overview of adolescent substance abuse & treatment joan e. zweben, ph.d. executive director,...
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Overview of Adolescent Substance Abuse & Treatment
Overview of Adolescent Substance Abuse & Treatment
Joan E. Zweben, Ph.D.Executive Director, EBCRP
Clinical Professor of Psychiatry, UCSF
PREP Program TrainingJune 23, 2011
Adolescent Substance Use Critical time for onset of SUDS Experimentation is prevalent; most do not
develop SUDS Prevalence rates in higher risk samples is
approx 24% or higher Social factors, esp peer influence, are
strongest determinants of initiation of use. Psychological factors and effects of the
substances more closely linked to abuse.(Millin &
Walker, 2011)
Adolescent Substance AbuseAdolescent Substance Abuse Marijuana is the most prevalent, then
alcohol. Polydrug use is the norm Tobacco: most smokers initiate during
adolescence Prescription drug abuse is rising Adolescent brain more is susceptible to
alcohol and other drugs Prevention efforts target salient risk and
protective factors
Protective FactorsProtective Factors Positive temperament/self-acceptance Intellectual ability/academic performance Supportive family/home environment Caring relationship with at least one adult External support system that encourages
prosocial values Law abidance/avoidance of delinquent
peer friendships (Millin & Walker, 2011)
MarijuanaMarijuana Impact on developing brain Distortions of self-concept due to
disturbances of attention and concentration
Conclude they are not intelligent, don’t like school; seek peer group with negative attitudes and behaviors
Increased risk of psychotic illness Possible interference with medications
(Zweben & Martin, 2009)
TobaccoTobacco Most smokers initiate in adolescence;
1/3 are current smokers (Randall & Upadhyaya 2009)
Early onset smokers more like to develop SUDS
Approx 50% of the risk for nicotine dependence is genetic
Effective pharmacological tx – little is known
Adolescent smokers at significantly greater risk for relapse following tx
(de Dios et al, 2009; Meyers & Prochaska, 2008)
RelapseRelapse Low rates (50%) of continuous
abstinence at 3 months following tx
Common context: social situation, peer influence. (Adults: negative intra- or interpersonal states)
PREP clients seen long term; this is an advantage
Adolescent Treatment and Relapse PreventionAdolescent Treatment and Relapse Prevention Tailor to biopsychosocial level of
development Family involvement necessary; improves
outcomes Integrated treatment of comorbid
conditions is crucial; prevalence of COD is higher than in other age group populations
Comprehensive services, longer time in tx
Pharmacotherapy for SUDSPharmacotherapy for SUDS Usually used only for comorbid
conditions, not SUDS Barriers
Lack of safety and efficacy info Reluctance to use medications to
treat SUD Recent RCTs using buprenorphine
(for opiate dependence) show greater retention and abstinence
Adolescent Treatment Approaches for SUDSAdolescent Treatment Approaches for SUDS Family therapy
Multidimensional family therapy (MDFT) Brief strategic family therapy (BSFT) Multisystemic therapy (MST) Functional family therapy Behavioral family therapy
Cognitive behavioral therapy Twelve-step approaches Therapeutic communities Community reinforcement/contingency
management(Jaffe et al, 2009)
Treatment Outcome Parameters (Adolescents)Treatment Outcome Parameters (Adolescents) Attrition rates 20%-50% across
program types Low motivation Don’t perceive AOD use as a problem
Early therapeutic alliance increases retention and predicts better outcomes on drug use, internalizing and externalizing behaviors
BASIC ISSUES (AOD)BASIC ISSUES (AOD)
Capsule Definition of AddictionCapsule Definition of Addiction
Addiction is behavior that is compulsive, not under dependable control, and persists despite adverse consequences
Behavior is voluntary during the initiation stage, but becomes compulsive over time
Importance of physical dependence has evolved to concepts of dyscontrol, salience, and neuroadaptation.
BUTBUTAny amount of alcohol/drug use
is undesirable in persons with co-occurring disorders, and should be recognized and addressed
Compulsive Drug Seeking is Initiated Outside Consciousness
Compulsive Drug Seeking is Initiated Outside Consciousness
“cues are registered and acted upon by evolutionary primitive regions of the brain before consciousness occurs”
Set in motion by nucleus accumbens (limbic structure, “animal brain”)
Sets in motion a pattern of learned compulsive behavior
Difficult to override even when negative consequences are recognized
(Sellman 2009)
Role of Genetic HeritageRole of Genetic Heritage Heritability estimates range from 40% -
60%. Varies with different drugs. No single gene, or even a handful of
genes Complex interaction between genes,
especially those that influence temperament, and environmental factors
Current model is interactive, “nature via nurture”
Co-occurring Disorders (COD) are the Norm, not the Exception
Co-occurring Disorders (COD) are the Norm, not the Exception
We still design our treatment systems around our own limitations
Addiction treatment system is the default for almost everyone except those with SMI
Attitudes towards medications have changed in the addiction treatment system
Clinicians endorse the idea of integrated treatment, but research lags behind
Criteria for many addiction research studies exclude people with COD, particularly SMI
And, criteria for SMI studies exclude COD
Addiction is a Chronic Relapsing DisorderAddiction is a Chronic Relapsing Disorder Similar to diabetes, asthma, hypertension Key factors for all four:
Adherence to treatment recommendations Family and social support Poverty factors
Stigma influential in determining attitudes towards addiction (e.g, re-occurrence vs relapse)
Research often based on acute care model
(McLellan et al, JAMA, 2000)
Different Treatments Produce Similar OutcomesDifferent Treatments Produce Similar Outcomes
Main Models: Motivational enhancement Cognitive-behavioral (CBT) Twelve-step facilitation Community reinforcement
Modest effect sizes Therapeutic alliance not well studied in
addiction treatment research; many studies elsewhere
Inadequate understanding of key implementation factors
What About the Therapeutic Alliance?What About the Therapeutic Alliance?
Studies outside substance abuse show this accounts for a greater % of the variance than specific techniques
Different “specific” therapies yield similar outcomes, but there is wide variability across sites and therapists
More therapist education/experience does not improve efficacy
(Adapted from W.R. Miller, Oct 06)
Motivational EnhancementMotivational Enhancement Motivation is amenable to clinical
intervention (vs “come back when you are ready”)
Assess stage of motivation and select intervention accordingly
Remember that motivation is a variable state, not a fixed trait
Combination of internal motivation and external pressure is helpful
Treatment Should be Individualized and Comprehensive
Treatment Should be Individualized and Comprehensive
Addiction is a biopsychosocial disorder
Emphasis on evidence-based treatments can lead to another version of cookie-cutter treatment
Practical problems (legal, vocational) are important in addition to medical, psychiatric and family issues
The community context is relevant
Treatment Philosophies: Abstinence-OrientedTreatment Philosophies: Abstinence-Oriented
abstain from drug of choice abstain from other intoxicants
drug substitutionrole in precipitating relapse
dependable control not possible; hence detach
widest margin of safety
Treatment Philosophies:Harm ReductionTreatment Philosophies:Harm Reduction
“Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.”
The Harm Reduction Working Group & Coalition, 1995
Pitfalls of Abstinence-Oriented TreatmentPitfalls of Abstinence-Oriented Treatment Failure to assess motivation level before
pushing abstinence commitment Failure to understand factors promoting
continued use Unrealistic timetables Power struggle vs clinical approach Failure to recognize fluctuating
motivation Inappropriate termination of treatment
Pitfalls of Harm Reduction ApproachPitfalls of Harm Reduction Approach
Inappropriately low expectations for what client can achieve
Difficulty setting clear goals Reluctance to ask client to abstain
completely Underestimate risks/lethality Clinician alcohol and/or illicit drug
use
Abstinence & Harm ReductionAbstinence & Harm Reduction
It’s a continuum, not a polarity Clients choose goals; professionals
give clear recommendations and feedback
Considerations differ for individuals and groups, and especially for residential treatment
Self-Medication TheorySelf-Medication Theory
Two versions: etiological - psychiatric disorder
“causes” the person to develop substance abuse
coping method - substances are used to cope with the psychiatric disorder
VS: many factors initiate; those and
others perpetuate
Addressing the Client’s Self-Medication Perspective
Addressing the Client’s Self-Medication Perspective Acknowledge that drugs may work
in the short run Use journal to get long term view
“On balance, is your life getting better or worse since you started drinking/using?
Interference with prescribed medications
Offer alternatives to deal with social situations, emotional distress, etc.
Role of the Spiritual AwakeningRole of the Spiritual Awakening
Many recover without a dramatic spiritual awakening
Must reorient to a healthy sense of purpose and meaning
Higher power comes in many forms; can reframe to inner wisdom, higher consciousness, etc.
Recovery-Oriented Systems of Care (ROSC)Recovery-Oriented Systems of Care (ROSC)
System must address a chronic (not acute) disorder
Treatment plays an important role, but cannot meet all needs
Communities of recovery play a key role in long term success; must have assertive linkages
(William White, 2008)
Key Ingredients of the Community ModelKey Ingredients of the Community Model
Co-occurring disorders arise in a community context
Identification of problems must include the community context
Plans for recovery include building a healthy level of community support
Successful treatment isn’t just clinical
Post Treatment Recovery EnvironmentPost Treatment Recovery Environment
Mutual aid system (aka self help) Family Social network Living environment Recovery homes, schools, support
centers, churches, etc.
Essential Elements of TreatmentEssential Elements of Treatment
Start where pt is willing to begin Involve family members Structure, structure, structure Appropriate integration with
treatment of psychiatric disorder(s) Participation in a community that
supports the recovery process
What is Recovery?What is Recovery? Resolution of AOD problems Progressive achievement of physical,
emotional and relational health Citizenship: life meaning and
purpose, self-development, social stability, social contribution, elimination of threats to public safety
(William White, 2009)
www.ebcrp.org