Himanshu Upadhyaya, MBBS, MS

Many adolescent psychiatric patients who smoke are not getting the help they need to quit. When we asked 120 teen inpatients if they smoked and then checked their charts, we found only 6 of 47 smokers had been diagnosed as nicotine-dependent.¹

Adolescents who cannot quit on their own may benefit from smoking cessation therapies. Based on evidence and our experience, we offer a practical approach to treating nicotine dependence in adolescents, using drug and behavioral therapies.

PSYCHIATRIC COMORBIDITY

Psychiatric comorbidity is highly associated with cigarette smoking in adults and adolescents. In the United States:

• 44% of cigarettes smoked are sold to someone with a mental illness.²
• Persons with mental illness are 2.7 times more likely to smoke than are those without mental illness.²
• Most smokers start before age 18,³ and starting before age 13 is linked to psychopathology in later adolescence.⁴

Table

Smoking likelihood by age and comorbidity among adolescent psychiatric inpatients

Significant variable	Logistic regression odds ratio	95% confidence interval	Significance (P value)
Age	1.30	1.03, 1.64	0.03
Depressive disorders	4.02	1.267, 12.734	0.018
Conduct disorder	12.96	1.678, 100.07	0.014
Cannabis use disorder	24.60	3.7, 163.42	0.0009
Source: Data from 120 patients admitted to an inpatient child and adolescent psychiatry program.
Adapted with permission from reference 1.

Disruptive behavior disorders in adolescent smokers include oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD). Among psychiatric disorders, conduct disorder has the strongest association with smoking in adolescents.¹ ADHD is associated with smoking and perhaps with increased difficulty in quitting.^5,6

Mood disorders. Major depressive disorders have a strong, consistent, bidirectional association with smoking in the young. Depression may lead to smoking, and smoking to depression.⁷

Substance use disorders. Alcohol use disorders are strongly associated with smoking among adolescents, and the association is both bidirectional and dosedependent.⁸ Cannabis use disorder is also associated with cigarette smoking among adolescents (Table).⁹

Anxiety disorders. Evidence is emerging that anxiety disorders—especially social phobia—may be linked to smoking among adolescents.¹⁰

Nicotine withdrawal symptoms—irritability, anxiety, decreased concentration, increased appetite, craving for cigarettes—can mimic those of other psychiatric disorders. Adolescent smokers admitted to locked psychiatric units may experience withdrawal symptoms that require nicotine replacement treatment (Box).

Effect on quit rates. Psychiatric comorbidity may reduce quit rates during smoking cessation treatment.⁶ When smokers are trying to quit, watch for remission, worsening, or emergence of psychiatric conditions.

ASSESSING ADOLESCENT SMOKING

Adolescents with psychiatric diagnoses can be assessed for nicotine dependence—and vice versa—although accurately gauging their smoking habits is more difficult than in adults. For example:

• Rating scales for nicotine dependence severity—such as the modified Fagerstrom Tolerance Questionnaire¹¹—lack standard cutoff scores for adolescents.
• Unlike adults, many adolescents cannot reliably report use in “packs per day” because the number of cigarettes they smoke varies widely from day to day.

Biological markers commonly used to assess smoking in adults include expired-air carbon monoxide (CO), cotinine (nicotine metabolite), and thiocynate levels. Preliminary evidence indicates that cotinine may be a more sensitive and specific biological marker for smoking among adolescents than CO levels.¹² Thiocynate has not been evaluated as a marker for smoking in adolescents.

CO levels typically reflect smoking in the previous few hours, whereas the half-life of cotinine is longer (1 day or more). Also, factors such as environmental pollution or marijuana use can inflate CO levels. Thus, cotinine levels have greater accuracy and specificity, reflecting only the amount of nicotine consumed.

Unfortunately, most laboratories do not measure cotinine levels, and the expired-air CO test (CO Breathalyzer) is relatively expensive for most clinicians. Commercially available single-use cotinine test kits are modestly priced and provide semi-quantitative (a range instead of an exact number) urine cotinine levels. These tests, however, might not be covered by third-party insurers.

Until cotinine testing becomes widely available, we recommend a combination of self-report and expired-air CO level to monitor abstinence.

Self-report monitoring. Most clinicians rely on self-report rate of smoking among adolescents, as no screening assessment has been validated in this age group. As initial prompts, we recommend asking all adolescents if they smoke cigarettes, if they smoke regularly, and if they smoke daily.

We recommend using the “time line follow-back” method¹³ to monitor the self-reported smoking rate. Begin by providing the patient with a 30-day calendar, starting backwards from the day of assessment. Cite anchor points, such as special holidays and school or family events, to help the patient recall his or her cigarette use. Then have the patient fill in the number of cigarettes smoked each day for 30 days.

This assessment method appears more reliable than asking an adolescent “how many cigarettes do you smoke per day?”. After the initial time line follow-back assessment, encourage adolescent smokers to keep a daily diary of how many cigarettes they smoke, and monitor the diary at each visit.

 

Box

We have found daily smoking to be a good indicator of nicotine dependence, and anyone who smokes daily would receive significant health benefits from quitting. Hence, any daily smoker who wants to quit, regardless of DSM-IV nicotine dependence status, is a candidate for treatment.

BEHAVIORAL THERAPY

Unlike adults, adolescents usually lack smoking-related medical consequences, such as heart or lung disease. Even so, most adolescent smokers report that they would like to quit but face barriers such as:

• having to inform parents they smoke
• not knowing how to get help for smoking cessation
• lack of transportation for treatment
• lack of third-party reimbursement for smoking cessation treatment.

To help adolescents, we recommend following the U.S. Public Health Service guideline for smoking cessation.¹⁴ At least provide and discuss smoking cessation brochures developed specifically for adolescents. For example, one Centers for Disease Control and Prevention brochure describes what symptoms to expect when quitting, how to cope with craving, and other topics (see Related resources).

To manage peer pressure, we counsel teens to let their friends know they are trying to quit so that friends do not smoke in front of them. If that does not work, we ask patients to avoid being around friends who smoke at least for the first 2 weeks and preferably 2 months.

Many states have free telephone quit lines that provide support and advice on how to stop smoking. Several Web sites also are available for smokers (including adolescents) wanting to quit (see Related resources).

PHARMACOLOGIC TREATMENT

For adults, first-line FDA-approved medications for smoking cessation include nicotine replacement therapies (NRT)in transdermal, gum, inhaler, and lozenge forms and sustained-release bupropion. Nortriptyline, doxapine, and clonidine have shown effectiveness for smoking cessation but are not FDA-approved for this indication.¹⁵ Selegiline and mecamylamine have shown initial efficacy and are being examined in larger clinical trials.

For adolescents, little is known about what medications might help them stop smoking. Nicotine replacement therapies and bupropion SR have been most explored in adolescent smokers. The effect of psychiatric comorbidity on the quit rate is not well-studied in adolescents.

The transdermal nicotine patch (TNP) has shown modest results in preliminary trials among adolescents. One study found 11% abstinence at 6 weeks,¹⁶ and another found a <5% quit rate.¹⁷ A third study reported an 18% abstinence rate with a combination of TNP and contingency management therapy.¹⁸ Discussion of contingency management and other behavioral therapies is beyond the scope of this article.

A recent study comparing TNP, nicotine gum, and placebo in adolescent smokers found the lowest drop-out rate and highest compliance among the TNP group. Three-month abstinence rates were 17.6% for TNP, 6.5% for nicotine gum, and 2.5% for placebo. The difference between the TNP and placebo groups’ abstinence rates was statistically significant.¹⁹

Bupropion SR. In an open-label pilot study, our group treated 16 adolescent smokers weighing >90 lbs with bupropion SR, 150 mg bid. Average age was 18, and two-thirds of patients had ADHD. The endpoint abstinence rate—as measured by self-report and CO levels—was 31%, which is similar to rates reported in adult smokers treated with this dosage of bupropion SR.²⁰

The adolescents did not gain weight during the study, which may be important to this age group. Reported side effects were similar to those in adults, with one adolescent reporting an allergic reaction (urticaria). We are conducting a larger follow-up study using bupropion SR with and without behavioral therapy.

A PRACTICAL CLINICAL APPROACH

Smoking behavior. For treatment, we propose two categories of adolescent smokers: regular (daily) and nonregular (nondaily) (see Algorithm). We recognize that many nondaily smokers smoke frequently and may benefit from aggressive treatment. However, we propose this two-track approach as a starting point because of limited data and medication risks, such as possible seizures with bupropion SR. We suggest:

 

• using behavioral therapy and patient education as first-line treatment for nonregular adolescent smokers
• using medication and behavioral therapy as first-line treatment for regular smokers and medication as second-line treatment for nonregular smokers who do not respond to behavior therapy/patient education.

Algorithm Suggested smoking cessation approaches for adolescents

Offer a treatment for at least 6 to 8 weeks before considering a change in therapy. One definition of initial success is no tobacco use in a 7-day period by self-report and biological verification (such as CO levels).

Behavioral therapy is relatively low-risk and helps many adult smokers. Despite a lack of evidence, some sort of behavioral therapy in combination with pharmacologic therapy might also help adolescent smokers.

When adolescents get disheartened by a slip or relapse to smoking, be patient and encourage them to try again. Inform them that smokers often require multiple attempts before they can quit completely.

Medication. Based on the limited published evidence, we consider TNP and bupropion SR first-line medications for adolescent smokers who want to quit.

For adult smokers, clinicians often combine medication and NRT to increase success rates.¹⁵ No data suggest that combining TNP and bupropion SR may be more effective than monotherapy in adolescents, but the combination might help those who do not respond to either agent alone.

We recommend starting bupropion SR treatment at least 1 week before the patient’s quit date. Titrate the dosage based on the package insert and patient tolerance.

Start NRT according to package instructions, and titrate dosages based on response:

• increase if the patient reports substantial craving and withdrawal symptoms, such as irritability and anxiety.
• decrease in case of toxicity (such as nausea).

In our experience, adolescent smokers require slightly lower NRT dosages than adults, although this varies among individuals.

Related resources

• Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). www.cdc.gov/tobacco/quit/iquit.htm
• National Institute of Drug Abuse. NIDA for Teens. The Science Behind Drug Abuse. http://teens.drugabuse.gov/index.asp
• Society for Research on Nicotine and Tobacco. www.srnt.org

Drug brand names

• Bupropion SR • Zyban
• Clonidine • Catapres
• Doxapine • Sinequan
• Mecamylamine • Inversine
• Nortriptyline • Pamelor
• Selegiline • Eldepryl

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Many adolescent psychiatric patients who smoke are not getting the help they need to quit. When we asked 120 teen inpatients if they smoked and then checked their charts, we found only 6 of 47 smokers had been diagnosed as nicotine-dependent.¹

Adolescents who cannot quit on their own may benefit from smoking cessation therapies. Based on evidence and our experience, we offer a practical approach to treating nicotine dependence in adolescents, using drug and behavioral therapies.

PSYCHIATRIC COMORBIDITY

Psychiatric comorbidity is highly associated with cigarette smoking in adults and adolescents. In the United States:

• 44% of cigarettes smoked are sold to someone with a mental illness.²
• Persons with mental illness are 2.7 times more likely to smoke than are those without mental illness.²
• Most smokers start before age 18,³ and starting before age 13 is linked to psychopathology in later adolescence.⁴

Table

Smoking likelihood by age and comorbidity among adolescent psychiatric inpatients

Significant variable	Logistic regression odds ratio	95% confidence interval	Significance (P value)
Age	1.30	1.03, 1.64	0.03
Depressive disorders	4.02	1.267, 12.734	0.018
Conduct disorder	12.96	1.678, 100.07	0.014
Cannabis use disorder	24.60	3.7, 163.42	0.0009
Source: Data from 120 patients admitted to an inpatient child and adolescent psychiatry program.
Adapted with permission from reference 1.

Disruptive behavior disorders in adolescent smokers include oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD). Among psychiatric disorders, conduct disorder has the strongest association with smoking in adolescents.¹ ADHD is associated with smoking and perhaps with increased difficulty in quitting.^5,6

Mood disorders. Major depressive disorders have a strong, consistent, bidirectional association with smoking in the young. Depression may lead to smoking, and smoking to depression.⁷

Substance use disorders. Alcohol use disorders are strongly associated with smoking among adolescents, and the association is both bidirectional and dosedependent.⁸ Cannabis use disorder is also associated with cigarette smoking among adolescents (Table).⁹

Anxiety disorders. Evidence is emerging that anxiety disorders—especially social phobia—may be linked to smoking among adolescents.¹⁰

Nicotine withdrawal symptoms—irritability, anxiety, decreased concentration, increased appetite, craving for cigarettes—can mimic those of other psychiatric disorders. Adolescent smokers admitted to locked psychiatric units may experience withdrawal symptoms that require nicotine replacement treatment (Box).

Effect on quit rates. Psychiatric comorbidity may reduce quit rates during smoking cessation treatment.⁶ When smokers are trying to quit, watch for remission, worsening, or emergence of psychiatric conditions.

ASSESSING ADOLESCENT SMOKING

Adolescents with psychiatric diagnoses can be assessed for nicotine dependence—and vice versa—although accurately gauging their smoking habits is more difficult than in adults. For example:

• Rating scales for nicotine dependence severity—such as the modified Fagerstrom Tolerance Questionnaire¹¹—lack standard cutoff scores for adolescents.
• Unlike adults, many adolescents cannot reliably report use in “packs per day” because the number of cigarettes they smoke varies widely from day to day.

Biological markers commonly used to assess smoking in adults include expired-air carbon monoxide (CO), cotinine (nicotine metabolite), and thiocynate levels. Preliminary evidence indicates that cotinine may be a more sensitive and specific biological marker for smoking among adolescents than CO levels.¹² Thiocynate has not been evaluated as a marker for smoking in adolescents.

CO levels typically reflect smoking in the previous few hours, whereas the half-life of cotinine is longer (1 day or more). Also, factors such as environmental pollution or marijuana use can inflate CO levels. Thus, cotinine levels have greater accuracy and specificity, reflecting only the amount of nicotine consumed.

Unfortunately, most laboratories do not measure cotinine levels, and the expired-air CO test (CO Breathalyzer) is relatively expensive for most clinicians. Commercially available single-use cotinine test kits are modestly priced and provide semi-quantitative (a range instead of an exact number) urine cotinine levels. These tests, however, might not be covered by third-party insurers.

Until cotinine testing becomes widely available, we recommend a combination of self-report and expired-air CO level to monitor abstinence.

Self-report monitoring. Most clinicians rely on self-report rate of smoking among adolescents, as no screening assessment has been validated in this age group. As initial prompts, we recommend asking all adolescents if they smoke cigarettes, if they smoke regularly, and if they smoke daily.

We recommend using the “time line follow-back” method¹³ to monitor the self-reported smoking rate. Begin by providing the patient with a 30-day calendar, starting backwards from the day of assessment. Cite anchor points, such as special holidays and school or family events, to help the patient recall his or her cigarette use. Then have the patient fill in the number of cigarettes smoked each day for 30 days.

This assessment method appears more reliable than asking an adolescent “how many cigarettes do you smoke per day?”. After the initial time line follow-back assessment, encourage adolescent smokers to keep a daily diary of how many cigarettes they smoke, and monitor the diary at each visit.

 

Box

We have found daily smoking to be a good indicator of nicotine dependence, and anyone who smokes daily would receive significant health benefits from quitting. Hence, any daily smoker who wants to quit, regardless of DSM-IV nicotine dependence status, is a candidate for treatment.

BEHAVIORAL THERAPY

Unlike adults, adolescents usually lack smoking-related medical consequences, such as heart or lung disease. Even so, most adolescent smokers report that they would like to quit but face barriers such as:

• having to inform parents they smoke
• not knowing how to get help for smoking cessation
• lack of transportation for treatment
• lack of third-party reimbursement for smoking cessation treatment.

To help adolescents, we recommend following the U.S. Public Health Service guideline for smoking cessation.¹⁴ At least provide and discuss smoking cessation brochures developed specifically for adolescents. For example, one Centers for Disease Control and Prevention brochure describes what symptoms to expect when quitting, how to cope with craving, and other topics (see Related resources).

To manage peer pressure, we counsel teens to let their friends know they are trying to quit so that friends do not smoke in front of them. If that does not work, we ask patients to avoid being around friends who smoke at least for the first 2 weeks and preferably 2 months.

Many states have free telephone quit lines that provide support and advice on how to stop smoking. Several Web sites also are available for smokers (including adolescents) wanting to quit (see Related resources).

PHARMACOLOGIC TREATMENT

For adults, first-line FDA-approved medications for smoking cessation include nicotine replacement therapies (NRT)in transdermal, gum, inhaler, and lozenge forms and sustained-release bupropion. Nortriptyline, doxapine, and clonidine have shown effectiveness for smoking cessation but are not FDA-approved for this indication.¹⁵ Selegiline and mecamylamine have shown initial efficacy and are being examined in larger clinical trials.

For adolescents, little is known about what medications might help them stop smoking. Nicotine replacement therapies and bupropion SR have been most explored in adolescent smokers. The effect of psychiatric comorbidity on the quit rate is not well-studied in adolescents.

The transdermal nicotine patch (TNP) has shown modest results in preliminary trials among adolescents. One study found 11% abstinence at 6 weeks,¹⁶ and another found a <5% quit rate.¹⁷ A third study reported an 18% abstinence rate with a combination of TNP and contingency management therapy.¹⁸ Discussion of contingency management and other behavioral therapies is beyond the scope of this article.

A recent study comparing TNP, nicotine gum, and placebo in adolescent smokers found the lowest drop-out rate and highest compliance among the TNP group. Three-month abstinence rates were 17.6% for TNP, 6.5% for nicotine gum, and 2.5% for placebo. The difference between the TNP and placebo groups’ abstinence rates was statistically significant.¹⁹

Bupropion SR. In an open-label pilot study, our group treated 16 adolescent smokers weighing >90 lbs with bupropion SR, 150 mg bid. Average age was 18, and two-thirds of patients had ADHD. The endpoint abstinence rate—as measured by self-report and CO levels—was 31%, which is similar to rates reported in adult smokers treated with this dosage of bupropion SR.²⁰

The adolescents did not gain weight during the study, which may be important to this age group. Reported side effects were similar to those in adults, with one adolescent reporting an allergic reaction (urticaria). We are conducting a larger follow-up study using bupropion SR with and without behavioral therapy.

A PRACTICAL CLINICAL APPROACH

Smoking behavior. For treatment, we propose two categories of adolescent smokers: regular (daily) and nonregular (nondaily) (see Algorithm). We recognize that many nondaily smokers smoke frequently and may benefit from aggressive treatment. However, we propose this two-track approach as a starting point because of limited data and medication risks, such as possible seizures with bupropion SR. We suggest:

 

• using behavioral therapy and patient education as first-line treatment for nonregular adolescent smokers
• using medication and behavioral therapy as first-line treatment for regular smokers and medication as second-line treatment for nonregular smokers who do not respond to behavior therapy/patient education.

Algorithm Suggested smoking cessation approaches for adolescents

Offer a treatment for at least 6 to 8 weeks before considering a change in therapy. One definition of initial success is no tobacco use in a 7-day period by self-report and biological verification (such as CO levels).

Behavioral therapy is relatively low-risk and helps many adult smokers. Despite a lack of evidence, some sort of behavioral therapy in combination with pharmacologic therapy might also help adolescent smokers.

When adolescents get disheartened by a slip or relapse to smoking, be patient and encourage them to try again. Inform them that smokers often require multiple attempts before they can quit completely.

Medication. Based on the limited published evidence, we consider TNP and bupropion SR first-line medications for adolescent smokers who want to quit.

For adult smokers, clinicians often combine medication and NRT to increase success rates.¹⁵ No data suggest that combining TNP and bupropion SR may be more effective than monotherapy in adolescents, but the combination might help those who do not respond to either agent alone.

We recommend starting bupropion SR treatment at least 1 week before the patient’s quit date. Titrate the dosage based on the package insert and patient tolerance.

Start NRT according to package instructions, and titrate dosages based on response:

• increase if the patient reports substantial craving and withdrawal symptoms, such as irritability and anxiety.
• decrease in case of toxicity (such as nausea).

In our experience, adolescent smokers require slightly lower NRT dosages than adults, although this varies among individuals.

Related resources

• Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). www.cdc.gov/tobacco/quit/iquit.htm
• National Institute of Drug Abuse. NIDA for Teens. The Science Behind Drug Abuse. http://teens.drugabuse.gov/index.asp
• Society for Research on Nicotine and Tobacco. www.srnt.org

Drug brand names

• Bupropion SR • Zyban
• Clonidine • Catapres
• Doxapine • Sinequan
• Mecamylamine • Inversine
• Nortriptyline • Pamelor
• Selegiline • Eldepryl

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Many adolescent psychiatric patients who smoke are not getting the help they need to quit. When we asked 120 teen inpatients if they smoked and then checked their charts, we found only 6 of 47 smokers had been diagnosed as nicotine-dependent.¹

Adolescents who cannot quit on their own may benefit from smoking cessation therapies. Based on evidence and our experience, we offer a practical approach to treating nicotine dependence in adolescents, using drug and behavioral therapies.

PSYCHIATRIC COMORBIDITY

Psychiatric comorbidity is highly associated with cigarette smoking in adults and adolescents. In the United States:

• 44% of cigarettes smoked are sold to someone with a mental illness.²
• Persons with mental illness are 2.7 times more likely to smoke than are those without mental illness.²
• Most smokers start before age 18,³ and starting before age 13 is linked to psychopathology in later adolescence.⁴

Table

Smoking likelihood by age and comorbidity among adolescent psychiatric inpatients

Significant variable	Logistic regression odds ratio	95% confidence interval	Significance (P value)
Age	1.30	1.03, 1.64	0.03
Depressive disorders	4.02	1.267, 12.734	0.018
Conduct disorder	12.96	1.678, 100.07	0.014
Cannabis use disorder	24.60	3.7, 163.42	0.0009
Source: Data from 120 patients admitted to an inpatient child and adolescent psychiatry program.
Adapted with permission from reference 1.

Disruptive behavior disorders in adolescent smokers include oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD). Among psychiatric disorders, conduct disorder has the strongest association with smoking in adolescents.¹ ADHD is associated with smoking and perhaps with increased difficulty in quitting.^5,6

Mood disorders. Major depressive disorders have a strong, consistent, bidirectional association with smoking in the young. Depression may lead to smoking, and smoking to depression.⁷

Substance use disorders. Alcohol use disorders are strongly associated with smoking among adolescents, and the association is both bidirectional and dosedependent.⁸ Cannabis use disorder is also associated with cigarette smoking among adolescents (Table).⁹

Anxiety disorders. Evidence is emerging that anxiety disorders—especially social phobia—may be linked to smoking among adolescents.¹⁰

Nicotine withdrawal symptoms—irritability, anxiety, decreased concentration, increased appetite, craving for cigarettes—can mimic those of other psychiatric disorders. Adolescent smokers admitted to locked psychiatric units may experience withdrawal symptoms that require nicotine replacement treatment (Box).

Effect on quit rates. Psychiatric comorbidity may reduce quit rates during smoking cessation treatment.⁶ When smokers are trying to quit, watch for remission, worsening, or emergence of psychiatric conditions.

ASSESSING ADOLESCENT SMOKING

Adolescents with psychiatric diagnoses can be assessed for nicotine dependence—and vice versa—although accurately gauging their smoking habits is more difficult than in adults. For example:

• Rating scales for nicotine dependence severity—such as the modified Fagerstrom Tolerance Questionnaire¹¹—lack standard cutoff scores for adolescents.
• Unlike adults, many adolescents cannot reliably report use in “packs per day” because the number of cigarettes they smoke varies widely from day to day.

Biological markers commonly used to assess smoking in adults include expired-air carbon monoxide (CO), cotinine (nicotine metabolite), and thiocynate levels. Preliminary evidence indicates that cotinine may be a more sensitive and specific biological marker for smoking among adolescents than CO levels.¹² Thiocynate has not been evaluated as a marker for smoking in adolescents.

CO levels typically reflect smoking in the previous few hours, whereas the half-life of cotinine is longer (1 day or more). Also, factors such as environmental pollution or marijuana use can inflate CO levels. Thus, cotinine levels have greater accuracy and specificity, reflecting only the amount of nicotine consumed.

Unfortunately, most laboratories do not measure cotinine levels, and the expired-air CO test (CO Breathalyzer) is relatively expensive for most clinicians. Commercially available single-use cotinine test kits are modestly priced and provide semi-quantitative (a range instead of an exact number) urine cotinine levels. These tests, however, might not be covered by third-party insurers.

Until cotinine testing becomes widely available, we recommend a combination of self-report and expired-air CO level to monitor abstinence.

Self-report monitoring. Most clinicians rely on self-report rate of smoking among adolescents, as no screening assessment has been validated in this age group. As initial prompts, we recommend asking all adolescents if they smoke cigarettes, if they smoke regularly, and if they smoke daily.

We recommend using the “time line follow-back” method¹³ to monitor the self-reported smoking rate. Begin by providing the patient with a 30-day calendar, starting backwards from the day of assessment. Cite anchor points, such as special holidays and school or family events, to help the patient recall his or her cigarette use. Then have the patient fill in the number of cigarettes smoked each day for 30 days.

This assessment method appears more reliable than asking an adolescent “how many cigarettes do you smoke per day?”. After the initial time line follow-back assessment, encourage adolescent smokers to keep a daily diary of how many cigarettes they smoke, and monitor the diary at each visit.

 

Box

We have found daily smoking to be a good indicator of nicotine dependence, and anyone who smokes daily would receive significant health benefits from quitting. Hence, any daily smoker who wants to quit, regardless of DSM-IV nicotine dependence status, is a candidate for treatment.

BEHAVIORAL THERAPY

Unlike adults, adolescents usually lack smoking-related medical consequences, such as heart or lung disease. Even so, most adolescent smokers report that they would like to quit but face barriers such as:

• having to inform parents they smoke
• not knowing how to get help for smoking cessation
• lack of transportation for treatment
• lack of third-party reimbursement for smoking cessation treatment.

To help adolescents, we recommend following the U.S. Public Health Service guideline for smoking cessation.¹⁴ At least provide and discuss smoking cessation brochures developed specifically for adolescents. For example, one Centers for Disease Control and Prevention brochure describes what symptoms to expect when quitting, how to cope with craving, and other topics (see Related resources).

To manage peer pressure, we counsel teens to let their friends know they are trying to quit so that friends do not smoke in front of them. If that does not work, we ask patients to avoid being around friends who smoke at least for the first 2 weeks and preferably 2 months.

Many states have free telephone quit lines that provide support and advice on how to stop smoking. Several Web sites also are available for smokers (including adolescents) wanting to quit (see Related resources).

PHARMACOLOGIC TREATMENT

For adults, first-line FDA-approved medications for smoking cessation include nicotine replacement therapies (NRT)in transdermal, gum, inhaler, and lozenge forms and sustained-release bupropion. Nortriptyline, doxapine, and clonidine have shown effectiveness for smoking cessation but are not FDA-approved for this indication.¹⁵ Selegiline and mecamylamine have shown initial efficacy and are being examined in larger clinical trials.

For adolescents, little is known about what medications might help them stop smoking. Nicotine replacement therapies and bupropion SR have been most explored in adolescent smokers. The effect of psychiatric comorbidity on the quit rate is not well-studied in adolescents.

The transdermal nicotine patch (TNP) has shown modest results in preliminary trials among adolescents. One study found 11% abstinence at 6 weeks,¹⁶ and another found a <5% quit rate.¹⁷ A third study reported an 18% abstinence rate with a combination of TNP and contingency management therapy.¹⁸ Discussion of contingency management and other behavioral therapies is beyond the scope of this article.

A recent study comparing TNP, nicotine gum, and placebo in adolescent smokers found the lowest drop-out rate and highest compliance among the TNP group. Three-month abstinence rates were 17.6% for TNP, 6.5% for nicotine gum, and 2.5% for placebo. The difference between the TNP and placebo groups’ abstinence rates was statistically significant.¹⁹

Bupropion SR. In an open-label pilot study, our group treated 16 adolescent smokers weighing >90 lbs with bupropion SR, 150 mg bid. Average age was 18, and two-thirds of patients had ADHD. The endpoint abstinence rate—as measured by self-report and CO levels—was 31%, which is similar to rates reported in adult smokers treated with this dosage of bupropion SR.²⁰

The adolescents did not gain weight during the study, which may be important to this age group. Reported side effects were similar to those in adults, with one adolescent reporting an allergic reaction (urticaria). We are conducting a larger follow-up study using bupropion SR with and without behavioral therapy.

A PRACTICAL CLINICAL APPROACH

Smoking behavior. For treatment, we propose two categories of adolescent smokers: regular (daily) and nonregular (nondaily) (see Algorithm). We recognize that many nondaily smokers smoke frequently and may benefit from aggressive treatment. However, we propose this two-track approach as a starting point because of limited data and medication risks, such as possible seizures with bupropion SR. We suggest:

 

• using behavioral therapy and patient education as first-line treatment for nonregular adolescent smokers
• using medication and behavioral therapy as first-line treatment for regular smokers and medication as second-line treatment for nonregular smokers who do not respond to behavior therapy/patient education.

Algorithm Suggested smoking cessation approaches for adolescents

Offer a treatment for at least 6 to 8 weeks before considering a change in therapy. One definition of initial success is no tobacco use in a 7-day period by self-report and biological verification (such as CO levels).

Behavioral therapy is relatively low-risk and helps many adult smokers. Despite a lack of evidence, some sort of behavioral therapy in combination with pharmacologic therapy might also help adolescent smokers.

When adolescents get disheartened by a slip or relapse to smoking, be patient and encourage them to try again. Inform them that smokers often require multiple attempts before they can quit completely.

Medication. Based on the limited published evidence, we consider TNP and bupropion SR first-line medications for adolescent smokers who want to quit.

For adult smokers, clinicians often combine medication and NRT to increase success rates.¹⁵ No data suggest that combining TNP and bupropion SR may be more effective than monotherapy in adolescents, but the combination might help those who do not respond to either agent alone.

We recommend starting bupropion SR treatment at least 1 week before the patient’s quit date. Titrate the dosage based on the package insert and patient tolerance.

Start NRT according to package instructions, and titrate dosages based on response:

• increase if the patient reports substantial craving and withdrawal symptoms, such as irritability and anxiety.
• decrease in case of toxicity (such as nausea).

In our experience, adolescent smokers require slightly lower NRT dosages than adults, although this varies among individuals.

Related resources

• Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). www.cdc.gov/tobacco/quit/iquit.htm
• National Institute of Drug Abuse. NIDA for Teens. The Science Behind Drug Abuse. http://teens.drugabuse.gov/index.asp
• Society for Research on Nicotine and Tobacco. www.srnt.org

Drug brand names

• Bupropion SR • Zyban
• Clonidine • Catapres
• Doxapine • Sinequan
• Mecamylamine • Inversine
• Nortriptyline • Pamelor
• Selegiline • Eldepryl

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Assessing an adolescent for a possible substance use disorder can be streamlined by choosing age-appropriate screening tools and asking targeted questions. Based on our experience, we offer a 4-step approach to these at-risk patients¹ (Box) that focuses on:

• quantifying alcohol or drug abuse and/or dependence
• identifying and treating psychiatric comorbidity
• evaluating and addressing social influences that contribute to substance use
• assessing negative consequences associated with substance abuse.

Box

INITIAL EVALUATION

Adolescents generally do not seek substance abuse treatment but are referred because of alcohol- or drug-related legal, school, or family problems. Thus, most present for evaluation with their parents, legal guardians, or officers of the court.

We begin by finding out from parents or guardians the reasons for the evaluation, their perspectives on the adolescent’s behavior, and their expectations of treatment. Then we interview the adolescent alone, assessing for substance use and evaluating peer relationships.

Components. A typical initial evaluation takes 90 minutes to 2 hours and includes:

• psychiatric history and symptoms
• medical history
• previous hospitalizations (medical and psychiatric)
• family history
• social history.

Specifically, the assessment focuses on the reason for the evaluation, with attention to diagnostic criteria for substance use/dependence.

STEP 1: QUANTIFYING DEPENDENCE

As with adults, clinical diagnosis of substance abuse or dependence in adolescents is based on DSM-IV diagnostic criteria (Table 1). Adolescents, however, differ from adults in diagnostic presentation, risk of dependence, and patterns of substance use.

Diagnostic ‘orphans.’ DSM-IV criteria for alcohol use disorders have limitations in adolescents.² Teens who report one or two dependence symptoms and no abuse symptoms have been described as “diagnostic orphans”³—they fall short of criteria for dependence or abuse but clearly demonstrate substance use patterns. This presentation is common; in a survey of 74,008 high school students, almost 10% of 12th graders reported one or two dependence symptoms and no abuse symptoms.⁴

Risk of dependence. Adolescents who begin using alcohol or drugs develop dependence more rapidly than adults do.⁵

Patterns of use. Adolescents are more likely than adults to binge with alcohol and drugs, which may conceal the severity of their abuse. DSM-IV diagnostic criteria for substance abuse or dependence do not consider quantity of use, such as number of drinks or percent of days drinking or using drugs.

Assessment instruments. Many assessment instruments are available to explore adolescent substance use and its associated consequences. Some are described in detail and are available on the Internet. Common screening instruments that can be used for adolescent substance use are compared in Table 2.

DUSI-A and POSIT. Two self-report instruments—Drug Use Screening Inventory-Adolescents (DUSI-A)⁶ and Problem Oriented Screening Instrument for Teenagers (POSIT)⁷—can help explore alcohol or drug use in teens who admit to substance use. Anyone who endorses at least one DSM-IV abuse or dependence criterion requires further evaluation. Either test is a good starting point, and both have a built-in “lie” scale.

T-ASI and CASI. The Teen Addiction Severity Index (T-ASI)⁸ and Comprehensive Adolescent Severity Inventory (CASI)⁹ are more labor-intensive and require training to administer. These assessments are more appropriate for adolescents with extensive alcohol or drug abuse.

A-OCDS and Deas-MOCS. Our group recently developed the Adolescent Obsessive Compulsive Drinking Scale (A-OCDS)¹⁰ and the Deas-Marijuana Obsessive Compulsive Scale (Deas-MOCS).¹¹

These self-report instruments have been validated in treatment- and nontreatment-seeking adolescents and young adults in inpatient and outpatient populations. They are sensitive and specific in identifying problem drinkers and marijuana users, respectively, and are quick, useful screens to determine need for further assessment.

Toxicology is useful for initial assessment and to monitor substance use patterns during treatment.

Urine samples are used to assess marijuana, sedative/hypnotic, amphetamine, cocaine, opiate, and phencyclidine use. Alcohol may be detected in urine, but alcohol levels detected by blood and breath testing are more accurate.

 

Table 1

Diagnostic criteria for substance abuse and dependence

Substance abuse	1 of these 4 symptoms in a 12-month period: Role impairment Hazardous use Legal problems associated with use Social problems
Substance dependence	At least 3 of the following: Tolerance Withdrawal Using more or longer than intended Attempting to quit or cut down Much time spent using Activities given up to use Psychological/physical problems resulting from use Subtyped as with or without physiologic features (tolerance or withdrawal symptoms)
Source: DSM-IV-TR

Marijuana may be detected in the urine for 3 days to 4 weeks, depending on level of use. Cocaine can be detected for 2 to 4 days in urine and longer in hair analysis.

Random screening. Adolescents who use drugs usually know how long substances can be detected, so random urine drug screening is important to treatment progress. We inform adolescents at the beginning of treatment that random screening will be performed to corroborate self-report of substance use. To ensure a reliable urine sample, same-gender staff observe while the adolescent gives the sample.

Table 2

Common screening instruments for alcohol and drug use in adolescents

Instrument	Items (#)	How administered	Administration time
Drug Use Screening Inventory (DUSI-R), Revised	159	Self-report	20 to 40 minutes
Problem-Oriented Screening Instrument for Teenagers (POSIT)	139	Self-report	20 to 30 minutes
Teen Addiction Severity Index (T-ASI)	133	Clinician	20 to 45 minutes
Comprehensive Adolescent Severity Inventory (CASI)	245	Clinician	Varies with experience of administrator
Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS)	14	Self-report	About 5 minutes
Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS)	14	Self-report	About 5 minutes

STEP 2: IDENTIFYING PSYCHIATRIC COMORBIDITY

In adolescents, substance use disorder frequently goes hand-in-hand with psychiatric disorders, particularly:

• mood and anxiety disorders
• disruptive disorders (attention-deficit/hyperactivity, oppositional defiant, and conduct disorders)¹²
• and posttraumatic stress disorder.¹³

Uncontrolled psychiatric disorders may sabotage substance abuse treatment. Therefore, assess any adolescent presenting with substance use for psychiatric illness.

Did psychiatric symptoms predate or postdate substance use? The answer may suggest self-medication or a substance-induced phenomenon. This assumption does not always apply, however, as many factors affect the relationship between substance use and psychiatric disorders.

Adolescents who meet DSM-IV criteria for conduct disorder—especially those who are highly aggressive—tend to initiate substance use much earlier than adolescents without conduct disorder, and they continue their use longer.

Most adolescents with comorbid psychiatric and substance use disorders develop the psychiatric disorder first. Some report using various substances to medicate their psychiatric symptoms. Early diagnosis and treatment of the psychiatric disorder may prevent or decrease the adolescent’s substance use.

STEPS 3 AND 4: EVALUATING SOCIAL INFLUENCES AND CONSEQUENCES

Social influences that contribute to adolescent alcohol and drug abuse include family dynamics and peer relationships. Consequences include educational and legal problems. We explore these areas with the adolescents and their parents/guardians. In most cases, adolescents are honest when reporting how their alcohol or drug use has affected their lives.

What is his family like? Assess the adolescent’s family, including its structure and history of substance abuse, psychiatric illness, or trauma (Table 3). Adolescents whose parents or siblings use alcohol or drugs are at increased risk for substance use.¹⁴ To what extent this association is genetic, environmental, or both is undetermined, but the genetic influence increases as adolescents age.¹⁵

Who are her friends? Adolescents who try alcohol or drugs and continue to use them tend to have peers who use these substances.¹⁶ Moreover, the severity of adolescents’ substance use is correlated with the number of substance-using peers. To explore peer relationships, ask about:

• peer group composition, including whether peers use alcohol or drugs
• peer interactions, including the adolescent’s ability to assert him- or herself in the peer group
• markers for risky sexual behaviors related to substance use, including infection with HIV and other sexually transmitted diseases.

How is she doing in school? Inquire about the teen’s academic performance, attendance, disciplinary problems, and motivation. Even a small decline in school performance or an increase in disciplinary problems that result in suspension or expulsion can indicate substance use or other at-risk behaviors.

Poor grades or attendance problems suggest but are not the only clues to substance use. Some adolescents with good school performance engage in substance use and may be impaired in other life domains.

Has he been arrested? Substance-abusing adolescents tend to engage in delinquent behaviors, including shoplifting, vandalism, curfew violations, disorderly conduct, and drunken driving. When assessing for delinquency, ask about behaviors that did or did not result in arrest. The teen who avoided arrest for illegal activities may perceive his/her behaviors as less severe than those involving arrest, and it may help to address this denial in individual or group therapy.

Table 3

Questions to assess family influence on an adolescent’s substance use

Family structure
With whom does the adolescent live? How many people live in the home? What is the quality of the adolescent’s relationship with parents and siblings?
Parenting styles
Are parents authoritative or permissive? What disciplinary methods are used? How is conflict managed?
Substance abuse
Are any family members using alcohol or drugs? Is there a family history of substance abuse or dependence? What has been the extent of treatment?
Psychiatric disorders
Do any family members have psychiatric disorders (diagnosed or not)? What treatments were given? Outcome? What treatment does the family perceive to have been most effective?
Trauma
Has the adolescent experienced physical or sexual abuse or other trauma?

 

TREATMENT

We consider any adolescent with dependence symptoms—whether or not the presentation meets full DSM-IV diagnostic criteria—to be a candidate for further assessment and treatment. Early intervention may prevent progression to substance dependence.

Effective treatments:

• are intensive and of sufficient duration to change attitude and behaviors
• are comprehensive and target multiple domains of the adolescent’s life
• are sensitive to cultural and socioeconomic realities
• involve the family
• emphasize pro-social recreational activities, such as playing sports, attending movies, camping, having lunch or dinner with peers, etc.

Inpatient or outpatient? Managed care and insurance restrictions limit many patients’ eligibility for inpatient or residential treatment, so partial hospitalization and outpatient settings have become standard for substance abuse treatment. Partial hospitalization programs vary but may entail several hours, several days per week. Outpatient treatment may encompass individual, group, and family therapy, including after-school programs.

Inpatient treatment is usually reserved for adolescents:

• who need detoxification
• with comorbid psychiatric disorders
• or who may harm themselves or others.

PSYCHOTHERAPIES

Behavioral therapy, family-based therapy, multisystematic therapy (MST), and 12-step approaches have shown efficacy in treating adolescents with substance use disorders.

Behavioral therapy. Behavioral therapy is recommended as initial treatment because substance use plays a functional role in the adolescent’s life and is learned and reinforced in the adolescent’s environment. Homework assignments and role-play are commonly used in therapy.

Three central ingredients are:

• functional analysis (identifying internal and external triggers for starting and continuing substance use)
• skills training (targeting problems identified in the functional analysis)
• and relapse prevention.

Behavioral therapy is more effective than supportive therapy in improving family relationships and school and work attendance and in decreasing substance use, as indicated by fewer positive urine toxicology screens.¹⁷

Cognitive-behavioral therapy (CBT) approaches substance use as a maladaptive response to life problems. Its goal is to teach new skills to help the adolescent recognize and avoid high-risk situations and cope with associated problems and behaviors.

In a recent study, Kaminer et al randomly assigned 82 adolescents with psychiatric and substance use disorders to 8 weeks of CBT or psychoeducational therapy (didactic or videotaped presentations of ways to address problems associated with substance use). Substance use was reduced in both treatment groups, but:

• adolescents receiving CBT had significantly fewer positive urine toxicology tests
• adolescents with comorbid conduct disorder were least likely to complete treatment or return for follow-up
• those with depressive and anxiety disorders were most likely to complete treatment.¹⁸

Family-based therapy. Two detailed reviews^19,20 demonstrate that the adolescent’s family, community, and school relationships affect his or her perceptions and behaviors. Maladaptive relationships in any of these systems may lead to high-risk behaviors. Therefore, family therapy is core to the adolescent’s treatment, regardless of what modality is chosen.

Goals of family therapy may be:

• to help the adolescent abstain from substance use
• to engage in pro-social activities
• to decrease parental denial of the adolescent’s substance use
• to decrease resistance to treatment
• treatment maintenance
• to establish or re-establish structure in the adolescent’s environment
• to improve communication in the family.

Multisystemic therapy is comprehensive and involves all systems that relate to the adolescent’s substance use, including the family, school, community, and legal system. MST requires special training and intensive supervision, so it is usually reserved for adolescents who have not benefited from other forms of treatment.²¹

12-step approaches. For adolescents, 12-step programs usually augment other treatments and are rarely used alone. Alcoholics Anonymous, Narcotics Anonymous, and other 12-step programs have been studied more extensively in adults than in adolescents.

Adolescents, who often feel invulnerable, may have difficulty accepting the 12-step doctrine of lack of control. A modified 12-step program and workbook for adolescents are available through the American Academy of Child and Adolescent Psychiatry.²²

Referral tips. If possible, refer an adolescent to a 12-step group specifically for adolescents. Teens who attend adult groups often perceive their substance use as normal, compared with the more severe and chronic patterns of some adults. Most adolescents relate better to peers with similar problems and may benefit from reminders of the negative consequences of substance use and the benefits of abstinence.

DRUG THERAPY

Drug therapy for adolescents with substance use disorders is usually considered in the context of detoxification, treating withdrawal symptoms, and treating comorbid psychiatric disorders. The same detoxification and withdrawal treatment principles used in adults apply to adolescents.

Clinical withdrawal symptoms are less common in adolescents than adults, probably because of adolescents’ binge patterns of substance use. Even so, some adolescents do experience withdrawal and may be at risk for complications if improperly treated.

Psychiatric comorbidity. To our knowledge, only two double-blind, placebo-controlled studies of drug therapy in treating adolescent substance use disorders have been published.

 

Depression. Deas et al²³ randomized 10 adolescents with alcohol use disorders and depression to 12 weeks of group CBT plus sertraline or placebo. Sertraline was started at 25 mg/d and titrated to a maximum of 100 mg/d. Drinks per drinking day, percent of days drinking, and Hamilton Rating Scale for Depression scores declined similarly in both groups.

Drinking decreased significantly from baseline (by an average 4.7 drinks), and adolescents in both groups no longer met DSM-IV criteria for depression at the end of treatment. CBT’s effectiveness in treating alcohol use disorders and depression might have concealed any difference in effect between sertaline and placebo.

Bipolar disorder. Geller et al²⁴ randomly assigned 25 adolescents with bipolar disorder and substance dependence to lithium or placebo for 6 weeks. Lithium was started as an evening dose of 600 mg and titrated to achieve a lithium blood level of 0.9 to 1.3 mEq/L. Among the 21 adolescents who completed the trial, those receiving lithium had significantly fewer positive urine toxicology screens and higher clinical global assessment of function scores.

Related resources

• National Clearinghouse for Alcohol and Drug Information, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. www.health.org/govpubs/bkd306/31k.aspx
• National Institute on Alcohol Abuse and Alcoholism (assessment instruments). www.niaaa.nih.gov/publications/instable.htm
• Deas D, Thomas SE. An overview of controlled studies of adolescent substance abuse treatment. Am J Addict 2001;10:178-89.

Drug brand names

• Sertraline • Zoloft

Disclosure

Dr. Deas receives grant support from Pfizer, Inc. and the National Institute of Alcohol Abuse and Alcoholism.

Dr. Upadhyaya receives grant support from the National Institute of Drug Abuse and GlaxoSmithKline.

Acknowledgment

The authors wish to thank Alva Blair for assistance with preparing this manuscript and Natalie Johnson, MA, Kess Mughelli, BS, and Lakeleia Middleton-Robinson, MA, for technical support.

Assessing an adolescent for a possible substance use disorder can be streamlined by choosing age-appropriate screening tools and asking targeted questions. Based on our experience, we offer a 4-step approach to these at-risk patients¹ (Box) that focuses on:

• quantifying alcohol or drug abuse and/or dependence
• identifying and treating psychiatric comorbidity
• evaluating and addressing social influences that contribute to substance use
• assessing negative consequences associated with substance abuse.

Box

INITIAL EVALUATION

Adolescents generally do not seek substance abuse treatment but are referred because of alcohol- or drug-related legal, school, or family problems. Thus, most present for evaluation with their parents, legal guardians, or officers of the court.

We begin by finding out from parents or guardians the reasons for the evaluation, their perspectives on the adolescent’s behavior, and their expectations of treatment. Then we interview the adolescent alone, assessing for substance use and evaluating peer relationships.

Components. A typical initial evaluation takes 90 minutes to 2 hours and includes:

• psychiatric history and symptoms
• medical history
• previous hospitalizations (medical and psychiatric)
• family history
• social history.

Specifically, the assessment focuses on the reason for the evaluation, with attention to diagnostic criteria for substance use/dependence.

STEP 1: QUANTIFYING DEPENDENCE

As with adults, clinical diagnosis of substance abuse or dependence in adolescents is based on DSM-IV diagnostic criteria (Table 1). Adolescents, however, differ from adults in diagnostic presentation, risk of dependence, and patterns of substance use.

Diagnostic ‘orphans.’ DSM-IV criteria for alcohol use disorders have limitations in adolescents.² Teens who report one or two dependence symptoms and no abuse symptoms have been described as “diagnostic orphans”³—they fall short of criteria for dependence or abuse but clearly demonstrate substance use patterns. This presentation is common; in a survey of 74,008 high school students, almost 10% of 12th graders reported one or two dependence symptoms and no abuse symptoms.⁴

Risk of dependence. Adolescents who begin using alcohol or drugs develop dependence more rapidly than adults do.⁵

Patterns of use. Adolescents are more likely than adults to binge with alcohol and drugs, which may conceal the severity of their abuse. DSM-IV diagnostic criteria for substance abuse or dependence do not consider quantity of use, such as number of drinks or percent of days drinking or using drugs.

Assessment instruments. Many assessment instruments are available to explore adolescent substance use and its associated consequences. Some are described in detail and are available on the Internet. Common screening instruments that can be used for adolescent substance use are compared in Table 2.

DUSI-A and POSIT. Two self-report instruments—Drug Use Screening Inventory-Adolescents (DUSI-A)⁶ and Problem Oriented Screening Instrument for Teenagers (POSIT)⁷—can help explore alcohol or drug use in teens who admit to substance use. Anyone who endorses at least one DSM-IV abuse or dependence criterion requires further evaluation. Either test is a good starting point, and both have a built-in “lie” scale.

T-ASI and CASI. The Teen Addiction Severity Index (T-ASI)⁸ and Comprehensive Adolescent Severity Inventory (CASI)⁹ are more labor-intensive and require training to administer. These assessments are more appropriate for adolescents with extensive alcohol or drug abuse.

A-OCDS and Deas-MOCS. Our group recently developed the Adolescent Obsessive Compulsive Drinking Scale (A-OCDS)¹⁰ and the Deas-Marijuana Obsessive Compulsive Scale (Deas-MOCS).¹¹

These self-report instruments have been validated in treatment- and nontreatment-seeking adolescents and young adults in inpatient and outpatient populations. They are sensitive and specific in identifying problem drinkers and marijuana users, respectively, and are quick, useful screens to determine need for further assessment.

Toxicology is useful for initial assessment and to monitor substance use patterns during treatment.

Urine samples are used to assess marijuana, sedative/hypnotic, amphetamine, cocaine, opiate, and phencyclidine use. Alcohol may be detected in urine, but alcohol levels detected by blood and breath testing are more accurate.

 

Table 1

Diagnostic criteria for substance abuse and dependence

Substance abuse	1 of these 4 symptoms in a 12-month period: Role impairment Hazardous use Legal problems associated with use Social problems
Substance dependence	At least 3 of the following: Tolerance Withdrawal Using more or longer than intended Attempting to quit or cut down Much time spent using Activities given up to use Psychological/physical problems resulting from use Subtyped as with or without physiologic features (tolerance or withdrawal symptoms)
Source: DSM-IV-TR

Marijuana may be detected in the urine for 3 days to 4 weeks, depending on level of use. Cocaine can be detected for 2 to 4 days in urine and longer in hair analysis.

Random screening. Adolescents who use drugs usually know how long substances can be detected, so random urine drug screening is important to treatment progress. We inform adolescents at the beginning of treatment that random screening will be performed to corroborate self-report of substance use. To ensure a reliable urine sample, same-gender staff observe while the adolescent gives the sample.

Table 2

Common screening instruments for alcohol and drug use in adolescents

Instrument	Items (#)	How administered	Administration time
Drug Use Screening Inventory (DUSI-R), Revised	159	Self-report	20 to 40 minutes
Problem-Oriented Screening Instrument for Teenagers (POSIT)	139	Self-report	20 to 30 minutes
Teen Addiction Severity Index (T-ASI)	133	Clinician	20 to 45 minutes
Comprehensive Adolescent Severity Inventory (CASI)	245	Clinician	Varies with experience of administrator
Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS)	14	Self-report	About 5 minutes
Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS)	14	Self-report	About 5 minutes

STEP 2: IDENTIFYING PSYCHIATRIC COMORBIDITY

In adolescents, substance use disorder frequently goes hand-in-hand with psychiatric disorders, particularly:

• mood and anxiety disorders
• disruptive disorders (attention-deficit/hyperactivity, oppositional defiant, and conduct disorders)¹²
• and posttraumatic stress disorder.¹³

Uncontrolled psychiatric disorders may sabotage substance abuse treatment. Therefore, assess any adolescent presenting with substance use for psychiatric illness.

Did psychiatric symptoms predate or postdate substance use? The answer may suggest self-medication or a substance-induced phenomenon. This assumption does not always apply, however, as many factors affect the relationship between substance use and psychiatric disorders.

Adolescents who meet DSM-IV criteria for conduct disorder—especially those who are highly aggressive—tend to initiate substance use much earlier than adolescents without conduct disorder, and they continue their use longer.

Most adolescents with comorbid psychiatric and substance use disorders develop the psychiatric disorder first. Some report using various substances to medicate their psychiatric symptoms. Early diagnosis and treatment of the psychiatric disorder may prevent or decrease the adolescent’s substance use.

STEPS 3 AND 4: EVALUATING SOCIAL INFLUENCES AND CONSEQUENCES

Social influences that contribute to adolescent alcohol and drug abuse include family dynamics and peer relationships. Consequences include educational and legal problems. We explore these areas with the adolescents and their parents/guardians. In most cases, adolescents are honest when reporting how their alcohol or drug use has affected their lives.

What is his family like? Assess the adolescent’s family, including its structure and history of substance abuse, psychiatric illness, or trauma (Table 3). Adolescents whose parents or siblings use alcohol or drugs are at increased risk for substance use.¹⁴ To what extent this association is genetic, environmental, or both is undetermined, but the genetic influence increases as adolescents age.¹⁵

Who are her friends? Adolescents who try alcohol or drugs and continue to use them tend to have peers who use these substances.¹⁶ Moreover, the severity of adolescents’ substance use is correlated with the number of substance-using peers. To explore peer relationships, ask about:

• peer group composition, including whether peers use alcohol or drugs
• peer interactions, including the adolescent’s ability to assert him- or herself in the peer group
• markers for risky sexual behaviors related to substance use, including infection with HIV and other sexually transmitted diseases.

How is she doing in school? Inquire about the teen’s academic performance, attendance, disciplinary problems, and motivation. Even a small decline in school performance or an increase in disciplinary problems that result in suspension or expulsion can indicate substance use or other at-risk behaviors.

Poor grades or attendance problems suggest but are not the only clues to substance use. Some adolescents with good school performance engage in substance use and may be impaired in other life domains.

Has he been arrested? Substance-abusing adolescents tend to engage in delinquent behaviors, including shoplifting, vandalism, curfew violations, disorderly conduct, and drunken driving. When assessing for delinquency, ask about behaviors that did or did not result in arrest. The teen who avoided arrest for illegal activities may perceive his/her behaviors as less severe than those involving arrest, and it may help to address this denial in individual or group therapy.

Table 3

Questions to assess family influence on an adolescent’s substance use

Family structure
With whom does the adolescent live? How many people live in the home? What is the quality of the adolescent’s relationship with parents and siblings?
Parenting styles
Are parents authoritative or permissive? What disciplinary methods are used? How is conflict managed?
Substance abuse
Are any family members using alcohol or drugs? Is there a family history of substance abuse or dependence? What has been the extent of treatment?
Psychiatric disorders
Do any family members have psychiatric disorders (diagnosed or not)? What treatments were given? Outcome? What treatment does the family perceive to have been most effective?
Trauma
Has the adolescent experienced physical or sexual abuse or other trauma?

 

TREATMENT

We consider any adolescent with dependence symptoms—whether or not the presentation meets full DSM-IV diagnostic criteria—to be a candidate for further assessment and treatment. Early intervention may prevent progression to substance dependence.

Effective treatments:

• are intensive and of sufficient duration to change attitude and behaviors
• are comprehensive and target multiple domains of the adolescent’s life
• are sensitive to cultural and socioeconomic realities
• involve the family
• emphasize pro-social recreational activities, such as playing sports, attending movies, camping, having lunch or dinner with peers, etc.

Inpatient or outpatient? Managed care and insurance restrictions limit many patients’ eligibility for inpatient or residential treatment, so partial hospitalization and outpatient settings have become standard for substance abuse treatment. Partial hospitalization programs vary but may entail several hours, several days per week. Outpatient treatment may encompass individual, group, and family therapy, including after-school programs.

Inpatient treatment is usually reserved for adolescents:

• who need detoxification
• with comorbid psychiatric disorders
• or who may harm themselves or others.

PSYCHOTHERAPIES

Behavioral therapy, family-based therapy, multisystematic therapy (MST), and 12-step approaches have shown efficacy in treating adolescents with substance use disorders.

Behavioral therapy. Behavioral therapy is recommended as initial treatment because substance use plays a functional role in the adolescent’s life and is learned and reinforced in the adolescent’s environment. Homework assignments and role-play are commonly used in therapy.

Three central ingredients are:

• functional analysis (identifying internal and external triggers for starting and continuing substance use)
• skills training (targeting problems identified in the functional analysis)
• and relapse prevention.

Behavioral therapy is more effective than supportive therapy in improving family relationships and school and work attendance and in decreasing substance use, as indicated by fewer positive urine toxicology screens.¹⁷

Cognitive-behavioral therapy (CBT) approaches substance use as a maladaptive response to life problems. Its goal is to teach new skills to help the adolescent recognize and avoid high-risk situations and cope with associated problems and behaviors.

In a recent study, Kaminer et al randomly assigned 82 adolescents with psychiatric and substance use disorders to 8 weeks of CBT or psychoeducational therapy (didactic or videotaped presentations of ways to address problems associated with substance use). Substance use was reduced in both treatment groups, but:

• adolescents receiving CBT had significantly fewer positive urine toxicology tests
• adolescents with comorbid conduct disorder were least likely to complete treatment or return for follow-up
• those with depressive and anxiety disorders were most likely to complete treatment.¹⁸

Family-based therapy. Two detailed reviews^19,20 demonstrate that the adolescent’s family, community, and school relationships affect his or her perceptions and behaviors. Maladaptive relationships in any of these systems may lead to high-risk behaviors. Therefore, family therapy is core to the adolescent’s treatment, regardless of what modality is chosen.

Goals of family therapy may be:

• to help the adolescent abstain from substance use
• to engage in pro-social activities
• to decrease parental denial of the adolescent’s substance use
• to decrease resistance to treatment
• treatment maintenance
• to establish or re-establish structure in the adolescent’s environment
• to improve communication in the family.

Multisystemic therapy is comprehensive and involves all systems that relate to the adolescent’s substance use, including the family, school, community, and legal system. MST requires special training and intensive supervision, so it is usually reserved for adolescents who have not benefited from other forms of treatment.²¹

12-step approaches. For adolescents, 12-step programs usually augment other treatments and are rarely used alone. Alcoholics Anonymous, Narcotics Anonymous, and other 12-step programs have been studied more extensively in adults than in adolescents.

Adolescents, who often feel invulnerable, may have difficulty accepting the 12-step doctrine of lack of control. A modified 12-step program and workbook for adolescents are available through the American Academy of Child and Adolescent Psychiatry.²²

Referral tips. If possible, refer an adolescent to a 12-step group specifically for adolescents. Teens who attend adult groups often perceive their substance use as normal, compared with the more severe and chronic patterns of some adults. Most adolescents relate better to peers with similar problems and may benefit from reminders of the negative consequences of substance use and the benefits of abstinence.

DRUG THERAPY

Drug therapy for adolescents with substance use disorders is usually considered in the context of detoxification, treating withdrawal symptoms, and treating comorbid psychiatric disorders. The same detoxification and withdrawal treatment principles used in adults apply to adolescents.

Clinical withdrawal symptoms are less common in adolescents than adults, probably because of adolescents’ binge patterns of substance use. Even so, some adolescents do experience withdrawal and may be at risk for complications if improperly treated.

Psychiatric comorbidity. To our knowledge, only two double-blind, placebo-controlled studies of drug therapy in treating adolescent substance use disorders have been published.

 

Depression. Deas et al²³ randomized 10 adolescents with alcohol use disorders and depression to 12 weeks of group CBT plus sertraline or placebo. Sertraline was started at 25 mg/d and titrated to a maximum of 100 mg/d. Drinks per drinking day, percent of days drinking, and Hamilton Rating Scale for Depression scores declined similarly in both groups.

Drinking decreased significantly from baseline (by an average 4.7 drinks), and adolescents in both groups no longer met DSM-IV criteria for depression at the end of treatment. CBT’s effectiveness in treating alcohol use disorders and depression might have concealed any difference in effect between sertaline and placebo.

Bipolar disorder. Geller et al²⁴ randomly assigned 25 adolescents with bipolar disorder and substance dependence to lithium or placebo for 6 weeks. Lithium was started as an evening dose of 600 mg and titrated to achieve a lithium blood level of 0.9 to 1.3 mEq/L. Among the 21 adolescents who completed the trial, those receiving lithium had significantly fewer positive urine toxicology screens and higher clinical global assessment of function scores.

Related resources

• National Clearinghouse for Alcohol and Drug Information, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. www.health.org/govpubs/bkd306/31k.aspx
• National Institute on Alcohol Abuse and Alcoholism (assessment instruments). www.niaaa.nih.gov/publications/instable.htm
• Deas D, Thomas SE. An overview of controlled studies of adolescent substance abuse treatment. Am J Addict 2001;10:178-89.

Drug brand names

• Sertraline • Zoloft

Disclosure

Dr. Deas receives grant support from Pfizer, Inc. and the National Institute of Alcohol Abuse and Alcoholism.

Dr. Upadhyaya receives grant support from the National Institute of Drug Abuse and GlaxoSmithKline.

Acknowledgment

The authors wish to thank Alva Blair for assistance with preparing this manuscript and Natalie Johnson, MA, Kess Mughelli, BS, and Lakeleia Middleton-Robinson, MA, for technical support.

Assessing an adolescent for a possible substance use disorder can be streamlined by choosing age-appropriate screening tools and asking targeted questions. Based on our experience, we offer a 4-step approach to these at-risk patients¹ (Box) that focuses on:

• quantifying alcohol or drug abuse and/or dependence
• identifying and treating psychiatric comorbidity
• evaluating and addressing social influences that contribute to substance use
• assessing negative consequences associated with substance abuse.

Box

INITIAL EVALUATION

Adolescents generally do not seek substance abuse treatment but are referred because of alcohol- or drug-related legal, school, or family problems. Thus, most present for evaluation with their parents, legal guardians, or officers of the court.

We begin by finding out from parents or guardians the reasons for the evaluation, their perspectives on the adolescent’s behavior, and their expectations of treatment. Then we interview the adolescent alone, assessing for substance use and evaluating peer relationships.

Components. A typical initial evaluation takes 90 minutes to 2 hours and includes:

• psychiatric history and symptoms
• medical history
• previous hospitalizations (medical and psychiatric)
• family history
• social history.

Specifically, the assessment focuses on the reason for the evaluation, with attention to diagnostic criteria for substance use/dependence.

STEP 1: QUANTIFYING DEPENDENCE

As with adults, clinical diagnosis of substance abuse or dependence in adolescents is based on DSM-IV diagnostic criteria (Table 1). Adolescents, however, differ from adults in diagnostic presentation, risk of dependence, and patterns of substance use.

Diagnostic ‘orphans.’ DSM-IV criteria for alcohol use disorders have limitations in adolescents.² Teens who report one or two dependence symptoms and no abuse symptoms have been described as “diagnostic orphans”³—they fall short of criteria for dependence or abuse but clearly demonstrate substance use patterns. This presentation is common; in a survey of 74,008 high school students, almost 10% of 12th graders reported one or two dependence symptoms and no abuse symptoms.⁴

Risk of dependence. Adolescents who begin using alcohol or drugs develop dependence more rapidly than adults do.⁵

Patterns of use. Adolescents are more likely than adults to binge with alcohol and drugs, which may conceal the severity of their abuse. DSM-IV diagnostic criteria for substance abuse or dependence do not consider quantity of use, such as number of drinks or percent of days drinking or using drugs.

Assessment instruments. Many assessment instruments are available to explore adolescent substance use and its associated consequences. Some are described in detail and are available on the Internet. Common screening instruments that can be used for adolescent substance use are compared in Table 2.

DUSI-A and POSIT. Two self-report instruments—Drug Use Screening Inventory-Adolescents (DUSI-A)⁶ and Problem Oriented Screening Instrument for Teenagers (POSIT)⁷—can help explore alcohol or drug use in teens who admit to substance use. Anyone who endorses at least one DSM-IV abuse or dependence criterion requires further evaluation. Either test is a good starting point, and both have a built-in “lie” scale.

T-ASI and CASI. The Teen Addiction Severity Index (T-ASI)⁸ and Comprehensive Adolescent Severity Inventory (CASI)⁹ are more labor-intensive and require training to administer. These assessments are more appropriate for adolescents with extensive alcohol or drug abuse.

A-OCDS and Deas-MOCS. Our group recently developed the Adolescent Obsessive Compulsive Drinking Scale (A-OCDS)¹⁰ and the Deas-Marijuana Obsessive Compulsive Scale (Deas-MOCS).¹¹

These self-report instruments have been validated in treatment- and nontreatment-seeking adolescents and young adults in inpatient and outpatient populations. They are sensitive and specific in identifying problem drinkers and marijuana users, respectively, and are quick, useful screens to determine need for further assessment.

Toxicology is useful for initial assessment and to monitor substance use patterns during treatment.

Urine samples are used to assess marijuana, sedative/hypnotic, amphetamine, cocaine, opiate, and phencyclidine use. Alcohol may be detected in urine, but alcohol levels detected by blood and breath testing are more accurate.

 

Table 1

Diagnostic criteria for substance abuse and dependence

Substance abuse	1 of these 4 symptoms in a 12-month period: Role impairment Hazardous use Legal problems associated with use Social problems
Substance dependence	At least 3 of the following: Tolerance Withdrawal Using more or longer than intended Attempting to quit or cut down Much time spent using Activities given up to use Psychological/physical problems resulting from use Subtyped as with or without physiologic features (tolerance or withdrawal symptoms)
Source: DSM-IV-TR

Marijuana may be detected in the urine for 3 days to 4 weeks, depending on level of use. Cocaine can be detected for 2 to 4 days in urine and longer in hair analysis.

Random screening. Adolescents who use drugs usually know how long substances can be detected, so random urine drug screening is important to treatment progress. We inform adolescents at the beginning of treatment that random screening will be performed to corroborate self-report of substance use. To ensure a reliable urine sample, same-gender staff observe while the adolescent gives the sample.

Table 2

Common screening instruments for alcohol and drug use in adolescents

Instrument	Items (#)	How administered	Administration time
Drug Use Screening Inventory (DUSI-R), Revised	159	Self-report	20 to 40 minutes
Problem-Oriented Screening Instrument for Teenagers (POSIT)	139	Self-report	20 to 30 minutes
Teen Addiction Severity Index (T-ASI)	133	Clinician	20 to 45 minutes
Comprehensive Adolescent Severity Inventory (CASI)	245	Clinician	Varies with experience of administrator
Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS)	14	Self-report	About 5 minutes
Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS)	14	Self-report	About 5 minutes

STEP 2: IDENTIFYING PSYCHIATRIC COMORBIDITY

In adolescents, substance use disorder frequently goes hand-in-hand with psychiatric disorders, particularly:

• mood and anxiety disorders
• disruptive disorders (attention-deficit/hyperactivity, oppositional defiant, and conduct disorders)¹²
• and posttraumatic stress disorder.¹³

Uncontrolled psychiatric disorders may sabotage substance abuse treatment. Therefore, assess any adolescent presenting with substance use for psychiatric illness.

Did psychiatric symptoms predate or postdate substance use? The answer may suggest self-medication or a substance-induced phenomenon. This assumption does not always apply, however, as many factors affect the relationship between substance use and psychiatric disorders.

Adolescents who meet DSM-IV criteria for conduct disorder—especially those who are highly aggressive—tend to initiate substance use much earlier than adolescents without conduct disorder, and they continue their use longer.

Most adolescents with comorbid psychiatric and substance use disorders develop the psychiatric disorder first. Some report using various substances to medicate their psychiatric symptoms. Early diagnosis and treatment of the psychiatric disorder may prevent or decrease the adolescent’s substance use.

STEPS 3 AND 4: EVALUATING SOCIAL INFLUENCES AND CONSEQUENCES

Social influences that contribute to adolescent alcohol and drug abuse include family dynamics and peer relationships. Consequences include educational and legal problems. We explore these areas with the adolescents and their parents/guardians. In most cases, adolescents are honest when reporting how their alcohol or drug use has affected their lives.

What is his family like? Assess the adolescent’s family, including its structure and history of substance abuse, psychiatric illness, or trauma (Table 3). Adolescents whose parents or siblings use alcohol or drugs are at increased risk for substance use.¹⁴ To what extent this association is genetic, environmental, or both is undetermined, but the genetic influence increases as adolescents age.¹⁵

Who are her friends? Adolescents who try alcohol or drugs and continue to use them tend to have peers who use these substances.¹⁶ Moreover, the severity of adolescents’ substance use is correlated with the number of substance-using peers. To explore peer relationships, ask about:

• peer group composition, including whether peers use alcohol or drugs
• peer interactions, including the adolescent’s ability to assert him- or herself in the peer group
• markers for risky sexual behaviors related to substance use, including infection with HIV and other sexually transmitted diseases.

How is she doing in school? Inquire about the teen’s academic performance, attendance, disciplinary problems, and motivation. Even a small decline in school performance or an increase in disciplinary problems that result in suspension or expulsion can indicate substance use or other at-risk behaviors.

Poor grades or attendance problems suggest but are not the only clues to substance use. Some adolescents with good school performance engage in substance use and may be impaired in other life domains.

Has he been arrested? Substance-abusing adolescents tend to engage in delinquent behaviors, including shoplifting, vandalism, curfew violations, disorderly conduct, and drunken driving. When assessing for delinquency, ask about behaviors that did or did not result in arrest. The teen who avoided arrest for illegal activities may perceive his/her behaviors as less severe than those involving arrest, and it may help to address this denial in individual or group therapy.

Table 3

Questions to assess family influence on an adolescent’s substance use

Family structure
With whom does the adolescent live? How many people live in the home? What is the quality of the adolescent’s relationship with parents and siblings?
Parenting styles
Are parents authoritative or permissive? What disciplinary methods are used? How is conflict managed?
Substance abuse
Are any family members using alcohol or drugs? Is there a family history of substance abuse or dependence? What has been the extent of treatment?
Psychiatric disorders
Do any family members have psychiatric disorders (diagnosed or not)? What treatments were given? Outcome? What treatment does the family perceive to have been most effective?
Trauma
Has the adolescent experienced physical or sexual abuse or other trauma?

 

TREATMENT

We consider any adolescent with dependence symptoms—whether or not the presentation meets full DSM-IV diagnostic criteria—to be a candidate for further assessment and treatment. Early intervention may prevent progression to substance dependence.

Effective treatments:

• are intensive and of sufficient duration to change attitude and behaviors
• are comprehensive and target multiple domains of the adolescent’s life
• are sensitive to cultural and socioeconomic realities
• involve the family
• emphasize pro-social recreational activities, such as playing sports, attending movies, camping, having lunch or dinner with peers, etc.

Inpatient or outpatient? Managed care and insurance restrictions limit many patients’ eligibility for inpatient or residential treatment, so partial hospitalization and outpatient settings have become standard for substance abuse treatment. Partial hospitalization programs vary but may entail several hours, several days per week. Outpatient treatment may encompass individual, group, and family therapy, including after-school programs.

Inpatient treatment is usually reserved for adolescents:

• who need detoxification
• with comorbid psychiatric disorders
• or who may harm themselves or others.

PSYCHOTHERAPIES

Behavioral therapy, family-based therapy, multisystematic therapy (MST), and 12-step approaches have shown efficacy in treating adolescents with substance use disorders.

Behavioral therapy. Behavioral therapy is recommended as initial treatment because substance use plays a functional role in the adolescent’s life and is learned and reinforced in the adolescent’s environment. Homework assignments and role-play are commonly used in therapy.

Three central ingredients are:

• functional analysis (identifying internal and external triggers for starting and continuing substance use)
• skills training (targeting problems identified in the functional analysis)
• and relapse prevention.

Behavioral therapy is more effective than supportive therapy in improving family relationships and school and work attendance and in decreasing substance use, as indicated by fewer positive urine toxicology screens.¹⁷

Cognitive-behavioral therapy (CBT) approaches substance use as a maladaptive response to life problems. Its goal is to teach new skills to help the adolescent recognize and avoid high-risk situations and cope with associated problems and behaviors.

In a recent study, Kaminer et al randomly assigned 82 adolescents with psychiatric and substance use disorders to 8 weeks of CBT or psychoeducational therapy (didactic or videotaped presentations of ways to address problems associated with substance use). Substance use was reduced in both treatment groups, but:

• adolescents receiving CBT had significantly fewer positive urine toxicology tests
• adolescents with comorbid conduct disorder were least likely to complete treatment or return for follow-up
• those with depressive and anxiety disorders were most likely to complete treatment.¹⁸

Family-based therapy. Two detailed reviews^19,20 demonstrate that the adolescent’s family, community, and school relationships affect his or her perceptions and behaviors. Maladaptive relationships in any of these systems may lead to high-risk behaviors. Therefore, family therapy is core to the adolescent’s treatment, regardless of what modality is chosen.

Goals of family therapy may be:

• to help the adolescent abstain from substance use
• to engage in pro-social activities
• to decrease parental denial of the adolescent’s substance use
• to decrease resistance to treatment
• treatment maintenance
• to establish or re-establish structure in the adolescent’s environment
• to improve communication in the family.

Multisystemic therapy is comprehensive and involves all systems that relate to the adolescent’s substance use, including the family, school, community, and legal system. MST requires special training and intensive supervision, so it is usually reserved for adolescents who have not benefited from other forms of treatment.²¹

12-step approaches. For adolescents, 12-step programs usually augment other treatments and are rarely used alone. Alcoholics Anonymous, Narcotics Anonymous, and other 12-step programs have been studied more extensively in adults than in adolescents.

Adolescents, who often feel invulnerable, may have difficulty accepting the 12-step doctrine of lack of control. A modified 12-step program and workbook for adolescents are available through the American Academy of Child and Adolescent Psychiatry.²²

Referral tips. If possible, refer an adolescent to a 12-step group specifically for adolescents. Teens who attend adult groups often perceive their substance use as normal, compared with the more severe and chronic patterns of some adults. Most adolescents relate better to peers with similar problems and may benefit from reminders of the negative consequences of substance use and the benefits of abstinence.

DRUG THERAPY

Drug therapy for adolescents with substance use disorders is usually considered in the context of detoxification, treating withdrawal symptoms, and treating comorbid psychiatric disorders. The same detoxification and withdrawal treatment principles used in adults apply to adolescents.

Clinical withdrawal symptoms are less common in adolescents than adults, probably because of adolescents’ binge patterns of substance use. Even so, some adolescents do experience withdrawal and may be at risk for complications if improperly treated.

Psychiatric comorbidity. To our knowledge, only two double-blind, placebo-controlled studies of drug therapy in treating adolescent substance use disorders have been published.

 

Depression. Deas et al²³ randomized 10 adolescents with alcohol use disorders and depression to 12 weeks of group CBT plus sertraline or placebo. Sertraline was started at 25 mg/d and titrated to a maximum of 100 mg/d. Drinks per drinking day, percent of days drinking, and Hamilton Rating Scale for Depression scores declined similarly in both groups.

Drinking decreased significantly from baseline (by an average 4.7 drinks), and adolescents in both groups no longer met DSM-IV criteria for depression at the end of treatment. CBT’s effectiveness in treating alcohol use disorders and depression might have concealed any difference in effect between sertaline and placebo.

Bipolar disorder. Geller et al²⁴ randomly assigned 25 adolescents with bipolar disorder and substance dependence to lithium or placebo for 6 weeks. Lithium was started as an evening dose of 600 mg and titrated to achieve a lithium blood level of 0.9 to 1.3 mEq/L. Among the 21 adolescents who completed the trial, those receiving lithium had significantly fewer positive urine toxicology screens and higher clinical global assessment of function scores.

Related resources

• National Clearinghouse for Alcohol and Drug Information, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. www.health.org/govpubs/bkd306/31k.aspx
• National Institute on Alcohol Abuse and Alcoholism (assessment instruments). www.niaaa.nih.gov/publications/instable.htm
• Deas D, Thomas SE. An overview of controlled studies of adolescent substance abuse treatment. Am J Addict 2001;10:178-89.

Drug brand names

• Sertraline • Zoloft

Disclosure

Dr. Deas receives grant support from Pfizer, Inc. and the National Institute of Alcohol Abuse and Alcoholism.

Dr. Upadhyaya receives grant support from the National Institute of Drug Abuse and GlaxoSmithKline.

Acknowledgment

The authors wish to thank Alva Blair for assistance with preparing this manuscript and Natalie Johnson, MA, Kess Mughelli, BS, and Lakeleia Middleton-Robinson, MA, for technical support.