NIDA Principles to Assess Adolescent Substance Abuse Treatment

							             NIDA Principles to Assess Adolescent Substance Abuse Treatment Programs

    Principle One: No single treatment is appropriate for all individuals.
    Matching treatment settings, interventions, and services to each individual's particular problems and needs
    is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and
    society.
           Screening of all adolescents
           Comprehensive assessment of all adolescents who are found to have a substance abuse disorder
               to determine the types and levels of services needed
           Treatment should not be viewed as “one-size fits all”; should be aware of the range and types of
               services available in the community

         Screening
          Brief                                                         Capable of identifying need for
          Orally administered                                            treatment
          Simple to score                                               CRAFFT Questions
          Developmentally appropriate

         Individualized assessments should gather information on the following:
              History of drug and alcohol use                     School history
              Medical health history and physical                 Vocational history
                 exam                                              Sexual history
              Psycho-social developmental                         Peer relationships
                 issues                                            JJS involvement and delinquency
              Mental health history                               Social service agency program
              Strength or resiliency factors                         involvement
              Family history                                      Leisure activities

    Treatment can be outpatient, intensive outpatient or residential
         Residential treatment can be based on a therapeutic community (TC) or on a 12 step model
         Adolescent treatment should involve the family (broadly defined)

Principle Two: Treatment needs to be readily available.
Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of
opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is
not immediately available or is not readily accessible.
      Need to have enough “spaces” available for all the adolescents who may need treatment
      Need to locate services in the community and have a continuum of care available (prevention, intervention,
        outpatient treatment, intensive outpatient treatment, residential treatment, aftercare, follow-up)

Principle Three: Effective treatment attends to multiple needs of the individual, not just his or her
drug use.
To be effective, treatment must address the individual's drug use and any associated medical, psychological, social,
vocational, and legal problems.
Needs to be considered included: Adolescents with substance use disorders often have mood disorders (particularly
depression), conduct disorders, attention deficit/hyperactivity disorders, also consider:
 Gender Differences: Special services for young women - e.g. need for childcare, prenatal care
 Disabilities- learning, physical, developmental                  Family Problems
 Sexual Orientation                                               Truancy and School Problems
 Homelessness                                                     Developmental needs
Principle Three Continued:
        Adolescents may use psychoactive substances to self-medicate to deal with mental disorders
        AD/HD are at high risk for developing substance use disorders and are often associated with conduct
        disorders. AD/HD adolescents are often impulsive and inattentive and may have learning disorders

Principle Four: An individual's treatment and services plan must be assessed continually and
modified as necessary to ensure that the plan meets the person's changing needs.
A patient may require varying combinations of services and treatment components during the course of treatment
and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical
services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that
the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture.
                   Comorbidity
                    Present in 40%-90% of youth with Major Depressive Disorder (MDD); two or more comorbid
                       disorders present in 20%-50% youth with MDD
                    Comorbidity in youth with MDD: Dysthymia or anxiety disorders (30%-80%), disruptive
                       disorders (10-80%), substance abuse disorders (20%-30%)
                    MDD onset after comorbid disorders, except for substance abuse
                    Conduct problems: May be a complication of MDD & persist after MDD episode resolves
                    Children manifest separation anxiety; adolescents manifest social phobia, GAD, conduct
                       disorder, substance abuse

              Differential Diagnosis: Nonaffective Psychiatric Disorders
                    Anxiety disorders: separation anxiety, GAD, etc
                    Disruptive and ADHD Disorders
                    Learning Disorders
                    Substance abuse
                    Eating Disorders: Anorexia Nervosa
                    Personality Disorders
                    Premenstrual Dysphoric Disorder

              Things to consider on an ongoing basis:
                   For adolescents consider developmental issues and peer pressures
                   Plan must address adolescent and family needs
                   Progress toward goals should be recorded at every session
                   Objectives should be set that are attainable and realistic
                   Adolescent’s and family’s strengths should be identified

Principle Five: Remaining in treatment for an adequate period of time is critical for treatment
effectiveness.
The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for
most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold
is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment
prematurely, programs should include strategies to engage and keep patients in treatment.
         To enhance engagement consider the person’s readiness to change:
              Stages of Change: Pre-contemplation; Contemplation; Preparation; Action and Maintenance
              Using Motivational Interviewing (Miller and Rollnick, 1991) may retain adolescents who are
                   remanded to treatment- (Acceptance of problem without labeling; Emphasis is on personal choice;
                   Patient’s concerns are elicited; Reflection is used for dealing with resistance; Treatment goals are
                   negotiated with patients and patient is involved in treatment strategies)
              Recognize possible delays in the adolescent’s social, emotional and cognitive development
Principle Six: Counseling (individual/family and/or group) and other behavioral therapies are critical
components of effective treatment for addiction.
In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with
constructive and rewarding non-drug-using activities, and improve problem-solving abilities. Behavioral therapy also
facilitates interpersonal relationships and the individual's ability to function in the family and community.
       Family counseling is critical in adolescent drug treatment and their engagement in the process will help
           achieve the goals of drug treatment
       Family can be defined as extended family including guardians, grandparents, aunts, uncles, etc. Different
           cultures and values must be considered when defining “family” in the context of counseling and drug
           treatment programs
       Family treatment can be provided in-home or in the treatment center. It can include multifamily education
           and treatment groups or family network counseling as well as substance abuse education classes.

Principle Seven: Medications are an important element of treatment for many patients, especially
when combined with counseling and other behavioral therapies.
Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or
other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some
opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine
replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective
component of treatment. For patients with mental disorders, both behavioral treatments and medications can be
critically important.
       Use of pharmacotherapy with adolescents needs careful attention
       Medications for psychiatric conditions should be continued under a doctor’s care
       If detoxification is needed, appropriate care must be taken and must be conducted under a physician’s care
       Use of stimulants for AD/HD or minor tranquilizers must be carefully controlled for adolescents who are
            substance abusers
       Methadone maintenance use is controversial for this age group and is often not recommended for
            adolescents

Principle Eight: Addicted or drug-abusing individuals with coexisting mental disorders should have
both disorders treated in an integrated way.
Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either
condition should be assessed and treated for the co-occurrence of the other type of disorder.

Principle Nine: Medical detoxification is only the first stage of addiction treatment and by itself does
little to change long-term drug use.
Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use.
While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a
strongly indicated precursor to effective drug addiction treatment.
     Physiological withdrawal is not common in adolescents but must be considered depending on the circumstances
     surrounding drug use
      Detox must be monitored by trained staff
      Referral to treatment is critical once medical crisis is over
      Effective planning and the use of sanctions can provide effective treatment
      Use of Motivational Interviewing; family therapy; comprehensive care and case management have been
          shown to be effective in reducing substance use disorders
Principle Ten: Treatment does not need to be voluntary to be effective.
Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or
criminal justice system can increase significantly both treatment entry and retention rates and the success of drug
treatment interventions.
      Effective planning and the use of sanctions can provide effective treatment
      Use of Motivational Interviewing; family therapy; comprehensive care and case management have been
          shown to be effective in reducing substance use disorders

Principle Eleven: Possible drug use during treatment must be monitored continuously.
Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol use during
treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such
monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted.
      Feedback to patients who test positive for illicit drug use is an important element of monitoring.
      Random urine drug screens (UDS) should be used as part of treatment plan
      Substance use is defined as compulsive disorder
      Addiction is a brain disease and has been shown to change the brain often for long periods of time. As a
         chronic disease, slips are to be expected and must be dealt with in therapy
      Abstinence should remain the long-term goal recognizing that relapse prevention is an ongoing process

Principle Twelve: Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C,
tuberculosis and other infectious diseases, and counseling to help patients modify or change
behaviors that place themselves or others at risk of infection.
Counseling can help patients avoid high-risk behavior. Counseling can also help people who are already infected
manage their illness.
    HIV/AIDS, Hepatitis B and C and other infectious diseases are common among substance users
    Information about high risk behaviors can reduce the spread of infectious diseases
    All youth who have substance use disorders should be tested for sexually transmitted diseases and other
        infectious diseases
    Education about transmission of these diseases and how to prevent further infection should be incorporated
        in treatment

Principle Thirteen: Recovery from drug addiction can be a long-term process and frequently
requires multiple episodes of treatment.
As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes.
Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term
abstinence and fully restored functioning. Participation in self-help support programs during and following treatment
often is helpful in maintaining abstinence.
      Continuing or Aftercare is a critical component of treatment and should include: relapse prevention; self-help
          group participation; reintegration into the community and school
      Follow-up for at least a year is important
                            A Quick Checklist for Adolescent and Family Services

1. Do you have a continuum of services available for the patients and their families?
    Prevention
    Intervention
    Outpatient
    Intensive Outpatient
    Residential

2. Have you identified all the treatment modalities that may be needed by adolescents?
    Behavior Therapy
    Family Therapy

3. Have you defined the treatment outcomes and expectations?
    Discontinuation of Drug Use
    Reduction in Delinquent Behavior- No further arrests
    Improvement in School
    Better Family Relations/Functioning
    Reduction in High Risk Behaviors
    Treatment for Co-occurring Illnesses (mental and physical)

4. Have you located all the service providers that will be needed to provide comprehensive care?
    Addiction Treatment Providers
    Social Services
    Medical Services
    Education System

5. Have you established uniform eligibility and acceptance criteria for those requiring the Juvenile Justice
   System?
    Status Offenders
    Preadjudicated Delinquent Offenders
    Adjudicated Youth
    Juveniles on Probation
    Non-violent Offenders

6. Have you selected screening and assessment tools and developed screening and assessment
   processes to ensure appropriate placement of patients into treatment?
    Screening is done on all youth who come into the system
    Assessment is conducted on all youth who have been screened with possible substance abuse disorders
    Assessments are conducted by trained staff who do a full biopsychosocial evaluation of the patients which
       will be used to develop a comprehensive treatment plan
    Treatment services are based on the assessments.

7. Have you defined the role of all the systems involved in your program including the specific role of the
   substance abuse providers?
    Established an advisory board that will have oversight of the program and its organization
    Possess written policies and procedures
    Defined the role of all the agencies involved
8. Have you developed resources to be able to address the multiple needs of a diverse population?
    Staff and other resources are available to handle cultural, racial and ethnic diversity of patients
    Gender- specific services are available
    Considerations have been made for developmental disabilities
    Services are available for those with special needs

9. Are federal and state regulations regarding confidentiality (Federal Confidentiality Regulations- 42
   C.F.R.) strictly observed?
    Consent forms for youth and families are developed, explained and used as required by law
    Careful consideration about what information has to be shared with which agencies has been determined
    Written Report formats are developed and used which provide maximum protection to the adolescents and
       allow for adequate sharing of information

10. Have you built in an evaluation system that will provide data to support your efforts?
     Evaluator is involved from the outset of the development of the program
     Evaluator is an objective person who is outside the agencies involved in providing services
     Outcomes to be measured are decided at the beginning of the process and include reduction in recidivism
       and drug use.
     Follow-up data is collected at specific intervals-i.e. 30, 60, 90 days and one year after completion of
       treatment



References

Family-Based Substance Abuse Treatment for Young Adolescents: Twelve-Month Treatment Outcomes; Craig
Henderson, Ph.D., Cynthia Rowe, PhD., Paul Greenbaumb, Ph.D., Gayle A. Dakof, Ph.D., Shi Huang, M.S., &
Howard A. Liddle, Ed.D. Center for Treatment Research on Adolescent Drug Abuse, University of Miami School of
Medicine, University of South Florida

Using the NIDA Principles of Addiction to Assess Your Juvenile or Family Drug Treatment Court, Linda Kaplan, MA
Executive Director, Danya Institute

Knight J, Shrier L, Bravender T, Farrell M, VanderBilt J, Shaffer H. A new brief screen for adolescent substance
abuse. Arch Pediatr Adolesc Med 1999; 153:591-596.