Adolescence, a developmental period of physical and psychological changes, marks the commencement of greater independence, increased experimentation, and risk-taking among youth between the ages of 12 to 18 years (1). Experimentation with illicit substances (i.e., marijuana, nonmedical use of prescription medications, hallucinogens, etc.) and licit substances (i.e., alcohol, tobacco, prescription drugs, etc.) has onset during the adolescent years with noticeable peaks at young adult ages (2). Substance use has shown to cause a number of adverse physical (i.e., death from injury and increased participation in risky behaviors), mental (i.e., depression, personality disorders, and developmental lags), and social (i.e., poor academic performances, withdrawal, delinquency, and disengagement from family and peers) health effects among adolescents (3–6). Furthermore, research has revealed that adolescent substance use problems increase the risk of developing a substance use disorder (SUD) later in life (7).
In order to effectively implement interventions and evidence-based practices that provide the best patient outcomes for adolescents with substance use and abuse, it is critical that treatment providers are aware of recent trends in adolescent substance use, associated risk and protective factors, as well as current clinical practices.
Prevalence and recent trends
Despite continual prevention efforts by health practitioners, recent estimates from national surveys such as Monitoring the Future (MTF) and the National Survey on Drug Use and Health (NSDUH) suggest that adolescent substance use and abuse continues to be a persistent and commonly widespread public health issue (8–10). Conducted annually to monitor and analyze drug use among 8th, 10th, and 12th graders, recent MTF results suggest that experimentation with drugs among adolescents has remained relatively steady over the past few years and use continues to increase with age (11). Specifically, current MTF data indicate that 50% of 12th graders reported trying an illicit drug in their lifetime, 40% used one or more illicit drugs in the past year, and 25% used one or more illicit drugs in the past month. However, among 10th graders, the results are lower but still disturbing, with 38% of 10th graders reporting having tried an illicit drug in their lifetime, 31% using an illicit drug within the past year, and 19% using at least one illicit drug within the past month. The results for 8th graders are similar; with 20% reporting trying an illicit drug in their lifetime, 15% using an illicit drug in the past year, and 9% using at least one illicit drug within the past month (11). Furthermore, while MTF data suggests slight decreases in alcohol and cigarette use among this population in recent years, approximately 40% of 12th graders continue to report either alcohol use in the past month or having tried cigarettes by the 12th grade, which represents a significant public health concern (11). When looking at specific categories of licit and illicit drugs, MTF data are more alarming for rates of marijuana and nonmedical prescription medication use. According to MTF, nonmedical prescription medication use among adolescents has held a steady and high prevalence rate since 2005; with an approximate range between 14.5% and 17.5% among 12th graders reporting use in the past year. Moreover, daily marijuana use has continued to increase among the three cohorts from 2007to 2011 (+0.5%, +0.8%, and +1.5%, respectively) (11).
The 2010 NSDUH report showed that 7% and 4.5% of youth aged 12 to 17 meet past year substance dependence/abuse and alcohol dependence/abuse criteria, respectively (9). In addition, NSDUH data also provide insight into potential risk for future substance use through the identification of perception of risk for the use of specific licit and illicit drugs. A recent NSDUH report showed that the percentage of adolescents between the ages of 12 and 17 perceiving great risk from using selected illicit substances once or twice a week has declined since 2002. Specifically, in 2010, 65.5% of youth perceived great risk with smoking one or more packs of cigarettes per day, a decline of 4.2% since 2008. The decline in the percentage of youth that perceived great risk with smoking marijuana once or twice a week is even more alarming with a 7.2% decrease (from 54.7% in 2007 to 47.5% in 2010) (9). Such declines in perceived risk are similar for cocaine, heroin, and LSD. Typically, a reduction in perceived risk for the use of a specific substance has been shown to be directly proportional to future and immediate increases in use of that substance. In addition, there has been a recent increase in the misuse of prescription medications (i.e., opioids, stimulants, and sedatives). According to the Treatment Episode Data Set (TEDS), adolescents entering publicly funded treatment programs reported marijuana (71.9%) or alcohol (17.7%) as their primary substance of abuse and over half (56.3%) reported first using their primary substance between the ages of 12 and 14 (12).
The recent prevalence rates and drug use trends not only confirm that adolescent substance use continues to be a major health concern, but also, as demonstrated by the MTF and NSDUH data findings, while rates of use of some licit drugs have remained steady, there have been considerable increases in illicit drug use among this population. In addition, new drugs and rediscovery of older drugs have facilitated the cyclic patterns of substance use and abuse among American youth in recent years (9, 11). Furthermore, the extant literature suggests that age of onset of substance use is highly correlated with future use and abuse in adulthood as well as the development of substance use disorders and dependence later in life (7, 13, 14). Therefore, it is imperative that pediatric and adolescent treatment providers become competent in the identification of misuse and abuse among youth and employ strategies to intervene effectively.
Risk and protective factors
According to the National Institute on Drug Abuse (NIDA), crucial to informing effective substance abuse prevention and intervention programs has been the identification of risk and protective factors impacting youth substance use (15). Although adolescence alone represents a developmental risk period for experimentation with alcohol and other substances, a variety of contextual or individual risk and protective factors have been found to be significant. Contextual factors, that include ecological factors such as availability of and access to substances, are often directly related to community policies and social norms. Individual factors include biological vulnerability; early exposure to substance use (either proximal such as prenatal exposure or distal through a family member or peer); preexisting psychiatric and or psychological issues such as depression, anxiety, attention deficit hyperactivity disorder, conduct disorder, trauma and impulsivity; and neurobiological developmental factors including immature frontal lobe development (normative) and lowered serotonergic function (nonnormative) (6, 16–20).
Risk and protective factors exist at each interaction level in a person’s life—individual level, organizational/local network level, community level, and population/societal level (15). Some individual risk factors can be identified as early as infancy or early childhood, such as aggressive behavior, lack of self-control, or difficult temperament. As the child gets older, contextual risk factors such as interactions with family, with peers and within school, and within the community can affect that child’s risk for later drug abuse and dependence. Research has shown that the key risk periods for drug abuse are during major transitions in children’s lives (21–24). The first significant transition for children is when they leave the security of the family and enter school. Later, when they advance from elementary school to middle school, they often experience new academic and social situations, such as learning to get along with a wider group of peers. It is at this stage—early adolescence—that children are likely to encounter drugs for the first time (6, 25). When they enter high school, adolescents face additional social, emotional, and educational challenges. At the same time, they may be exposed to greater availability of drugs, drug abusers, and social activities involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other substances (26). When young adults leave home for college or to enter the workforce and are on their own for the first time, their risk for drug and alcohol abuse increases significantly (27, 28).
Substance use in adolescent years is often a result of proximal and distal precursors originating in early childhood and possibly even during the prenatal period (29, 30). The level of exposure to these precursors is often directly correlated with the success of subsequent treatment interventions. Therefore, it is imperative that treatment providers are aware of risk and protective factors at multiple levels of a patient’s environment so that they may target these factors in their treatment planning and implementation.
The foundation for many effective behavioral substance use disorder treatments is the identification of potential risk factors for that population and the enhancement of protective factors to prevent or reduce current use within the target population. Hence, it is important to begin the intervention with a standardized assessment that collects history on biological, psychological and social domains in addition to substance use/abuse, to better inform how best to tailor evidence-based interventions.
Research looking at outcomes of various psychosocial treatment modalities in the adolescent population has suggested positive effects for all treatment models as compared with comparison groups (31). However, the best outcomes have come from cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), and family-based treatments; all described in more detail below. In addition, it is important to consider the format of psychosocial treatment modalities, such as individual and group formats, which allow a patient or a group of patients to participate in a psychosocial therapeutic session with a therapist or counselor. Although both individual and group formats are used in adolescent substance abuse treatment, research has shown that group therapy is most common in practice (32, 33).
Cognitive Behavioral Therapy (CBT).
CBT is a manual-guided approach in which the therapist assists the youth with acquiring cognitive skills (e.g., identifying and addressing distorted thought patterns in order to change behaviors) which are combined with behavioral strategies (e.g., coping with cravings for substances; anger management) to address the substance use problem. CBT is typically offered in outpatient settings, via either individual or via group sessions of 12-16 week duration (34–36).
Contingency Management (CM).
CM is based on the principle of operant conditioning, in which consequences (i.e. reinforcement or punishment) are used to reduce substance use with the ultimate goal of weakening the influence of the reinforcement derived from substance abuse. Positive reinforcement, (i.e. prizes or cash vouchers) such as immediate and tangible rewards, may be delivered via either fixed or intermittent intervals (37). Although, typically a therapist delivers CM in person, there is emerging evidence for training parents to deliver CM and the use of web-based delivery with adolescents as well (38, 39).
Motivational Enhancement Therapy (MET).
MET is an adaptation of motivational interviewing (MI) that includes one or more patient feedback sessions in which normative feedback is presented and discussed in an explicitly nonconfrontational manner (36). MET is typically not meant as a stand-alone treatment, but used to engage the patient into treatment. MET shows promise for application within the time constraints of busy general medical practices, especially to target less severe forms of substance abuse.
These manual-based approaches, in which the adolescent and at least one parent/legal guardian are involved in the treatment sessions, have been found to be highly efficacious and in some comparisons, superior to other treatments available for substance abusing adolescents (31). Family treatments have been derived from various theories of family functioning and ecological models and highlight the need to engage and involve families in treatment. The following approaches have been shown to be efficacious in reducing substance use among youth
Multidimensional Family Therapy (MDFT) includes both an adolescent and a parent/ family and extra familial domains that target parent monitoring, conflict resolution, communication, fostering family competency and collaborative work with involved systems (e.g. school, juvenile justice) during a 4-month duration. MDFT has been shown to be effective in dealing with higher severity substance use and feasible in community reintegration of substance abusing juvenile detainees (40).
Multi-Systemic Therapy (MST) is a comprehensive and intensive family-and community-based treatment (i.e. home, school-based, etc.) of 4-6 month duration. This modality views the substance abusing youth/juvenile offender as a complex of interconnected systems that encompass individual, family, and extrafamilial (peer, school, neighborhood) factors (41). MST also appears to be effective in higher severity youth with delinquent and/or violent substance-abusing adolescents (42).
Brief Strategic Family Therapy (BSFT) is based on an integrative theoretical model that combines structural and strategic family therapy theory and intervention techniques. It operates on the principle that problem behaviors stem from maladaptive family interactions and, therefore, it seeks to transform how the family functions to help improve the presenting problem (43).
Functional Family Therapy (FFT) is based on an integrative ecological model that typically involves two intervention phases: a) engaging families in the treatment process and enhancing motivation for change, and b) effecting behavioral changes in the family using contingency management, communication and problem solving, behavioral contracting, and other behavioral interventions (34).
Adolescent Community Reinforcement Approach (a-CRA) is a comprehensive substance use treatment intervention that involves both the adolescent and their families in the sessions. It seeks to increase the family, social, and educational/vocational reinforcers of an adolescent to support recovery and to encourage prosocial activities (44). Assertive Continuing Care (ACC), a home-based intervention, combines a-CRA and case management for a duration of 12–14 weeks, to work with adolescents discharged from residential or outpatient treatment to help maintain the progress achieved during active treatment.
In addition to the above mentioned manual-driven treatments there are other forms of less well-evaluated yet popular treatment modalities. Twelve-step programs encompass self-help approaches with a focus on reciprocal support from other individuals facing the same substance use problems, e.g., Alcoholics Anonymous (AA), Narcotics Anonymous, and Cocaine Anonymous (45). The therapeutic community approach uses holistic treatment practices to address adolescent substance use problems. In this approach, the community is viewed as the primary agent of change with emphasis placed on shared self-help and values for a healthy lifestyle, and behavioral consequences (46).
Several FDA-approved medications have been found efficacious in increasing abstinence in the treatment of nicotine, alcohol, or opioid dependence. The mechanism of action for these medications ranges from substitution (e.g. nicotine products for nicotine dependence), reduction of cravings (e.g., naltrexone for alcohol dependence), and receptor blockades (e.g., naltrexone for opioid dependence) to management of withdrawal symptoms and cravings (e.g., buprenorphine). However, these medications have not yet been FDA-approved for use among youth with addictive disorders (except for buprenorphine in youth 16 years or older) due to the lack of sufficient evidence demonstrating efficacy.
As mentioned above, while some medications have been approved for the treatment of specific drug dependence in adults (i.e. alcohol, nicotine, opioid dependence); to date, no medication has received FDA approval for the treatment of cocaine, methamphetamine or cannabis dependence (12). The following is a brief description/listing of all available FDA approved addiction medications.
I. Medications as Aids to Smoking Cessation/Nicotine Dependence (47–51).
1) Nicotine replacement therapies (NRT) are nicotine receptor agonists and are available in patch, gum, lozenge, and nasal spray and inhaler preparations. 2) Bupropion is a dopamine and norepinephrine reuptake inhibitor. 3) Varenicline is a partial nicotine agonist. It is important to recognize that current practice guidelines for youth smoking cessation treatments only recommend counseling approaches (52).
II. Medications for the Treatment of Opioid Dependence.
1) Buprenorphine is a partial agonist of the mu opioid receptor. Buprenorphine is available combined with naloxone (an opioid antagonist) and as a standalone preparation. Naloxone, which is not absorbed sublingually, is added to buprenorphine, in order to reduce diversion by injection drug use (if injected naloxone will precipitate opioid withdrawal). FDA reports that buprenorphine has been found to be safe for use in opioid dependent patients ages 16 and older, which is particularly noteworthy, especially since the vast majority of opioid dependent youth who might benefit from this treatment are older (53). Two randomized controlled outpatient trials (including a large NIDA Clinical Trials Network multisite trial) showed that sublingual buprenorphine is safe and superior to clonidine in a 4-week trial (N=38; ages 14-18) (54) and that 12 weeks of buprenorphine is both safe and superior to detoxification with up to 2 weeks on an outpatient basis (N=152, ages 15-21 years) (55). In both trials buprenorphine was offered along with a psychosocial treatment and was found to work well for dependence to either prescription opioids or heroin, and for both males and females. 2) Naltrexone is an antagonist of the mu opioid receptor and is efficacious in relapse prevention (i.e. in maintaining opioid abstinence in those who achieve any abstinence from opioids) (56). 3) Methadone, a full-agonist of the mu opioid receptor is only available for dispensing at specially licensed Opioid Treatment Programs (OTP). Methadone is not a feasible option for most youth <18 years due to strict regulations which stipulate that individuals ages 16-18 years need a) consent from their legal guardian(s) for the use of methadone; and b) have documented failure for at least two prior treatment attempts.
III. Medications for Treatment of Alcohol Dependence (57, 58).
1) Naltrexone has been shown to decrease alcohol-induced euphoria, time to relapse, and the quantity and frequency of drinking among alcohol dependent adults who relapse. 2) Acamprosate is proposed to normalize the deregulation of N-methyl-d-aspartate (NMDA)-mediated glutamatergic (excitatory) neurotransmission and stimulate inhibitory GABA transmission that occurs during chronic alcohol consumption and withdrawal. 3) Disulfiram is an aversive agent that inhibits alcohol dehydrogenase (involved in the metabolism of alcohol), resulting in an accumulation of acetaldehyde which provides an aversive reaction if alcohol is consumed after taking the medication. The histamine-induced aversive experience can consist of flushing of the skin, hypotension, reflex tachycardia, tachypnea, a sensation of warmth, palpitations, anxiety, headache, nausea and, in some instances, vomiting.
Even in the adult population, for whom efficacy has been established, medications for the treatment of SUDs are not meant to be delivered as stand-alone treatments, but in combination with counseling/therapy. Also, in the context of recent FDA “black box” warnings of hostility, agitation, depressed mood, suicidal thoughts or actions and/or psychotic behaviors with several of the psychotropic medications (e.g. selective serotonin reuptake inhibitors, bupropion, psychostimulants, varenicline, etc.), treatment providers remain skeptical about the use of psychotropic medications for adolescents. However, based on the limited research evidence, it appears that, when available, the use of medications in combination with therapy appears to be well-tolerated and superior to use of placebo or therapy alone.
Further research is needed to not only establish the safety and efficacy of medications, but also their impact on the developing brain.
In order to effectively address the consistent and growing public health problem of substance use and abuse among adolescents, healthcare practitioners and clinicians need to modify patient (and family) behaviors and attitudes by screening and better identifying either risk for or current problem substance use as well as integrating more evidence-based strategies. Research has shown that identification and early intervention by a healthcare practitioner and/or clinician for adolescent substance use and abuse can greatly impact the incidence of use and abuse and consequently decrease the prevalence of addiction (59). The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry highlight the need to address practice gaps and have urged membership to increase their knowledge and practice of integrating substance abuse treatments into their respective practices (60, 61).
In practice, particularly due to third party reimbursement requirements, most providers utilize the expert consensus-driven Patient Placement Criteria published by American Society of Addiction Medicine to determine levels of treatment care. The levels are as follows: (1) early intervention services, (2) outpatient treatment, (3) intensive outpatient, (4) residential/inpatient treatment, and (5) medically managed intensive inpatient (62). Once a level has been determined, practitioners can then integrate appropriate evidenced-based practices to treat their adolescent patients within the levels of care.
While evidence is limited for pharmacotherapeutic approaches and efficacious behavioral and family treatments for SUDs are labor-intensive and require high levels of fidelity for success, the extant literature demonstrates for adolescent substance abuse that a number of effective programs, both inpatient and outpatient, are creating comprehensive treatment frameworks by integrating multiple therapeutic practices (33). With recent legislation mandating the meaningful use of electronic health records as a provision of the Health Information Technology for Economic and Clinical Health (HITECH) Act – a component of the American Recovery and Reinvestment Act of 2009 (63), practitioners are not only encouraged to become familiar and competent in the use of existing, albeit limited, tools for screening and assessment, brief interventions, and evidence-based treatments for SUDs, but to also capitalize on the currently available financial incentives for such use (64). These new legislative actions provide unprecedented opportunities to integrate prevention and treatment of SUDs in multiple medical settings and expand benefits to cover treatment for vulnerable populations including youth (65, 66). Outside of the healthcare and medical fields, it is vital that all stakeholders, i.e. clinicians, parents, policymakers, and researchers advocate for youth substance use issues on a global level to change social norms, policies and to diminish the often devastating consequences of substance misuse.