According to a 2011 study conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, substance use by teens is the most significant public heath problem in the United States. The CASA study found that 46% of all high school students are currently using addictive substances (i.e., nicotine, alcohol and other drugs), and 1 in 3 of those students meet criteria for addiction.
Probably not surprising to front-line practitioners in the substance abuse treatment field, the CASA report revealed that 90% of adult Americans with addiction began using substances prior to age 18. Addiction as a progressive brain disease has its origins in adolescence, related in large part to the vulnerability of the developing brain during that period.
In addition to the significant increase of risk for addiction, substance use during adolescence has numerous negative consequences and costs, including fatal and nonfatal injuries due to motor vehicle accidents; unintended overdose; sexually risky practices and unwanted pregnancies; and increased risk for medical and mental illnesses. Early identification of, and effective intervention for adolescents with, substance use problems can prevent the disease’s progression from abuse to addiction and, for teens already addicted, the possibility of recovery before incurring the increasingly severe damage and losses tragically associated with adult addiction.
But for intervention to be effective, it is crucial, especially for adolescents, to distinguish between drug abuse and drug addiction. This distinction provides an opportunity for more individualized and effective treatment.
A diagnosis of substance abuse essentially involves impairment in role functioning and repeated harmful consequences without the physiological cravings, tolerance, or withdrawal associated with addiction. Addiction, on the other hand, changes the brain’s structure, chemistry and function in fundamental ways, resulting in a convolution of a person’s hierarchy of needs. With the reward and pleasure centers of the brain hijacked, the result is compulsive behavior that overrides the ability to control impulses despite persistent and severe negative consequences. Addiction, then, is essentially a disorder of thought and behavior.
Not all adolescents who receive substance abuse treatment are substance-addicted. Unfortunately, many adolescent rehabilitation programs are predicated on adult treatment models that fail to appreciate both the general developmental differences between adolescents and adults and the relative severity of the substance use problem along the abuse-addiction continuum. These oversights can result in a failure to engage and retain teens in treatment, unnecessary resistance or superficial compliance, and poor outcomes.
The concept of integrating harm reduction and abstinence-based treatment has been gaining attention during the past decade. Particularly for an adolescent population with co-occurring mental health and substance use disorders, this integration is more powerful than either treatment individually.1 The strengths of each framework can be combined to provide individualized and comprehensive treatment to adolescent substance users across the continuum of use. Integrating the models provides the opportunity for decreased resistance to treatment, more genuine engagement, and a stronger platform for addressing co-occurring mental health disorders.
It is important to note, and is often misunderstood, that abstinence from all addictive substances is always the goal when working with adolescents. There is no such thing as “safe use” for teens. But in contrast to many strictly abstinence-based programs, an assertion of commitment to abstinence is not a prerequisite for treatment. However, an ultimate goal of abstinence is necessary for physical and psychological health in adolescence, and reinforces a nurturing approach.
At Rushford at Stonegate, a developmentally focused residential treatment facility in Connecticut for adolescent males with co-occurring disorders, a comprehensive multidisciplinary assessment of each resident is completed for diagnostic clarification. Based on the assessment’s results, a resident’s substance use disorder (i.e., abuse, dependence, or a combination of both) is clearly defined, with treatment then matched to level of use. Furthermore, this assessment provides cognitive, emotional, behavioral and personality information that is essential in determining the most appropriate interventions for the resident.
The evidence-based harm reduction model utilized at Rushford at Stonegate is The Seven Challenges, which has been shown to be particularly effective in reducing mental health and trauma-related symptoms.2 The Seven Challenges program is a holistic approach to adolescent substance use that addresses not only use, but also reasons for using. It incorporates cognitive, emotional and health decision-making processes that promote self-efficacy by encouraging teens to think for themselves and to make their own informed decisions.
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