Overview of adolescent substance abuse treatment
Download
1 / 36

Overview of Adolescent Substance Abuse & Treatment - PowerPoint PPT Presentation


  • 657 Views
  • Uploaded on

Overview of Adolescent Substance Abuse & Treatment. Joan E. Zweben, Ph.D. Executive Director, EBCRP Clinical Professor of Psychiatry, UCSF PREP Program Training June 23, 2011. Adolescent Substance Use. Critical time for onset of SUDS Experimentation is prevalent; most do not develop SUDS

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Overview of Adolescent Substance Abuse & Treatment' - adie


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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 Training

June 23, 2011


Adolescent substance use
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 abuse
Adolescent 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 factors
Protective 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)


Marijuana
Marijuana

  • 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)


Tobacco
Tobacco

  • 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)


Relapse
Relapse

  • 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 prevention
Adolescent 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 suds
Pharmacotherapy 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 suds
Adolescent 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



Capsule 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.

Capsule Definition of Addiction


BUT dependable control, and persists despite adverse consequences

Any 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 dependable control, and persists despite adverse consequences

  • “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 heritage
Role of Genetic Heritage dependable control, and persists despite adverse consequences

  • 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 dependable control, and persists despite adverse consequences

  • 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 disorder
Addiction is a Chronic Relapsing Disorder dependable control, and persists despite adverse consequences

  • 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 outcomes
Different Treatments Produce Similar Outcomes dependable control, and persists despite adverse consequences

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 dependable control, and persists despite adverse consequencesTherapeutic 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 enhancement
    Motivational Enhancement dependable control, and persists despite adverse consequences

    • 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 dependable control, and persists despite adverse consequences

    • 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 oriented
    Treatment Philosophies: Abstinence-Oriented dependable control, and persists despite adverse consequences

    • abstain from drug of choice

    • abstain from other intoxicants

      drug substitution

      role in precipitating relapse

    • dependable control not possible; hence detach

    • widest margin of safety


    Treatment philosophies harm reduction
    Treatment Philosophies: dependable control, and persists despite adverse consequencesHarm 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 treatment
    Pitfalls of Abstinence-Oriented Treatment dependable control, and persists despite adverse consequences

    • 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 approach
    Pitfalls of Harm Reduction Approach dependable control, and persists despite adverse consequences

    • 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 reduction
    Abstinence & Harm Reduction dependable control, and persists despite adverse consequences

    • 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 theory
    Self-Medication Theory dependable control, and persists despite adverse consequences

    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 dependable control, and persists despite adverse consequences

    • 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 awakening
    Role of the Spiritual Awakening dependable control, and persists despite adverse consequences

    • 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) dependable control, and persists despite adverse consequences

    • 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 model
    Key Ingredients of the Community Model dependable control, and persists despite adverse consequences

    • 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 environment
    Post Treatment Recovery Environment dependable control, and persists despite adverse consequences

    • Mutual aid system (aka self help)

    • Family

    • Social network

    • Living environment

    • Recovery homes, schools, support centers, churches, etc.


    Essential elements of treatment
    Essential Elements of Treatment dependable control, and persists despite adverse consequences

    • 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? dependable control, and persists despite adverse consequences

    • 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

    www.ebcrp.org dependable control, and persists despite adverse consequences


    ad