Journal Articles Substance Abuse and Family Counseling 2014
Am Fam Md. 2008 February one;77(3):331-336.
Article Sections
- Abstract
- Telescopic and Prevalence
- Etiology and Pathophysiology
- Screening and Diagnosis
- Treatment
- References
Substance abuse in adolescents is undertreated in the Usa. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attending-deficit/hyperactivity disorder. Office-, habitation-, and schoolhouse-based drug testing is non routinely recommended. Screening tools for adolescent substance corruption include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance utilise disorders. Although family physicians may exist able to treat adolescents with substance use disorders in the office setting, it is frequently necessary and prudent to refer patients to one or more than appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, schoolhouse-based drug-counseling programs, outpatient substance corruption clinics, day treatment programs, and inpatient and residential programs. Working within customs and family contexts, family physicians tin can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents.
Nearly 1.1 million American adolescents (ages 12 through 17) met substance corruption treatment criteria in 2001, even so fewer than 100,000 received handling.1 Substance abuse is associated with an increased hazard of motor vehicle crashes, emergency department admissions, and suicide.2 Although the scope of substance corruption may exist daunting, family physicians are well positioned to recognize and address the problem in adolescents.three
SORT: KEY RECOMMENDATIONS FOR Practise
| Clinical recommendation | Evidence rating | References | Comments |
|---|---|---|---|
| Cultural and ethnic factors affect patterns of substance misuse and handling response in adolescents who use substances. | B | 19, 20 | Instance-control study and RCT |
| Screening for substance use is recommended for all adolescents. | C | 6 | Recommendation from consensus-based practice guideline |
| Motivational interviewing is effective in adolescents. | A | 23,25 | Consequent findings from RCTs and recommendation from evidence-based do guideline |
| Main care handling for boyish substance corruption should occur in conjunction with treatment from psychiatrists or other mental wellness experts. | A | 6, 33, 34 | Consequent findings from RCTs and recommendation from show-based practice guideline |
The Substance Abuse and Mental Health Services Administration has proposed considering substance use as minimal or experimental use with minimal consequences, and substance abuse as regular use or corruption with several and more astringent consequences.4 Substance employ disorders are maladaptive patterns of use accompanied past clinically significant damage or distress. The Diagnostic and Statistical Manual of Mental Disorders, quaternary ed. rev., is the major guideline for assessing problematic substance use (Tabular array 1),v although criteria have not yet been established for adolescents.half dozen
Table 1
Diagnostic Criteria for Substance Abuse
| A. A maladaptive pattern of substance utilise leading to clinically significant impairment or distress, equally manifested by i (or more) of the following, occurring within a 12-month flow: | |
| ane. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or dwelling house (eastward.1000., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; fail of children or household) | |
| ii. Recurrent substance use in situations in which it is physically hazardous (due east.g., driving an car or operating a machine when dumb by substance use) | |
| 3. Recurrent substance-related legal problems (e.one thousand., arrests for substance-related disorderly conduct) | |
| 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (east.g., arguments with spouse about consequences of intoxication, physical fights) | |
| B. The symptoms have never met the criteria for substance dependence for this course of substance | |
Scope and Prevalence
- Abstruse
- Scope and Prevalence
- Etiology and Pathophysiology
- Screening and Diagnosis
- Treatment
- References
Substance employ before age 18 is associated with an eightfold greater likelihood of developing substance dependence in adulthood.ii Adults who began to utilize booze earlier historic period xv are 5 times more likely to report previous-twelvemonth alcohol dependence or abuse than those who began alcohol utilize at historic period 21 or older.7 In customs samples, lifetime prevalence estimates for boyish booze corruption range from 0.6 to four.iii pct.six,eight,9 Prevalence estimates for boyish substance abuse or dependence range from 3.three percent in 15-year-olds to nine.8 percent in 17- to 19-yr-olds.half-dozen The charge per unit of illicit drug use among youths 12 to 17 years of age was 9.9 percent in 2005; dependence or corruption of illicit drugs was iv.7 pct; and the charge per unit of booze dependence or corruption was 5.5 percent.10 One written report found that only 35 percent of adolescents reported discussing substance use with their primary care physicians, although 65 percent of the sample said they wanted to.1
Estimated rates of comorbid mental illness amid adolescents with substance use disorders range from 60 to 75 percent.11,12 Among adolescents with no prior substance employ, the rates of first-time use of booze and other substances in the previous year are higher in those who had depression than in those who did non.thirteen Other usually documented comorbid mental disorders include conduct disorder, oppositional defiant disorder, attending-deficit/hyperactivity disorder, anxiety, and postal service-traumatic stress disorder (particularly in girls).11,12,14
Etiology and Pathophysiology
- Abstract
- Telescopic and Prevalence
- Etiology and Pathophysiology
- Screening and Diagnosis
- Treatment
- References
Factors contributing to adolescent substance use and misuse evolve from a complex relationship betwixt personal and community variables.xv Genetic vulnerability may be influenced past ecology factors,nine and psychological dysregulation (i.e., delayed evolution of behavioral, emotional, or cognitive regulation) may explain a correlation between babyhood mental disorders and substance employ issues in adolescents.sixteen–eighteen Other variables predicting adolescent substance utilise disorders include parents' poor parenting skills, parental substance employ, and childhood mistreatment.9
Cultural and indigenous factors affect patterns of substance misuse and recovery among adolescents. Ane cross-sectional study showed ethnic and gender substance use patterns in adolescents.nineteen A controlled trial involving juvenile Hispanic offenders showed that cultural factors such as discrimination, acculturation, and ethnic pride influence treatment issue; for example, youth with greater "ethnic pride" responded improve to treatment, and youth with greater "ethnic mistrust" showed a lesser response to treatment.20 References highlighting cultural issues can be found at http://world wide web.attcne.org/pubs/ccsat.pdf (Table 2).
Table 2
Adolescent Substance Corruption Resource
| Full general information | ||
| National Institute on Drug Abuse | ||
| Spider web site: http://world wide web.nida.nih.gov/students.html | ||
| SAMHSA'southward National Clearing Business firm for Booze and Drug Information: | ||
| Tips for Teens | ||
| Costless alcohol and drug informational brochures | ||
| Spider web site: http://ncadistore.samhsa.gov/itemize/pubseries.aspx | ||
| SAMHSA's National Mental Health Information Center | ||
| Comprehensive information on children's mental health, hotlines, and links to other useful sites | ||
| Web site: http://www.samhsa.gov/ | ||
| Support and treatment | ||
| Al-Betimes | ||
| Help for families and friends of alcoholics | ||
| Spider web site: http://www.al-anon.alateen.org | ||
| Alateen (part of Al-Anon) | ||
| Recovery program for immature persons; groups sponsored by Al-Betimes members | ||
| Web site: http://www.al-anon.alateen.org/alateen.html | ||
| Hazelden | ||
| Alcohol and drug addiction treatment | ||
| Spider web site: http://www.hazelden.org | ||
| Jaffe SL. Step Workbook for Adolescent Chemical Dependency Recovery: | ||
| A Guide to the Start 5 Steps. Washington, D.C.: American Academy of Child and Adolescent Psychiatry, 1990 | ||
| Cultural factors | ||
| Addiction Technology Transfer Heart of New England. Cultural Competence in Substance Abuse Treatment, Policy Planning, and Program Evolution: An Annotated Bibliography Reference for cultural competency and substance use Web site: http://world wide web.attcne.org/pubs/ccsat.pdf | ||
A master cistron in the pathophysiology of substance use leading to addiction is neurophysiologic reinforcement. One such reward pathway involves dopaminergic neurons, which lead to increased levels of dopamine, serotonin, and norepinephrine.21 Adolescents are at greater risk of neuropathology every bit a result of substance abuse considering their brains are yet developing.16
Screening and Diagnosis
- Abstract
- Scope and Prevalence
- Etiology and Pathophysiology
- Screening and Diagnosis
- Treatment
- References
Parents or teachers may refer adolescents to a physician because of behavioral changes that impact school performance or social performance, such as verbal or physical aggression, academic difficulties, impulsivity, hyperactivity, depressed mood, and poor social skills. Such behavioral changes frequently are indicative of substance corruption.6
Although many family physicians feel unprepared to diagnose substance abuse,22 practice parameters for the cess and management of substance use disorders recommend screening all adolescents for utilize of alcohol and other substances.6 The CRAFFT questionnaire is a cursory, reliable tool for adolescent substance abuse screening23 (Tabular array iii24). Many free informational resources can be made available in physician'south offices (Tabular array 2). Some practices have individual waiting rooms for adolescents where they can wait upward information or pick upwardly brochures about health-related topics.
If screening indicates the possibility of substance use, the doctor can conduct a more in-depth evaluation in the office or refer the patient to a subspecialist. Information technology is important to evaluate the boyish for co-occurring mental illness. A family history of substance use and psychiatric disorders should be taken. The doctor should ask about school functioning, social and psychological functioning, peer attitudes, substance utilise patterns, consequences of use, and willingness for treatment.
Table 3
The CRAFFT Questionnaire: A Brief Screening Test for Adolescent Substance Abuse
| C – Have you ever ridden in a CAR driven past someone (including yourself) who was "loftier" or who had been using alcohol or drugs? |
| R – Exercise you ever utilise alcohol or drugs to RELAX, experience amend virtually yourself, or fit in? |
| A – Do you always use alcohol or drugs while you are ALone? |
| F – Do you e'er FORGET things you did while using alcohol or drugs? |
| F – Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? |
| T – Have you gotten into TROUBLE while y'all were using alcohol or drugs? |
If the patient reports substance experimentation, the physician can outline the risks of such behaviors. If the problem seems more severe, the approach should be more intensive to elicit responses from the patient.
Motivational interviewing is suggested as a style to open an exchange with the boyish and develop conditions for positive change.25 Interviewing domains include assessment and feedback; negotiation and goal setting; behavioral modification techniques; self-help directions; and follow-up and reinforcement.26 For example, physicians might ask adolescents what their friends practise for fun, if they experiment with alcohol or drug use, or if they feel pressure from their peers to experiment. Alternatively, physicians might enquire patients what they take learned about alcohol or drug use, and if they have whatever questions. Physicians can heed and encourage adolescents to maintain positive peer relationships and avoid friends who make poor choices. Cursory interventions can make a positive difference,27 because the longer adolescents defer experimentation, the less probable they are to develop long-term substance use problems.
CONFIDENTIALITY
Confidentiality and the demand for legal protection for adolescents contribute to the underreporting of substance use disorders.1,28 It is of import to interview the patient without the presence of a parent for at least part of the visit.29 Physicians must assure patients of their business for privacy if a trusting relationship is to be adult.30 Each state has laws that establish confidentiality rules, and states vary in their laws assuasive minors to give consent for substance abuse treatment. Physicians should be aware of their state's laws when providing health intendance to adolescents.
LABORATORY TESTING
The American Academy of Pediatrics does not recommend routine office-, home-, or school-based drug testing.31 Yet, toxicologic testing may be an important function of ongoing cess of substance apply and abuse during and after handling. Confidentiality guidelines should be followed rigorously.6
Treatment
- Abstract
- Scope and Prevalence
- Etiology and Pathophysiology
- Screening and Diagnosis
- Treatment
- References
The handling of adolescents with substance corruption should have into account age, sex, ethnicity, cultural background, and readiness to modify.4 It involves a system of professionals and therapeutic components, likewise every bit family and community support.
Family unit AND COMMUNITY
Parents are integral to the management of substance employ disorders in adolescents. The physician should screen parents for substance use and corruption and refer those who screen positive to an developed treatment program. Family therapy is crucial, and the provision of family support and force building is well inside the realm of family exercise.32 The family doctor should piece of work with parents to remove alcohol from the dwelling house and keep narcotic hurting medications locked away.
Peer groups play a vital role in promoting forbearance as well as corruption. Unsupervised adolescents are likely to seek out peers of similar backgrounds. While undergoing treatment, patients volition be involved in new peer groups that are committed (at least superficially) to sobriety and that can back up ane some other in remaining abstemious. The physician can encourage participation in activities such as sports, after-school clubs, and volunteerism to maximize positive peer interactions and salubrious lifestyles and minimize antisocial connections.
The dr. should exist knowledgeable most community programs for children whose parents take substance employ disorders. Programs such as Alateen can often exist of aid to children and adolescents (Table 2).
REFERRAL AND CONSULTATION
Although the family physician may care for adolescents with substance employ disorders in the office setting, information technology is often necessary and prudent to refer them to exterior professionals. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance corruption clinics, day treatment programs, and inpatient and residential programs. Referral depends on the severity of abuse, comorbid psychiatric diagnoses, family and social bug, whether the youth has been involved in the juvenile justice organization, motivation, and back up, besides as the availability of treatments in the community. This has been termed "patient–treatment matching."33
Substance Utilize Disorders. Information technology is imperative that the doctor identify a network of competent and trustworthy handling professionals, including child and adolescent psychiatrists, psychologists, and social workers, who specialize in adolescent habit, as well every bit outpatient and inpatient substance detoxification and rehabilitation programs. This may involve advocating with managed care organizations to get sufficiently intensive and continuing treatment for the patient.
In that location will be many opportunities to follow up with the adolescent referred to outside treatment. For example, when the adolescent presents with an acute medical problem, the medico can enquire how substance abuse treatment is progressing. If the boyish has discontinued treatment (as is frequently the case), the doctor may be able to intervene. Information technology is the dr.'south responsibleness to validate the boyish's concerns while encouraging compliance.
Comorbid Disorders. Because feet, depression, and disruptive behavior disorders are mutual comorbid diagnoses with substance corruption, information technology can be helpful to determine when the symptoms first occurred. This may involve a review of school records and reports from other treatment professionals.
Abstinence from substance utilize for at least one calendar month tin can help make up one's mind whether the substance utilise disorder or the psychiatric diagnosis is principal. However, this could filibuster the conclusion to initiate psychotropic medications, which is unacceptable in adolescents with depression, bipolar disorder, or psychosis, or when there are concerns of lethality. Therefore, referral to a child and adolescent psychiatrist should be concurrent with ongoing substance corruption handling in adolescents with comorbidities. If psychiatric consultation is not readily available, the family physician should collaborate closely with therapists, such as child psychologists or social workers, to stabilize the psychiatric condition, and the physician should take responsibility for medication management (Table four34). Although abstinence from substance use should precede the use of psychotropic medication, there is a chance that untreated psychiatric illness will impede treatment initiation, precipitate early dropout, or interfere with achievement of abstinence.34
Tabular array 4
Principles of Medication Management for Adolescents with Substance Abuse
| Establish mechanisms to closely monitor medication compliance, adverse furnishings, target symptom response (due east.g., depression, feet), and ongoing substance use (self-report and toxicology) |
| Monitor compliance with substance corruption treatment |
| Monitor patient treatment motivation, behavior changes, and psychosocial operation |
| Provide data nigh potential interactions betwixt medications and substance of corruption |
| Utilize medication with good safety profiles, low abuse potential, and once-a-24-hour interval dosing |
When psychiatric stability is achieved, the md and mental health collaborators should develop a program for monitoring substance employ and for regular substitution of information.
ASSESSMENT OF SUICIDE Run a risk
Ongoing lethality assessment is of great importance throughout substance abuse handling for adolescents. The physician should ask about suicidal ideation, intention, or planning. Adolescents who are intoxicated are at high risk of successful suicide and of hurting others through accidents or violence.35 While intoxicated, an adolescent who has just broken up with a romantic partner or who has failed an test may act against others in a mode he or she would non when unimpaired. The family unit doc should ask about the accessibility of guns or other weapons and recommend to parents that these exist removed from the adolescent'due south possession. If the physician determines that impairment is imminent, the adolescent should be hospitalized.
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