Evidence-Based Reviews

Crossing the line: When does teen substance use become abuse or dependence?

Current Psychiatry. 2003 July;2(7):31-41

References

1. Johnston LD, O’Malley PM, Bachman JG. Monitoring the Future: national results on adolescent drug use. Overview of key findings, 2002. Bethesda, MD: National Institute on Drug Abuse, 2003 (in press).

2. Martin CS, Kaczynski NA, Maisto SA, et al. Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. J Stud Alcohol 1995;56:672-80.

3. Pollock NK, Martin CS. Diagnostic orphans: adolescents with alcohol symptoms who do not qualify for DSM-IV abuse or dependence diagnoses. Am J Psychiatry 1999;156:897-901.

4. Harrison PA, Fulkerson JA, Beebe TJ. DSM-IV substance use disorder criteria for adolescents: a critical examination based on a statewide school survey. Am J Psychiatry 1998;155:486-92.

5. Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM-IV alcohol abuse/dependence: results from the National Longitudinal Alcohol Epidemiological Survey. J Subst Abuse 1997;9:103-10.

6. Tarter RE, Laird SB, Bukstein O, Kaminer Y. Validation of the adolescent drug use screening inventory: preliminary findings. Psychol Addict Behav 1992;6:322-6.

7. Rahdert E (ed). The adolescent assessment/referral system manual. DHHS pub. no. (ADM) 91-1735. Rockville, MD: U.S. Department of Health and Human Services, 1991.

8. Kaminer Y, Bukstein OG, Tarter RE. The teen addiction severity index (T-ASI): rationale and reliability. Int J Addict 1991;26:219-26.

9. Meyers K, McLellan AT, Jaeger JL, Pettinati A. The development of the Comprehensive Addiction Severity Index for Adolescents (CASI-A): an interview for assessing multiple problems of adolescents. J Subst Abuse Treat 1995;12:181-93.

10. Deas DV, Roberts JS, Randall CL, Anton RF. Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS): an assessment tool for problem drinking. J Natl Med Assoc 2001;93:92-103.

11. Deas D, Randall CL, Thomas S. The utility of the Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS) in an inpatient adolescent substance abusing sample. Drug Alcohol Depend 2002;66(June):S43.-

12. Deas-Nesmith D, Campbell S, Brady KT. Substance use disorders in an adolescent inpatient psychiatric population. JAMA 1998;90:233-8.

13. Clark DB, Lesnick L, Hegedus AM. Traumas and other adverse life events in adolescents with alcohol abuse and dependence. Am Acad Child Adolesc Psychiatry 1997;36:1744-51.

14. Kilpatrick DG, Acierno R, Saunders B, et al. Risk factors for adolescent substance abuse and dependence: data from a national sample. J Consult Clin Psychol 2000;68:19-30.

15. Rose RJ. A developmental behavioral-genetic perspective on alcoholism risk. Alcohol Health Res World 1998;22:131-43.

16. Swadi H. Individual risk factors for adolescent substance use. Drug Alcohol Depend 1999;55:209-24.

17. Azrin N, McMahon P, Donohue B, et al. Behavior therapy for drug abuse: a controlled treatment outcome study. Behav Res Ther 1994;32:857-66.

18. Kaminer Y, Burleson JA, Goldberger R. Cognitive-behavioral coping skills and psychoeducation therapies for adolescent substance abuse. J Nerv Ment Dis 2002;190:737-45.

19. Liddle H, Dakof G. Efficacy of family therapy for drug abuse: promising but not definitive. J Marital Fam Ther 1995;21:511-43.

20. Waldron HB. Adolescent substance abuse and family therapy outcome: a review of randomized trials. Adv Clin Child Psychol 1997;19:199-234.

21. Henggeler SW, Melton LA. Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: a progress report from two outcome studies. Family Dynamics of Addiction Quarterly 1991;1:40-51.

22. Jaffe S. Step workbook for adolescent chemical dependency recovery. Washington, DC: American Academy of Child and Adolescent Psychiatry, 1990.

23. Deas DV, Randall C, Roberts J, Anton R. A double-blind, placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study. Human Psychopharmacology Clinical and Experimental 2000;15:461-9.

24. Geller B, Cooper T, Sun K, et al. Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. J Am Acad Child Adolesc Psychiatry 1998;37:171-8.

TREATMENT

We consider any adolescent with dependence symptoms—whether or not the presentation meets full DSM-IV diagnostic criteria—to be a candidate for further assessment and treatment. Early intervention may prevent progression to substance dependence.

Effective treatments:

are intensive and of sufficient duration to change attitude and behaviors
are comprehensive and target multiple domains of the adolescent’s life
are sensitive to cultural and socioeconomic realities
involve the family
emphasize pro-social recreational activities, such as playing sports, attending movies, camping, having lunch or dinner with peers, etc.

Inpatient or outpatient? Managed care and insurance restrictions limit many patients’ eligibility for inpatient or residential treatment, so partial hospitalization and outpatient settings have become standard for substance abuse treatment. Partial hospitalization programs vary but may entail several hours, several days per week. Outpatient treatment may encompass individual, group, and family therapy, including after-school programs.

Inpatient treatment is usually reserved for adolescents:

who need detoxification
with comorbid psychiatric disorders
or who may harm themselves or others.

PSYCHOTHERAPIES

Behavioral therapy, family-based therapy, multisystematic therapy (MST), and 12-step approaches have shown efficacy in treating adolescents with substance use disorders.

Behavioral therapy. Behavioral therapy is recommended as initial treatment because substance use plays a functional role in the adolescent’s life and is learned and reinforced in the adolescent’s environment. Homework assignments and role-play are commonly used in therapy.

Three central ingredients are:

functional analysis (identifying internal and external triggers for starting and continuing substance use)
skills training (targeting problems identified in the functional analysis)
and relapse prevention.

Behavioral therapy is more effective than supportive therapy in improving family relationships and school and work attendance and in decreasing substance use, as indicated by fewer positive urine toxicology screens.¹⁷

Cognitive-behavioral therapy (CBT) approaches substance use as a maladaptive response to life problems. Its goal is to teach new skills to help the adolescent recognize and avoid high-risk situations and cope with associated problems and behaviors.

In a recent study, Kaminer et al randomly assigned 82 adolescents with psychiatric and substance use disorders to 8 weeks of CBT or psychoeducational therapy (didactic or videotaped presentations of ways to address problems associated with substance use). Substance use was reduced in both treatment groups, but:

adolescents receiving CBT had significantly fewer positive urine toxicology tests
adolescents with comorbid conduct disorder were least likely to complete treatment or return for follow-up
those with depressive and anxiety disorders were most likely to complete treatment.¹⁸

Family-based therapy. Two detailed reviews^19,20 demonstrate that the adolescent’s family, community, and school relationships affect his or her perceptions and behaviors. Maladaptive relationships in any of these systems may lead to high-risk behaviors. Therefore, family therapy is core to the adolescent’s treatment, regardless of what modality is chosen.

Goals of family therapy may be:

to help the adolescent abstain from substance use
to engage in pro-social activities
to decrease parental denial of the adolescent’s substance use
to decrease resistance to treatment
treatment maintenance
to establish or re-establish structure in the adolescent’s environment
to improve communication in the family.

Multisystemic therapy is comprehensive and involves all systems that relate to the adolescent’s substance use, including the family, school, community, and legal system. MST requires special training and intensive supervision, so it is usually reserved for adolescents who have not benefited from other forms of treatment.²¹

12-step approaches. For adolescents, 12-step programs usually augment other treatments and are rarely used alone. Alcoholics Anonymous, Narcotics Anonymous, and other 12-step programs have been studied more extensively in adults than in adolescents.

Adolescents, who often feel invulnerable, may have difficulty accepting the 12-step doctrine of lack of control. A modified 12-step program and workbook for adolescents are available through the American Academy of Child and Adolescent Psychiatry.²²

Referral tips. If possible, refer an adolescent to a 12-step group specifically for adolescents. Teens who attend adult groups often perceive their substance use as normal, compared with the more severe and chronic patterns of some adults. Most adolescents relate better to peers with similar problems and may benefit from reminders of the negative consequences of substance use and the benefits of abstinence.

DRUG THERAPY

Drug therapy for adolescents with substance use disorders is usually considered in the context of detoxification, treating withdrawal symptoms, and treating comorbid psychiatric disorders. The same detoxification and withdrawal treatment principles used in adults apply to adolescents.

Clinical withdrawal symptoms are less common in adolescents than adults, probably because of adolescents’ binge patterns of substance use. Even so, some adolescents do experience withdrawal and may be at risk for complications if improperly treated.

Psychiatric comorbidity. To our knowledge, only two double-blind, placebo-controlled studies of drug therapy in treating adolescent substance use disorders have been published.