it to be. “This is evidence that adolescents indeed care about their health,” he said. “They use when they think it’s safe, and they use less when they think it’s unsafe.” Recent Monitoring the Future data also demonstrate that e-cigarette use is outpacing cigarette use among 8th, 10th, and 12th graders, while the past-year misuse of acetaminophen/hydrocodone (Vicodin) among 12th graders has dropped dramatically in the past 5 years. So has misuse of all prescription opioids among 12th graders despite high opioid overdose rates among adults.
Adolescents are more likely to be secretive about their substance use, compared with older adults. “Also, with many substances, especially alcohol, they are more likely to use in a binge pattern,” Dr. Jackson said. “They haven’t accumulated as many negative consequences from their use, so voluntarily seeking treatment is less common than in adults. They’re most often referred through the justice department or legal channels.”
Screening instruments to consider using include the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), which has been validated as an adolescent-specific screening instrument. A score of two or more has a strong correlation with meeting criteria for an SUD. The American Academy of Pediatrics recommends the Screening, Brief Intervention, and Referral to Treatment (SBIRT), though this intervention has not been as rigorously evaluated in adolescents, compared with adults.
Dr. Jackson frowned on the notion perpetuated by some parents and caregivers that novelty seeking behavior involving alcohol and other substances is okay if it’s controlled somehow, with statements such as, “I just make sure they’ve given up their car keys and make sure it stays in my own basement. That way nobody leaves here drunk.”
“I think we can do better than that,” Dr. Jackson said.
Well-validated behavioral treatment approaches for adolescent patients include the adolescent community reinforcement approach (A-CRA); cognitive-behavioral therapy (particularly in groups); motivational enhancement therapy (MET); contingency management, and 12-step facilitation.
“Colloquially, in pop culture, we’ve been pressed on this message at times that adolescents don’t care what their parents think; they only care what their peers think,” Dr. Jackson said. “That’s not true from literature we’ve seen, so we need to put the family back in its important place.”
In a meta-analysis of promising behavioral approaches for adolescent SUD, five out of six found to have promising to excellent empirical support were family-based therapies: multidimensional family therapy, functional family therapy, multisystemic family therapy, behavioral strategic family therapy, and family behavior therapy (J Child and Adolesc Psychology. 2008;37[1]:236-59). “That’s a huge take-home point when working with adolescents: Involve the family,” Dr. Jackson said. “As providers, do we have a tendency to side only with the parent or side only with the adolescent? If we do, we should be cautious and thoughtful, because we can very effectively work with both parties. If you have an adolescent who shows up [for counseling] but then walks right out the door, you still have a parent, maybe two parents or other concerned loved ones sitting there. You still have a target for intervention.”
Even if the adolescent never returns to your office, he continued, clinicians can do an intervention with the family to statistically decrease the SUD for the adolescent. “That’s really promising,” he said. In adults, the best evidence for treatment engagement of a loved one following these family-specific interventions is for the Community Reinforcement and Family Training (CRAFT) method (64%-74%), followed by the Johnson Intervention (23%-30%) and Al-Anon/Nar-Anon facilitation (13%-29%). These interventions are being studied more specifically in adolescents and young adults.
A key tip for parents of teens coping with substance abuse is the old adage actions speak louder than words. “You can tell your child not to smoke marijuana until you’re blue in the face, but then if you go out on the back porch and smoke marijuana, that’s a really bad message for behavior change,” Dr. Jackson said. “Words also speak louder than no words. Some parents have never told their adolescent children what their opinion is, and that they’re concerned. Maybe those parents have been convinced that adolescents don’t care what they think. In fact, they do care what they think.”