(p. 619) The American Treatment System for Adolescent Substance Use Disorders in the 21st Century: Challenges Remain But Change Is on the Horizon
(p. 620) Overview
The number of youth in need of various levels of substance abuse intervention is staggering. There are 1.7 million U.S. youth (ages 12–17 years) struggling with a substance use disorder, with an additional 1.65 million new adolescent substance use initiators (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). These data are cause for concern as at no other point in an individual’s development are the stakes for addiction so high: adolescence is the at-risk period for developing a substance use disorder (Dennis, 2009; Hingson, Heeren, Winter, & Wechsler, 2003; Hingson & Zha, 2009; Hingson, Zha, & Weitzman, 2009; Kandel, Yamaguchi, & Chen, 1992; Wagner & Anthony, 2002), with youth five times more likely to develop a substance use disorder compared to adults (Hingson, Heeren, & Winter, 2006; Miller, Naimi, Brewer, & Jones, 2007). To make matters worse, only 8.4% of the 1.7 million youth (ages 12–17 years) in need of addiction treatment are receiving specialty care (SAMHSA, 2012).
There are many reasons why adolescents do not access treatment. At the individual level, adolescents (perhaps even more than adults) minimize or fail to recognize an alcohol or other drug problem (Melnick, De Leon, Hawke, Jainchill, & Kressel, 1997). Moreover, adolescent concerns about disclosing sensitive information to parents and competing priorities for families with multiple problems render access problematic (Cheng, Savageau, Sattler, & DeWitt, 1993; Cornelius, Pringle, Jernigan, Kirisci, & Clark, 2001; Ford, Millstein, Halpern-Felsher, & Irwin, 1997). While these individual problems are significant, there are efforts to bring about problem recognition and motivation for change through parent-focused interventions (Rahdert & Czechowicz, 1995; Wagner & Waldron, 2001).
The purpose of this chapter is to discuss an additional complicating factor that impacts adolescent treatment and goes beyond the individual youth and his or her family: the service delivery system. While adolescent substance use represents a continual national concern, the American substance abuse treatment system continues to underperform in terms of its ability to prevent, identify, treat, and support substance-abusing youth despite numerous scientific advances (e.g., Adolescent Community Reinforcement Approach [A-CRA], cognitive-behavioral therapy [CBT], Motivational Enhancement Therapy [MET], Multisystemic Therapy, Multidimensional Family Therapy [MDFT], Seeking Safety, and Seven Challenges; Jainchill, 2012; Muck, et al., 2001; Rahdert & Czechowicz, 1995; Segal, Morral, & Stevens, 2014; Wagner & Waldron, 2001). The focus on the acute phases of the disease, coupled with the limited number of adolescent specialty programs, the quality concerns of programs that do exist, and the fact that only small proportions of youth access any type of treatment including continuing care, means that youth who use and/or abuse alcohol or other drugs as well as those with a substance use disorder cannot take advantage of scientific developments within a full continuum of care (Meyers, Cacciola, Ward, Kaynak, & Woodworth, 2014).
Fortunately, we are at a watershed moment in the way in which substance use disorders are perceived and are about to be managed in this country. We have the real opportunity to open service doors to increasing numbers of youth with varying degrees of substance use (e.g., mild, moderate, severe), but we must improve the treatment system (e.g., screening, early intervention, treatment, and recovery) so that these scientific advances can be capitalized upon.
Health Insurance Reform and Parity Legislation
Two pieces of legislation make it possible to finally integrate substance use and mental health disorders into the rest of healthcare and to ensure that these illnesses are cared for at par with other medical disorders. Specifically, the Affordable Care Act (ACA) requires providers and insurers to implement and cover the full range of prevention, early intervention, and care management services for substance use disorders in virtually all healthcare (p. 621) organizations, and it extends dependent coverage under a parent’s healthcare plan until the age of 26 years. Given that substance use disorders typically develop during adolescence and manifest as serious problems among emerging adults, preventing and treating this disease in its early form should prove most cost-effective, benefiting not only adolescents, their families, and society, but insurers as well. In addition to the ACA, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires that care for substance use disorders must have generally the same type, duration, range of service options, and patient financial burden as the care currently available to patients with comparable physical illnesses. This combined legislation requires a change in the national discourse and approach to the treatment and financing of substance use disorders (including in adolescents): they are to be treated like other chronic illnesses, and health plans are to offer care for the full spectrum of substance use disorders at par with other medical disorders. The time has come to address system inadequacies so that important and sustained changes occur in the way care is delivered to adolescents and young adults who are at risk for substance use disorders, who have used alcohol or other drugs, and who are recovering from substance use disorders.
Acute Versus Chronic Care
The number of youth in need of varying levels of treatment is staggering. Yet, in many ways, the American system of substance abuse treatment for adolescents is antiquated as it has not kept pace with numerous scientific advances. For example, scientific evidence clearly indicates that addiction is similar to other chronic conditions (e.g., asthma, hypertension, type 2 diabetes) necessitating a chronic disease model for management (McLellan et al., 2000; Saitz et al., 2008). This means identifying and treating this disease (or its pre-disease state) as early as possible, and treating and managing the full expression of the disease over time (McLellan et al., 2000; Saitz et al., 2008). Despite this knowledge, acute care dominates the system for treating substance use disorders in adolescents: failing to recognize or ignoring warning signs, treating only the acute expression of this chronic disease, and failing to provide any follow-up monitoring or care. Reimbursement for care is generally restricted to adolescents who are already “in deep” with a disorder, usually with associated juvenile justice and/or mental health problems. This is in direct contrast to informed public health approaches to other chronic conditions.
Like other chronic illnesses with social, biological, and environmental determinants, substance use disorders are best addressed with a full continuum of care, including screening, early intervention, treatment, and continuing care and supportive services. Unfortunately, the currently used approaches to screening and early intervention are largely inadequate. The availability and the quality of adolescent treatment are insufficient, and continuing care and supportive services are basically nonexistent. However, there are systematic opportunities to transform the adolescent substance abuse treatment system at every point on the service continuum.
Adolescents with varying degrees of substance use can be found throughout U.S. communities, coming into contact with a variety of settings and service systems. Identification of these teens by their levels of use is important because different stages of substance use require qualitatively different types of targeted interventions (e.g., brief interventions, outpatient treatment, long-term residential treatment, continuing care services; Wagner & Waldron, 2001; Winters, 1999). This has the potential to halt the trajectory to addiction and reduce the morbidity and mortality related to this condition. Thus, screening for risk factors, early use, or early disease presence is one of the first lines of defense against a disease that begins in adolescence and is routinely associated with a costly combination of social, physical, mental, and public health problems (Meyers et al., 2014). Unfortunately, there is a pervasive failure (p. 622) to identify substance use as well as the emerging signs of a developing disorder. As a result, youth are not treated early, their substance use and other problems escalate, and more intensive and expensive care is needed.
Adolescents should be screened within all treatment and social services systems that they come in contact with (e.g., mental health system, foster care system, juvenile justice system). However, there are two settings that are ideal for early case finding: healthcare settings (e.g., primary care facilities) and schools. Large numbers of “general population” youth can be found at each these sites.
Screening in Healthcare Settings
The majority of adolescents see a healthcare provider at least annually, making healthcare settings particularly good sites for case finding (Freeborn, Polen, & Mullooly, 1995; National Association of State Alcohol and Drug Abuse Directors [NASADAD], 1998, 2002; Newacheck, Brindis, Cart, Marchi, & Irwin, 1999; Sterling & Weisner, 2007). There are now federally supported Screening, Brief Intervention, and Referral to Treatment (SBIRT) projects (Madras et al., 2009) designed to encourage school nurses and primary care physicians to screen, conduct a brief intervention for a positive screen, and when necessary refer adolescents with substance use problems to treatment. A growing body of evidence demonstrates the utility and/or efficacy of SBIRT in reducing adolescent substance use in emergency rooms, primary care settings, and federal qualified healthcare centers (Bernstein et al., 2010; Knight et al., 2005; Madras et al., 2009; Mitchell, Gryczynski, O’Grady, & Schwartz, 2013; Mitchell et al., 2016; Monti et al., 1999; Spirito et al., 2004; Tait, Hulse, Robertson, & Sprivulis, 2005; Tanner-Smith, Wilson, & Lipsey, 2013; Walton et al., 2010). It is not surprising, then, that SBIRT is endorsed by the National Institute of Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, and most importantly the American Academy of Pediatrics (Levy & Kokotailo, 2011) and the American Medical Association.
While promising, all three components of adolescent SBIRT are challenging for healthcare providers. This will be discussed below.
Screening in Schools
Schools are a logical location to identify and appropriately intervene with youth at various points on the addiction continuum. Unfortunately, random drug testing and zero-tolerance policies are the predominant school-based approach to identifying and addressing adolescent substance use. Introduced in 1994 to address weapons in schools, with Elementary and Secondary Education Act funding contingent upon their enactment (Martin, 2000; McAndrews, 2001), zero-tolerance policies quickly expanded to include a wide range of disciplinary issues such as drug use (through school drug-testing practices). While the original intent of school drug-testing policies was substance use identification and early intervention, they have not increased access to care and thus have made limited contributions to the subsequent well-being of adolescents (Lear, 2002; Wagner, Kortlander, & Morris, 2001).
While advocates of school drug testing do not encourage reports to law enforcement or breaks in student confidentiality, the on-the-ground reality tends to be harsh punishment, including reports to law enforcement, suspension from athletic teams, and school suspension and expulsion (National Center on Addiction and Substance Abuse [CASA], 2011; Ringwalt et al., 2009). All of these are contraindicated by federal advisory guides.
The negative psychosocial outcomes of such policies are compounded by the real potential for physical harm, given (1) the toxicity, overdose potential, and dangerous electrolyte imbalances associated with detection-avoidance techniques used to “clean” urine; (2) the adolescent’s move to using drugs with metabolites that remain in the body far less than marijuana to avoid detection; and (3) the move toward use of illicit drugs not included in the testing panel (Centers for Disease Control and Prevention, 2007; Chaloupka & Laixuthal, 2002; Terry-McElrath, O’Malley, & Johnston, (p. 623) 2013; Yamaguchi, Johnston, & O’Malley, 2003a, 2003b; Zeese, 2002).
It is not surprising that the American Academy of Pediatrics (Levy et al., 2015) and the American Bar Association (Henault, 2001) do not support drug testing and zero-tolerance policies in schools. This does not mean, however, that schools are not relevant to the early detection and intervention of adolescent substance use: quite the contrary. There are three reasons why schools are uniquely positioned to implement screening and targeted intervention:
1. At least 60% of high school students report that drugs are used, kept, or sold on school grounds, over half (52%) say that there is a place on school grounds or near their school where students go to get high, and over one third (36%) report that it is easy for students to smoke, drink, or use drugs during the day at their school without getting caught (Center for Substance Abuse Research, 2012).
2. The National Association of School Nurses (2015) has been vocal about school nurses’ role as agents for substance use prevention in school communities, specifically addressing marijuana and prescription opiate use and the need for onsite naloxone at schools throughout the country. (Naloxone is an opioid overdose antidote that reverses life-threatening respiratory depression [Hardesty, 2014]).
3. School health services—delivered in school-based health centers or the school nurse’s office—are a “normalized” part of the school community, thus destigmatizing visits and ensuring anonymity for the specific service received.
SBIRT services could naturally be imbedded within school-based health centers. More than half of the roughly 1,930 school-based health centers in 50 states already provide substance abuse counseling (53.2%), with nearly one in 10 having a trained alcohol and drug counselor on staff (Lofink et al., 2013), making them exceptionally suited to SBIRT services. Their ability to increase access to behavioral health services; decrease emergency room visits; reduce funding, stigma, and confidentiality concerns (Clayton, Chin, Blackburn, & Echeverria, 2010; Santelli, Kouzis, & Newcomer, 1996; Sterling, Valkanoff, Hinman, & Weisner, 2012); and even increase school attendance and student achievement (Walker, Kerns, Lyon, Bruns, & Cosgrove, 2010) adds to the appeal of embedding screening protocols into their day-to-day operations.
While the inclusion of SBIRT services would clearly have the best fit within schools that have school-based health centers, there is evidence (although limited) that these programs can also be incorporated into schools without health centers provided that a substance use counselor from a local treatment provider works within the school (Curtis, McLellan, & Gabellini, 2014). The extent of alcohol and other drug accessibility in schools, coupled with the large numbers of teens who attend school, makes schools practical locations to implement SBIRT and related protocols that include follow-up, case management, and the delivery of preventive care and brief interventions (Clayton et al., 2010; Sterling, Valkanoff, et al., 2012). While more work is clearly needed in both settings, routinely incorporating SBIRT or other substance use screening and referral services into various school-based protocols is a much needed and clearly achievable step in expanding screening, early intervention, and treatment.
Barriers to Adolescent SBIRT
It is clear that the research on SBIRT and the future increase of dependent coverage for a variety of medical and behavioral screenings holds great promise: early risk and use can be identified and reduced, decreasing the likelihood of a future substance use disorder. There are, however, challenges that could hinder bringing SBIRT services to scale.
While there is a growing body of evidence supporting SBIRT for adolescents (Tanner-Smith et al., 2013), gaps in evidence remain such that it has yet to be endorsed by the U.S. Preventive Services Task Force, a critical entity (p. 624) in garnering service coverage among private and public insurers. Second, workforce issues impede widespread implementation of SBIRT. The limited number of certificates in adolescent medicine (466 certificates awarded over a 10-year period), the dearth of pediatric residency programs with an approved adolescent medicine fellowship (only 12% of residency programs), and the belief among pediatricians that they are not well trained to care for adolescents (83%) limit the ability of the healthcare system to meet even the basic medical needs of the estimated 40 million adolescents in this country (Cullen & Salganicoff, 2011). In terms of screening for and addressing adolescent substance use disorders, workforce issues are even more pronounced. For example, nurse practitioner graduate programs include less than 3 hours of addictions education (Campbell-Heider et al., 2009). Among physicians and other healthcare providers, over half (56%) do not feel equipped to discuss (or comfortable when discussing) adolescent substance use issues, and less than half stay current on related literature (Sterling, Kline-Simon, Wibbelsman, Wong, & Weisner, 2012). In fact, they are less concerned about alcohol and marijuana versus other drugs (e.g., opiates) even though (1) alcohol and marijuana are typically the substances of use and abuse among teenagers (Sterling, Weisner, Hinman, & Parthasarathy, 2010) and (2) alcohol and marijuana are not benign substances of abuse, particularly on the developing adolescent brain. At a most basic level, the adolescent brain is more susceptible to the addictive effects of substances, making use in and of itself a risky proposition. Also, marijuana, alcohol, and all other drugs of abuse show diverse neurotoxic effects, adversely affecting brain development and maturation in the areas related to motivation, memory and learning, and inhibition (Brown & Tapert, 2004; CASA, 2011; Squeglia, Jacobus, & Tapert, 2009; Squeglia, Spadoni, Infante, Myers, & Tapert, 2009; White & Swartzwelder, 2005).
These perspectives are compounded by the fact that many healthcare providers feel unprepared to address a positive drug screen (Van Hook et al., 2007). It is not surprising, then, that adolescents who screen positive or show early signs of substance use problems rarely receive recommended levels of preventive care through primary care visits (American Academy of Pediatrics, Division of Child Health Research, 1998; Bethell, Klein, & Peck, 2001). For those who require and receive a treatment referral, healthcare staff typically provide the contact information of potential treatment providers, requiring families to navigate networks of services and insurers on their own (Sterling et al., 2010).
SBIRT is further hampered by a lack of information about available adolescent treatment programs designed to treat substance use disorders that are appropriate, effective, and of high quality once the need for treatment is established (Cacciola et al., 2015). When referral sources are unaware of which programs actually treat adolescents with substance use disorders, timely, efficient, and appropriate referrals are compromised. This lack of information is compounded by the fact that the quality of care provided within the adolescent treatment system is variable and often inadequate, as few scientific advances have made it into adolescent community treatment programs (see Kaminer, Burleson, & Burke, 2008; Knudsen, 2009; Mark et al., 2006; McLellan & Meyers, 2004; Meyers & McLellan, 2005a, 2005b; Roman & Johnson, 2002; Young, Dembo, & Henderson, 2007). This reduces confidence in the treatment system. Healthcare providers who do not have the resources or confidence in the system to make a quality referral have been shown to skip the screening process completely (Horwitz et al., 2007).
Finally, while school-based health centers are uniquely positioned to embed SBIRT services into their array of health services, not all schools have health centers. The one study that examined SBIRT services in general school settings is not enough to demonstrate its feasibility or effectiveness in schools without health centers.
The Future of Screening
The future of adolescent screening is promising, as federal and private initiatives are in place to address screening-related limitations (p. 625) and gaps in knowledge. First, increases in healthcare provider training about substance use disorders are being driven by SAMHSA. Since 2003, SAMHSA has funded 17 medical residency cooperative agreements (SAMHSA, 2015a) and will invest an additional $3.75 million in SBIRT health professions student training grants (SAMHSA, 2008). These are designed to develop and implement training programs to teach students in the health professions (physician assistants, dentists, psychologists, pharmacists, nurses, social workers, counselors, and medical students and residents) the skills necessary to provide SBIRT services, with the ultimate goal of helping clients avoid substance use disorders (SAMHSA, 2015b). In the private sector, a web-based medical school curriculum on substance use disorders incorporates lectures, case presentations, and fieldwork designed to integrate substance use education into the general medicine curriculum (McLellan, Curtis, Nordstrom, & Skrajewski, 2014). A module on SBIRT in general and adolescent SBIRT specifically could be easily integrated into the course. Within the nursing field, specialized certification programs are available and could be expanded (e.g., Certified Addictions Registered Nurse [CARN] and Certified Addictions Registered Nurse—Advanced Practice [CARN-AP]). Further, family nurse practitioner programs include specialty courses in addiction nursing (Finnell, Garbin, & Scarborough, 2004), which could be enhanced with specialty courses in adolescent addiction nursing; this could benefit school-based health centers and other school nursing programs.
A comprehensive strategy to address training, financing, and SBIRT implementation is being funded by the Hilton Foundation. Projects are working to identify effective healthcare training models (with the American Board of Addiction Medicine Foundation and the American Academy of Pediatrics), to enact policy changes needed to sustain SBIRT financing, and to advance learning to improve SBIRT implementation. Finally, the ACA contains numerous provisions to encourage public health, including the Prevention and Public Health Fund ($15 billion) to support screenings, prevention, wellness, and public health activities.
While all of this is good news in terms of case-finding efforts, other system-of-care components (i.e., early intervention, treatment, continuing care, and supports) require improvement to provide an adequate and effective response.
Hundreds of billions of dollars are spent annually to treat diseases that are preventable (Robert Wood Johnson Foundation, 2013). Far too often healthcare providers in general, and behavioral health providers in particular, focus on treating the full expression (vs. the early signs) of disease. Treating early disease states is the most commonsense and cost-effective approach for most disorders, and adolescent substance use disorders are no exception. In fact, early intervention targeted at substance use and emerging signs of substance use disorders has the real potential to minimize the future utilization of high-cost residential/inpatient treatment programs, to increase the probability of a positive outcome, and to arrest the trajectory of addiction—thereby reducing downstream social, personal, and financial costs (Doherty et al., 2011; Meyers et al., 2014). This level of service is essential not only because early intervention can forestall addiction, but also because not all adolescents who have experienced serious consequences as a result of substance use will meet the diagnostic criteria for a substance use disorder due to the short-term nature of their history with substances (Martin & Winters, 1998; Pollock & Martin, 1999). Although they do not have a diagnostic label, the immediate and long-term consequences of substance use can be detrimental to the developing brain, to educational attainment, and to social relationships.
Unfortunately, the early stages of adolescent substance use disorders are often not addressed, in part because early intervention services are not accessible and higher-level interventions (p. 626) are not yet appropriate. Hence, targeted intervention that addresses early signs before the youth meets the criteria for a DSM diagnosis (i.e., preclinical levels of service) is basically nonexistent and nonreimbursable within financing systems and funding streams. Model development in terms of intervention specifics and financing strategies is needed.
The American Society for Addiction Medicine (ASAM) has established an early intervention level of care referred to as the ASAM .5 Level of Care (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, 2013). Operationalized with professionally vetted criteria to determine eligibility for this level of care, this ASAM level-of-care code is ready for justifying and receiving reimbursement for service provision. However, ASAM’s .5 Level of Care is rarely reimbursed or funded.
Inroads in the funding and provision of early intervention services could be made in two ways. First, the ACA can address critical service gaps if reimbursement streams for this level of care can be identified. One possibility is the repurposing of a portion of block grant dollars, the funding mechanism currently used to treat the uninsured. Since more Americans should have insurance coverage under the ACA either through Medicaid expansion or employer-based healthcare insurance expansion, block grant dollars could be redirected to fund early intervention services. This underutilized service (which exists largely in theory rather than in practice) could then become available and accessible.
Second, the American Academy of Pediatrics has shown tremendous leadership in developing, promoting, and disseminating health supervision guidelines through its Bright Futures initiative for health promotion and disease prevention. If early intervention services for substance use could be included within the Bright Futures framework, they would no longer be overlooked, and the potential for service reimbursement would be increased.
Screening coupled with early intervention services has the potential to reduce the number of adolescents requiring the next component on the service delivery continuum: treatment.
Adolescent Substance Abuse Treatment
Lack of Specialty Adolescent Substance Abuse Treatment
We have discussed the multiple and complex system-level problems associated with identifying and intervening early with adolescents who use and/or abuse substances. One might think that it would be comparatively easy for adolescents with substance use disorders to access treatments suited to their needs, as “treatment” fits within the acute-care approach that dominates the treatment of addiction, but this is not the case.
First, there have always been few adolescent treatment programs (White, 1998). In the early 1980s, when it became apparent that adolescents with substance use disorders were a unique client group requiring specific assessment and particular therapeutic approaches (see Deas, Riggs, Langenbucher, Goldman, & Brown, 2000, for a discussion; Poulin, Dishion, & Burraston, 2001), traditional substance abuse treatment facilities had to adapt their adult-oriented programs if they were to accept and appropriately treat an adolescent clientele (Winters, Stinchfield, Opland, Weller, & Latimer, 2000). Few responded to this challenge then, and the numbers are equally discouraging now. Less than 30% of the roughly 13,600 substance abuse treatment programs in this country now offer special programming for adolescents (Mericle et al., 2015), and only 8.4% of the 1.7 million youth in need of addiction treatment are receiving specialty care (SAMHSA, 2012). This limited number of adolescent treatment programs, coupled with problems of access, can only worsen if the screening phase (demand side) of the system improves without parallel improvements in the treatment phase (supply side) of the system. However, even if the treatment component of the system could absorb additional (p. 627) adolescents, the quality of treatment for adolescents is of concern.
Varying Quality of Treatment
A substantial body of evidence demonstrates that providing adequate and appropriate evidence-based practices and evidence-based treatments can improve substance use outcomes (e.g., reduce alcohol or other drug use) and have a positive impact on other life domains (e.g., interpersonal functioning) (Jainchill, 2012). Substance abuse treatment can lessen the rate, duration, and intensity of many health and behavioral health problems and cut or at least control the growth of overall healthcare costs (Hutchings & King, 2009). Societal costs can also be lessened by increases in productivity (e.g., academic success) and reductions in public health threats (Hutchings & King, 2009).
Unfortunately, the relatively limited number of adolescent treatment programs within the substance abuse treatment system is further encumbered by a lack of treatment quality in the programs that exist. In other words, there is great variability in the availability, provision, and quality of those treatment practices and features that have been shown to be effective in combating this disease (Brannigan, Schackman, Falco, & Millman, 2004; Ducharme, Mello, Roman, Knudsen, & Johnson, 2007; Kaminer et al., 2008; Knudsen, 2009; Mark et al., 2006; Roman & Johnson, 2002; Young et al., 2007), making a bad situation worse.
Specifically, there are 10 broad principles with 64 corresponding discrete practices (evidence-based practices) that have strong empirical, clinical, and expert support as being associated with reductions in substance use and co-occurring problems among adolescents with substance use disorders (Brannigan et al., 2004; Cacciola et al., 2015). For example, attention to mental health practices (e.g., onsite mental health services or linkages to mental health assessment, treatment, and/or medication management), family involvement in treatment (e.g., providing family intervention and multiple-family education and support groups), and continuing care and recovery supports (e.g., continuing care plan complements treatment plan) are a few of the practice indicators of the quality of adolescent substance abuse treatment.
There are also evidence-based treatments that, when implemented with fidelity, improve the outcome of adolescents with substance use disorders. For example, extensive research has shown that family-based treatment (e.g., MDFT, functional family therapy), psychosocial treatment (e.g., CBT, MET), pharmacotherapies, and integrative models (CBT/MET) reduce substance use among teenagers (CASA, 2011; Jainchill, 2012; Kaminer, 1994; Lipsey, Tanner-Smith, & Wilson, 2010). In fact, research is clear that adolescents exhibit significant reductions in substance use shortly after the end of treatment provided they complete treatment in quality treatment programs that implement evidence-based practices well (Lipsey et al., 2010). Family therapy and multiple-service packages yield greater reductions in overall substance use than most other types of treatment.
Despite the importance of evidence-based care for adolescent substance use disorders, studies conducted over the past 10 years identified underutilization of evidence-based practices and treatments within and between general community programs, high- and low-cost programs, “highly regarded programs,” and programs for juvenile offenders (Brannigan et al., 2004; Ducharme et al., 2007; Kaminer et al., 2008; Knudsen, 2009; Mark et al., 2006; Roman & Johnson, 2002; Young et al., 2007). In other words, the majority of adolescent treatment programs in this country offer very few of the clinical and social support services that have been demonstrated to be effective. Without quality and targeted intervention (and adequate post-acute care, as discussed in the following section), relapse and retreatment are essentially ensured. The same youth is more likely to cycle in and out of multiple systems of care (Soler, 1992), with each intervention “failure” accompanied by a “repeat” cost to some sector of the system, a truly inefficient use of public health resources (Meyers & McLellan, (p. 628) 2005a, 2005b). The use of evidence-based practices and treatments, with subsequent improvement in quality within the already limited adolescent treatment system, is vital.
Since knowledge of adolescent development and skill and interest in treating youth are of paramount importance (Deas et al., 2000; Winters et al., 2000), staff credentialing processes should require adolescent-specific knowledge. The National Association of Alcoholism and Drug Abuse Counselors’ certification program recently added a National Certified Adolescent Addictions Counselor certification to their credentialing portfolio. Recognizing the different set of competencies and clinical practices needed to treat adolescents with substance use disorder, this group’s competency-based tiered system now includes adolescent-specific specialization credentials and endorsements. To be eligible for this certification, applicants must have (1) a bachelor’s degree or higher degree from an accredited college or university in addiction or a counseling-related field (e.g., psychology, social work); (2) a current credential or license as a substance use disorder/addiction counselor issued by a state or credentialing authority; (3) at least 5 years of supervised experience working as a licensed addiction counselor, with 2.5 of these years with adolescents; and (4) at least 70 contact hours of training related to adolescent treatment, with 50% or more face to face. They must also pass a certification exam. There are no data available on the number of such certified counselors in the country, making it difficult to assess whether staff in adolescent treatment programs have this certification.
When one looks at state credentialing practices, there is an average of 6.5 certification programs per state. In addition to the traditional alcohol and drug counselor certifications, states also offer specialization certifications. Of these, certifications related to serving patients involved in the criminal justice system (35%) and those with co-occurring disorders (33%) are most common. Only one state in the country even came close to adolescent credentialing: Illinois offers an adolescent treatment endorsement certificate that documents an individual’s specialization in services to adolescents.
The Future of Adolescent Substance Abuse Treatment
The limited number of adolescent substance abuse treatment providers would be less worrisome if youth were treated in quality programs offering the constellation of services they need. Efficiencies would be created as unnecessarily intensive treatment and repeat treatments (and associated costs) could be avoided. It stands to reason, then, that improving the quality of adolescent substance abuse treatment has been—and remains—a national priority (Institute of Medicine, 1989, 2006; National Institute of Mental Health, 2001; New Freedom Commission on Mental Health, 2003). To this end, the Network for the Improvement of Addiction Treatment (NIATx) has designed a model of process improvement in addiction treatment. The NIATx quality improvement model focuses on improving access to and retention in treatment by reducing waiting times and missed appointments, and increasing treatment admissions and retention. The underlying premise is that when individuals have (and take advantage of) opportunities to receive beneficial dosages of treatment, the cost and the effectiveness of the care delivery system are improved. NIATx strategies have enhanced the quality of care for adult substance use disorders (i.e., reduction in days to treatment, increases in retention in care), and participating programs were able to institutionalize the changes that led to enhanced performance (Ford et al., 2008; McCarty et al., 2007).
Specifically designed to drive quality improvement in adolescent substance use treatment; to support optimal specialty care referrals by pediatric, primary care, and family practice physicians and the justice system; and to improve the performance of programs (e.g., retention rates) and patients (e.g., reduced substance use), a web-based prototype of the Consumer Guide to Adolescent Treatment (Cacciola et al., 2015; (p. 629) Meyers et al., 2014) has been designed. It uses a systematic methodology to measure treatment quality across 10 dimensions of care and translates the data into a practical and science-based “report card.” It includes comparative treatment program information, consumer education, and a navigator function to guide users to treatment options. Program-specific management reports highlight quality scores across the 10 programmatic areas, with recommendations of ways to improve quality in problematic areas. The use of the Consumer Guide’s web-based system of data dissemination should enhance quality improvement efforts because publicly reported performance stimulates quality improvements (Robert Wood Johnson Foundation, 2011) and informed consumers are essential to improving the quality of services, particularly in healthcare (Hibbard, Stockard, & Tusler, 2005; Hirth, 1999; Ippolito, 1992). This kind of consumer information can immediately inform and direct an individual consumer’s choice and increase the chances that a young person arrives at an appropriate treatment door at an earlier stage in his or her disease. Over time, receipt of treatment that is related to the adolescent’s problems/needs and is of higher quality should result in more success and ultimately less treatment and associated costs.
Evidence-based adolescent substance abuse treatment works, at least in the short term, if the youth attends and completes treatment. As mentioned above, research from 29 unique treatment samples (yielding 489 effect size estimates) is clear: adolescents with substance use disorders exhibit significant reductions in substance use shortly after the end of treatment (Tanner-Smith et al., 2013). Observed reductions are strongest for those youth completing treatment and for youth who attend quality programs that implement evidence-based practices well. Unfortunately, approximately 40% of youth do not complete treatment (Mutter, Ali, Smith, & Strashny, 2015). Further, treatment gains significantly and rapidly diminish following treatment. Generally within 3 to 6 months after care, between 66% and 79% of youth return to substance use (Brown, Vik, & Creamer, 1989; Cornelius et al., 2003; Myers, Brown, & Mott, 1995). For youth with comorbid conditions, median survival time to relapse (i.e., first use after 7 days of nonuse) is just 19 days, less than 3 weeks (Cornelius et al., 2004).
Driven by research supporting the view that addiction is similar to other chronic conditions (e.g., asthma, hypertension, type 2 diabetes), it is not surprising that relapse occurs: continuing care and monitoring are needed to sustain treatment gains (McLellan et al., 2000; Saitz et al., 2008). Importantly, there is a growing literature illustrating the protective effect of continuing care on longer-term rates of abstinence among adolescents who receive it (Garner et al., 2009; Godley & Godley, 2012). However, for adolescents who have a substance use disorder, find themselves at the end of an acute treatment, and are not in research protocols, little to no monitoring or continuing care is provided (Meyers et al., 2014). These posttreatment services are rarely available in adequate quantity or quality to forestall a relapse.
For adolescents, there are three approaches to the traditional continuing care paradigm (e.g., stepdown treatment) that have yet to truly penetrate the field: (1) recovery high schools (followed by collegiate recovery services, including sober college housing), (2) youth development programs such as A-CRA and alternative peer groups, and (3) technology check-ins. Each can help youth with different challenges and needs and can help in different ways; all can substantially add to the sparse continuing care that is currently in place.
Emerging research indicates that attending a recovery school for at least 3 months enabled students to (1) maintain sobriety for an average of eight times longer than before they attended a sober school, (2) decrease negative feelings and delinquent and offending behavior, and (3) increase interest in school, work, family, and friends (Moberg & Finch, 2008). Continuing care through youth development is realized through A-CRA (Godley et al., 2001) and alternative peer groups (Morrison & Bailey, 2011). Both approaches have found positive outcomes (p. 630) (Godley & Godley, 2011; Godley, Godley, Dennis, Funk, & Passetti, 2002) and recognize that for recovery to have a chance it has to be fun and developmentally appropriate, that peer relationships are as important to recovery as they are to the initiation and continued support of substance use, and that skill-building activities that are engaging and challenging and focus on how to have fun without the use of alcohol and other drugs are necessary.
The use of technology as a continuing care approach with adolescents is gaining momentum, undoubtedly due to the prominence of it in the life of adolescents and the seminal work of McKay et al.’s telephone follow-ups (McKay, Lynch, Shepard, & Pettinati, 2005; McKay et al., 2004), Scott and Dennis’s recovery checkups (Scott, Dennis, & Foss, 2005), Cacciola et al.’s clinical monitoring (Cacciola, Camilleri, Kolwicz, Brooks, & Alterman, 2012), and Gustafson et al.’s automated Addiction-Comprehensive Health Enhancement Support System (Gustafson et al., 2014). In a pilot study conducted by Trudeau et al. (2012), 86% of counselors (n = 16) and 84% of adolescents (n = 24) found an online relapse-prevention program easy to use, rated the content as relevant to recovery (e.g., setting boundaries with peers, following through with decisions), and reported interest in using this type of technology to meet and manage recovery challenges. Gonzales et al. (2014) took this early work further, developing and testing Educating & Supporting Inquisitive Youth in Recovery (ESQYIR), an automated mobile monitoring and feedback aftercare intervention for youth. Pilot data demonstrated significantly better substance use and recovery behavior outcomes among ESQYIR youth compared to an aftercare-as-usual condition.
Taken together, recovery high schools, continuing care through youth development, and technology should have a place in the future of continuing care.
Adolescents in all states and the District of Columbia are protected by minor-consent laws wherein adolescents as young as 14 can consent to treatment for drug use, pregnancy and pregnancy prevention, sexually transmitted infections, mental health issues, and emergencies without parental consent or knowledge (English, Gold, Nash, & Levine, 2012). However, the complex maze of insurance-related billing procedures and electronic health records may inadvertently compromise confidentiality, thereby preventing already reluctant youth from agreeing to care (or seeking it in the first place) even within a well-functioning system of care.
Insurance companies normally communicate with, and send explanation of benefits (EOB) statements to, the policyholder (generally a parent). While EOBs were designed to increase transparency of the health insurance process, mitigate insurance fraud, and reduce medical identify theft, EOBs unintentionally violate confidentiality, especially for services rendered to individuals insured as dependents (English et al., 2012). EOBs typically identify the individual who received the service, the type of service received, the healthcare provider who delivered the service, the cost of the service, insurance coverage of the service, and the remaining cost balance (e.g., policyholder’s financial liability).
Electronic health records were designed to improve information sharing and care within a clinical system. Impressively, they have been shown to improve treatment for adolescents with attention-deficit/hyperactivity disorder and depression, to increase human papillomavirus vaccination rates, and to reduce unnecessary antibiotic prescribing (Co et al., 2010; Fiks et al., 2013; Gonzales et al., 2013; Valuck et al., 2012). Despite these benefits, many electronic health records do not have default privacy settings for adolescents, allowing parents access to online personal health information of their minor child (Gray et al., 2014). Currently, 60% of American children’s hospitals (Nakamura, Harper, & Jha, 2013) and 69% of primary care practices have an electronic health record (Schoen et al., 2012).
Tebb et al. (2014) summarize eight current attempts (including the pros and cons of each) (p. 631) to address the tension between healthcare transparency and confidentiality (e.g., applies a generic Current Procedural Terminology [CPT] code to sensitive services). While no strategy has emerged as “the strategy” to adopt, it provides valuable options as the best way forward is determined.
If we are to reduce the burden of substance use disorders, the most humane and cost-effective time to do so is during adolescence, the developmental stage in which they so frequently present. Treatment and policies are poised to be positively transformed in the coming years by both the current state of scientific knowledge and the legislative changes to the healthcare system. Legislative advances have brought us ever closer to parity and integrated care, the research base is expanding so that we can better address the social and biological determinants of these disorders, and mechanisms for system improvements exist, if only in small-scale, pilot, or prototype form. The necessary elements for change are now in place, and with proper alignment and leveraging of these forces, there is an enormous opportunity to have a significant impact on the adolescent substance abuse treatment system.
This chapter has described the challenges that our field must address in order to quell the tide of adolescent substance abuse in this country. The changes that are needed will not be simple or quick, and they will require coordinated efforts. But necessary changes are achievable, with an actual possibility that they will result in important and sustained modifications in the way care is delivered to adolescents who are at risk for substance use disorder, who have used or abused alcohol or other drugs, and who are recovering from substance use.
This work was supported in part by the National Institute on Drug Abuse (NIDA) grant P50-DA02784 and the Bridge Foundation. (p. 632)