Principles of Adolescent Substance Use Disorder Treatment PDF

Principles of Adolescent
Substance Use Disorder Treatment:

A Research-Based Guide
Principles of Adolescent
Substance Use Disorder Treatment:
A Research-Based Guide
This publication is in the public domain and may be used or reproduced in

its entirety without permission from NIDA. Citation of the source is appreciated.
NIDA wishes to thank the following individuals for their
helpful comments during the review of this publication:
Tina Burrell, M.A., Washington State Department of Social and Health Services
Connie Cahalan, Missouri Department of Mental Health
Barbara Cimaglio, Vermont Department of Health
Michael L. Dennis, Ph.D., Chestnut Health Systems
Rochelle Head-Dunham, M.D., Louisiana Department of Health and Hospitals
Scott W. Henggeler, Ph.D., Medical University of South Carolina
Sharon Levy, M.D., M.P.H., Children’s Hospital Boston
Kenneth J. Martz, Psy.D., CAS, Pennsylvania Department of Drug and Alcohol Programs
Kathy Paxton, M.S., West Virginia Bureau for Behavioral Health and Health Facilities
Paula D. Riggs, M.D., University of Colorado School of Medicine

Contents
FROM THE DIRECTOR.............................................................................................................................................1
I. INTRODUCTION ................................................................................................................................................2
II. PRINCIPLES OF ADOLESCENT SUBSTANCE USE DISORDER TREATMENT.............................................. 8

1. Adolescent substance use needs to be identified and addressed as soon as possible................................ 9
2. Adolescents can benefit from a drug abuse intervention even if they are not addicted to a drug................. 9
3. Routine annual medical visits are an opportunity to ask adolescents about drug use.................................. 9
4. Legal interventions and sanctions or family pressure may play an important role in getting
adolescents to enter, stay in, and complete treatment..................................................................................9
5. Substance use disorder treatment should be tailored to the unique needs of the adolescent...................... 9
6. Treatment should address the needs of the whole person, rather than just focusing on his
or her drug use............................................................................................................................................10
7. Behavioral therapies are effective in addressing adolescent drug use....................................................... 10
8. Families and the community are important aspects of treatment................................................................ 10
9. Effectively treating substance use disorders in adolescents requires also identifying and
treating any other mental health conditions they may have........................................................................10
10. Sensitive issues such as violence and child abuse or risk of suicide should be identified
and addressed............................................................................................................................................. 11
11. It is important to monitor drug use during treatment.................................................................................... 11
12. Staying in treatment for an adequate period of time and continuity of care afterward are important.......... 11
13. Testing adolescents for sexually transmitted diseases like HIV, as well as hepatitis B and C,
is an important part of drug treatment......................................................................................................... 11
III. FREQUENTLY ASKED QUESTIONS ...............................................................................................................12

1. Why do adolescents take drugs? ...............................................................................................................13
2. What drugs are most frequently used by adolescents? .............................................................................13
3. How do adolescents become addicted to drugs, and which factors increase risk?.................................... 14
4. Is it possible for teens to become addicted to marijuana?..........................................................................14
5. Is abuse of prescription medications as dangerous as other forms of illegal drug use?............................. 15
6. Are steroids addictive and can steroid abuse be treated?..........................................................................15
7. How do other mental health conditions relate to substance use in adolescents?....................................... 16
8. Does treatment of ADHD with stimulant medications like Ritalin® and Adderall® increase
risk of substance abuse later in life?...........................................................................................................16
9. What are signs of drug use in adolescents, and what role can parents play in getting treatment?............ 16
10. How can parents participate in their adolescent child’s treatment? ........................................................... 17
11. What role can medical professionals play in addressing substance abuse
(including abuse of prescription drugs) among adolescents?.....................................................................17
12. Is adolescent tobacco use treated similarly to other drug use?.................................................................. 18
13. Are there medications to treat adolescent substance abuse? ................................................................... 18
14. Do girls and boys have different treatment needs? ....................................................................................18
15. What are the unique treatment needs of adolescents from different racial/ethnic backgrounds?............... 19
16. What role can the juvenile justice system play in addressing adolescent drug abuse?.............................. 19
17. What role do 12-step groups or other recovery support services play in addiction
treatment for adolescents?..........................................................................................................................19
IV. TREATMENT SETTINGS..................................................................................................................................20
Outpatient/Intensive Outpatient.........................................................................................................................21
Partial Hospitalization........................................................................................................................................21
Residential/Inpatient Treatment.........................................................................................................................21
V. EVIDENCE-BASED APPROACHES TO TREATING ADOLESCENT SUBSTANCE

USE DISORDERS.............................................................................................................................................22

BEHAVIORAL APPROACHES...........................................................................................................................23
Adolescent Community Reinforcement Approach (A-CRA)..........................................................................23
Cognitive-Behavioral Therapy (CBT)............................................................................................................24
Contingency Management (CM)...................................................................................................................24
Motivational Enhancement Therapy (MET) .................................................................................................24
Twelve-Step Facilitation Therapy..................................................................................................................24
FAMILY-BASED APPROACHES........................................................................................................................25
Brief Strategic Family Therapy (BSFT).........................................................................................................25
Family Behavior Therapy (FBT)....................................................................................................................25
Functional Family Therapy (FFT)..................................................................................................................26
Multidimensional Family Therapy (MDFT)....................................................................................................26
Multisystemic Therapy (MST).......................................................................................................................26

ADDICTION MEDICATIONS.............................................................................................................................26
Opioid Use Disorders....................................................................................................................................27
Alcohol Use Disorders..................................................................................................................................27
Nicotine Use Disorders.................................................................................................................................28

RECOVERY SUPPORT SERVICES..................................................................................................................28
Assertive Continuing Care (ACC).................................................................................................................28
Mutual Help Groups......................................................................................................................................29
Peer Recovery Support Services..................................................................................................................29
Recovery High Schools.................................................................................................................................29
TREATMENT REFERRAL RESOURCES................................................................................................................31
REFERENCES.........................................................................................................................................................32
From the Director
Since its first edition in 1999, NIDA’s Principles of Drug Addiction Treatment
has been a widely used resource for health care providers, families, and others
needing information on addiction and treatment for people of all ages. But recent
research has greatly advanced our understanding of the particular treatment
needs of adolescents, which are often different from those of adults. I thus am
very pleased to present this new guide, Principles of Adolescent Substance Use
Disorder Treatment, focused exclusively on the unique realities of adolescent
substance use—which includes abuse of illicit and prescription drugs, alcohol,
and tobacco—and the special treatment needs for people aged 12 to 17.
The adolescent years are a key window for both substance use and the
development of substance use disorders. Brain systems governing emotion and
reward-seeking are fully developed by this time, but circuits governing judgment
and self-inhibition are still maturing, causing teenagers to act on impulse, seek new sensations, and be
easily swayed by their peers—all of which may draw them to take risks such as trying drugs of abuse.
What is more, because critical neural circuits are still actively forming, teens’ brains are particularly
susceptible to being modified by those substances in a lasting way—making the development of a
substance use disorder much more likely.
Addiction is not the only danger. Abusing drugs during adolescence can interfere with meeting crucial
social and developmental milestones and also compromise cognitive development. For example, heavy
marijuana use in the teen years may cause a loss of several IQ points that are not regained even if users
later quit in adulthood. Unfortunately, that drug’s popularity among teens is growing—possibly due in part
to legalization advocates touting marijuana as a “safe” drug. Nor do most young people appreciate the
grave safety risks posed by abuse of other substances like prescription opioids and stimulants or newly
popular synthetic cannabinoids (“Spice”)—and even scientists still do not know much about how abusing
these drugs may affect the developing brain.
These unknowns only add to the urgency of identifying and intervening in substance use as early as
possible. Unfortunately, this urgency is matched by the difficulty of reaching adolescents who need help.
Only 10 percent of adolescents who need treatment for a substance use disorder actually get treatment.
Most teens with drug problems don’t want or think they need help, and parents are frequently blind to
indications their teenage kids may be using drugs—or they may dismiss drug use as just a normal part of
growing up.
Historically the focus with adolescents has tended to be on steering young people clear of drugs
before problems arise. But the reality is that different interventions are needed for adolescents at
different places along the substance use spectrum, and some require treatment, not just prevention.
Fortunately, scientific research has now established the efficacy of a number of treatment approaches
that can address substance use during the teen years. This guide describes those approaches, as well
as presents a set of guiding principles and frequently asked questions about substance abuse and
treatment in this age group. I hope this guide will be of great use to parents, health care providers, and
treatment specialists as they strive to help adolescents with substance use problems get the help they
need.
Nora D. Volkow, M.D.

Director
National Institute on Drug Abuse
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 1

I. Introduction
2 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

P
eople are most likely to begin
abusing drugs*—including
tobacco, alcohol, and illegal
and prescription drugs—
during adolescence and young
adulthood.‡ By the time they are seniors,
almost 70 percent of high school students will
have tried alcohol, half will have taken an illegal
drug, nearly 40 percent will have smoked a
cigarette, and more than 20 percent will have
used a prescription drug for a nonmedical
purpose.1 There are many reasons adolescents
use these substances, including the desire
for new experiences, an attempt to deal with
The brain continues to develop through early adulthood. Mature brain regions at each
problems or perform better in school, and simple developmental stage are indicated in blue. The prefrontal cortex (red circles), which governs
judgment and self-control, is the last part of the brain to mature.
peer pressure. Adolescents are “biologically Source: PNAS 101:8174–8179, 2004.
wired” to seek new experiences and take
risks, as well as to carve out their own identity. health conditions such as depression, anxiety,
Trying drugs may fulfill all of these normal or ADHD; and beliefs such as that drugs are
developmental drives, but in an unhealthy “cool” or harmless make it more likely that an
way that can have very serious long-term adolescent will use drugs.2
consequences.
The teenage years are a critical window of
Many factors influence whether an adolescent vulnerability to substance use disorders,
tries drugs, including the availability of drugs because the brain is still developing
within the neighborhood, community, and school and malleable (a property known as
and whether the adolescent’s friends are using neuroplasticity), and some brain areas are
them. The family environment is also important: less mature than others. The parts of the
Violence, physical or emotional abuse, mental brain that process feelings of reward and
illness, or drug use in the household increase pain—crucial drivers of drug use—are the first
the likelihood an adolescent will use drugs. to mature during childhood. What remains
Finally, an adolescent’s inherited genetic incompletely developed during the teen years
vulnerability; personality traits like poor impulse are the prefrontal cortex and its connections
control or a high need for excitement; mental to other brain regions. The prefrontal cortex is
responsible for assessing situations, making
sound decisions, and controlling our emotions
and impulses; typically this circuitry is not
The adolescent brain is often likened mature until a person is in his or her mid-20s
to a car with a fully functioning gas (see figure, above).
pedal (the reward system) but weak The adolescent brain is often likened to a car
brakes (the prefrontal cortex). with a fully functioning gas pedal (the reward
system) but weak brakes (the prefrontal
cortex). Teenagers are highly motivated to
pursue pleasurable rewards and avoid pain,
* In this guide, the terms drugs and substances are used interchangeably to refer to tobacco, alcohol, illegal drugs, and prescription medications used
for nonmedical reasons.
‡ Specifying the period of adolescence is complicated because it may be defined by different variables, and policymakers and researchers may
disagree on the exact age boundaries. For purposes of this guide, adolescents are considered to be people between the ages of 12 and 17.

but their judgment and decision-making Despite popular belief, willpower alone
skills are still limited. This affects their ability is often insufficient to overcome an
to weigh risks accurately and make sound addiction. Drug use has compromised
decisions, including decisions about using
the very parts of the brain that make it
drugs. For these reasons, adolescents are
a major target for prevention messages
possible to “say no.”
promoting healthy, drug-free behavior and
giving young people encouragement and skills
to avoid the temptations of experimenting with and all the other highly motivating experiences for
drugs.3 teenagers—cause the release of this chemical in
moderate amounts. This reinforces behaviors that
Most teens do not escalate from trying drugs contribute to learning, health, well-being, and the
to developing an addiction or other substance strengthening of social bonds.
use disorder;* however, even experimenting
with drugs is a problem. Drug use can be Drugs, unfortunately, are able to hijack this process.
part of a pattern of risky behavior including The “high” produced by drugs represents a flooding
unsafe sex, driving while intoxicated, or other of the brain’s reward circuits with much more
hazardous, unsupervised activities. And in dopamine than natural rewards generate. This
cases when a teen does develop a pattern of creates an especially strong drive to repeat the
repeated use, it can pose serious social and experience. The immature brain, already struggling
health risks, including: with balancing impulse and self-control, is more
• school failure likely to take drugs again without adequately
considering the consequences.4 If the experience
• problems with family and other relationships
is repeated, the brain reinforces the neural links
• loss of interest in normal healthy activities between pleasure and drug-taking, making the
• impaired memory association stronger and stronger. Soon, taking
• increased risk of contracting an infectious the drug may assume an importance in the
disease (like HIV or hepatitis C) via risky adolescent’s life out of proportion to other rewards.
sexual behavior or sharing contaminated
The development of addiction is like a vicious
injection equipment
cycle: Chronic drug use not only realigns a person’s
• mental health problems—including priorities but also may alter key brain areas
substance use disorders of varying severity necessary for judgment and self-control, further
• the very real risk of overdose death reducing the individual’s ability to control or stop
their drug use. This is why, despite popular belief,
How drug use can progress to addiction. willpower alone is often insufficient to overcome
Different drugs affect the brain differently, but an addiction. Drug use has compromised the very
a common factor is that they all raise the level parts of the brain that make it possible to “say no.”
of the chemical dopamine in brain circuits that
control reward and pleasure. Not all young people are equally at risk for
developing an addiction. Various factors including
The brain is wired to encourage life-sustaining inherited genetic predispositions and adverse
and healthy activities through the release experiences in early life make trying drugs and
of dopamine. Everyday rewards during developing a substance use disorder more likely.
adolescence—such as hanging out with Exposure to stress (such as emotional or physical
friends, listening to music, playing sports, abuse) in childhood primes the brain to be sensitive
* For purposes of this guide, the term addiction refers to compulsive drug seeking and use that persists even in the face of devastating consequences;
it may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5, 2013). The spectrum of substance use disorders in the DSM-5 includes the criteria for the DSM-4 diagnostic categories of abuse and
dependence.

Adolescents Differ from Adults in Substances Most Abused
80
12 – 17
18 – 25
70
Percent of those who received past-year treatment 26+
66.5
60
50
65.5
57.2
40
38.7
46.3
30
42.9
33.1
42.6
20
17.1
18.3
6.7
10
12.6
4.6
12.4
11.7
11.1
3.3
3.0
9.9
8.7
0 8.6
Alcohol Marijuana Prescription Cocaine Heroin Hallucinogens Inhalants
Drugs
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.
to stress and seek relief from it throughout age 13 or younger develop a substance use
life; this greatly increases the likelihood of disorder at some time in their lives.9 Tobacco,
subsequent drug abuse and of starting drug use alcohol, and marijuana are the first addictive
early.5 In fact, certain traits that put a person substances most people try. Data collected
at risk for drug use, such as being impulsive in 2012 found that nearly 13 percent of those
or aggressive, manifest well before the first with a substance use disorder began using
episode of drug use and may be addressed marijuana by the time they were 14.10
by prevention interventions during childhood.6
By the same token, a range of factors, such When substance use disorders occur in
as parenting that is nurturing or a healthy adolescence, they affect key developmental
school environment, may encourage healthy and social transitions, and they can interfere
development and thereby lessen the risk of later with normal brain maturation. These potentially
drug use. lifelong consequences make addressing
adolescent drug use an urgent matter. Chronic
Drug use at an early age is an important marijuana use in adolescence, for example, has
predictor of development of a substance use been shown to lead to a loss of IQ that is not
disorder later. The majority of those who have recovered even if the individual quits using in
a substance use disorder started using before adulthood.11 Impaired memory or thinking ability
age 18 and developed their disorder by age 20.7 and other problems caused by drug use can
The likelihood of developing a substance use derail a young person’s social and educational
disorder is greatest for those who begin use in development and hold him or her back in life.
their early teens. For example, 15.2 percent of
people who start drinking by age 14 eventually The serious health risks of drugs compound
develop alcohol abuse or dependence (as the need to get an adolescent who is abusing
compared to just 2.1 percent of those who wait drugs into treatment as quickly as possible.
until they are 21 or older),8 and 25 percent of Also, adolescents who are abusing drugs are
those who begin abusing prescription drugs at likely to have other issues such as mental health

problems accompanying and possibly contributing substance use problems often feel they do
to their substance use, and these also need to not need help, engaging young patients in
be addressed.12 Unfortunately, less than one treatment often requires special skills and
third of adolescents admitted to substance abuse patience.
treatment who have other mental health issues
receive any care for their conditions.13 Many treatment approaches are available to
address the unique needs of adolescents.
Adolescents’ drug use and treatment needs The focus of this guide is on evidence-based
differ from those of adults. Adolescents in treatment approaches―those that have been
treatment report abusing different substances than scientifically tested and found to be effective
adult patients do. For example, many more people in the treatment of adolescent substance
aged 12–17 received treatment for marijuana abuse. Whether delivered in residential or
use than for alcohol use in 2011 (65.5 percent inpatient settings or offered on an outpatient
versus 42.9 percent), whereas it was the reverse basis, effective treatments for adolescents
for adults (see figure, page 5). When adolescents primarily consist of some form of behavioral
do drink alcohol, they are more likely than adults therapy. Addiction medications, while effective
to binge drink (defined as five or more drinks in a and widely prescribed for adults, are not
row on a single occasion).14 Adolescents are less generally approved by the U.S. Food and
likely than adults to report withdrawal symptoms Drug Administration (FDA) for adolescents.
when not using a drug, being unable to stop However, preliminary evidence from controlled
using a drug, or continued use of a drug in spite trials suggest that some medications may
of physical or mental health problems; but they assist adolescents in achieving abstinence,
are more likely than adults to report hiding their so providers may view their young patients’
substance use, getting complaints from others needs on a case-by-case basis in developing a
about their substance use, and continuing to use personalized treatment plan.
in spite of fights or legal trouble.
Whatever a person’s age, treatment is not “one
Adolescents also may be less likely than adults size fits all.” It requires taking into account the
to feel they need help or to seek treatment on needs of the whole person—including his or
their own. Given their shorter histories of using her developmental stage and cognitive abilities
drugs (as well as parental protection), adolescents and the influence of family, friends, and others
may have experienced relatively few adverse in the person’s life, as well as any additional
consequences from their drug use; their incentive mental or physical health conditions. Such
to change or engage in treatment may correspond issues should be addressed at the same time
to the number of such consequences they have as the substance use treatment. When treating
experienced.15 Also, adolescents may have more adolescents, clinicians must also be ready
difficulty than adults seeing their own behavior and able to manage complications related to
patterns (including causes and consequences of their young patients’ confidentiality and their
their actions) with enough detachment to tell they dependence on family members who may or
need help. may not be supportive of recovery.
Only 10 percent of 12- to 17-year-olds needing Supporting Ongoing Recovery—Sustaining

substance abuse treatment actually receive any Treatment Gains and Preventing Relapse
services.16 When they do get treatment, it is often Enlisting and engaging the adolescent in
for different reasons than adults. By far, the largest treatment is only part of a sometimes long and
proportion of adolescents who receive treatment complex recovery process.17 Indeed, treatment
are referred by the juvenile justice system (see is often seen as part of a continuum of care.
figure, page 7). Given that adolescents with When an adolescent requires substance

Number of Adolescents Aged 12–17 Admitted to Publicly Funded
Substance Abuse Treatment Facilities on an Average Day, by Principal
Source of Referral: Treatment Episode Data Set 2008*
200
184
150
100
50 63
46 43
28 18
0 Juvenile Self or Community Schools Treatment Other
Justice Others Organizations Providers Health
System Care
Professionals
Source: 2008 SAMHSA Treatment Episode Data Set (TEDS)
abuse treatment, follow-up care and recovery monitoring by the adolescent, parents, and
support (e.g., mutual-help groups like 12-step teachers, as well as follow-up by treatment
programs) may be important for helping teens providers. Although recovery support programs
stay off drugs and improving their quality of life. are not a substitute for formal evidence-based
treatment, they may help some adolescents
When substance use disorders are identified maintain a positive and productive drug-free
and treated in adolescence—especially if they lifestyle that promotes meaningful and beneficial
are mild or moderate—they frequently give relationships and connections to family, peers,
way to abstinence from drugs with no further and the community both during treatment and
problems. Relapse is a possibility, however, as after treatment ends. Whatever services or
it is with other chronic diseases like diabetes programs are used, an adolescent’s path to
or asthma. Relapse should not be seen as a recovery will be strengthened by support from
sign that treatment failed but as an occasion family members, non-drug-using peers, the
to engage in additional or different treatment. school, and others in his or her life.
Averting and detecting relapse involves
* “Treatment providers” in this chart refers to “alcohol/drug abuse care providers.” Treatment providers can and do refer people to treatment if, for
example, a person is transferring from one level of treatment to another and the original facility does not provide the level of treatment that the person
needs, or if a person changes facilities for some other reason. “Other health care professionals” refers to physicians, psychiatrists, or other licensed
health care professionals or general hospitals, psychiatric hospitals, mental health programs, or nursing homes.

II. Principles of Adolescent
Substance Use Disorder
Treatment

1. Adolescent substance use needs to
be identified and addressed as soon
as possible. Drugs can have long-lasting
effects on the developing brain and
may interfere with family, positive peer
relationships, and school performance.
Most adults who develop a substance use
disorder report having started drug use in
adolescence or young adulthood, so it is
important to identify and intervene in drug
use early.
2. Adolescents can benefit from a drug

abuse intervention even if they are
not addicted to a drug.18 Substance use
disorders range from problematic use to
addiction and can be treated successfully
at any stage, and at any age. For young
people, any drug use (even if it seems 4. Legal interventions and sanctions or
like only “experimentation”), is cause for family pressure may play an important
concern, as it exposes them to dangers role in getting adolescents to enter, stay
from the drug and associated risky in, and complete treatment. Adolescents
behaviors and may lead to more drug use with substance use disorders rarely feel
in the future. Parents and other adults they need treatment and almost never
should monitor young people and not seek it on their own. Research shows that
underestimate the significance of what may treatment can work even if it is mandated or
appear as isolated instances of drug taking. entered into unwillingly.22
3. Routine annual medical visits are 5. Substance use disorder treatment

an opportunity to ask adolescents should be tailored to the unique
about drug use. Standardized screening needs of the adolescent. Treatment
tools are available to help pediatricians, planning begins with a comprehensive
dentists, emergency room doctors, assessment to identify the person’s
psychiatrists, and other clinicians determine strengths and weaknesses to be
an adolescent’s level of involvement (if addressed. Appropriate treatment considers
any) in tobacco, alcohol, and illicit and an adolescent’s level of psychological
nonmedical prescription drug use.19 When development, gender, relations with family
an adolescent reports substance use, and peers, how well he or she is doing in
the health care provider can assess its school, the larger community, cultural and
severity and either provide an onsite brief ethnic factors, and any special physical or
intervention or refer the teen to a substance behavioral issues.
abuse treatment program.20, 21

Components of Comprehensive
Drug Abuse Treatment
7. Behavioral therapies are effective
in addressing adolescent drug use.
Behavioral therapies, delivered by trained
clinicians, help an adolescent stay off drugs
Vocational
Services by strengthening his or her motivation to
Family
change. This can be done by providing
Services
Mental incentives for abstinence, building skills
Health to resist and refuse substances and deal
Assessment Services
Evidence-Based Treatment with triggers or craving, replacing drug use
Substance Use Monitoring with constructive and rewarding activities,
Legal
Services Clinical and Case Management improving problem-solving skills, and
Recovery Support Programs facilitating better interpersonal relationships.
Medical
Continuing Care Services
8. Families and the community are

HIV/AIDS
important aspects of treatment. The
Services Educational
Services
support of family members is important
for an adolescent’s recovery. Several
evidence-based interventions for adolescent
drug abuse seek to strengthen family
The best treatment programs provide a combination of therapies
and other services to meet the needs of the individual patient. relationships by improving communication
and improving family members’ ability to
support abstinence from drugs. In addition,
members of the community (such as school
6. Treatment should address the needs counselors, parents, peers, and mentors)
of the whole person, rather than can encourage young people who need help
just focusing on his or her drug to get into treatment—and support them
use. The best approach to treatment along the way.
includes supporting the adolescent’s
larger life needs, such as those related
to medical, psychological, and social 9. Effectively treating substance use
well-being, as well as housing, school, disorders in adolescents requires
transportation, and legal services. also identifying and treating any other
Failing to address such needs mental health conditions they may have.
simultaneously could sabotage the Adolescents who abuse drugs frequently
adolescent’s treatment success. also suffer from other conditions including
depression, anxiety disorders, attention-
deficit hyperactivity disorder (ADHD),
oppositional defiant disorder, and conduct
problems.23 Adolescents who abuse drugs,
particularly those involved in the juvenile
justice system, should be screened for other
Many adolescents who abuse drugs psychiatric disorders. Treatment for these
have a history of physical, emotional, problems should be integrated with the
and/or sexual abuse or other trauma. treatment for a substance use disorder.

10. Sensitive issues such as violence
and child abuse or risk of
suicide should be identified and
addressed. Many adolescents who
abuse drugs have a history of physical,
emotional, and/or sexual abuse or
other trauma.24 If abuse is suspected,
referrals should be made to social
and protective services, following local
regulations and reporting requirements.
11. It is important to monitor drug use

during treatment. Adolescents recovering
from substance use disorders may
experience relapse, or a return to drug
use. Triggers associated with relapse
vary and can include mental stress and
social situations linked with prior drug A relapse signals the need for more
use. It is important to identify a return treatment or a need to adjust the
to drug use early before an undetected
relapse progresses to more serious
individual’s current treatment plan.
consequences. A relapse signals the need
for more treatment or a need to adjust the
individual’s current treatment plan to better 13. Testing adolescents for sexually
meet his or her needs. transmitted diseases like HIV, as well
as hepatitis B and C, is an important
part of drug treatment. Adolescents
12. Staying in treatment for an adequate who use drugs—whether injecting or
period of time and continuity of care non-injecting—are at an increased risk
afterward are important. The minimal for diseases that are transmitted sexually
length of drug treatment depends on as well as through the blood, including
the type and extent of the adolescent’s HIV and hepatitis B and C. All drugs
problems, but studies show outcomes are of abuse alter judgment and decision
better when a person stays in treatment for making, increasing the likelihood that an
3 months or more.25 Because relapses often adolescent will engage in unprotected
occur, more than one episode of treatment sex and other high-risk behaviors
may be necessary. Many adolescents including sharing contaminated drug
also benefit from continuing care following injection equipment and unsafe tattooing
treatment,26 including drug use monitoring, and body piercing practices––potential
follow-up visits at home,27 and linking the routes of virus transmission. Substance
family to other needed services. use treatment can reduce this risk both
by reducing adolescents’ drug use (and
thus keeping them out of situations in
which they are not thinking clearly) and
by providing risk-reduction counseling to
help them modify or change their high-
risk behaviors.28,29

III. FREQUENTLY ASKED QUESTIONS

1. Why do adolescents glues, or pens; see “The Dangers of Inhalants,”
take drugs? page 15), whereas older teens are more likely
to use synthetic marijuana (“K2” or “Spice”) and
Adolescents experiment with drugs or continue prescription medications—particularly opioid
taking them for several reasons, including: pain relievers like Vicodin® and stimulants like
Adderall®. In fact, the Monitoring the Future
• To fit in: Many teens use drugs “because
survey of adolescent drug use and attitudes
others are doing it”—or they think others
shows that prescription and over-the-counter
are doing it—and they fear not being
medications account for a majority of the drugs
accepted in a social circle that includes
drug-using peers. most commonly abused by high-school seniors.
• To feel good: Abused drugs interact with
the neurochemistry of the brain to produce
feelings of pleasure. The intensity of this Most Commonly Abused Drugs by
euphoria differs by the type of drug and how High School Seniors (Other than
it is used.
Tobacco and Alcohol)
• To feel better: Some adolescents suffer
from depression, social anxiety, stress-
Marijuana
related disorders, and physical pain. Using 40
drugs may be an attempt to lessen these
feelings of distress. Stress especially plays
a significant role in starting and continuing 35
drug use as well as returning to drug use ■ Illegal Drugs
36.4
Percent of High School Seniors Using in the Past Year
■ Prescription or OTC Drugs
(relapsing) for those recovering from an
addiction.
30
• To do better: Ours is a very competitive
society, in which the pressure to perform
athletically and academically can be
25
intense. Some adolescents may turn to
certain drugs like illegal or prescription
stimulants because they think those
substances will enhance or improve their 20
Prescription Painkillers*
performance.
Synthetic Marijuana
• To experiment: Adolescents are often

Amphetamines A
motivated to seek new experiences, 15

particularly those they perceive as thrilling
Cough Medicine
or daring. MDMA (Ecstasy)

Hallucinogens
Tranquilizers
10
Sedatives
2. What drugs are most

frequently used by
Salvia
adolescents? 5
8.7
7.9
7.1
Alcohol and tobacco are the drugs most

5.0
4.8
4.5
4.6
4.0
3.4
commonly abused by adolescents, followed by

0
marijuana. The next most popular substances
differ between age groups. Young adolescents The top drug used in this category is Adderall (7.4%)
A
*The top drugs used in this category are Vicodin (5.3%) and OxyContin (3.6%)
tend to favor inhalant substances (such as Source: Monitoring the Future National Results on Adolescent
breathing the fumes of household cleaners, Drug Use: Summary of Key Findings, 2013.

3. How do adolescents
become addicted to
drugs, and which factors
increase risk?
Addiction occurs when repeated use of drugs
changes how a person’s brain functions over
time. The transition from voluntary to compulsive
drug use reflects changes in the brain’s natural
inhibition and reward centers that keep a
person from exerting control over the impulse
to use drugs even when there are negative
consequences—the defining characteristic of
addiction.
Some people are more vulnerable to this
process than others, due to a range of possible
risk factors. Stressful early life experiences such
as being abused or suffering other forms of
trauma are one important risk factor. Adolescents Long-term marijuana users who try to quit
with a history of physical and/or sexual abuse report withdrawal symptoms including irritability,
are more likely to be diagnosed with substance sleeplessness, decreased appetite, anxiety, and
use disorders.30 Many other risk factors, drug craving, all of which can make it difficult
including genetic vulnerability, prenatal exposure to stay off the drug. Behavioral interventions,
to alcohol or other drugs, lack of parental including Cognitive-Behavioral Therapy and
supervision or monitoring, and association with Contingency Management (providing tangible
drug-using peers also play an important role.31 incentives to patients who remain drug-free)
have proven to be effective in treating marijuana
At the same time, a wide range of genetic and addiction (see Page 24 for descriptions of
environmental influences that promote strong these treatments). Although no medications
psychosocial development and resilience may are currently available to treat marijuana
work to balance or counteract risk factors, addiction, it is possible that medications to ease
making it ultimately hard to predict which marijuana withdrawal, block its intoxicating
individuals will develop substance use effects, and prevent relapse may emerge from
disorders and which won’t. recent discoveries about the workings of the
endocannabinoid system, a signaling system in
the body and brain that uses chemicals related
4. Is it possible for teens to the active ingredients in marijuana.
to become addicted to
Legalization of marijuana for adult recreational
marijuana? use and for medicinal purposes is currently
Yes. Contrary to common belief, marijuana is the subject of much public debate. Whatever
addictive. Estimates from research suggest that the outcome, public health experts are worried
about 9 percent of users become addicted to about use increasing among adolescents,
marijuana; this number increases among those since marijuana use as a teen may harm the
who start young (to about 17 percent, or 1 in developing brain, lower IQ, and seriously impair
6) and among daily users (to 25–50 percent).32 the ability to drive safely, especially when
Thus, many of the nearly 7 percent of high- combined with alcohol.
school seniors who (according to annual survey
Parents seeking more information about the
data)33 report smoking marijuana daily or almost
effects of marijuana on teens are encouraged
daily are well on their way to addiction, if not
to see information offered on NIDA’s Web
already addicted, and may be functioning at a
site: http://www.drugabuse.gov/drugs-abuse/
sub-optimal level in their schoolwork and in
marijuana.
other areas of their lives.

In the case of opioid pain relievers such
The Dangers of Inhalants as Vicodin® or OxyContin®, there is a great
risk of addiction and death from overdose
Various household products, including associated with such abuse. Especially when
cleaning fluids, glues, lighter fluid, aerosol pills are crushed and injected or snorted, these
sprays, and office supplies like markers medications affect the brain and body very much
and correction fluid, have fumes that are like heroin, including euphoric effects and a
sometimes breathed to obtain a brief, hazardous suppression of breathing (the reason
typically alcohol-like high. Because of their for death in cases of fatal opioid overdose).
ready availability, these are frequently In fact, some young people who develop
among the earliest substances youth abuse; prescription opioid addictions shift to heroin
they are generally less popular among older because it may be cheaper to obtain.35
teens, who have greater access to other
substances like alcohol or marijuana. ADHD medications such as Adderall® (which
contains the stimulant amphetamine) are
Although the high from inhalants typically increasingly popular among young people who
wears off quickly, immediate health take them believing it will improve their school
consequences of inhalant abuse may be performance. This too is a dangerous trend.
severe: In addition to nausea or vomiting, Prescription stimulants act in the brain similarly
users risk suffocation and heart failure— to cocaine or illegal amphetamines, raising heart
called “sudden sniffing death.” Serious rate and blood pressure, as well as producing
long-term consequences include liver and an addictive euphoria. Other than promoting
kidney damage, hearing loss, bone marrow wakefulness, it is unclear that such medications
damage, and brain damage. Although actually provide much or any cognitive benefit,
addiction to inhalants is not very common, it however, beyond the benefits they provide when
can occur with repeated abuse. taken as prescribed to those with ADHD.36
Early abuse of inhalants may also be a
warning sign for later abuse of other drugs. 6. Are steroids addictive
One study found that youth who used and can steroid abuse be
inhalants before age 14 were twice as likely
treated?
to later use opiate drugs.34 So it is important
for parents to safeguard household products Some adolescents—mostly male—abuse
and be alert to signs that their younger anabolic-androgenic steroids in order to improve
teens may be abusing these substances. their athletic performance and/or improve their
appearance by helping build muscles. Steroid
abuse may lead to serious, even irreversible,
health problems including kidney impairment,
5. Is abuse of prescription liver damage, and cardiovascular problems that
medications as raise the risk of stroke and heart attack (even
dangerous as other in young people). An undetermined percentage
of steroid abusers may also become addicted
forms of illegal drug use? to the drugs—that is, continuing to use them
Psychoactive prescription drugs, which include despite physical problems and negative effects
opioid pain relievers, stimulants prescribed for on social relations—but the mechanisms
ADHD, and central nervous system depressants causing this addiction are more complex than
prescribed to treat anxiety or sleep disorders, are those for other drugs of abuse.
all effective and safe when taken as prescribed Steroids are not generally considered
by a doctor for the conditions they are intended intoxicating, but animal studies have shown that
to treat. However, they are frequently abused— chronic steroid use alters the same dopamine
that is, taken in other ways, in other quantities, reward pathways in the brain that are affected
or by people for whom they weren’t prescribed— by other substances. Other factors such as
and this can have devastating consequences. underlying body image problems also contribute
to steroid abuse.37 Moreover, when people stop

using steroids, they can experience withdrawal 8. Does treatment of
symptoms such as hormonal changes that ADHD with stimulant
produce fatigue, loss of muscle mass and sex
drive, and other unpleasant physical changes. medications like Ritalin®
One of the more dangerous withdrawal and Adderall® increase
symptoms is depression, which has led to risk of substance abuse
suicide in some people discontinuing steroids. later in life?
Steroid abuse is also frequently complicated
by abuse of other substances taken either as Prescription stimulants are effective at treating
part of a performance-enhancing regimen (such attention disorders in children and adolescents,
as stimulants) or to help manage pain-, sleep-, but concerns have been raised that they could
or mood-related side effects (such as opioids, make a young person more vulnerable to
cannabis, and alcohol).38 developing later substance use disorders. On
balance, the studies conducted so far have
Because of this complicated mix of issues, found no differences in later substance use for
treatment for steroid abuse necessarily involves ADHD-affected children who received treatment
addressing all related mental and physical versus those that did not. This suggests that
health issues and substance use disorders treatment with ADHD medication does not affect
simultaneously. This may involve behavioral (either negatively or positively) an individual’s
treatments as well as medications to help risk for developing a substance use disorder.39
normalize the hormonal system and treat
any depression or pain issues that may be
present. If symptoms are severe or prolonged, 9. What are signs of drug
hospitalization may be needed. use in adolescents,
and what role can
7. How do other mental parents play in getting
health conditions relate treatment?
to substance use in
If an adolescent starts behaving differently for
adolescents? no apparent reason––such as acting withdrawn,
Drug use in adolescents frequently overlaps with frequently tired or depressed, or hostile–it could
other mental health problems. For example, a be a sign he or she is developing a drug-related
teen with a substance use disorder is more likely problem. Parents and others may overlook such
to have a mood, anxiety, learning, or behavioral signs, believing them to be a normal part of
disorder too. Sometimes drugs can make puberty.
accurately diagnosing these other problems Other signs include:
complicated. Adolescents may begin taking
drugs to deal with depression or anxiety, for • a change in peer group
example; on the other hand, frequent drug use • carelessness with grooming
may also cause or precipitate those disorders. • decline in academic performance
Adolescents entering drug abuse treatment
should be given a comprehensive mental health • missing classes or skipping school
screening to determine if other disorders are • loss of interest in favorite activities
present. Effectively treating a substance use • changes in eating or sleeping habits
disorder requires addressing drug abuse and
• deteriorating relationships with family
other mental health problems simultaneously.
members and friends
Parents tend to underestimate the risks or
Addiction occurs when repeated use seriousness of drug use. The symptoms listed
of drugs changes how a person’s here suggest a problem that may already have
become serious and should be evaluated to
brain functions over time. determine the underlying cause—which could
be a substance abuse problem or another

11. What role can medical
professionals play in
addressing substance
abuse (including abuse of
prescription drugs) among
adolescents?
Medical professionals have an important role to
play in screening their adolescent patients for
drug use, providing brief interventions, referring
them to substance abuse treatment if necessary,
and providing ongoing monitoring and follow-up.
Screening and brief interventions do not have to be
mental health or medical disorder. Parents who time-consuming and can be integrated into general
are unsure whether their child is abusing drugs medical settings.
can enlist the help of a primary care physician, • Screening. Screening and brief assessment
school guidance counselor, or drug abuse tools administered during annual routine
treatment provider. medical checkups can detect drug use before
it becomes a serious problem. The purpose
Parents seeking treatment for an adolescent of screening is to look for evidence of any use
child are encouraged to see NIDA’s booklet, of alcohol, tobacco, or illicit drugs or abuse of
Seeking Drug Abuse Treatment: Know What to prescription drugs and assess how severe the
Ask (http://www.drugabuse.gov/publications/ problem is. Results from such screens can
seeking-drug-abuse-treatment) and see the indicate whether a more extensive assessment
Treatment Referral Resources section of this and possible treatment are necessary (see
guide (page 31). “Screening Tools and Brief Assessments Used
with Adolescents,” below).40 Screening as a
10. How can parents part of routine care also helps to reduce the
stigma associated with being identified as
participate in their having a drug problem.
adolescent child’s
treatment?
Screening Tools and Brief
Parents can actively support their child and Assessments Used with
engage with him or her during the treatment and
recovery process. Apart from providing moral Adolescents
and emotional support, parents can also play a
Screening tools are available and outlined
crucial role in supporting the practical aspects
in the American Academy of Pediatrics
of treatment, such as scheduling and making
(AAP) publications, Tobacco, Alcohol, and
appointments, as well as providing needed
Other Drugs: The Role of the Pediatrician in
structure and supervision through household
Prevention, Identification, and Management
rules and monitoring. Also, several evidence-
of Substance Abuse41 and Substance Use
based treatments for adolescents specifically
Screening, Brief Intervention and Referral to
address drug abuse within the family context.
Treatment for Pediatricians.42
Family-based drug abuse treatment can help
improve communication, problem-solving, In addition, the Alcohol Screening and Brief
and conflict resolution within the household. Intervention for Youth: A Practitioner’s Guide
Treatment professionals can help parents developed by the National Institute on Alcohol
and other family members identify ways they Abuse and Alcoholism provides information
can support the changes the adolescent on identifying adolescents at high risk for
achieves through treatment (see “Family-Based alcohol abuse.43
Approaches,” pages 25–26).

• Brief Intervention. Adolescents who report Common treatment approaches like Cognitive-
using drugs can be given a brief intervention Behavioral Therapy are now being used
to reduce their drug use and other risky to help adolescents quit smoking (and quit
behaviors. Specifically, they should be using other drugs) by helping them “train their
advised how continued drug use may harm brains” so they learn to recognize and control
their brains, general health, and other areas their cravings and better deal with life stress.
of their life, including family relationships Other therapies like Contingency Management
and education. Adolescents reporting no and Motivational Enhancement use incentives
substance use can be praised for staying and motivation techniques to help teens
away from drugs and rescreened during their reduce or stop smoking.44 (See page 24 for
next physical. descriptions of these treatments.)
• Referral. Adolescents with substance Tobacco use often accompanies other drug
use disorders or those that appear to be use and needs to be addressed as part of
developing a substance use disorder may other substance use disorder treatment. In
need a referral to substance abuse treatment a recent survey, nearly 55 percent of current
for more extensive assessment and care. adolescent cigarette smokers (ages 12 to 17)
• Follow-up. For patients in treatment, medical were also illicit drug users (by comparison,
professionals can offer ongoing support of only about 6 percent of those who did
treatment participation and abstinence from not smoke used any illicit drugs).45 Also,
drugs during follow-up visits. Adolescent cigarette smoking can be an indicator of other
patients who relapse or show signs of psychiatric disorders, which can be identified
continuing to use drugs may need to be through comprehensive screening
referred back to treatment. by a treatment provider.
• Before prescribing medications that can
potentially be abused, clinicians can assess 13. Are there medications
patients for risk factors such as mental illness
or a family history of substance abuse, to treat adolescent
consider an alternative medication with less substance abuse?
abuse potential, more closely monitor patients
at high risk, reduce the length of time between Several medications are approved by the
visits for refills so fewer pills are on hand, FDA to treat addiction to opioids, alcohol, and
and educate both patients and their parents nicotine in individuals 18 and older. In most
about appropriate use and potential risks cases, little research has been conducted
of prescription medications, including the to evaluate the safety and efficacy of these
dangers of sharing them with others. medications for adolescents; however,
some health care providers do use these
medications “off-label,” especially in older
12. Is adolescent tobacco use adolescents (see “Addiction Medications,”
treated similarly to other pages 26–28).
drug use?
14. Do girls and boys have
Yes. People often don’t think of tobacco use as a
kind of “drug abuse” that requires treatment, and different treatment
motives for quitting smoking may be somewhat needs?
different than motives for quitting other drugs.
But tobacco use has well-known health risks–– Adolescent girls and boys may have different
especially when begun in the teen years––and developmental and social issues that may
the highly addictive nicotine in tobacco can make call for different treatment strategies or
treatment a necessity to help an adolescent quit. emphases. For example, girls with substance
Laboratory research also suggests that nicotine use disorders may be more likely to also have
may increase the rewarding and addictive effects mood disorders such as depression or to have
of other drugs, making it a potential contributor to experienced physical or sexual abuse. Boys
other substance use disorders. with substance use disorders are more likely

to also have conduct, behavioral, and learning
problems, which may be very disruptive to their
school, family, or community. Treatments should
take into account the higher rate of internalizing
and traumatic stress disorders among adolescent
girls, the higher rate of externalizing disruptive
disorders and juvenile justice problems among
adolescent boys, and other gender differences
that may play into adolescent substance use
disorders.
15. What are the unique

treatment needs of
adolescents from
different racial/ethnic Coordination and collaboration between juvenile
justice professionals, drug abuse treatment
backgrounds?
providers, and other social service agencies
Treatment providers are urged to consider the are essential in getting needed treatment to
unique social and environmental characteristics adolescent offenders, about one half of whom
that may influence drug abuse and treatment have substance use disorders.48
for racial/ethnic minority adolescents, such as
stigma, discrimination, and sparse community
17. What role do 12-step
resources. With the growing number of immigrant
children living in the United States, issues of groups or other recovery
culture of origin, language, and acculturation support services play in
are important considerations for treatment. The addiction treatment for
demand for bilingual treatment providers to work adolescents?
with adolescents and their families will also be
increasing as the diversity of the U.S. population Adolescents may benefit from participation
increases. in self- or mutual-help groups like 12-step
programs or other recovery support services,
which can reinforce abstinence from drug use
16. What role can the and other changes made during treatment, as
juvenile justice system well as support progress made toward important
play in addressing goals like succeeding in school and reuniting
adolescent drug abuse? with family. Peer recovery support services and
recovery high schools provide a community
Involvement in the juvenile justice system is setting where fellow recovering adolescents can
unfortunately a reality for many substance- share their experiences and support each other
abusing adolescents, but it presents a valuable in living a drug-free life.
opportunity for intervention. Substance use
treatment can be incorporated into the juvenile It is important to note that recovery support
justice system in several ways. These include: services are not a substitute for drug abuse
treatment. Also, there is sometimes a risk in
• screening and assessment for drug abuse support-group settings that conversation among
upon arrest adolescents can turn to talk extolling drug use;
• initiation of treatment while awaiting trial group leaders need to be aware of such a
• access to treatment programs in the community possibility and be ready to direct the discussion
in lieu of incarceration (e.g., juvenile treatment in more positive directions if necessary.
drug courts)46,47
• treatment during incarceration followed by
community-based treatment after release

IV. TREATMENT SETTINGS

T
reatment for substance use disorders mental health problems, and a supportive living
is delivered at varying levels of care environment, although evidence suggests that
in many different settings. Because more severe cases can be treated in outpatient
no single treatment is appropriate settings as well. Outpatient treatment varies in
for every adolescent, treatments the type and intensity of services offered and
must be tailored for the individual. Based on may be delivered on an individual basis or in
the consensus of drug treatment experts, the a group format (although research suggests
American Society of Addiction Medicine (ASAM) group therapy can carry certain risks; see
has developed guidelines for determining the “Group Therapy for Adolescents,” page 23).
appropriate intensity and length of treatment for Low- or moderate-intensity outpatient care
adolescents with substance abuse problems, is generally delivered once or twice a week.
based on an assessment involving six areas:49 Intensive outpatient services are delivered more
frequently, typically more than twice a week for
(1) Level of intoxication and potential for at least 3 hours per day. Outpatient programs
withdrawal may offer drug abuse prevention programming
(2) Presence of other medical conditions (focused on deterring further drug use) or other
(3) Presence of other emotional, behavioral, or behavioral and family interventions.50,51
cognitive conditions
Partial Hospitalization
(4) Readiness or motivation to change
Adolescents with more severe substance use
(5) Risk of relapse or continued drug use disorders but who can still be safely managed
(6) Recovery environment (e.g., family, peers, in their home living environment may be
school, legal system) referred to a higher level of care called partial
hospitalization or “day treatment.” This setting
With a substance use disorder—as with any offers adolescents the opportunity to participate
other medical condition—treatment must in treatment 4–6 hours a day at least 5 days a
be long enough and strong enough to be week while living at home.52
effective. Just as an antibiotic must be taken for
sufficient time to kill a bacterial infection, even Residential/Inpatient Treatment
though symptoms may already have subsided, Residential treatment is a resource-intense high
substance abuse treatment must continue for level of care, generally for adolescents with
a sufficient length of time to treat the disease. severe levels of addiction whose mental health
Undertreating a substance use disorder— and medical needs and addictive behaviors
providing lower than the recommended level require a 24-hour structured environment to
of care or a shorter length of treatment than make recovery possible. These adolescents
recommended—will increase the risk of relapse may have complex psychiatric or medical
and could cause the patient, his or her family problems or family issues that interfere with
members, or the referring juvenile justice system their ability to avoid substance use. One well-
to lose hope in the treatment because they will known long-term residential treatment model
see it as ineffective. is the therapeutic community (TC). TCs use
This section will review the settings in which a combination of techniques to “resocialize”
adolescent drug abuse treatment most often the adolescent and enlist all the members of
occurs. the community, including residents and staff,
as active participants in treatment. Treatment
Outpatient/Intensive Outpatient focuses on building personal and social
Adolescent drug abuse treatment is most responsibility and developing new coping skills.
commonly offered in outpatient settings. When Such programs offer a range of family services
delivered by well-trained clinicians, this can and may require family participation if the TC is
be highly effective. Outpatient treatment is sufficiently close to where the family lives. Short-
traditionally recommended for adolescents term residential programs also exist.53
with less severe addictions, few additional

V. EVIDENCE-BASED
APPROACHES TO
TREATING ADOLESCENT
SUBSTANCE USE
DISORDERS

R
esearch evidence supports the
effectiveness of various substance
Group Therapy for Adolescents
abuse treatment approaches for
adolescents. Examples of specific Adolescents can participate in group
evidence-based approaches therapy and other peer support programs
are described below, including behavioral during and following treatment to help them
and family-based interventions as well as achieve abstinence. When led by well-
medications. Each approach is designed trained clinicians following well-validated
to address specific aspects of adolescent Cognitive-Behavioral Therapy (CBT)
drug use and its consequences for the protocols (see page 24), groups can provide
individual, family, and society. In order for positive social reinforcement through peer
any intervention to be effective, the clinician discussion and help enforce incentives
providing it needs to be trained and well- to staying off drugs and living a drug-free
supervised to ensure that he or she adheres lifestyle.
to the instructions and guidance described in However, group treatment for adolescents
treatment manuals. Most of these treatments carries a risk of unintended adverse effects:
have been tested over short periods of Group members may steer conversation
12–16 weeks, but for some adolescents, toward talk that glorifies or extols drug
longer treatments may be warranted; such a use, thereby undermining recovery goals.
decision is made on a case-by-case basis. Trained counselors need to be aware of that
The provider should use clinical judgment possibility and direct group activities and
to select the evidence-based approach that discussions in a positive direction.
seems best suited to the patient and his or
her family.*
BEHAVIORAL APPROACHES Adolescent Community

Reinforcement Approach (A-CRA)
Behavioral interventions help adolescents
to actively participate in their recovery from A-CRA is an intervention that seeks to help
drug abuse and addiction and enhance their adolescents achieve and maintain abstinence
ability to resist drug use. In such approaches, from drugs by replacing influences in their
therapists may provide incentives to remain lives that had reinforced substance use with
abstinent, modify attitudes and behaviors healthier family, social, and educational or
related to drug abuse, assist families in vocational reinforcers. After assessing the
improving their communication and overall adolescent’s needs and levels of functioning,
interactions, and increase life skills to the therapist chooses from among 17 A-CRA
handle stressful circumstances and deal procedures to address problem-solving, coping,
with environmental cues that may trigger and communication skills and to encourage
intense craving for drugs. Below are some active participation in constructive social and
behavioral treatments shown to be effective in recreational activities.54
addressing substance abuse in adolescents
(listed in alphabetical order).
* The treatments listed in this book are not intended to be a comprehensive list of efficacious evidence-based treatment approaches for adolescents.
NIDA continues supporting research developing new approaches to address adolescent drug abuse.

Cognitive-Behavioral Therapy (CBT) Motivational Enhancement Therapy
CBT strategies are based on the theory that (MET)
learning processes play a critical role in the MET is a counseling approach that helps
development of problem behaviors like drug adolescents resolve their ambivalence about
abuse. A core element of CBT is teaching engaging in treatment and quitting their drug
participants how to anticipate problems and use. This approach, which is based on a
helping them develop effective coping strategies. technique called motivational interviewing,
In CBT, adolescents explore the positive and typically includes an initial assessment of
negative consequences of using drugs. They the adolescent’s motivation to participate in
learn to monitor their feelings and thoughts and treatment, followed by one to three individual
recognize distorted thinking patterns and cues sessions in which a therapist helps the patient
that trigger their substance abuse; identify and develop a desire to participate in treatment by
anticipate high-risk situations; and apply an providing non-confrontational feedback. Being
array of self-control skills, including emotional empathic yet directive, the therapist discusses
regulation and anger management, practical the need for treatment and tries to elicit self-
problem solving, and substance refusal. CBT motivational statements from the adolescent
may be offered in outpatient settings in either to strengthen his or her motivation and build
individual or group sessions (see “Group a plan for change. If the adolescent resists,
Therapy for Adolescents,” page 23) or in the therapist responds neutrally rather than by
residential settings.55 contradicting or correcting the patient. MET,
while better than no treatment, is typically not
Contingency Management (CM) used as a stand-alone treatment for adolescents
Research has demonstrated the effectiveness with substance use disorders but is used to
of treatment using immediate and tangible motivate them to participate in other types of
reinforcements for positive behaviors to modify treatment.57
problem behaviors like substance abuse. This
approach, known as Contingency Management Twelve-Step Facilitation Therapy
(CM), provides adolescents an opportunity Twelve-Step Facilitation Therapy is designed to
to earn low-cost incentives such as prizes or increase the likelihood that an adolescent with
cash vouchers (for food items, movie passes, a drug abuse problem will become affiliated
and other personal goods) in exchange for and actively involved in a 12-step program
participating in drug treatment, achieving like Alcoholics Anonymous (AA) or Narcotics
important goals of treatment, and not using Anonymous (NA). Such programs stress the
drugs. The goal of CM is to weaken the influence participant’s acceptance that life has become
of reinforcement derived from using drugs and unmanageable, that abstinence from drug use
to substitute it with reinforcement derived from is needed, and that willpower alone cannot
healthier activities and drug abstinence. For overcome the problem. The benefits of 12-
adolescents, CM has been offered in a variety step participation for adults in extending the
of settings, and parents can be trained to apply benefits of addiction treatment appear to apply
this method at home. CM is typically combined to adolescent outpatients as well, according
either with a psychosocial treatment or a to recent research. Research also suggests
medication (where available). Recent evidence adolescent-specific 12-step facilitation strategies
also supports the use of Web-based CM to help may help enhance outpatient attendance rates.58
adolescents stop smoking.56
Behavioral interventions help adolescents to actively participate in their
recovery from drug abuse and addiction and enhance their ability to resist
drug use.

FAMILY-BASED APPROACHES
Family-based approaches to treating
adolescent substance abuse highlight
the need to engage the family, including
parents, siblings, and sometimes peers,
in the adolescent’s treatment. Involving
the family can be particularly important,
as the adolescent will often be living with
at least one parent and be subject to the
parent’s controls, rules, and/or supports.
Family-based approaches generally address
a wide array of problems in addition to the
young person’s substance problems, including
family communication and conflict; other co-
occurring behavioral, mental health, and
learning disorders; problems with school or
work attendance; and peer networks. Research
shows that family-based treatments are highly
efficacious; some studies even suggest they are interaction patterns. BSFT can be adapted to
superior to other individual and group treatment a broad range of family situations in various
approaches.59 Typically offered in outpatient settings (mental health clinics, drug abuse
settings, family treatments have also been tested treatment programs, social service settings,
successfully in higher-intensity settings such as families’ homes) and treatment modalities (as a
residential and intensive outpatient programs. primary outpatient intervention, in combination
Below are specific types of family-based with residential or day treatment, or as an
treatments shown to be effective in treating aftercare/continuing-care service following
adolescent substance abuse. residential treatment).60
Brief Strategic Family Therapy (BSFT) Family Behavior Therapy (FBT)

BSFT is based on a family systems approach FBT, which has demonstrated positive results
to treatment, in which one member’s problem in both adults and adolescents, combines
behaviors are seen to stem from unhealthy behavioral contracting with contingency
family interactions. Over the course of 12–16 management to address not only substance
sessions, the BSFT counselor establishes a abuse but other behavioral problems as
relationship with each family member, observes well. The adolescent and at least one parent
how the members behave with one another, participate in treatment planning and choose
and assists the family in changing negative specific interventions from a menu of evidence-
based treatment options. Therapists encourage
family members to use behavioral strategies
taught in sessions and apply their new skills
Involving the family can be to improve the home environment. They set
particularly important in behavioral goals for preventing substance
adolescent substance abuse use and reducing risk behaviors for sexually
treatment. transmitted diseases like HIV, which are
reinforced through a contingency management
(CM) system (see description on page 24).
Goals are reviewed and rewards provided at
each session.61

Multidimensional Family Therapy
(MDFT)
MDFT is a comprehensive family- and
community-based treatment for substance-
abusing adolescents and those at high risk for
behavior problems such as conduct disorder
and delinquency. The aim is to foster family
competency and collaboration with other
systems like school or juvenile justice. Sessions
may take place in a variety of locations,
including in the home, at a clinic, at school, at
family court, or in other community locations.
MDFT has been shown to be effective even with
more severe substance use disorders and can
facilitate the reintegration of substance abusing
juvenile detainees into the community.63
Multisystemic Therapy (MST)

Functional Family Therapy (FFT) MST is a comprehensive and intensive family-
and community-based treatment that has been
FFT combines a family systems view of family shown to be effective even with adolescents
functioning (which asserts that unhealthy whose substance abuse problems are severe
family interactions underlie problem behaviors) and with those who engage in delinquent and/
with behavioral techniques to improve or violent behavior. In MST, the adolescent’s
communication, problem-solving, conflict substance abuse is viewed in terms of
resolution, and parenting skills. Principal characteristics of the adolescent (e.g., favorable
treatment strategies include (1) engaging attitudes toward drug use) and those of his or
families in the treatment process and enhancing her family (e.g., poor discipline, conflict, parental
their motivation for change and (2) modifying drug abuse), peers (e.g., positive attitudes
family members’ behavior using CM techniques, toward drug use), school (e.g., dropout, poor
communication and problem solving, behavioral performance), and neighborhood (e.g., criminal
contracts, and other methods.62 subculture). The therapist may work with the
family as a whole but will also conduct sessions
with just the caregivers or the adolescent
alone.64
ADDICTION MEDICATIONS
Undertreating a substance use Several medications have been found to
disorder will increase the risk of be effective in treating addiction to opioids,
relapse. alcohol, or nicotine in adults, although none of
these medications have been approved by the
FDA to treat adolescents. In most cases, only
preliminary evidence exists for the effectiveness
and safety of these medications in people
under 18, and there is no evidence on the
neurobiological impact of these medications

on the developing brain. However, despite Adolescent drug abuse treatment is
the relative lack of evidence, some health
care providers do use medications “off-label”
most commonly offered in outpatient
when treating adolescents (especially older settings.
adolescents) who are addicted to opioids,
nicotine, or (less commonly) alcohol. Newer
compounds continue to be studied for possibly
treating substance use disorders in adults and It has a long history of use in treatment of
adolescents, but none other than those listed opioid dependence in adults, and is available
here have shown conclusive results. in specially licensed methadone treatment
programs. In select cases and in some States,
Note that there are currently no FDA-approved opioid-dependent adolescents between the ages
medications to treat addiction to cannabis, of 16 and 18 may be eligible for methadone
cocaine, or methamphetamine in any age treatment, provided they have two documented
group. failed treatments of opioid detoxification or
drug-free treatment and have a written consent
Opioid Use Disorders for methadone signed by a parent or legal
guardian.69
Buprenorphine reduces or eliminates opioid
withdrawal symptoms, including drug cravings, Naltrexone is approved for the prevention of
without producing the “high” or dangerous side relapse in adult patients following complete
effects of heroin and other opioids. It does this detoxification from opioids. It acts by blocking
by both activating and blocking opioid receptors the brain’s opioid receptors (i.e., an opioid
in the brain (i.e., it is what is known as a partial antagonist), preventing opioid drugs from acting
opioid agonist). It is available for sublingual on them and thus blocking the high the user
(under-the-tongue) administration both in a would normally feel and/or causing withdrawal if
stand-alone formulation (called Subutex®) recent opioid use has occurred. It can be taken
and in combination with another agent called orally in tablets or as a once-monthly injection
naloxone. The naloxone in the combined given in a doctor’s office (a preparation called
formulation (marketed as Suboxone®) is Vivitrol®).70
included to deter diversion or abuse of the
medication by causing a withdrawal reaction Alcohol Use Disorders‡
if it is intravenously injected.65 Physicians with
Acamprosate (Campral®) reduces withdrawal
special certification may provide office-based
symptoms by normalizing brain systems
buprenorphine treatment for detoxification
disrupted by chronic alcohol consumption in
and/or maintenance therapy.66 It is sometimes
adults.
prescribed to older adolescents on the basis
of two research studies indicating its efficacy Disulfiram (Antabuse®) inhibits an enzyme
for this population,67,68 even though it is not involved in the metabolism of alcohol, causing an
approved by the FDA for pediatric use.* unpleasant reaction if alcohol is consumed after
taking the medication.71
Methadone also prevents withdrawal
symptoms and reduces craving in opioid-
addicted individuals by activating opioid
receptors in the brain (i.e., a full opioid agonist).
* According to the FDA label, “SUBOXONE and SUBUTEX are not recommended for use in pediatric patients. The safety and effectiveness of
SUBOXONE and SUBUTEX in patients below the age of 16 have not been established.”
‡ Medication-assisted therapies are rarely used to treat adolescent alcohol use disorders.

Naltrexone decreases alcohol-induced euphoria as 12-step programs), peer recovery support
and is available in both oral tablets and long- services, and recovery high schools. Such
acting injectable preparations (as in its use for programs provide a community setting where
the treatment of opioid addiction, above). fellow recovering persons can share their
experiences, provide mutual support to each
Nicotine Use Disorders other’s struggles with drug or alcohol problems,
Bupropion, commonly prescribed for and in other ways support a substance-free
depression, also reduces nicotine cravings and lifestyle. Note that recovery support services are
withdrawal symptoms in adult smokers.72 not substitutes for treatment. Also, the existing
research evidence for these approaches (with
Nicotine Replacement Therapies (NRTs) the exception of Assertive Continuing Care) is
help smokers wean off cigarettes by activating preliminary; anecdotal evidence supports the
nicotine receptors in the brain. They are effectiveness of peer recovery support services
available in the form of a patch, gum, lozenge, and recovery high schools, for example, but
nasal spray, or inhaler.73 their efficacy has not been established through
controlled trials.
Varenicline reduces nicotine cravings and
withdrawal in adult smokers by mildly stimulating Assertive Continuing Care (ACC)
nicotine receptors in the brain.74 ACC is a home-based continuing-care
approach delivered by trained clinicians to
RECOVERY SUPPORT SERVICES prevent relapse, and is typically used after
To reinforce gains made in treatment and to an adolescent completes therapy utilizing
improve their quality of life more generally, the Adolescent Community Reinforcement
recovering adolescents may benefit from Approach (A-CRA, see page 23). Using positive
recovery support services, which include and negative reinforcement to shape behaviors,
continuing care, mutual help groups (such along with training in problem-solving and

communication skills, ACC combines A-CRA
and assertive case management services
(e.g., use of a multidisciplinary team of
professionals, round-the-clock coverage,
assertive outreach) to help adolescents and
their caregivers acquire the skills to engage in
positive social activities.75
Mutual Help Groups

Mutual help groups such as the 12-step
programs Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) provide ongoing
support for people with addictions to alcohol
or drugs, respectively, free of charge and in
a community setting. Participants meet in a
group with others in recovery, once a week or
more, sharing their experiences and offering
mutual encouragement. Twelve-step groups Recovery High Schools
are guided by a set of fundamental principles Recovery high schools are schools specifically
that participants are encouraged to designed for students recovering from
adopt––including acknowledging that willpower substance abuse issues. They are typically part
alone cannot achieve sustained sobriety, of another school or set of alternative school
that surrender to the group conscience must programs within the public school system,
replace self-centeredness, and that long- but recovery school students are generally
term recovery involves a process of spiritual separated from other students by means
renewal.76 of scheduling and physical barriers. Such
programs allow adolescents newly in recovery
Peer Recovery Support Services to be surrounded by a peer group supportive of
Peer recovery support services, such as recovery efforts and attitudes. Recovery schools
recovery community centers, help individuals can serve as an adjunct to formal substance
remain engaged in treatment and/or the abuse treatment, with students often referred by
recovery process by linking them together treatment providers and enrolled in concurrent
both in groups and in one-on-one relationships treatment for other mental health problems.78
with peer leaders who have direct experience
with addiction and recovery. Depending on
the needs of the adolescent, peer leaders
may provide mentorship and coaching and
help connect individuals to treatment, 12-
step groups, or other resources. Peer leaders
may also facilitate or lead community-building
activities, helping recovering adolescents build
alternative social networks and have drug- and
alcohol-free social options.77

TREATMENT
REFERRAL
RESOURCES
Substance Abuse and Mental Health Services Administration
(SAMHSA) Treatment Locator: 1-800-662-HELP or search
www.findtreatment.samhsa.gov
The “Find A Physician” feature on the American Society

of Addiction Medicine (ASAM) Web site:
http://community.asam.org/search/default.asp?m=basic
The Patient Referral Program on the American Academy

of Addiction Psychiatry Web site:
http://www.aaap.org/patient-referral-program
The Child and Adolescent Psychiatrist Finder on the American

Academy of Child and Adolescent Psychiatry Web site:
http://www.aacap.org/cs/root/child_and_adolescent_
psychiatrist_finder/child_and_adolescent_psychiatrist_finder

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January 2014
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Principles of Adolescent

Substance Use Disorder Treatment:

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Connie Cahalan, Missouri Department of Mental Health

Barbara Cimaglio, Vermont Department of Health

Michael L. Dennis, Ph.D., Chestnut Health Systems

Rochelle Head-Dunham, M.D., Louisiana Department of Health and Hospitals

Scott W. Henggeler, Ph.D., Medical University of South Carolina

Sharon Levy, M.D., M.P.H., Children’s Hospital Boston

Paula D. Riggs, M.D., University of Colorado School of Medicine

II. PRINCIPLES OF ADOLESCENT SUBSTANCE USE DISORDER TREATMENT.............................................. 8

III. FREQUENTLY ASKED QUESTIONS ...............................................................................................................12

V. EVIDENCE-BASED APPROACHES TO TREATING ADOLESCENT SUBSTANCE

TREATMENT REFERRAL RESOURCES................................................................................................................31

Nora D. Volkow, M.D.

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Only 10 percent of 12- to 17-year-olds needing Supporting Ongoing Recovery—Sustaining

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2. Adolescents can benefit from a drug

3. Routine annual medical visits are 5. Substance use disorder treatment

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8. Families and the community are

10 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

11. It is important to monitor drug use

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• To experiment: Adolescents are often

motivated to seek new experiences, 15

or daring. MDMA (Ecstasy)

2. What drugs are most

Alcohol and tobacco are the drugs most

commonly abused by adolescents, followed by

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15. What are the unique

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BEHAVIORAL APPROACHES Adolescent Community

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Brief Strategic Family Therapy (BSFT) Family Behavior Therapy (FBT)

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Multisystemic Therapy (MST)

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