William White, Michael Dennis and Mark Godfrey
The risk and severity of substance-related problems are magnified by lowered age of onset of regular use. The risk of substance abuse; dependence is not uniform across substance-using youth. Those who begin drug use before age 15 are six times more likely than those who begin drug use after age 18 to develop adult symptoms of drug dependence. Nearly 85% of the Cannabis Youth Treatment (CYT) study adolescents started using between the ages of 12 and 74. There is a growing body of evidence that early onset of drug use is associated with increased risk of adult substance use disorders, increased severity of those disorders, poorer treatment outcomes, and longer addiction careers (the length of time between first use to achievement of stable recovery) (Chou & Pickering, 1992; Grant & Dawson, 1997). This lowered age of drug experimentation reflects the rise in the number of children who are approaching and entering adolescence in family/social environments characterized by high drug availability and norms that tolerate or promote drug experimentation. Reduced age of drug exposure may become recognized as one of the most clinically and socially significant drug trends of the twentieth century. The growing recognition of substance use in early adolescence has spurred the redesign of prevention efforts since the late 1970s (Evans, Rozelle, Mittlemark, Hansen, Banc, & Havis, 1978). Accumulating data about the social and clinical significance of the progressive lowering of the age of onset of drug use is spurring more focused and sustained prevention and early intervention strategies, particularly among high-risk youth. Postponing, if not preventing, exposure to intoxicants to the latest point in the transition from childhood to young adulthood is a crucial strategy in the goal of reducing alcohol- and other drug-related problems.
Substance use disorders of adolescence rarely occur in isolation from other problems (Grella, Hser, Joshi, & Rounds-Bryant, 2001; Hser, et al., 2001). Of the adolescents admitted to treatment within the CYT study 95% reported one or more other problems (83% had three or more). The most frequent psychiatric problems included major depression, generalized anxiety, suicidal thoughts or actions, traumatic stress disorders (60% reported a history of victimization), conduct disorder, and Attention Deficit Hyperactivity Disorder. Other commonly reported problems included family instability, school failure, enmeshment in deviant peer cultures, and criminality. Two findings are consistent within the recent research literature: 1) youth with pre-existing problems are at higher risk for substance use disorders, and 2) substance use plays a role in the onset and exacerbation of other problems. These findings reinforce the need for broad-spectrum biopsychosocial (as opposed to problem-specific) screening and assessment procedures, and the need for multi-disciplinary, multi-agency intervention models that can provide an integrated response to multiple, co-occurring problems of youth and families.
Adolescent substance use disorders present in both acute and chronic patterns. The former are more likely to respond to brief outpatient or residential therapies as evidenced by sustained abstinence (or only minor relapses) and significant improvement in functioning following treatment. The five brief interventions tested in the CYT study were all associated with major reductions in substance use, symptoms of dependence or abuse, behavioral problems, family problems, school problems, and illegal activity. At 12 months, nearly a third of those youth completing CYT treatment were living in the community without any marijuana use or substance-related problems. This reflects the good news of adolescent treatment outcome research: There are brief treatments that can have positive and enduring effects on the lives of many young people and their families.
The more ominous news within recent adolescent treatment outcome studies is documentation of the presence of many youth for whom substance use has already become a chronic condition and way of life. In the CYT study, 41% of the adolescents had failed earlier attempts to quit on their own, a quarter reported earlier admission to treatment, and a third were re-admitted to treatment in the year following their discharge from the CYT study. While such findings may stir therapeutic pessimism about the treatment of adolescent substance use disorders, we believe these findings instead confirm the need for different types and levels of care within the rubric of adolescent treatment.
Most treated adolescents will vacillate between periods of recovery and periods of drug use and drug-related problems in the year following their first treatment episode. The portrayal of adolescent substance use treatment as a brief clinical encounter that either works (complete and enduring abstinence following treatment) or does not work (any drug use following treatment) is inconsistent with the actual phenomenon of adolescent addiction and recovery. After CYT treatment, we found that 60"o had some period of recovery; 29% went into recovery but later relapsed; 7% went into recovery, relapsed, but then resumed recovery; 15% did not respond to treatment right away but did get better during the subsequent months; and 9% recovered right away and stayed in recovery through the first year following treatment. These findings suggest that most adolescents are precariously balanced between recovery and reactivation of substance use in the months (and particularly the first 90 days) following completion of treatment. Most disturbing is the fact that addiction professionals are typically not present in the lives of treated adolescents and their families when the shifts to stable recovery or reactivation of substance use occurs in the weeks and months following acute intervention (Godley, Godley, Dennis, Funk, & Passetti, in press).
Post-treatment monitoring and recovery support services offer promise in enhancing adolescent treatment outcomes (Stout, Rubin, Zwiak & Bellino, 1999; Godley, et al., in press). The fragile and fluid nature of the post-treatment recovery experience invites a new service model that shifts from the "diagnose, admit, treat, discharge" approach of the hospital emergency room to a sustained model of recovery management that more closely resembles the model of disease management used to treat diabetes, hypertension, and asthma (McLellan, Lewis, O'Brien, & Kleber, 2000; White, Boyle, & Loveland, in press). These latter approaches focus on problem stabilization, recovery education, ongoing monitoring, professionally hosted support networks, and, when needed, early re-intervention (White & Dennis, 2002).
Greater attention must be given to the ecology of recovery from adolescent substance use disorders. The advancements in the treatment of substance-use disorders point toward the family, the peer culture, the school, and the larger community as important mediators in post-treatment recovery or relapse. It is becoming increasingly clear that the substance-impacted adolescent cannot be treated without treating the environment in which he or she resides. What is needed is nothing short of building indigenous cultures of recovery that can nurture adolescents during and following their experiences in professionally directed treatment. This requires constructing and utilizing recovery support systems within the world the adolescent inhabits: within the family, the school, the neighborhood, and the wider community. For those adolescents most deeply involved in substance use, the goal is to move them from a drug-saturated culture of addiction to a youth-oriented culture of recovery (White, 1996).
White, W.L,. Dennis, M.L. and Godley, M.D. (2002). Adolescent substance abuse disorders: From acute treatment to recovery management. Reclaiming Children and Youth, 11, 3. pp.172-175
Chou, S.P., & Pickering, R.P. (1992). Early onset of drinking as a risk factor for lifetime alcohol-related problems. British Journal of Addiction 37, 1199-1204.
Evans, R. L, Rozelle, R M., Mittlemark, M. B., Hansen, W. B., Bane, A. L., & Havis, J. (1978). Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. Journal of Applied Social Psychology, 3, 126-135.
Godley, M. D., God ley S.H., Dennis, M. L., Funk, R. & Passetti L. (In press). preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment
Grant, B. F., & Dawson, D. A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence. Journal of Substance Abuse 9, 103-110.
Grella, C. E., Hser Y. l., Joshi, V., & Rounds-Bryant, J. (2001). Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. Journal of Nervous and Mental Disease. 739(6), 384-392.
Hser, Y. L, Grella, C. E., Hubbard, R. L., Hsieh, S., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in 4 U.S. cities. Archives of General Psychiatry, 53, 689-695.
McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284(13), 1689-1695.
Stout, R. L. Rubin, A., Zwick, W., Zywiak, W., & Bellino, L. (1999). Optimizing the cost-effectiveness of alcohol treatment: A rationale for extended case monitoring. Addictive Behaviors 24(1), 17-35.
White, W. (1996). Pathways from the culture of addiction to he culture of recovery. Center City, MN: Hazelden Publishing.
White, W., & Dennis, M. (2002). The Cannabis Youth Treatment Stud-\: Key lessons for student assistance programs. Student Assistance Journal 14(3), 16-19.
White, W., Boyle M., & Loveland, D. (In press). Addiction as a chronic disease: From rhetoric to clinical reality. Alcoholism Treatment Quarterly.