Adolescent Substance Use Disorder Treatment - IU

AdolescentSubstance Use DisorderTreatmentZachary W. Adams, Ph.D., HSPPRiley Adolescent Dual Diagnosis ProgramAdolescent Behavioral Health Research ProgramDepartment of Psychiatry

Monitoring the Future, 2017

Screening Interview: ex: KSADS, SCID, HEADSS Questionnaires–––––––CRAFFT: Car, Relax, Alone, Forget, Friends, TroubleS2BI: Gate questions, follow-upBSTAD: adaptation of NIAAA questions, self and friends’ usePOSIT: Problem Oriented Screening Instrument for TeachersAUDIT: Alcohol Use Disorders Identification TestCAGE-A: Cut down, Annoyed, Guilty, Eye OpenerBright Futures: Tailored to different agesCohen, Reif, Knight, Latimer, 1991; Knight, 1999; Levy et al., 2014; Kelley et al., 2014

Substance Use in Teens Developmental perspective– Level of risk varies(substance, amount, frequency, circumstances)– Progressive nature of SUDs Not binary, not just the extremes Can be harmful at low levelsAbstainerExperimentOccasionaluseRisky UseHarmfulUseHeavy Use

Evidence-Based Treatment Models(Outpatient)Level of SupportTreatments1: Works well, Wellestablished Group CBTIndividual CBTFamily-based treatment (ecological; MDFT, FFT, EBFT)Combined MET/CBTCombined MET/CBT/Family-based treatment (behavioral)2: Works, Probablyefficacious Family-based treatment (behavioral)Motivational interviewing/METCombined family-based treatment (ecological)/ContingencyManagementCombined MET/CBT/Family-based treatment(behavioral)/Contingency management 3: Might work, Possiblyefficacious Drug counseling/12-stepHogue, Henderson, Ozechowski, & Robbins, 2014, JCCAP

Common Goals Reduce substance use (behavior) Enhance motivation and efficacy in reducing use Identify drivers of substance use problems and implement evidencebased interventions to address the drivers Bolster protective factors against substance abuse Teach realistic refusal skills Replace needs met by substance use with more adaptive strategies– Activating the reward system in other ways!– Encourage and link to prosocial activities Monitor use with random screening (ideally by caregiver)

ProtectiveRisk Strong family relationshipsConsistent parental monitoringClear rules and contingenciesSocial supportPro-social activitiesSchool successNon-using peersHealthy coping skillsGood problem-solving skillsChaotic home environmentParental use, sibling useIntrauterine exposureInconsistent parentingPoor parent-child relationshipPoor copingSchool failureDelinquent peersEasy access to substancesImpulsivityPsychopathology (externalizing &internalizing) Trauma and adversity

Comorbidities (80-90%) Externalizing Disorders– ADHD, ODD, CD Internalizing Disorders– Depressive Disorders– Anxiety Disorders Psychotic Disorders (less common) PTSD

ENCOMPASS (MET CBT CM Med)CORE Diagnostic evaluation and baseline measures Weekly, individual CBT MI 3 family sessions Week 1: Personal rulers (ready/willing/able), Supportive People,Functional Analysis of Pro-Social Activities Week 2: Personal Feedback (develop discrepancy), Goal Setting,Happiness Scale, Summarize change talk Week 3: Functional Analysis of Drug Use Behavior, Patterns of UseExpectation of Effects, Consequences of Use 13 Skills Training Modules: Coping with cravingsCommunicationManaging angerNegative moodsProblem solvingRealistic refusal skillsSupport systemsSchool & employment Coping with a slipSeemingly irrelevantdecisionsHIV preventionSaying goodbyeBringing in the family(3 sessions)Riggs et al

ENCOMPASS Strategies & Goals Builds youth motivation for change using MI approaches Focuses on reducing drug use Increasing pro-social activities (incompatible with drug use)and recovery support Cognitive components-- decision making, problem solving,planning ahead Behavioral/skills based training— coping strategies Pharmacotherapy, as indicated Progress monitoring Treatment fidelity monitoring

Cognitive and Behavioral Strategies Modeling and role playing Breaking tasks into small increments (goal setting) Activity scheduling (relaxation, recreation; pro-social non-drug activities;non-using peers) Systematic desensitization, imaginary and in vivo Skills Training Modules Cognitive skills (decision-making, problem solving; seemingly irrelevantdecisions; anger/negative mood awareness, regulation, andmanagement ) Social skills (communication, job-seeking/interviews) Behavioral skills -- Coping skills/strategies (coping with craving;substance refusal; negative mood regulation)

Module # 1: Motivation & Engagement: Explain confidentiality, recording policyReview logistics (weekly, 12-16 weeks, 45-60m, etc.)Most sessions will be individual; some “family sessions”Describe rationale and expectations Collaborative spiritRegular attendance and not coming to sessions “high”At home practiceFocus on substance use but not exclusivelyWill explore feelings and thoughts to understand behaviorWill discover and experiment to find what works to change

Module #2: Personal FeedbackReport & Goal Setting Check in & review of home practice Session rationale Transitioning to goal setting WHY?–––––Foster sense of directionHelp patients feel more hopefulPrevent therapist driftReinforce collaborationEvaluate therapeutic progress and outcome

Module # 3: Functional Analysis/Exploring High Risk Situations Better understand the function and triggers forsubstance use (behavior) before developingtreatment plan to individualize intervention Encourage an interactive and collaborativeprocess which will be continued in the next phaseof treatment (skill acquisition).

Module # 3: Functional Analysis Explore links between thoughts, feelings, & behavior Identify triggers for cravings and substance use Compare the “pros” (positive consequences) and“cons” (negative consequences) of substance useusing a decisional balance Teach patients to become “experts” about their ownhabits (self-efficacy) Motivate and enhance readiness for change, action,and commitment

Contingency Management Strong data to support decrease in drug use inadults and adolescents “Prize draws” for positive target behaviors:– Session attendance– Negative urine drug screen (UDS) – immediate feedback– Pro-social activities Bonus prizes for sustained or early abstinence Builds motivation for engagement and treatmentprogress

Evidence-Based TreatmentsNIDA Principles of AdolescentSubstance Use Disorder Treatment:A Research-Based Guidewww.drugabuse.gov

NIDA for drugs-abuse/commonly-abused-drugs-charts

Effective Child Therapy ubstance-abuse

Adolescent Substance Use Disorder Treatment Zachary W. Adams, Ph.D., HSPP. . Identify drivers of substance use problems and implement evidence- . NIDA Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide. www.drugabuse.gov. NIDA for Teens.