Understanding and Treating Adolescent Substance Abuse: A Preliminary Review

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.

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.

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).

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.