There is a dearth of information on treatments for adolescent substance misuse and few well-controlled studies of specific treatment modalities have been conducted. Traditionally, studies have failed to demonstrate the superiority of any one treatment, although there is a general consensus that some treatment is better than none (Catalano, Hawkins, Wells, Miller & Brewer, 1990-1991). More recently, several clinical trials have demonstrated the efficacy of psychosocial treatment interventions for adolescent substance use disorders, including family based, behavioural and cognitive behavioural therapies (CBT) (Azrin, Donohue, Besalel, Kogan & Acierno, 1994; Deas & Thomas, 2001; Deas-Nesmith et al., 1998; Kaminer, Burleson & Goldberger, 2002; Muck et al., 2001; Waldron, Slesnick, Brody, Turner & Peterson, 2001). However, these studies have a number of methodological limitations including the use of small sample sizes, uncontrolled designs, non-standardised measures and inadequate follow up (Kaminer et al., 2002).
Cognitive behavioural interventions
Family and multi-systemic interventions
PharmacotherapiesPsychostimulant substitution has been common practice in some countries (White, 2000), but is not widely available in Australia. A full review of the literature is available in Chapter 8: Pharmacological interventions. Most of the literature describes studies of adult populations and although many of the studies include clients in the 18-25 year old age bracket, no specific conclusions can be drawn about the outcomes of these studies for young people.
Other pharmacotherapies have also received mixed reviews and there are currently none that have been identified as highly effective for detoxification or aftercare (see Chapter 7: Psychostimulant withdrawal and detoxification and Chapter 8: Pharmacological interventions). Again, although there have been many trials of pharmacotherapies for the treatment of adult substance use disorders, none that we have located have focused on their effectiveness for a younger population. Thus, given their questionable efficacy for adults, controversy remains as to whether any of these drugs are efficacious with young people. However, two controlled trials of lithium and sertraline have found positive results in the treatment of adolescent substance users with comorbid psychopathology (Deas-Nesmith et al., 1998; Geller, Cooper & Sun, 1998).Top of page
Cognitive behavioural interventionsCognitive Behavioural Therapy (CBT) is a psychotherapeutic approach that focuses on the interaction between behaviours, cognitions and emotions (Buckstein et al., 1997). Typical CBT approaches to the treatment of youth substance misuse include behavioural contingency management, skills training and relapse prevention (Deas & Thomas, 2001). Relapse prevention is a core component in which environmental, intra- and inter-personal triggers are identified and strategies for coping with stressors, cues and lapses into substance use are developed (Heather & Tebbutt, 1989; Jarvis, Tebbutt & Mattick, 1995). CBT skills training may include relaxation and stress management, drinking/drug refusal, problem solving, coping, self-control, and social and living skills training (Muck et al., 2001).
Although there are no studies on the use of CBT in young people with psychostimulant use problems, CBT is considered best practice in the treatment of problematic psychostimulant use and dependence in adults (see Chapter 5: Psychosocial interventions). Furthermore, there is a growing evidence base for the use of CBT in the treatment of child and adolescent internalising (e.g. depression) (Compton, Burns, Egger & Robertson, 2002; Deas & Thomas, 2001; Lewinsohn & Clarke, 1999; Muck et al., 2001) and externalising psychiatric disorders (e.g. conduct disorder, ADHD) (see Farmer, Compton, Burns & Robertson, 2002 for a review). However, the majority of these trials have excluded young people with comorbid substance use disorders (Muck et al., 2001).
Several RCTs have recently provided preliminary evidence for the efficacy of CBT in the treatment of youth substance misuse. For example, Azrin and colleagues (1994) found significant reductions in substance use and positive urine screens amongst young people receiving behaviour therapy compared to supportive therapy. Similarly, a small pilot study comparing CBT and insight-orientated interactional therapy (IT) group treatments found adolescents in the CBT group had significant reductions in the severity of their drug use compared to the IT group at three-month follow-up (Kaminer, Burleson, Blitz, Sussman & Rousanville, 1998). At 15-month follow-up, no treatment group differences were found, although reductions in substance use were maintained in both the CBT and IT groups (Kaminer & Burleson, 1999). In a later study, Kaminer and colleagues (2002) compared the efficacy of a CBT Coping Skills group and a psychoeducational therapy (PET) group amongst 88 adolescent substance users with comorbid psychopathology. At three-month follow-up, male participants and older youth in the CBT group had significantly lower rates of positive urinalysis than the PET group. However, similar relapse rates for both groups were found at nine-month follow-up, although both treatments resulted in an overall reduction in substance use.
Finally, Waldron and colleagues (2001) conducted an RCT comparing individual CBT, functional family therapy (FFT), combined CBT and FFT, and a group intervention amongst 114 substance abusing adolescents. All interventions had some efficacy, although there were differences in outcomes. Adolescents in the combined FFT and CBT and FFT-only interventions had significantly fewer days of cannabis use and achieved minimal levels of use post treatment. Youths in the individual CBT condition also achieved minimal levels of use following treatment. However, these treatment gains were not maintained at seven-month follow-up, although they were maintained when CBT was combined with FFT.
Thus, whilst CBT has not been used in the treatment of youth psychostimulant users, there is promising evidence for its effectiveness in the treatment of adolescent substance use disorders either alone or in combination with FFT. Future research determining the short and long-term outcomes of individual and group CBT in the treatment of youth psychostimulant and other substance use is warranted.Top of page
Family and multi-systemic interventionsThe family and other social environments of young people including peer relations, school and the community play an important role in adolescent substance use (Deas & Thomas, 2001). Thus, family therapy is considered to be a critical component of the management of adolescent substance use problems. The early involvement of the family in treatment via assertive outreach can assist with the engagement and retention of young people (Buckstein et al., 1997; Hando, Howard & Zibert, 1997; Kalajian, 1992).
Family and Multi-Systemic Therapies have received the most attention in the adolescent substance use literature. Whilst there are many theoretical approaches to family therapy, most approaches are based on four models including strategic, structural, behavioural and functional approaches or a combination of these (Muck et al., 2001). Common components include family and individual psychoeducation, parent management training and communication skills training (Buckstein et al., 1997).
Several reviews of the literature on family therapies in the treatment of adolescent substance use have been published elsewhere (Liddle & Dakof, 1995; Ozechowski & Liddle, 2000; Waldron et al., 2001). A number of RCTs comparing family therapy with other treatment modalities have been conducted. Family therapy was found to be superior to family education and adolescent group therapy in reducing drug use severity in several studies (Joanning, Quinn, Thomas & Mullen, 1992; Lewis, Piercy, Sprenkle & Trepper, 1990). Furthermore, although Functional Family Therapy (FFT) was equivocal with a parent group and CBT in reducing substance use over a 9 and 4 month period respectively (Friedman, 1989; Waldron et al., 2001), it was superior to individual CBT in reducing substance misuse at 7 months follow-up (Waldron et al., 2001). Finally, a comparison of Multidimensional Family Therapy (MDFT; Liddle, Dakof, Diamond, Barrett & Tejeda, 2001), adolescent group therapy and family psychoeducation, found that reductions in drug use were superior in the MDFT group at 6 and 12 months follow-up compared to the other treatments.
Multi-Systemic Therapy (MST) takes the family therapy approach further by providing interventions in a variety of systems and processes known to be related to psychosocial problems in young people. These include the family, peer group, educational and vocational settings, as well as the individual (Henggeler, Bourdin, Melton, Mann et al., 1991).
Three large-scale RCTs have evaluated the efficacy of MST compared to individual counselling and Department of Youth Services (DYS) treatment as usual in young offenders (Henggeler et al., 1991). In the first study, a significant reduction in the number of substance-related arrests was found in the MST group compared to individual counselling over a four-year follow-up period. Similarly, offenders receiving MST had significantly lower levels of alcohol and marijuana use in a second study compared to the DYS treatment as usual group post treatment. However, mixed results were found in youth offenders with substance abuse or dependence when MST was compared to outpatient community substance abuse treatment (Henggeler, Clingempeel, Brondino & Pickrel, 2002). No differences between groups emerged on marijuana, alcohol or other drug use at four-year follow-up, although the MST group had higher rates of abstinence for cannabis use according to biological measures (Henggeler et al., 2002).
Whilst no single approach to family therapy has emerged as superior in the clinical research literature, there is solid empirical support for the use of family therapy in the treatment of adolescent substance misuse (Overall & Gorham, 1962; Ozechowski & Liddle, 2000; Stanton & Shadish, 1997). Thus, family interventions are a promising area for development in the treatment of youth psychostimulant users.Top of page
Residential treatmentQuestions have long been raised as to the appropriateness of residential treatment for young psychostimulant users (Brook & Whitehead, 1973; Coulson, Went & Kozlinski, 1974). Howard and Arcuri (2003a) found that clients presenting to residential treatment with psychostimulant dependence were not dissimilar to those presenting as primarily heroin or alcohol dependent on admission. This was despite low retention rates, with close to 60% leaving in the first 30 days of the 90-day in-patient treatment.
However, of those clients who completed a substantial component of the program (at least six weeks), at three-month post treatment, the psychostimulant group did |as well as other groups, showing significantly less drug use from a self-reported pre-treatment base-line. This is important when one considers the more problematic pre-treatment presentation of the psychostimulant group in this study. Psychostimulant users were more likely to have reported greater mental and physical health problems, more financial problems and, during the three months prior to treatment, were more likely to have overdosed, committed person and property crimes and to have had more sexual partners.
Similarly, an American study of amphetamine users admitted to a residential therapeutic community drug treatment program found that the treatment outcomes of amphetamine users did not differ from other drug users despite having a more extensive history of drug use, criminal behaviour, family dysfunction, psychopathology and HIV risk-taking behaviours (Hawke et al., 2000). Both amphetamine and other drug users reported significant reductions in drug use (including amphetamines), criminal behaviour and HIV risk-taking behaviour and improved psychological functioning at 12-month follow-up (Hawke et al., 2000).
Thus, whilst there is some support for the efficacy of residential treatment for young amphetamine users, it is an expensive and potentially invasive option and, as such, should only be considered where external supports (e.g. family, school/work, accommodation, income, etc) have broken down, are openly hostile, are non-existent, or where there are significant mental health and other behavioural concerns present. Other risks associated with residential treatment include removing the young person from the functional aspects of their lives and exposing them to drug using peers.Top of page
Contingency programsContingency management programs have been shown to be effective in improving abstinence rates among adult drug users in treatment and there is some evidence for their effectiveness with psychostimulant users (see Chapter 5: Psychosocial interventions for a fuller review). A comprehensive description of contingency management procedures for adolescent substance misusers was recently provided by Kaminer (2000) and there is some evidence for its effectiveness in the treatment of adolescent smoking (Corby, Roll, Ledgerwood & Schuster, 2000). However, a recent study amongst adolescent and adult cocaine users found a voucher incentive program for multiple drug use was not effective (Katz, Chutuape, Jones & Stitzer, 2002) and overall there is little evidence of the efficacy of contingency management in the treatment of youth substance misuse.
12-step programsTwelve-step approaches to the treatment of substance use such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are the most commonly used model for the treatment of adolescent substance abusers in the USA (see Muck et al., 2001). They are based on the tenet that substance abuse and dependence is a disease, which can only be managed with a goal of abstinence (Winters, Stinchfield, Opland, Weller & Latimer, 2000). The approach is considered most appropriate for severely substance dependent youth with high levels of motivation (Kelly, Myers & Brown, 2002). Whilst some evidence has emerged for the effectiveness of this approach in reducing substance use amongst psychostimulant (cocaine and amphetamines) dependent youth over a four-year follow-up (Brown, D'Amic, McCarthy & Tapert, 2001), its overall suitability for the developmental level of young people is questionable as no RCTs have been conducted.
Peer programsThe popularity of peer programs for young people has increased immensely (World Health Organisation, 2001). This is largely due to the validity and acceptability of health peer-conveyed messages to young people. The WHO (2001) reviewed many peer programs that mainly targeted sexual and reproductive health, most of which had positive outcomes, including benefits for peer promoters, short-term individual behaviour change for participants (no long-term evaluations exist) and increased service utilisation.
One concern regarding the use of peers in this type of intervention is the question of how long peer educators can remain 'peers'. Educating young people to become educators or promoters places them in a privileged position whereby they are no longer peers and covert pressure may be exerted in some settings for them to remain in high-risk environments to positively influence others.