Prevention and Treatment of Substance Abuse

By The National Center on Addiction and Substance Abuse

Substance abuse prevention is most effective when it comes from the family and extended family of school, church and neighborhood. The wide range of programs by public health authorities, police and responsible media like the Partnership for a Drug-Free America, are likely to be most effective when they supplement what goes on in the family and extended family of an adolescent. They are less effective when they try to compensate for failures of parents, schools, churches and communities.Education is not prevention, as the ineffective staying power of early education programs which inform teens about the dangers of substance abuse demonstrates. Many teens know well the dangers of cigarettes, for example, but smoke anyway. Providing information helps, but it is not enough.

Comprehensive Community Programs -

Recognition of the importance of doing more than informing teens about the dangers of substance abuse has prompted a movement toward more comprehensive prevention approaches, which attempt to address a broader range of adolescent needs and seek to involve the family and the school as programs have been rigorously evaluated.Many prevention programs strive to build and maintain teenagers' skills so that they can cope successfully with the stresses that mark the adolescent years. Those that appear more effective are the most comprehensive and combine a variety of techniques and approaches to provide adolescents with a consistent and coordinated message that is clearly against substance use.

Peer Programs-

These programs recognize the critical impact of teen peer groups. While some peer groups encourage teens to use substances, a peer group of teens who do not use drugs and hold similar positive values creates an atmosphere which helps prevent teens from initiating drug use. Prevention programs incorporating peer leaders have found that these leaders quickly become role models and, by gaining credibility among fellow students, are able to set a non-use example. Through role-playing, this approach can help teens learn how to resist pressure to use addictive substances.

Life Skills Training -

These programs attempt to teach adolescents personal and social skills, including how to handle their own thoughts and feelings about addictive substances and how to act and react in many different challenging situations. Life skills programs often incorporate healthy alternatives to substance abuse, such as community service activities, after-school sports programs and outdoor adventure weekends. They offer opportunities for teens to develop supportive relations with adult mentors and peers. This combination of activities is designed to help teens acquire greater self-assurance and control and reduce anxiety and stress that may make substance use alluring. One of the best known such programs with a successful track record is the Life Skills training program designed by Gilbert J. Botvin and his associates at the Institute for Prevention Research at Cornell University Medical College.

Parenting Programs -

These programs help parents help their teens. They teach parents how to monitor a child's whereabouts, establish reasonable expectations and set specific rules that help children understand and internalize acceptable behavior. These programs often require parents and children to work together and improve parent-child communication. They often include parent groups which give parents a forum to discuss their prevention efforts, offer extra support to parents of high risk children, and reinforce parents in establishing family policies regarding alcohol, tobacco and drug use.

Community Programs -

Community partnerships link existing community services in order to improve the quality of life for everyone in the community. In some states, local medical societies and bar associations work together to set up substance abuse hotlines and other services for troubled teens. Community partnerships may involve businesses or Big Brother/Big Sister type programs. The success of these endeavors usually depends on the degree to which participating agencies work together to create an environment that bolsters prevention messages.

Comprehensive community-based programs include a wider set of participating service providers than community partnerships and are usually organized in a formal network of services for teens and their families. These programs try to change substance use behavior patterns throughout the entire community. They supplement school prevention programs and make special efforts to reach drop-outs.

Some comprehensive community-based programs incorporate job-training. Many include mentoring to increase the time adolescents spend with caring adults and good role models. Some mentoring programs have shown improvements in academic performance, high school completion and relations with parents—all factors linked to substance abuse. Many comprehensive community-based programs also use local media and law enforcement personnel to create a healthier and more supportive climate for adolescents.

Where adolescents are in need of more serious interventions, comprehensive community-based programs provide a much needed bridge to group or individual counseling and intensive treatment.

Treatment for Substance Abuse Disorders -

More than 100,000 children under the age of 18 are admitted to publicly funded treatment programs each year. The number of children receiving treatment in privately funded programs is unknown. The number of adolescents in need of treatment is also not known.There is no standard definition of the level of adolescent substance use at which treatment becomes necessary. The Diagnostic and Statistical Manual-IV produced by the American Psychiatric Association provides guidelines for the diagnosis of Substance Use Disorders in adults, but no formal scientific criteria have been designed specifically for diagnosing teens. To be diagnosed with a Substance Dependence Disorder, an adult must meet three of the following seven criteria at sometime during a 12-month period:

• Tolerance;
• Withdrawal;
• Substance taken in larger amounts or over a longer time period than was intended;
• Persistent desire or unsuccessful efforts to cut down or control substance use;
• Great deal of time spent in activities to obtain or use the substance, or to recover from its effects;
• Important social, occupational, or recreational activities given up or reduced because of substance use;
• Substance use continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or worsened by the substance.

Teen treatment needs differ from those of adults in several respects. Many teens who've moved beyond experimental use of addictive substances have a problem that requires treatment, but one that is not yet severe enough to meet criteria for a formal adult diagnosis of dependence. Teen typically require treatment for more gateway substances, like cigarettes, alcohol and marijuana, and are less likely than adults to use injectable drugs. Treatment of coexisting disorders, such as depression or attention deficit hyperactivity disorder (ADHD), is especially important in the treatment of adolescents because teen substance abuse is often linked to such underlying problems. Teens also may need special guidance and support in the essential processes of adolescent development, such as help with emotional and social development as substance use may have slowed the normal acquisition of these skills. For these reasons, and in order to protect teens from exposure to adults whose substance abuse is usually more advanced, the better treatment programs usually try to separate adolescent clients from adults. They also incorporate family therapy as a central element of treatment since most adolescents continue to be influenced by and dependent upon their families.Treatment programs are generally grouped into two categories: intervention and outpatient services which allow the adolescent to remain within the family environment and inpatient or residential treatment which include round-the-clock care.

Outpatient Programs -

Early interventions and outpatient programs try to help adolescents in their own communities and in as normal a setting as possible. They are attractive alternatives in the context of managed care because they are the least expensive options. These services can be provided on an individual basis by a professional therapist, in a group setting, or within a structured program. Family involvement is often included. Sometimes these services include alternative schooling for the teen. These services are also used to follow up residential or inpatient care, providing the recovering adolescent with extra support and services after more structured treatment.

Early intervention and outpatient programs include school-based student assistance programs, individual and family therapy, after-school programs, and day treatment (the most intensive form of non-residential care). Day treatment programs provide services for adolescents for most of the day, but permit them to go home at night. They include in-house schooling and remedial educational services, as well as afternoon activities and treatment both on an individual and group level. They allow the adolescent to focus on recovery and change outside the regular school and leisure environment, but remain within the teen's own family.

Inpatient Programs -

Inpatient or residential programs remove the adolescent from the family and community environment. This treatment is for children with significant problems who must be completely removed from their environment for recovery to occur. Continuing outpatient services after the residential program is completed helps the child readjust to the family and community environment and provides support and encouragement for dealing with the inevitable stresses.

Inpatient programs include: detoxification for adolescents who alcohol and drug problems require medical monitoring and treatment for withdrawal; the Minnesota model, a 28-day group-oriented program based on the 12-step Alcoholics Anonymous recovery program; therapeutic communities (TCs), which offer long-term intensive treatment environments where teens live for six to 24 months; military-style boot camps, with rigorous, discipline-oriented programs which use physical stamina-building techniques to enforce a drug-free lifestyle (widely used for adolescents involved in the juvenile justice system); and in-patient hospital care for teens who have other conditions that complicate their substance abuse, such as pregnant or HIV-positive adolescents, or those who are suicidal or have other serious psychiatric disorders. Hospital-based services are usually short-term programs after which adolescents are referred to other residential care or intensive outpatient services.

Pharmacological Approaches -

In recent years, as a result of significant advances in the field of neuroscience and in understanding addiction, we have seen new pharmacological treatments emerging for adults, currently including treatments for tobacco, heroin and alcohol addiction. These include transdermal patches, gum, inhalers and nasal spray for nicotine replacement therapy; methadone, LAAM and naltrexone for opiate dependence; and naltrexone, disulfiram and various sedatives and anti-seizure agents for alcohol addiction and detoxification. None of these agents, however, has been approved for use with adolescents except on an experimental basis. No effective pharmacological treatment has yet been discovered for cocaine, although a number of drugs as well as a potential vaccine are undergoing tests in the United States.

The goals of pharmacological treatment are to increase the holding power of outpatient treatment and thus reduce costs, create a window of opportunity during which patients can receive psychosocial intervention to decrease the risk of relapse, cure withdrawal or overdose and serve as long-term management agents. The emergence of new pharmacological treatments combined with the impact of managed care on more traditional treatments may mean that more treatment of substance abuse will be provided for teens in general medicine facilities by family practitioners, pediatricians and other primary care physicians.

What do We Know About Who Succeeds in Treatment?

Treatment Completion -

While treatment of substance abuse among adults has been studied, far less research has been undertaken in the field of adolescent treatment. It is difficult to identify which teens will be successful in treatment and why; however, studies have tried to measure abstinence at various checkpoints during and after treatment. An indicator of future adolescent abstinence from substance use is completion of the treatment program.Regardless of the type or length of the program, teens who stay the course with their treatment are more likely to remain abstinent than those who dropout.

Gender Differences -

Girls and boys use different substances at different rates for different reasons. It comes as no surprise that girls and boys also differ in treatment. Boys in treatment show more acting out, delinquency and school problems. Girls are more likely to have low-self esteem, be depressed and potentially suicidal. Girls are also more likely to describe family problems and to have experienced sexual abuse. Girls appear to do better in treatment than boys, perhaps because of their greater willingness to admit and discuss their problems in treatment.

Family Therapy and Multiple Services -

Family therapy has been found to be effective in adolescent substance abuse treatment and is often vital to adolescent recovery. Its effectiveness may be due to factors such as demonstrating to the adolescent that his or her family wants to help, improving family communication and showing the adolescent ways to solve problems without resorting to drug use. Programs serving adults which offer their clients multiple services seem to have better outcomes because they help the recovering person address a variety of life issues. This finding is likely to apply to adolescents as well.

The Impact of Managed Care -

Regulations and funding mechanisms for alcohol and drug abuse treatment have separated alcohol and drug treatment from mainstream medicine. Most public sector drug treatment is funded through block grants to states rather than through the federal health care budget but managed care is reshaping the practice of addiction medicine.

Managed care has denied impatient drug treatment to many patients. Detoxification is often the only inpatient alcohol or drug treatment benefit covered by most managed care plans/ Subsequent residential treatment is not usually covered. This approach does not recognize that treatment of substance abuse and addiction requires long term emotional and social interventions, and some period of separation from the people, places and things that are associated with the addiction, as well as immediate, short term medical help. This may be especially true for adolescents who live in dysfunctional families or find themselves in difficult school or community situations.