My career in Addiction Medicine began more than 40 years ago when I founded the Haight Ashbury Free Medical Clinic during the “Summer of Love” following my training at the University of California at San Francisco. As “Young Doctor Smith,” I dealt with young people who came for the Bay Area counterculture seeking “Drugs, Sex and Rock & Roll” and “Better Living through Chemistry,” only to see my neighborhood go from fantasy of psychedelics to a nightmare of speed. We dealt primarily with bad trips and methamphetamine psychosis with its associated medical and psychiatric problems (Brokaw, 2008; Owen, 2006).
Although our practice was based on the assumption that addiction was a disease and the addict had a right to treatment, consistent with the clinicís founding philosophy that “Health Care is a Right, not a Privilege,” our understanding of addiction and recovery was limited and conformed primarily to the 12-step fellowships of Alcoholics Anonymous and Narcotics Anonymous. Our relationship with law enforcement was confrontational as they often conflicted with our goal of treating the addict as a patient with a disease, rather than criminalizing them for using an illicit substance (Brokaw, 2008; Owen, 2006).
As “Old Doc Smith” I have returned to my roots, operating as Medical Director of Center Point in Northern California where I treat troubled young people being diverted to long-term treatment in a six-month therapeutic community. I have also taken the role of Chief of Addiction Medicine at Newport Academy in Southern California, a long-term adolescent addiction treatment program for young women.
Addiction medicine is now a mainstream medical specialty recognized by the American Medical Association, and our relationship with law enforcement is more cooperative, as evidenced by the use of Drug Court diversion to treatment initiatives. Knowledge of addiction as a brain disease and its long-term treatment has increased exponentially over this 40-year period.
The publicity given the drug problems of the late 1960s ultimately led to a skewed perception by the general public that the drug epidemic in the United States was basically over. Unfortunately, the problem of adolescent addiction with associated co-occurring disorders is much greater and more widespread now than ever. However, it appears that this dual diagnosis disorder occurs primarily in patients that have a pre-existing psychiatric disorder. In addition to exacerbating psychotic symptoms, marijuana has been reported to worsen mania in patients with bipolar disorders. The chronic cannabis-dependent adolescent also has a high incidence of underlying depression and may in fact be self-medicating that depression as a major comorbid factor in the development of cannabis dependence (Gurley, 1998).
Various investigators confirm that in adolescent and young adult populations, nonmedical use of prescription drugs is the most prevalent form of substance use, after marijuana and alcohol. For prescription analgesics and prescription stimulants, exposure opportunity and lifetime prevalence increase dramatically in the first two years of college, with prescription stimulants having the greatest proportional increase. Marijuana continues to be the most prevalent drug used among this population, with nearly one-third of teens reporting having ever tried marijuana in their lifetime. In chronic marijuana users, 15 percent reported clinical depression and psychotic symptoms (CESAR, 2009).
The next two most prevalent substances abused, however, are substances that are not illegal when used as directed, and are often readily available in teens’ households. Nearly one in five (an estimated 4.7 million) teens have abused inhalants, and the same number report abusing prescription drugs. In addition, 10 percent of teens (an estimated 2.5 million) have abused over-the-counter cough medicines—approximately the same percentage who have used crack/cocaine or ecstasy (see Figure 1). Abuse of inhalants and OTC cough medicine is defined as using the substance to get high and abuse of prescription drugs is defined as use without a doctor’s prescription. Perceived risk and availability may help explain the prevalence of prescription drug abuse — 41 percent of teens thought that prescription drugs are much safer to use than illegal drugs and 61 percent reported that prescription drugs are easier to get than illegal drugs (CESAR, 2009).
The most prevalent cause of adolescent morbidity and mortality is drug and alcohol abuse. Only 10 percent of the estimated 1.4 million adolescents (aged 12 to 17 years) with an illicit drug problem receive treatment (Brannigan, 2004). Adolescent addiction is a developmental disorder with peak onset between 15 and 21 years of age. Statistically, if addictive disease onset is before 15 years of age, severity and duration of disability with addiction is prolonged (NIDA, 1999, 2008). Additional risk factors for early onset addiction may include: genetic predisposition to addiction in first order relatives; childhood trauma; disruptive or addictive child rearing environments; and co-occurring disorders preceding the onset of addiction. The management of addictive disease and co-occurring disorders in a continuing care model of treatment must include consideration of the possibilities of dual diagnosis disorders, the level of detoxification, relapse prevention, depression, ADHD, and/or eating disorders, based on American Society of Addition Medicine (ASAM) treatment criteria (ASAM, 2003; Rawson, 2008; Zweben, 2003).
Early onset is highly correlated with non-medical use of drugs, including prescription psychostimulants, as well as being linked with co-occurring disorders. Studies have shown an increase in adolescents using non-prescribed pain relievers at least once in their lifetime. These youths are significantly more likely to report poly-drug abuse than those who did not use nonprescriptive pain relievers. The use falls into a myriad of classes: prescription pain killers, psychostimulants, benzodiazepine sedative hypnotics and barbiturate sedative hypnotics. In a recent study obtained by the Center for Substance Abuse Research, more teens report abusing prescription drugs and inhalants than any other illicit drug except marijuana. The nature of the drug problem in adolescents has changed, with the biggest increase being nonmedical misuse of prescription drugs diverted from the medical system mixing with street drugs, blurring the line between legal and illegal drug cultures (Arria, 2008).
Co-occurring disorders and addiction in adolescents
In working with high risk and traumatized adolescents a very careful clinical approach is necessary. The challenge is to treat both the trauma and the addiction in an integrated fashion. Traumatized adolescents with addictive disorders often have great difficulties with learning recovery skills as their attention is focused on family conflicts (Rothman, 2008; Joslyn, 2008; Joslyn, 2008).
Dr. Marc Schuckit, at a recent UCSF conference on the genetics of alcoholism, stressed that early onset alcoholism in high risk genetically pre-disposed youth is characterized by an altered initial response to alcohol coupled with “inborn tolerance,”or the ability to drink large quantities of alcohol to achieve intoxication and the gravitation to an adolescent peer group that also drinks heavily (University of California, San Francisco lecture, 3/23/09; Joslyn, 2008; Joslyn, 2008).
Recent efforts in the trauma field have focused on the difficulties that youth have to self-soothe, to literally calm themselves and their inner turmoil. This self-soothing inability explains why many of these traumatized youth turn to alcohol and other drugs in an attempt to quiet their inner thoughts and emotions. This population of adolescents with trauma that predated the onset of their substance abuse has a high incidence of co-occurring disorders, including depression and eating disorders. The experience of multiple chronic prolonged and developmentally adverse traumatic events of an interpersonal nature with early life onset requires an intensive, multifaceted pretreatment approach that addresses the issues in the context of the family, socialization and education (Rothman, 2008).
Adolescents need a somewhat different treatment model than adults. The adolescent model focuses on habilitation, emphasizing the teaching of new psycho-social recovery skills, whereas the adult rehabilitation model focuses on returning to pre-existing recovery skills while simultaneously learning new skills. Early onset addiction with co-occurring disorders has many characteristics that are different from adult treatment, and treatment has to be implemented early in the treatment cycle (NIDA, 1999, 2008). Inpatient residential treatment ranges from short-term to long-term in residential facilities, to sober living residences, which need to be age-differentiated (Rawson, 2008).
Alcohol and other drug addictions are increasing in adolescent girls, and necessitates gender-specific treatment. Evidence suggests that the shortcomings of the treatment system with regard to the unique needs of women and girls have resulted in a female death rate from alcoholism that is now 50 to 100 percent higher than in men. Other issues arguing for gender-specific treatment include physical and sexual abuse reported by 75 to 89 percent of addicted women, and sexual abuse reported by up to 70 percent of drug-using girls (more than 80 percent had at least one addicted parent) (Miller, 2003).
Early intervention is critical for treatment success with girls. Women rarely enter into treatment until late-stage addiction is upon them. Girls tend to move from experimentation to problematic drug use more quickly than boys; they have higher rates of binge drinking than boys; and they have higher rates of illicit drug use while pregnant than their adult counterparts (Miller, 2003).
Eating disorders are common in substance-abusing women; however, assessment and integrated treatment for these disorders are rare in most treatment programs. Eating disorders can co-exist with substance abuse, and drug use may mask or facilitate the disorder. For example, heroin use facilitates vomiting. Stimulants can suppress appetite, while creating a sense of power. Alcohol can provide a feeling of release and diminish the shame that follows an eating episode (Brannigan, 2004; Zweben, 2003).
The best model for treating addictive disease in adults is the integration of pharmacotherapy and psychosocial recovery. However, treatment protocols in pharmacotherapy for adolescent addition are not well established and there are very few studies involving co-occurring eating disorders. One of the difficulties in prescribing Serotonin Selective Re-uptake Inhibitors (SSRIs) for adolescent substance abusers with eating disorders is its increased propensity for weight gain, which leads to medication non-compliance by patients. Suboxone is the most promising new pharmaco-therapy for opioid addiction, but there are very few studies looking at its use for adolescents with prescription narcotic addiction. Therefore, the role of pharmaco-therapy in an integrated adolescent addiction program focusing on patients with co-occurring disorders has to be individualized and implemented by a skilled addiction psychiatrist with the cooperation of a trained clinical staff (Harris, 2008; NIDA, 1999, 2008; Rawson, 2008).
Research has shown significant differences between the treatment needs of male and female adolescent drug users. Programs designed to serve women can provide many services which more directly address womenís issues. They can increase effectiveness in addressing eating disorders and plan for nutritional stabilization to focus strategies to stop aberrant eating disorders. In addition, more appropriate models than the 12-step model can be created. Women-specific programs also can provide more careful inquiry during initial assessment, with specialized training, and encourage psychotherapy earlier in the recovery process (Nelson-Zlupko, 1995; Zweben, 2003).
Addictive and mental disorders often occur in the same individual and need to be treated in an integrated manner. Patients presenting for either condition need to be assessed and treated for co-occurrence of the other disorder (NIDA, 2008).
Effective adolescent substance abuse treatment programs provide the broader range of treatment necessary to address all aspects of adolescent life. They also meet the more challenging treatment needs of adolescents, who have a higher rate of dual diagnosis than adults. Developmentally appropriate programming targeted at adolescents is necessary.
Factors in treatment effectiveness include a strong motivation to facilitate the treatment process. A mix of sanctions or enticements from personal, professional and/or legal relationships can increase treatment entry and retention rates, as well as the success of interventions (ASAM, 2003; NIDA, 2008).
Denial among adolescents about drug problems is high and few seek treatment on their own. One of the most essential aspects of treatment is a positive alliance between the adolescent, the counselor and the staff. Programs need to focus on creative treatment techniques to engage and retain adolescents while they navigate their recovery. Gender-specific sessions offer a forum to address issues that may be difficult to discuss in mixed groups. Barbara Nosal, PhD, MFT, Newport Academy Clinical Director, an adolescent addiction treatment program for young women with co-occurring disorders, will publish the crucial criteria for same-sex treatment in a future issue of Counselor Magazine.
There is a critical need for adolescent treatment to be more effective and respond to the growing addiction problem in this high risk age group. It clearly will have to incorporate new evidence-based strategies, including gender-
David E. Smith, MD, FASAM, FAACT Dr. Smith is recognized as a national leader in the areas of the treatment of addictive disease, the psychopharmacology of drugs, new research strategies in the management of drug abuse problems, and proper prescribing practices for physicians. He is the Founder of the Haight Ashbury Free Clinics in San Francisco, which treats over 160,000 client visits per year in 23 sites in the San Francisco Bay area.
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This article is published in Counselor, The Magazine for Addiction Professionals, June 2009, v.10, n.3, pp.42-46.