SCRIPT FROM LIVE CHAT: Strengthening Substance Abuse Treatment Services for Adolescents
With: H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, Director of the Center for Substance Abuse Treatment
From Monday, September 25, 2000; 7:00 p.m.-10:00 p.m. EDT
Question:
It's 10 p.m. Is it time to go?The Center for Substance Abuse Treatment (CSAT) is concerned about inhalant abuse and the need for effective treatment options. At a National Treatment Plan hearing in Portland, Oregon, a mother testified about the death of her son from inhaling butane from a disposable lighter. CSAT is determined to help clinicians diagnose and treat inhalant abuse through our Treatment Improvement Protocols series (TIP #31, Screening and Assessing Adolescents for Substance Abuse Disorders, and TIP #32, Treatment of Adolescents with Substance Use Disorders), the Addiction Technology Transfer Centers, and by using our grant programs to seek out the most effective means of treating inhalant abuse.
CSAT Initiatives Focusing on Inhalants
CSAT currently supports a range of initiatives designed to improve the effectiveness of treatment for inhalant use. For example, the CSAT-funded grant program, Our Home, Inc., in Huron, South Dakota, provides long-term residential and therapeutic community treatment targeting 10- to 18-year-old American Indian adolescents with inhalant disorders referred by the juvenile justice and substance abuse systems. This is the only operational specialized inhalant treatment center in the U.S. Funding now continues through the Substance Abuse Prevention and Treatment Block Grant. A description of this program can be found in CSAT's Technical Assistance Publication Series (TAP) #17, entitled Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas.
CSAT’s Targeted Capacity Expansion program underscores CSAT's strong interest in funding projects that address a variety of concerns, including a rise in inhalant use and the need for treatment services. In Fiscal Year 2000, CSAT was mandated by Congress to reserve up to $1.5 million for the Yukon-Kuskokwim Health Corporation in Bethel, Alaska, to develop a facility to treat individuals with inhalant addictions. One in four children in Alaska have used inhalants. CSAT hopes that this new program will serve as a model for the nation.
Also through the Targeted Capacity Expansion program, CSAT funds the following projects targeting inhalants:
Additional Resources on Inhalant Treatment and Prevention
For more information on inhalant use, contact the:
National Inhalant Prevention CoalitionA recent journal article by H.J. Shaffer entitled “On The Nature And Meaning Of Addiction” explores the nature and meaning of addiction. Without a consensual definition of addiction, clinicians and social policy makers often are left to debate whether people who use drugs also abuse drugs. Treatment programs regularly mistake drug users for abusers; both of these groups are readily mistaken for those who are drug dependent.
Even under most established constructions of addiction, not all drug dependent patients evidence addictive behavior. If addiction can exist with or without physical dependence, then the concept of addiction must be sufficiently broad to include human predicaments that are related to either substances or activities. If addiction can exist both with and without physical dependence, then it might be possible to advance the field by considering the objects of addiction to be those things that can reliably and robustly shift subjective experience.
It is contended that addiction is not the product of a substance. Instead, it is the relationship of the addicted person with the object of his or her excessive behavior, a confluence of psychological, social, and biological forces, that defines addiction. (Source: "On The Nature And Meaning Of Addiction", National Forum , Source Id: Fall 1999, pp. 9-14 Authors: Shaffer, H.J., http://ncadi.samhsa.gov:80/res-brf/Mar00/22.htm)
According to the National Institute on Drug Abuse, people must change their pre-conceived notions about drug addiction and instead understand that it is a treatable disease. Brain function is modified by drug use—a modification that continues even after an individual stops taking drugs. Addiction also has to be recognized as a result of many biobehavioral factors.
A user does not have control over the change when voluntary drug use becomes a compulsive addiction. However, once addicted, a person is literally in a different brain state.
Determining the appropriate level of treatment for an adolescent is no small task. In addition to factors normally considered when placing an individual in treatment for a substance use disorder, such as severity of substance use, cultural background, and presence of coexisting disorders, treatment programs must also examine other variables such as age, level of maturity, and family and peer environment when working with adolescents. Once these factors are assessed and the problems are understood, the treatment program can then match the adolescent with the proper type of treatment. (Source: http://ncadi.samhsa.gov:80/pressrel/itn/rep/63.htm)
In addition, Chapter 2 from CSAT’s TIP #32 indicates that researchers and treatment professionals have found it useful to characterize adolescent substance use behavior on a continuum of severity. The Classification of Child and Adolescent Mental Diagnoses in Primary Care (American Academy of Pediatrics, 1996) views substance use disorders as occurring on a continuum that extends from the developmental variation of experimentation with substances through problem use, to the disorders of abuse and dependence. The degree of substance involvement is an important determinant of treatment, as are any coexisting disorders, the family and peer environment, and the individual's stage of mental and emotional development. This information should be used to refer to the appropriate treatment.
Treatment interventions fall along a continuum that ranges from minimal outpatient contacts to long-term residential treatment. All levels of care should be considered in making an appropriate referral. Any response to an adolescent who is using substances should be consistent with the severity of involvement. Although no explicit guidelines exist, the most intensive treatment services should be devoted to youth who show signs of dependency.
In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded that opiate drug addictions are diseases of the brain and medical disorders that indeed can be effectively treated. The panel strongly recommended broader access to methadone maintenance treatment programs for people who are addicted to heroin or other opiate drugs, and that Federal and State regulations and other barriers impeding this access be eliminated. This panel also stressed the importance of providing substance abuse counseling, psychosocial therapies, and other supportive services to enhance retention and successful outcomes in methadone maintenance treatment programs.
The widespread abuse of cocaine has stimulated extensive efforts to develop treatment programs for this type of drug abuse. According to the State Alcohol and Drug Abuse Profile, in FY 1995, States reported 333,359 patients entering publicly funded treatment with cocaine as the primary drug of abuse, representing almost 38.3 percent of treatment admissions.
In addition to treatment medications, behavioral interventions--particularly cognitive behavioral therapy--can be effective in decreasing drug use by patients in treatment for cocaine abuse. Providing the optimal combination of treatment services for each individual is critical to successful treatment outcome.
Women absorb and metabolize alcohol differently than men. They have higher BAC's after consuming the same amount of alcohol as men and are more susceptible to alcoholic liver disease, heart muscle damage, and brain damage. The difference in BAC's between women and men has been attributed to the smaller amount of body water in women, likened to dropping the same amount of alcohol into a smaller pail of water. An additional factor contributing to the difference in BAC's may be that women have lower activity of the alcohol metabolizing enzyme ADH in the stomach, causing a larger proportion of the ingested alcohol to reach the blood. The combination of these factors may render women more vulnerable than men to alcohol-induced liver and heart damage.
In short, a woman drinking an equal amount of alcohol in the same period of time as a man of an equivalent weight may have a higher blood alcohol level than that man. Research suggests that women are more vulnerable than men to alcohol-related organ damage, trauma, and legal and interpersonal difficulties.
Binge drinking is defined as the consumption of five or more drinks on a single occasion, which is approximately the amount of alcohol needed to raise the average sized person's blood alcohol concentration to about 0.10%. In other words, it is the amount of alcohol consumption that would raise the presumption of intoxication.
A recently completed Harvard School of Public Health survey indicates that binge drinking is a common practice among 4-year college and university students. Researchers collected data from a sample of 17,600 students at nearly 150 campuses nationwide to chart the extent, practices, and profiles of collegiate binge drinkers:
The liver can metabolize only a certain amount of alcohol per hour, regardless of the amount that has been consumed. The rate of alcohol metabolism depends, in part, on the amount of metabolizing enzymes in the liver, which varies among individuals and appears to have genetic determinants. A person’s blood alcohol level may be affected by his or her age, gender, physical condition, amount of food consumed, and any drugs or medication being taken.
In general, after the consumption of one standard drink, the amount of alcohol in the drinker's blood (blood alcohol concentration, or BAC) peaks within 30 to 45 minutes. (A standard drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits, all of which contain the same amount of alcohol.) Alcohol is metabolized more slowly than it is absorbed. Since the metabolism of alcohol is slow, consumption needs to be controlled to prevent accumulation in the body, which leads to intoxication.
Teens should avoid androstenedione. "Andro" is a popular supplement that is supposed to increase blood levels of the male hormone testosterone.
Because of alterations in sex hormone levels, high-dose "andro" should be avoided by women and children. It could cause masculine side effects in women---facial hair, aggressiveness or irritability for example. It could cause premature development in children.
It is also reported to raise levels of estrogen, a feminizing hormone, which could cause enlarged breasts and increased risk for heart disease in men.
In March of 2000, the National Basketball Association announced that it had banned the use of "Andro."
Given the current controversy at the Olympics, I would state the use of "Andro" in professional sports conveys a contradictory message to teen or young athletes. Thus, it should not be used in Professional sports.
We are working to prevent this "either or " paradigm from developing. You are correct to be concerned about such a development. However, this "either or" paradigm is not inevitable.
You should work at the local level to assure that public health dollars are not being diverted into the criminal justice system, a system that has its own funding streams.
Nevertheless, both the public health system and the public safety system have to work together. Some who are swept up in criminal activity move out of the criminal justice system into the public health system, and vice versa. Thus, programs and funding should work together for the benefit of the adolescents.
A series of studies on juvenile drug courts and drug treatment programs found that the most consistently effective programs--including skills training, ultiple services, community-based residential treatment, and restitution-probation parole-can reduce recidivism by 14 to 44 percent.
Substance abusing juvenile offenders who gain access to, participate in, and complete treatment decrease their subsequent abuse and delinquent behaviors. In one national study, treatment for adolescents reduced rates of criminal activity such as illicit drug dealing, property crime, and violent crime.
There is no convenient way to detect Rohypnol added or "slipped" in your drink at a party. Thus, most advise people not to leave their drinks unattended at parties. Others note that soft drinks in bottles should be consumed. Don't let anyone remove the bottle top for you. Take the top off yourself and place in back if necessary. Drinking bottled water can also be a defense.
If you "suspect" that your drink is contaminated, don't drink it. If you have consumed some of it, get yourself to an emergency room and tell them what you suspect. If you believe that you have consumed rohypnol, don't operate a motor vehicle.
You should call a cab or get a trusted friend to take you to the ER. If you believe that it is an emergency, then you should call 911.
Apart from the obvious, that one treats adults and the other treats adolescents :). Adolescent specific programs should be more developmentally dynamic---meaning that the phases of adolescents should be taken into consideration when treatment is provided.
Adolescent programs should also take into consideration the greater vulnerability of adolescents. Adolescent programs have to address family issues in a different manner than adult programs.
Staff should be trained to respond to teens, rather than simply to adults.
Confidentiality issues are managed differently in adolescent programs than in adult programs.
Since there are differences in the epidemiology of substance use exist for adolescents versus adults, the staff of such programs will have a different repertoire of knowledge and skills.
I see the developmental assets approach as a resiliency paradigm. If we hope to prevent alcohol, tobacco, and other drug use, we need to meet teen's basic needs for caring, connectedness, respect, challenge, power and meaning.
Programs that facilitate the development of youth's resilience, according to SAMHSA's Center for Substance Abuse Prevention, "Establish safety and basic trust through caring relationships that are grounded in listening and convey compassion, understanding, respect and interest."
"Communicate high expectation messages that provide firm guidance, structure, and challenge as well as convey a belief in the youth's innate resilience by focusing on strengths and assets, as opposed to problems and deficits."
"Create opportunities for the youth's meaningful participation in and contribution to the community."
NIDA has an active Club Drug campaign to educate both consumers and professionals about GHB.
Information about the effects of various club drugs is also available.
The NIDA site: http://www.clubdrugs.org
The Puerto Rico Addiction Technology Transfer Center initiative in Spanish.
Community Anti-Drug Coalitions of America would be a great place for you to start. You can reach this organization at: 1-800-54-CADCA.
The website is: http://cadca.org
Community anti-drug coalitions play a major role in prevention.
You may also check with your university to determine what efforts are being exercised at your school. Peer support can play a major role in helping other students.
You can call 1-877-Be-A-Mentor (a toll free number) operated by Save the Children that gives you access to the information to three mentoring and volunteering organizations in your local community.
First, it is important for you to know that as a trusted person in the lives of elementary school students, your opinion about drugs and alcohol counts!
Second, you can make drug and alcohol education an integral part of your school system's curriculum, beginning in kindergarten and continuing through 12th grade.
Select age-specific, culturally appropriate curricula. Make sure the curricula emphasize a consistent "no-use" message; encourage civic responsibility and respect for local laws; and promote good health, self-confidence, and resistance to negative peer pressure.
Involve parents and students in the development, implementation, and evaluation of your school system's drug and alcohol education effort.
You can contact: http://ncadi.samhsa.gov for materials.
CSAP, NIDA, NIAAA, and the Department of Education all offer materials consistent with your posture.
You can also check the ONDCP site: http://www.whitehousedrugpolicy.gov
The faith community can and should play a major role in supporting teens. This role can be both in prevention and in the treatment process.
CSAT is actively involved with engaging the faith community in substance abuse treatment.
The church/temple/mosque/ashram/synagogue and other places of worship can include support for teens.
CSAT is making information available and engaging in an ongoing effort to identify the information needs of the faith community. We are having regional meetings so that we can get a better picture of the faith community's needs.
We are helping the faith community recognize such issues as detoxification, co-occurring disorders, health issues, and complex behavioral issues associated with addiction.
Finally, the faith community can offer on-going support to facilitate recovery over time.
You raise a very sensitive issue. I think that as a member of the community you are not an outsider to a situation where a teen is using drugs.
Ideally, you should arrange a face to face discussion, so that the parents don't view you a prank caller. However, if you are reluctant to engage in a face to face discussion, a telephone call is better than nothing.
Prior to communicating to the parents, you should be clear in your mind why you believe the teen is engaging in drug abuse. Think through what it is you've seen. Then, initiate your communication.
Not all parents will welcome your message. However, you will have done what you can to help the teen and inform the parents.
While our FY2001 appropriations have not been made, our preliminary planning includes efforts to focus on, among other populations, adolescents.
Please keep watching our web sites or the SAMHSA web sites at: www.samhsa.gov. Grant announcements will be made.
Again, adolescents are a priority for us.
Among youths age 12-17, 10.9 percent reported past month use of illicit drugs in 1999. Marijuana is a major illicit drug used by this group. 7.7% of youths were current users of marijuana in 1999.
The rate of nonmedical use of psychotherapeutics was 2.9%.
The rate of hallucinogen use was 1.1% among youths age 12-17.
Many adolescent specific treatment programs will offer ongoing support for teens after more formal treatment.
There are 12-step programs that are also specific for teens.
There are some schools that offer support for teens. For instance, in Minneapolis, there is a school called "Sobriety High" where teens who are in recovery can attend and receive ongoing support.
Inpatient treatment programs in general have been declining as a result of decrease in the funding available from both public and private sources.
Data show that inpatient programs can be successful. Clearly, not every teen needs to be in an inpatient program. The issue is to determine which teen needs or requires inpatient versus outpatient care.
Given the vagaries of funding, it is difficult to conclude that inpatient programs are declining in success while outpatient programs are rising in success.
School is obviously a major center for activity for teens. Consequently, schools can play a major role in substance abuse prevention. The key issue is whether the school and the parents who monitor the school consider alcohol and drugs to be major health problems warranting the attention of the school.
Discussions about the physiology, psychology and toxicology of substances of abuse can be included in the curriculum. There are a number of prevention techniques that are science based and endorsed by the Center for Substance Prevention. School systems that are committed to addressing the issue of substance abuse should access this information.
Information is available from http://ncadi.samhsa.gov.
Information about models are available by http://prevention.samhsa.gov/.
If you are a teen, you should check with your family to see if they can facilitate support for you.
Then, You should check with the treatment center. There may be resources available to provide you with pre-treatment support.
Second, you should check to see if there are any 12-step programs in your community. These can provide you with pre-treatment support.
Third, you should check to see if your respective faith community offers support. If so, then this can assist you.
You should also touch base with clean and sober friends who can provide you with support.
As a result of financing issues, adolescent treatment programs have difficulty staying open. Hence, access becomes a major issue.
It is really important for parents to check with their individual benefit packages to make sure that their insurance covers the treatment of addictions.
The second most critical issue is the lack of availability of adolescent specific treatment models that take into consideration the various developmental phases associated with adolescence.
The third issue is denial on the part of the teen and the teen's family. Too often, people simply believe that the problem is one that will fade away. Hence, there is a reluctance to engage assistance until the problem has evolved beyond early intervention.
There are resources for children of all ages. For instance, www.boystown.org, will give you locations for Girls and Boys Town resources nation wide. You might also use: 1-800-448-3000.
A number of treatment centers have resources devoted to teens and pre-teens. In addition, both outpatient and inpatient resources exist.
You might access SAMHSA's facility locator site at: http://findtreatment.samhsa.gov
You can also call Parent Connection: 1-800-787-0707
Or, you can call 1-800-8KID-123.