Outpatient Treatment For Adolescent Substance Use - IU

Outpatient Treatment forAdolescent Substance UseZachary W. Adams, Ph.D., HSPPAdolescent Dual Diagnosis ProgramDepartment of Psychiatry

Monitoring the Future, 2017

Monitoring the Future, 2017

Monitoring the Future, 2017

Impacts of Adolescent Substance Use Those who began drinking or using drugs early in life are more likely todevelop substance use disorders.– Of people who began drinking before age 14, 47% became dependent atsome point, compared to 9% of people who began drinking at age 21 (Hingson et al., 2006)– Risk for illicit drug use disorder was 6X higher in people who startedcannabis use before age 14 compared to those who started after age 18. The adolescent brain is more sensitive to toxicity from drugs andalcohol: cognitive impairments as well as psychiatric Adolescence is a crucial developmental period with necessary progressthrough milestones. Substance use derails this progress.

Other Impacts Drug and alcohol use are associated with leadingcauses of death in teens (motor vehicle crashes,falls, suicide, overdoses, alcohol poisoning,homicide) Strongly linked to several serious health risks(injuries, assault, violence, unprotected sex, teenpregnancy, STIs including HIV/AIDS)

Adolescent Development isMultifaceted and SpiritualSexualMoral

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

NIDA Adolescent SUD Treatment Principles1. Adolescent substance use needs to be identified andaddressed as soon as possible.2. Adolescents can benefit from a drug intervention even ifthey are not addicted to a drug.3. Routine annual medical visits are an opportunity to askadolescents about drug use.4. Legal interventions and sanctions or family pressure mayplay an important role in getting adolescents to enter, stayin, and complete treatment.5. Substance use disorder treatment should be tailored tothe unique needs of the adolescent.

NIDA Adolescent SUD Treatment Principles6. Treatment should address the needs of the whole person,rather than just focusing on his or her drug use.7. Behavioral therapies are effective in addressingadolescent drug use.8. Families and the community are important aspects oftreatment.9. Effectively treating SUDs in adolescents requires alsoidentifying and treating any other mental health conditionsthey may have.10. Sensitive issues such as violence and child abuse or riskof suicide should be identified and addressed.

NIDA Adolescent SUD Treatment Principles11. It is important to monitor drug use during treatment.12. Staying in treatment for an adequate period of time andcontinuity of care afterward are important.13. Testing adolescents for sexually transmitted diseases likeHIV, as well as hepatitis B and C, is an important part ofdrug treatment.

ProtectiveRisk Strong family relationshipsConsistent parental monitoringClear rules and contingenciesSocial supportPro-social activitiesSchool successNon-using peersHealthy coping skillsGood problem-solving skills Chaotic home environmentParental use, sibling useIntrauterine exposureInconsistent parentingPoor parent-child relationshipPoor copingSchool failureDelinquent peersEasy access to substancesImpulsivityTrauma and adversity

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

Screening – S2BI(Promoted by NIDA)Levy et al., 2014, JAMA Pediatrics; C2BI Toolkit

Screening – S2BILevy et al., 2014, JAMA Pediatrics; C2BI Toolkit

Screening – S2BILevy et al., 2014, JAMA Pediatrics; C2BI Toolkit

Screening: CRAFFTCRAFFTHave you ever ridden in a CAR driven by someone (including yourself) who was“high” or had been using alcohol or drugs?Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?Do you ever use alcohol or drugs when you are by yourself, ALONE?Do you ever FORGET things you did while using alcohol or drugs?Do your family or FRIENDS ever tell you that you should cut down on yourdrinking or drug use?Have you ever gotten into TROUBLE while you were using alcohol or drugs?Source: Knight 1999

Family n4.Setting p

Treatment for SUDs in Youth Family therapies– Functional Family Therapy, Brief Strategic Family Therapy,Multisystemic Therapy, Multidimensional Family Therapy Individual & Group Behavioral/Psychotherapy– A-CRA, Contingency Management, CBT, MI/MET,CBT MI/MET, 12-Step Medications Inpatient, Partial Hospitalization, Residential, DetoxNIDA, SAMHSAWaldron & Turner, 2008

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 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)

COREENCOMPASS Weekly, individual CBT MI CM 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 systems Coping with a slipSeemingly irrelevantdecisionsHIV preventionSaying goodbyeBringing in the family(3 sessions)Riggs et al

ENCOMPASS: Key Elements Comprehensive baseline diagnostic andclinical evaluation (incorporated into personalfeedback report) Address co-occurring mental healthproblems/psychiatric symptoms especiallytriggers for substance use Systematic progress monitoring (TLFB, UDS,repeated measures; documentation Fidelity/adherence monitoring Contingency management/Motivational

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).

Patterns of Use Establishes the expectation of direct discussionabout their substance use. Gather as much specific information as possibleabout the substances they use, how much they areusing (e.g. joints, blunts, bowls, grams, etc.), howoften, and over how long a period of time (e.g.hours, days, weeks).

Triggers(Antecedents) External Triggers (who, where, when):– Describe a “typical” day with times they used– Help identify patterns to their substance use behavior– Looking for clues about the triggers (stimulus cues) Internal Triggers– Illustrate a scene to recognize and label thoughts and feelingsantecedent to substance use– Describe last use and preceding events, emotions, & thoughts– Outline steps leading up to use to help him/her recognize that a specificdecision was made under particular emotional/cognitive conditions

Consequences Short-term Positive Consequences– Gather as much information as possible including pleasant thoughts,feelings (mood states), and physical sensations associated with use Lasting Negative Consequences– Identify negative consequences associated with substance use– Use the principles of motivational interviewing, especially developingdiscrepancies– Examples include legal problems, poor school performance, difficultyobtaining a job, family conflicts, loss of non-using friends– Consider a “biphasic response” (a two-fold response which has bothpositive and negative immediate consequences)

Contingency Management Strong data to support decrease indrug use in adults and adolescents Approach to behavior change (A-B-C)– Can be used by parents alone or incoordination with a therapist Point-and-level system or “Prize draws”for positive behaviors:– Session attendance– Negative UDS– Pro-social activities Bonus prizes for sustained or earlyabstinenceHenggeler et al., 2012

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

NIAAA Guide & Pocket tioner/YouthGuide/YouthGuide.pdf

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

Effective Child Therapy ubstance-abuse

NIDA Adolescent SUD Treatment Principles 1. Adolescent substance use needs to be identified and addressed as soon as possible. 2. Adolescents can benefit from a drug intervention even if they are not addicted to a drug. 3. Routine annual medical visits are an opportunity to ask adolescents about drug use. 4.