Substance Use Spectrum and Goals for Office Intervention
Office Intervention Goals
The time before an individual has ever used drugs or alcohol (more than a few sips)
Prevent or delay initiation of substance use through positive reinforcement and patient/parent education
The first 1–2 times that a substance is used and the adolescent wants to know how intoxication from using a certain drug(s) feels
Promote patient strengths; encourage abstinence and cessation through brief, clear medical advice and educational counseling
Use together with ≥1 friends in relatively low-risk situations and without related problems; typically, use occurs at predictable times such as on weekends
Promote patient strengths; further encourage cessation through brief, clear medical advice and educational counseling
Use in a high-risk situation, such as when driving or babysitting; use associated with a problem such as a fight, arrest, or school suspension; or use for emotional regulation such as to relieve stress or depression
As stated above, plus initiate office visits or referral for brief intervention to enhance motivation to make behavioral changes; provide close patient follow-up; consider breaking confidentiality
Drug use associated with recurrent problems or that interferes with functioning, as defined in the DSM-IV-TR
Continue as stated above, plus enhance motivation to make behavioral changes by exploring ambivalence and triggering preparation for action; monitor closely for progression to alcohol and other drug addiction; refer for comprehensive assessment and treatment; consider breaking confidentiality
Loss of control or compulsive drug use, as defined in the DSM-IV-TR as “dependence”
As stated above, plus enhance motivation to accept referral to subspecialty treatment if necessary; consider breaking confidentiality; encourage parental involvement whenever possible
DSM-IV-TR indicates Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Substance Use Treatment
Group therapy is a mainstay of substance abuse treatment for adolescents with substance use disorders. It is a particularly attractive option, because it is cost-effective and takes advantage of the developmental preference for congregating with peers. However, group therapy has not been extensively evaluated as a therapeutic modality in this age group, and existing research has produced mixed results.46,48
Family-directed therapies are the best validated approach for treating adolescent substance abuse. A number of modalities have been demonstrated effective. Family counseling typically targets domains that figure prominently in the etiology of substance use disorders in adolescents: family conflict, communication, parental monitoring, discipline, child abuse/neglect, and parental substance use disorders.46
Intensive outpatient program
IOPs serve as an intermediate level of care for patients who have needs that are too complex for outpatient treatment but do not require inpatient services. These programs allow people to continue with their daily routine and practice newly acquired recovery skills both at home and at work.
IOPs generally comprise a combination of supportive group therapy, educational groups, family therapy, individual therapy, relapse prevention and life skills, 12-step recovery, case management, and aftercare planning. The programs range from 2 to 3 h/d, 2–5 d/wk, and last 1–3 months. These programs are appealing, because they provide a plethora of services in a relatively short period of time.49,a
Partial hospital program
Partial hospitalization is a short-term, comprehensive outpatient program in affiliation with a hospital that is designed to provide support and treatment for patients with substance use disorders. The services offered at these programs are more concentrated and intensive than regular outpatient treatment; they are structured throughout the entire day and offer medical monitoring in addition to individual and group therapy. Participants typically attend sessions for 7 or 8 h/d, at least 5 d/wk, for 1–3 weeks. As with IOPs, patients return home in the evenings and have a chance to practice newly acquired recovery skills.50,b
Detoxification refers to the medical management of symptoms of withdrawal. Medically supervised detoxification is indicated for any adolescent who is at risk of withdrawing from alcohol or benzodiazepines and might also be helpful for adolescents withdrawing from opioids, cocaine, or other substances. Detoxification may be an important first step but is not considered definitive treatment. Patients who are discharged from a detoxification program should then begin either an outpatient or residential substance abuse treatment program.47,48
Acute residential treatment
ART is a short-term (days to weeks) residential placement designed to stabilize patients in crisis, often before entering a longer-term residential treatment program.47 ART programs typically target adolescents with co-occurring mental health disorders.
Residential treatment programs are highly structured live-in environments that provide therapy for those with severe substance abuse, mental illness, or behavioral problems that require 24-hour care. The goal of residential treatment is to promote the achievement and subsequent maintenance of long-term abstinence and equip each patient with both the social and coping skills necessary for a successful transition back into society. Residential programs are classified as short-term (<30 d) or long-term (≥30 d).
Residential programs generally comprise individual and group-therapy sessions plus medical, psychological, clinical, nutritional, and educational components. Residential facilities aim to simulate real living environments with added structure and routine to prepare patients with the framework necessary for their lives to continue drug- and alcohol-free after completion of the program.51,c
Therapeutic boarding school
Therapeutic boarding schools are educational institutions that provide constant supervision for their students by a professional staff. These schools offer a highly structured environment with set times for all activities; smaller, more specialized classes; and social and emotional support. In addition to the regular services offered at traditional boarding schools, therapeutic schools also provide individual and group therapy for adolescents with mental health or substance use disorders.52,d