Treatment interventions–looking towards the millennium

Drug and Alcohol Dependence 55 (1999) 247 – 263

Treatment interventions–looking towards the millennium Ilana B. Crome * Department of Psychiatry, Uni6ersity of Wol6erhampton, 62 – 68 Lichfield Street, Wol6erhampton, WV1 1DJ, UK

Abstract This contribution is focused around treatment interventions employed when dealing with young substance misusers. By necessity, it draws on effective interventions which are applied to adult substance abusers. Where possible, research data on the effectiveness of interventions in young people are outlined and reviewed. The components of a comprehensive service are delineated. Suggestions for a framework for research are discussed, paying particular attention to some methodological difficulties in previous research. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Adolescent; Substance misuse; Treatment interventions; Outcome

1. Introduction This section delineates and evaluates the range of interventions provided by the specialist components of a comprehensive service. Experience of working with young substance abusers indicates that they present to substance misuse and other services with a vast array of needs and problems (Rahdert and Czechowiz, 1995). These include homelessness, impoverished educational background and training opportunities, offending, dysfunctional family environments, deliberate self-harm, anxiety, depression and occasionally psychotic illness (Jessor and Jessor, 1977; Kaminer and Bukstein, 1989; Farrell and Strang, 1991; Kaminer, 1991a,b, 1994; Boyle et al., 1993; Bukstein and Kaminer, 1994; Fergusson et al., 1994; Bukstein, 1995; Gabel et al., 1995; Johnson et al., 1995; Brown et al., 1996; Giancola et al., 1996; Marlin et al., 1996; Pagliaro and Pagliaro, 1996). Any treatment plan must take account of the complex psychosocial matrix in which any young person presenting to services is enmeshed. This contribution will begin by describing treatment interventions which are implemented in the clinical situation. It will, by necessity, briefly draw on effective * Present address: Drugcare, 23 Temple Street, Wolverhampton, West Midlands, WV2 4AN, UK. Tel.: + 44-1902-444736; fax: + 441902-444994.

interventions applied to adult substance abusers. Where possible, it will outline and review research data on the effectiveness of interventions in young people. The components of a comprehensive service will be delineated. Suggestions for a framework for research will then be discussed, paying particular attention to some previous methodological difficulties.

2. Types of treatment– psychological interventions Counselling is offered by many agencies which deal with substance misusers. The term ‘counselling’ may mean many things to many people. It may cover behavioural therapies (including cognitive behavioural, social skills and assertiveness training), 12-step therapy, as well as advice and support. Individuals, groups and families may participate. In this review the more common formal interventions for teenagers and their families will be discussed under the following subheadings: cognitive behavioural therapy, social skills therapy, family therapy, 12-step programmes and therapeutic communities (Beschner and Friedman, 1979; Beschner, 1985). Information from the adult literature informs us that the interventions where there is good evidence of effectiveness are motivational enhancement interviewing

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(MET), cognitive behavioural therapy (CBT) and 12step facilitation (TSF) (Project MATCH Research Group, 1997a,b). Moreover, the cost for treatments demonstrated to be good or promising are lower compared to residential treatment and psychotherapy (Miller and Hester, 1986).

2.1. Cogniti6e therapy Cognitive therapy is probably the most commonly used form of psychological treatment of problematic substance use in adolescents. Cognitive therapy is directed at the modification of maladaptive coping skills or dysfunctional cognitions. Problem solving and decision making skills, anger management, contingency management and relaxation and assertiveness training are components. Communication skills, social skills and coping with criticism are part of the process whereby self-awareness is raised and analysed so that positive thoughts are instilled. Awareness and handling negative thought processes, and focusing on pleasant thoughts and activities, also enhance the capacity to resist temptation and prevent relapse in high risk situations. Adolescents are helped to develop the skills required to deal with problems, including substance use.

2.2. Social skills training This technique is commonly applied to assist adolescents in dealing more effectively with a range of social situations and feelings. Role play and role modelling in individual and group situations train people how to initiate conversations, give or accept compliments, make requests and refuse offers, and cope with criticism as well as in dealing with anger and anxiety (Bartlett, 1986).

2.3. Family therapy As has been described in various parts of this special issue, the problems related to the whole family often find expression in a young person. Hence, an understanding of the role of the family, and if appropriate, the need for proactive involvement is required. In some situations family cohesiveness has disintegrated to such an extent that at the initiation of therapy this may not be an option. There are a number of approaches to family therapy, i.e. behavioural (assertiveness, contingency management, parent management training, problem solving skills), functional, systemic or an eclectic mix of components of various approaches. The major objectives, however, are to reduce resistance to treatment, to re-define the substance problem as a family issue, improve relationships with parental figures, develop strategies to change maladaptive patterns of behaviour and maintain these.

Behavioural family therapy is that most commonly used. The intervention consists of behavioural or contingency contracting. This involves the analysis of the problematic behaviour, defining achievable goals agreed by the adolescent, with rewards consequent on the maintenance of the modified behaviours. As with individual behaviour therapy, assertiveness training assists in attaining techniques to refuse substances or requests, whereas problem solving skills training addresses mechanisms for the discussion, definition, evaluation, selection and implementation of various options. Strategic-structural family therapy utilises the mechanisms of reframing, validation and paradoxical directives to alter family relationships which have inappropriate boundaries. Conceptualization of problems in a new way, with a non-judgemental attitude towards all family members, may engender support and understanding rather than punishment and blame. The paradoxical injunction paradigm, where adolescents are encouraged to continue with problematic behaviour, may also be a way forward, if prudently applied.

2.4. 12 -Step programmes–Alcoholics and Narcotics Anonymous This organisation has been established world-wide for over 60 years. It relies on a non-authoritative and informal structure where group members are known by their first names. According to its philosophy, alcoholism is a disease with no cure, and the fellowship provides a means to secure lifelong abstinence. It has groups for children of alcoholics, Alateen, and gives social support for alcoholics and their families, Alanon. The organisation has been extended to other substance problems, e.g. NA (Narcotics Anonymous). Evaluation of effectiveness has been hampered by the reluctance of the organisation to be appraised by independent research though more recently Project MATCH has highlighted the benefits of this approach. The specific value of this approach for adolescents has not been appraised.

2.5. Therapeutic communities The basic assumptions of this line of treatment revolve around assisting the addict in achieving independent functioning in the community by maintaining abstinence and learning to cope with distressing situations. The environments are structured so that young people become equipped to deal with responsibilities in the outside world (DeLeon, 1994). Success rates of 75% of those adolescents who complete the programmes have been reported (Rosenthal, 1984).

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3. Types of treatment – pharmacological interventions Pharmacological interventions are aimed at treating the effects of intoxication, amelioration of withdrawal symptoms, relapse prevention and additional psychiatric illness (Madden, 1995; Chick, 1996; Schuckit, 1996). This section will focus on the issue relating to the treatment of withdrawal symptoms and relapse prevention in young people who are under 18 years old.

3.1. Prescribing for young people It is important to emphasise that generally the pharmaceutical industry has not provided evidence for safety and efficacy of pharmacological treatments in this age group (British Association for Psychopharmacology, 1998). The explanation lies in the ethical difficulties in accessing the patient population. This clearly limits the evidence base to an older population, and necessitates the cautious use of medications tried and tested in adults. A recent consensus statement by the British Association for Psychopharmacology (British Association for Psychopharmacology, 1998) on ‘Child and learning disability psychopharmacology’ provided guidance on prescribing for depression, obsessive compulsive disorder, schizophrenia, attention deficit hyperactivity disorder and learning disabilities, but did not tackle substance problems. This report concluded that evaluation of treatment effectiveness in children would require greater input of resources than comparable adult studies, but these should be undertaken to develop optimal treatments (Turner et al., 1998).

3.1.1. Alcohol There has been considerable expansion in the development of new pharmacological agents in the treatment of alcohol problems. This is almost certainly a result of exciting advances in the neurosciences, though analysis of research data on these novel agents has engendered scepticism (Schuckit, 1996; Moncrieff and Drummond, 1997) and support (Kranzler and Babor, 1997; Nutt, 1997). 3.1.1.1. Detoxification. Although young people commonly use alcohol, few require detoxification because a very small minority have developed dependence (Crome, 1997). In two studies conducted in the UK and USA, the lag time from regular drinking at 22 years old to the development of alcohol dependence was 10 years (Schuckit et al., 1995; Crome, 1995). A meta-analysis on the pharmacological management of alcohol withdrawal (Mayo-Smith, 1997) demonstrated that benzodiazepines reduce withdrawal severity, the incidence of delirium, and reduce

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seizures. It was reported that beta-blockers, clonidine and carbamazepine impact upon withdrawal severity, but their effect on delirium and convulsions is not proven. While phenothiazines minimise withdrawal symptoms, they are less effective in reducing delirium and fits. Thus, these drugs should be regarded as adjunctive therapy only, and used cautiously in young people. The choice of the most appropriate benzodiazepine should be determined by withdrawal severity, duration of action, rapidity of onset and cost. When decisions regarding dosage are made, withdrawal severity (as measured by withdrawal scales), comorbid illness (e.g. anxiety), and a history of withdrawal seizures should be acknowledged. Chlormethiazole is not recommended because of addictive potential and respiratory depression. Attention should be paid to the possibility of nutritional deficits, and to a decision made regarding vitamin B supplementation (Cook and Thomson, 1997). Moreover, since the use of withdrawal scales leads to less medication and shorter treatment episodes, the adaptation, validation or development of adolescent appropriate scales need to be considered. The instruments developed for use in older age groups but not for adolescents include the SADQ (Severity of Alcohol Dependence Questionnaire) (Stockwell et al., 1979a,b), the SADD (Short Alcohol Dependence Data) questionnaire (Davidson and Raistrick, 1986), the SSA (Selective Severity Assessment) and TSA (Total Severity Assessment) (Gross et al., 1973) and the CIWA (Clinical Institute Withdrawal Assessment) (Shaw et al., 1981; Sullivan et al., 1989). Screening and diagnostic instruments too have not been applied to or modified for young people (Selzer, 1971; Ewing, 1984; Saunders et al., 1993; Heck and Williams, 1995).

3.1.1.2. Relapse pre6ention. Studies on the effectiveness of naltrexone, buspirone, acamprosate, serotonin uptake inhibitors, bromocriptine and the alcohol sensitising drug disulfiram have recently been assessed (Fuller et al., 1986; Schuckit, 1996; Moncrieff and Drummond, 1997; Hughes and Cook, 1997). The overall conclusion that none of these drugs were ‘‘clinically effective in the routine treatment of the average alcoholic’’ suggests that if these products are to be utilised in the treatment of adolescents, this should be in the context of proper pharmaceutical investigative processes. It is unsatisfactory, if deemed to be potentially clinically appropriate, to test these medications on young people without suitable supervision and safeguards. The best combination of treatment modalities, e.g. counselling, educational activities and behavioural therapies for the particular individual, is what matters (Nutt, 1996, 1997).

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3.1.2. Opiates 3.1.2.1. Detoxification. Young people presenting to services most commonly wish to be withdrawn from heroin. This must partially be due to the far more rapid development of dependence at an earlier age than alcohol dependence, and also partly because of the availability of a range of pharmaceutical agents which provide symptomatic relief or a substitute during withdrawal. The clinical assessment of dependence according to ICD-10 criteria (World Health Organisation, 1992) or DSM-IV (American Psychiatric Association, 1994) is clearly mandatory. As in the alcohol field, despite the availability of opiate withdrawal assessment instruments, these have not been developed, modified, applied or validated in a younger age group (Philips et al., 1987; Gossop, 1990; Raistrick et al., 1994; Crome, 1995; Crome, 1997; Gossop et al., 1995). Detoxification, whether in the community or, rarely, in an inpatient or residential unit setting, follows the same general principles as for the adult procedure. Based upon a thorough assessment, the level of use is determined, and this must be confirmed by urinalysis, preferably on the day the detoxification commences. Other factors to consider include the degree of motivation, support, level of dependence and the type and number of drug problems. In an optimum environment which is supportive and non-threatening, some adolescent heroin users manage to withdraw rapidly. Since, in a unique sample prescribed methadone the average age of initiation into heroin use was 15.8 years, and the development of dependence 17 years (Crome et al., 1998; Crome, 1999), it is clinically prudent to attempt a symptomatic detoxification with Lomotil (diphenoxylate hydrochloride) or Imodium (loperamide hydrochloride) and diazepam, or dihydrocodeine. Methadone, clonidine, lofexidine, accelerated lofexidine, and clonidine or lofexidine combined with naltrexone are regimes that have been implemented in adults (Bearn et al., 1996; Khan et al., 1997; Bearn et al., 1998; Carnwath and Hardman, 1998). Lofexidine is increasingly used in the community since it is less likely to be hypotensive than clonidine, though detoxification in inpatient settings is likely to be shorter. The capacity to undertake this range of techniques depends on accessibility to the appropriate community services, day care or inpatient services. Methadone is a very effective treatment, though most of the studies which demonstrate the benefits of methadone are American and most have been carried out on adult populations (Ball and Ross, 1991; Farrell et al., 1994; Report of an Independent Review of Drug Treatment Services in England, 1996; Ward et al., 1998). A trend of increasing accidental deaths from poisoning in young people has been reported (Roberts et al., 1997).

Some young people are prescribed methadone without adequate assessment, supervision, and information regarding the risks of methadone which they may perceive as a ‘medicine’. This injudicious prescribing may lead to dependence and fatalities.

3.1.2.2. Reduction programmes. Experience of a designated community reduction programme for adolescents has indicated that daily dispensing of methadone with adult supervision and which is contingent on weekly counselling in the context of the widest range of social support is that most likely to succeed (Crome et al., 1998). Although a rapid reduction is a major objective, outcome appeared to be better in the long term if the patient has some control over the rate of reduction. A successful, though gradual, withdrawal programme can last as long as 9 months. However, methadone maintenance should not be the initial objective of treatment, and very very rarely, if ever, considered. 3.1.2.3. Alternati6es to methadone. Despite limited evidence of effectiveness of heroin, buprenorphine and LAAM (laevoalphamethadyl acetate) in the adult population, these medications should only be considered when evidence of effectiveness in adolescents is confirmed (Farrell and Hall, 1998; Ling et al., 1998). Likewise, the current suggestions for ‘take home naloxone’ in this group of youngsters needs to be approached with caution (Strang et al., 1996). 3.1.3. Other substances Use or even co-dependence on benzodiazepines is seen in a substantial number of young people presenting to services. Although short inpatient detoxification regimes are recommended, as inpatient facilities for 16–18-year-old substance misusers are non-existent, the only option is a longer term outpatient withdrawal regime. Teenagers who misuse and are occasionally dependent on stimulant drugs like amphetamine and cocaine, often in the context of chaotic polydrug abuse, present to services with some regularity. The use of substitute medication for amphetamine, i.e. dexedrine, is a controversial area and one where research on effectiveness is required. A few adult services prescribe very selectively in an attempt to reduce harm, e.g. injecting, but this is certainly not a treatment that has gained currency in the UK. For cocaine users there is no pharmacological substitute, but the use of antidepressants has been advocated, though not proved (Kaminer, 1992a,b). 3.2. What about smoking? The indications are that children are taking up smoking in increasing numbers and dependence develops very rapidly (Goddard, 1990; McNeill, 1991). Young

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smokers do not ‘mature out’ of their habit (Stanton et al., 1996) and 60% adult of substance misusers rate smoking as more difficult to stop than drugs and alcohol (Kozlowsli et al., 1989). Nicotine replacement therapy in the form of gum, patches, nasal spray and an inhalator is licensed for clinical use. In the best well controlled and biochemically corroborated studies, the success rate is two to three times better than placebo. In a specialist clinic when nicotine nasal spray was compared to placebo the abstinence rate at 1 year was 26% compared to 10% (Sutherland et al., 1992). In general practice the use of a patch doubles the chances of success at 1 year. Increased dependence is associated with decreased success (Stapleton et al., 1995). There has been little work specifically testing interventions in a younger population (Stanton et al., 1995), although this is often a high risk group, and a sizeable proportion claim they would participate in a smoking cessation programme (Stanton et al., 1996). Often these are in clinical settings or school based, so adolescents with the highest rates of tobacco use are least likely to be reached through school based programmes (Glynn et al., 1991). Controlled intervention studies are indicated because of the worrying trend to increasing use, the rapid development of dependence, the association of smoking with other substance misuse as well as depression, anxiety and social deprivation (Hughes et al., 1986; Bobo and Davis, 1993; Glassman, 1993; Breslau et al. 1994).

4. Alternative therapies While the application of acupuncture, reflexology, aromatherapy and hypnotherapy have been subject to little evaluation in the young people’s literature, some centres offer such ‘alternatives’.

5. Outcome research

5.1. What does the adult literature ha6e to tell? Longitudinal follow-up studies of alcohol and opiate abusers illustrate a complex and varied picture with regard to mortality and morbidity (Doll et al., 1994a,b; Vaillant, 1995, 1996; Tobutt et al., 1996). Though there is room for some optimism, there is still substantial mortality and morbidity. In one 22-year follow-up study (Tobutt et al., 1996) 34% of opiate abusers were dead. In the work by Vaillant (1996), a 45-year study of alcohol use in ‘college’ and ‘city’ men, 10% were dead, 46% were ‘still alcoholic’ and 34% were abstinent, whereas in an 8-year follow-up in a clinical sample admitted for detoxification 27% were dead.

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Treatment outcome research has become increasingly sophisticated over the last three decades, before any of to-day’s adolescents were born! Randomised controlled studies using multiple sources of baseline information (assessment of physical and psychological adjustment, substance use and dependence, periods of abstinence, pre-treatment factors) and at follow-up points (at least 1 year) are standard (Miller and Hester, 1986; Hodgson, 1994). Abstinence rates at 1 year after completion of treatment demonstrate that 30–50% of patients manage to maintain abstinence, while 15–30% have not reverted to compulsive use. When O’Brien and McLellan (1996) defined ‘success’ as a ‘‘greater than 50% reduction on the drug taking scale of the ASI (Addiction Severity Index)’’, success rate for alcoholism was 50% and that for opiate dependence 60%. Nicotine dependence had the lowest rate at 30%. However, outcome improved if patients comply with counselling and pharmacotherapy, and outcomes which are favourable during treatment are extended beyond that period (Institute of Medicine, 1990; Moos et al., 1990; Higgins et al., 1994).

5.1.1. Brief 6ersus intensi6e inter6entions Over the last decade there have been a number of studies investigating the impact of less intensive or ‘brief’ interventions on ‘heavy’ drinkers, in the primary health care setting or in general hospital wards (Kristenson et al., 1983; Chick et al., 1985; Wallace et al., 1985; Effective Health Care Team, 1993; Heather, 1995; Chick et al., 1998). Though the widespread enthusiasm for brief interventions has been questioned (Drummond, 1997), the enhanced competence of the generalist (primary health care team, accident and emergency departments, paediatricians, child and adolescent psychiatrists) in the identification and treatment of alcohol problems remains an important component in comprehensive service provision for adolescent substance abusers. Of interest, Wallace et al. (1985) and Edwards and Rollnick (1997) reported that compliance was greater among older patients than among younger, heavier and less educated drinkers. Specialist inpatient treatment for adult drug users may confer benefit (Ghodse et al., 1987; Johns, 1994; Strang et al., 1997), whereas for adult alcoholics the picture is far less clear (Edwards et al., 1977). Finney et al. (1996) have sought to tease out why controlled trials did not appear to provide consistent evidence regarding the superiority of intensive or inpatient treatment. These investigations might enlighten us as to how to provide ‘‘both less and more inpatient/residential treatment-less treatment in terms of providing it to fewer people, but more intensive and/or extensive treatment for at least some of the people who receive it’’ (Welte et al., 1981; Finney et al., 1996).

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5.1.2. Project MATCH Research Group In Project MATCH (Project MATCH Research Group, 1997a,b) 1726 adult alcoholic subjects were randomly assigned to a 12-week treatment programme utilising one of the following three treatment interventions: CBT, MET or TSF. The majority of subjects experienced sustained positive improvements at 3-year follow-up, but there were was little difference in outcome by type of treatment modality. The key appears to be the expertise of the therapist. These results have clear implications for the professional training and treatment of young people. 5.1.3. NTORS (The National Treatment Outcome Study) In the United Kingdom a large 5-year national treatment outcome study has reported 12-month follow-up results (Department of Health, 1997). The four treatment modalities have been examined: inpatient units, residential rehabilitation units, outpatient community based methadone reduction programmes, and out-patient methadone maintenance programmes. At intake, the main substance problems included heroin (87%), non-prescribed methadone (49%), benzodiazepines (54%) and crack-cocaine (35%). Of the cohort twothirds were injecting and excessive drinking was also noted to be a problem, especially among those drinking more than ten units daily. At 12-month follow-up reductions in heroin use, cocaine and other illicit drugs were demonstrated as were reductions in injecting, sharing, and criminal behaviour together with improvements in physical and psychological health. Although there was substantial improvement in alcohol consumption, with daily drinkers consuming more than ten units a day falling from 75 to 41%, there was still considerable excessive drinking. Suicidal ideation fell to half the intake level, i.e. 29 to 16%. Patients in both residential and community settings demonstrated improved outcomes in substance use, physical and psychological health and criminal behaviour. The specific contribution of particular components of treatment or combinations have not been identified. Since under 18-year-olds were excluded from the study, it remains to be seen whether teenagers will have similar outcome. 5.1.4. A dynamic process Treatment for substance problems must be conceptualised as a dynamic, rather than a static process, where a developing evidence base and clinical judgement interact to provide the optimum option for a young person.

6. Outcome studies among teenagers While there is a great deal of descriptive literature on substance misuse services for young people, the effec-

tiveness of specific approaches or types of service has not been extensively scrutinised.

6.1. Outcome studies–United Kingdom In the United Kingdom, there have only been two studies investigating outcome in young people with severe alcohol or drug dependence. Doyle et al. (1994) report a follow-up study on 52 young (under 21) people treated at an inpatient alcohol treatment unit. All cases were dependent on alcohol according to DSM-III criteria. Abstinence or controlled drinking constituted a ‘good outcome’. An assessment of ‘poor outcome’ in relation to drinking was made in 61% of cases, and illicit drug use was associated as well as criminal activities. Groups were similar in terms of age of initiation into alcohol, i.e. about 14 years, which points to the earlier age over the last 10–15 years. Like the study described below, 25% had been expelled from school, and 66% experienced ‘unsatisfactory schooling’, 57% had a history of deliberate self harm and 11% were in residential care. Measures of problematic behaviour prior to presentation, e.g. deliberate self harm, disturbed childhood and assaultive behaviour, expulsion from school, attendance at child guidance and being brought up in care, as well as homelessness, lower social class and a trend to heavier weekly consumption, predicted poor prognosis. The good outcome group were more likely to be married, employed, to have used drugs less, to have fewer admissions for detoxification and less likely to have a recent forensic history. These authors suggested that young people feel alienated in treatment settings dominated by older age groups where their needs are not appropriately handled. A study was carried out on 48 patients diagnosed as severely heroin dependent and prescribed methadone in a unique designated adolescent community drug service in Stoke on Trent, United Kingdom (Crome et al., 1998, 1999). A clinical judgement on outcome was made after an average of 1 year in the service. This judgement was on the basis of attendance, compliance with a negotiated treatment plan, methadone reduction or cessation, and improvements in psychosocial functioning, i.e. relationships, education, training or work, and improved social circumstances. In the ‘good outcome’ group 37.5% reduced or stopped methadone, complied with or completed the treatment plan, and had improved psychosocial functioning. A total of 30% have remained engaged, but have not significantly altered their drug taking style, and another 12.5% have continued on methadone but without improved psychosocial functioning. The ‘poor outcome’ group comprised 20% of patients who proved unable to engage in the treatment plan and were ‘lost to treatment’. Those categorised as ‘good outcome’ were more likely to have had supportive parents who were together, to be in

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school, in training or employed, and to have passed examinations, and less likely to have had episodes of self harm or a criminal history. The group categorised as ‘poor outcome’ were more likely to have had an episode of deliberate self harm, a positive psychiatric history, a family history of substance problems, familial dysfunction, a forensic history and to have left school early. These two young populations, one severely alcohol dependent, the other severely heroin dependent, demonstrated commonalities in terms of ‘poor outcome’: a disturbed childhood, a psychiatric history, deliberate self harm, poor school attendance and forensic history (for drug users, stealing to fund the habit and for alcoholics, involvement in fights). The class structure of the two populations differed: opiate users were predominantly from lower socio-economic backgrounds, whereas alcohol problem users were more equally divided between upper and lower social class. These limited findings provide clear indications about the constitution of high risk groups, and opportunities for targeting multiagency prevention activities.

6.2. Outcome studies– USA Catalano et al. (1990) undertook a major review of 29 treatment outcome studies carried out between 1976 and 1989 in the United States. The range of treatment modalities and programmes described was immense. The modalities included individual, group and family therapy. These comprised psychotherapy, group treatments, covert sensitisation, contingency contracting, family therapy, skills training, educational intervention, cognitive behavioural relapse prevention, social support, ‘school based vocational’ intervention as well as methadone maintenance and detoxification. However, there is generally very little information on the nature of the specific interventions in treatment. The programmes were therapeutic community, inpatient residential, outpatient, community based drug and alcohol, street based agencies, day centres, and ‘detention facilities’ where young people were ‘incarcerated’. The samples were also drawn from young people being treated either with methods developed for adults, or in services orientated towards adults. To what extent this represents a treatment seeking population whose needs are best met by the services in which they found themselves, is also a subject for debate. Sample size spanned one to over 5000, but nine studies had less than 100 subjects. The age range reported was 9–19. Follow-up periods spanned 1 month to 6 years, and was more than a year in ten studies. The research design covered a wide spectrum of methodologies, e.g. pre-post treatment intervention, random assignment to a treatment condition, control conditions and single case studies. Opiate use, marijuana and

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alcohol were the substances most consistently reported at intake and outcome, but studies also reported on PCP (phenylcyclidine) and LSD. There was little in the way of standardisation in the assessment and measurement of substance use, abuse and dependence. Self-report was the major method of ascertaining information, thus reliability was questionable, due to over- or under-reporting. Parental involvement was occasionally a feature, as was contact with the school or criminal justice system. Other methods included review of records, structured questionnaires, telephonic interviews, face to face interviews with patients, parents and counsellors. Measures did not consistently include urinalysis. Comorbid conditions were included (e.g. ‘juvenile delinquents’), and there was a spectrum in terms of cultural, ethnic and regional background. Assessments included drugs knowledge, relationships with peers and family, mood and self esteem, social functioning in terms of education or employment, criminal activities, and religious involvement. The last two decades have witnessed dynamic changes in the substance use scene world-wide, especially the substantial increases in the prevalence of substance use in young people. There have been radical shifts in treatment philosophy from abstinence to harm reduction largely precipitated by the development of HIV. This period has also been very productive with more than 30 specialised journals and a steadily accumulating evidence base for treatment. Many of these influences could not have not been incorporated in the reported studies. Furthermore, as described, few reports base their findings on specific services geared for younger people with their own brand of related problems. This reflects the lack of specific services for young people, a factor which cannot be ignored.

6.2.1. Cohort studies Large cohort studies on the treatment of young substance abusers emerged in the late 1970s. Rush (1979) conducted research on 4738 young (62% under 18; 38% 18–19) drug misusers. Criteria for successful outcome included complete abstinence, as well as an index score combining education, training and employment (defined as productivity). In the outpatient programme, predictors of success were employment or in education at time of enrolment, abuse of only one psychoactive (non-opioid) substance, being white and later age of initiation into drug use. Sells and Simpson (1979) reported a 4–6-year posttreatment follow-up on 587 (under 19) adolescents drawn from the Drug Abuse Reporting Program (DARP). There were four treatment modalities, i.e. detoxification, methadone maintenance, drug-free outpatient and therapeutic community treatment, which were compared with a control no treatment group. Although for most comparisons no statistical tests were

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performed they demonstrated reduced drug use during and after treatment for all modalities. Reductions in opiate use were generally greater among treated groups. Similarly, decreases were found in subjects using nonopioid drugs in all modalities compared to the no treatment group where, in fact, drug use increased. However, alcohol and marijuana use increased in all groups except the drug free outpatient group. Abstinence rates increased for all drugs except marijuana, but drug-free outpatient programmes had the best effect on alcohol and marijuana. This might reflect the focus of the adult programmes on opiates, and point to the value of outpatient approaches for young people. Hubbard et al. (1985) compared during treatment and post-treatment drug use and related problems and pre-treatment behaviours in 240 (under 19) young people. These were randomly selected from the TOPS (Treatment Outcome Prospective Study). The treatment modalities were residential or outpatient drug free programmes. Follow-up was 1 year. Statistical tests were not reported, there was no control group and patients were not randomly assigned. Residential treatment was associated with substantial decreases in substance (opiate, alcohol and marijuana) use, and substance related problems, e.g. criminal activities, depression. Outpatient treatment also produced some reduction in substance use and related problems, but this was not as great as residential treatments. Younger (under 17) patients demonstrated an increase in marijuana use if they had less than 3 months’ treatment, and an increase in other drug use if they had more than 3 three months’ treatment. Friedman and colleagues (Friedman and Beschner, 1985; Friedman and Glickman, 1986, 1987; Friedman et al., 1986, 1989) reported on a survey of 30 drug free out patient treatment programmes incorporating two annual samples totalling 5789 adolescents. The important characteristics of the programs which predicted reduction in drug use (marijuana was ‘primary drug problem’ in 52%) were that the larger programs with more resources, i.e. funding, personnel, numbers of adolescent clients, and educational facilities, had a more successful outcome. Programs where staff were more experienced, better trained and where more services were available also had better outcomes. Group therapy, crisis intervention as well as art and music therapy were associated with improved outcome. Both staff and client perceptions, in terms of practicality and freedom of expression respectively, were shown to influence outcome in a positive manner. Thus, even the larger studies were not standardised with regard to control groups, length of the study period, and in the DARP and TOPS statistical tests were not reported. Some other studies, on diverse groups of young substance abusers in a variety of settings with a spectrum of treatment modalities which demonstrate a re-

duction in substance use, are briefly summarised. Intensive residential treatments were studied by Amini et al. (1982), Grenier (1985) and DeJong and Henrich (1980). Amini et al. (1982) compared intensive inpatient psychotherapy with conventional probation services. After 1 year there were no group differences, but both groups improved significantly in terms of substance use and substance problems. Grenier (1985) utilized a waiting list control group to assess effectiveness of adolescent residential treatment. Abstinence rates for the treated group were significantly higher at 65% compared to 14%. DeJong and Henrich (1980) followed 89 young people who had behaviour modification and reported that 33% were drug free. Friedman and Glickman (1987) reported significant reductions in substance use 3 years following treatment in 222 adolescents treated in day facilities. Community based educational programmes were described (Iverson et al., 1978; Iverson and Roberts, 1980; Feldman et al., 1983; Barrett et al., 1988). Significant reductions in drug use were reported. Iverson et al. (1978) treated parents and deviant drug users. Feldman et al. (1983) provided family intervention, counselling, recreational activities and legal services. Barrett et al. (1988) demonstrated no group differences between early intervention, alternative activities and drug abuse education, even though substance use decreased. Juvenile offenders were randomly assigned to skills training or a conventional programme (Hawkins et al., 1991; Jenson et al., 1993). The experimental group had significantly improved at discharge with regard to self control and avoidance of substances. Intervention based at group homes was the objective of a study by Braukmann et al. (1985). Where interventions were provided to families, significant improvements in social behaviour resulted. There was no difference in substance use.

6.2.2. Pre-treatment, during treatment and post-treatment factors as predictors An understanding of the wide range of potential influences on treatment effectiveness are of some importance in terms of attempting to target appropriate interventions. These were categorised into pre, during and post-treatment factors. Pre-treatment factors included age, sex, level and type of substance use, motivation (including self referral), family framework (support, parental control, history of substance misuse), father’s occupation, psychiatric symptomatology and previous treatment, religious involvement, race, ethnicity and peer drug use. During treatment factors comprised the duration of treatment, the spectrum of family support, parental abstinence, peer drug use, and attitudes towards the staff and programme, and perceptions about autonomy and progress in the programme. Post-treatment factors included peer drug use, peer pressure to use, lack of involvement in school/work/

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non-drug leisure facilities, skills deficits and negative life events. Age was not consistently a predictor of outcome (Sells and Simpson, 1979). Younger age was associated with better outcome in residential settings, with older age being predictive of superior outcome in outpatient settings (Friedman et al., 1986). Jewish people, children of fathers in managerial positions and mothers who had mental health problems were more likely to complete treatment. There was some suggestion that whites did better than other racial groups, but this was not a consistent predictor. Many studies have demonstrated that earlier age of initiation into substance use, severity of drug use and polydrug abuse were related to worse outcome. Similarly, in the United Kingdom study, predictors of good outcome included supportive parents, educational achievement, and no psychiatric or forensic history at first psychiatric consultation, whereas criminal involvement prior to treatment and educational failure were also linked to poorer completion and outcome (Crome et al., 1998; Crome, 1999). When influences operational during treatment were evaluated, treatment duration was not necessarily related to outcome: Hubbard et al. (1985) and Rush (1979) found that duration in residential or therapeutic community treatment was positively associated with successful outcome, whereas this was reversed for outpatient treatment. Patients were generally more successful if they had or perceived that they had more control over entry to treatment, and were in agreement with the level and degree of staff control and patient autonomy. Staff characteristics associated with better outcome included length of experience and use of practical problem solving methods (rather than psychodynamic principles). McLellan et al. (1992) reported recently that the provision of additional specialist services, e.g. educational, vocational, recreational, relaxation and contraceptive facilities, enhanced outcome. Involvement of the family, especially parents or significant figures, also led to positive outcome. Sometimes the young person’s involvement in treatment engaged other family members to seek help. This complements the work on post-treatment factors where DeJong and Henrich (1980) related poor outcome to the development of craving and withdrawal (or dependence), and less involvement with recreational, educational or occupational activities.

6.3. Implications of these findings for programme de6elopment Despite the many methodological flaws, the overall consensus is that treatment does confer a certain advantage to those young people who seek it. As described, the treatment modalities selected and examined varied widely so that standardisation is extremely limited. In

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the face of a great deal of inconsistency in the results reported above, the objective has to be to provide different programmes for different young people at different stages of their development. Substance misuse is often one aspect of multiple complex problems. Negative predictors at intake, which have been shown to be related to poor outcome, should not discriminate against those who may be most in need, especially when resources are scarce. Since pre-treatment severity and longer criminal histories are associated with worse outcomes, there may be potential for longer and more intensive treatment facilities, since this group may benefit from such input. In line with the development of craving and withdrawal in a significant number, treatment techniques which focus on behavioural and cognitive skills to reduce craving and withdrawal, and which also improve social skills seem to be more effective. The application of a range of detoxification techniques in appropriate settings is also feasible. Explicit personal care plans identifying personal goals, environmental and personal strengths and problems are a first step. Exploring ways of encouraging user choice and participation are vital. Leisure and educational activities which are engaging as well as the provision of special services are important. The best way forward at the present time is the provision of individualised treatment packages taking into account the need for convergence of resources and competency. The ability to assess and assign patients to appropriate types of treatment and treatment settings requires skilled workers in a multi-disciplinary team (Tarter, 1990; Fuller and Cavanaugh, 1995). The scarcity of trained and experienced personnel makes on-going training a necessary component of such treatment strategies, and this training should encourage a willingness to use existing programmes with flexibility (Glass, 1989; Crome et al., 1998).

7. The building blocks–components of a comprehensive service Adolescent substance misuse treatment services may be configured along the lines of adult services in that the young person may be ‘labelled’ as an ‘addict’ or drug user. This may result in young people being offered an identical service within existing adult facilities. Alternatively, programmes may view adolescents within a cultural and developmental process where labelling is discouraged. The consequence of this mode of operation is to locate services in community based projects which provide appropriate and relevant expertise, e.g. counselling, education and recreational facilities, group therapy and peer support groups. There is little empirical research to indicate what sort of teenager might do better in any particular kind of

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service model. Though from the perspective of those working in the front-line in designated services, there are questions to be raised regarding the applicability of models which are suitable for adults. Some young people are accessing some existing services, but the ability of services to respond to their specific spectrum of complex needs is often limited. Thus, young substance abusers may be found in hostels for the homeless, in local authority residential homes, child and adolescent psychiatric services, in primary health care, community paediatric settings and many others as described in the next contribution. The components of comprehensive specialist service provision include outreach, primary health care (including needle exchange), day care, community drug and alcohol services, outpatient and inpatient detoxification services and residential rehabilitation. Practitioners with something of value to offer young people include general practitioners, accident and emergency staff, community paediatricians, community midwives and health visitors, child and adolescent psychiatrists, addiction psychiatrists, community psychiatric nurses, psychologists and counsellors. Formalised links with youth justice, police and probation, educational, social and housing services are vital. Young people who attend specialist services require careful assessment, as stated in the previous contribution, not only of the consequences of drug and alcohol use, but also associated physical and mental health problems. The assessment should cover competencies, emotional maturity, positive familial and social resources, and importantly, his or her opinions and wishes. Many adolescents may have difficulties in understanding and internalising abstract values and concepts, e.g. denial, responsibility. This may lead to frustration among counsellors with whom trusting relationships are essential (McLellan et al., 1988). Substance abusing adolescents have a range of disorders, e.g. hyperactivity, learning disabilities which may have a bearing on treatment interventions.

8. What would an outcome study in 2000 look like?

8.1. Definition–who is the study population? As so lucidly stated in the HAS report (Health Advisory Service Report, 1996), the ‘‘distinction between use, often styled as experimental or recreational use and misuse, are hard to draw. Use of most drugs is also illegal, and some who experiment may also experience problems consequent on intoxication. Experience indicates that, while the trend towards increasing use of drugs and alcohol by young people is undesirable because of their increased exposure to the potential dangers of social, psychological and physical problems,

experimentation alone cannot be seen as indicative of personal disorders and is not styled as misuse. Misuse is defined as use that is harmful, dependent use or the use of the substance within a wider context of problematic or harmful behaviour. Young people who misuse substances may also have significant problems with their psychosocial development.’’ While the ICD-10 (World Health Organisation, 1992) and DSM-IV (American Psychiatric Association, 1994) criteria have been developed in the adult population, there are no age specific criteria for adolescents. Although clinical experience suggests that the manifestations of withdrawal and dependence may not be different in the younger person, a study by Stewart and Brown (1995) demonstrated that adolescents (mean age= 16 years) recruited from inpatient substance misuse programmes exhibited severe symptoms of dependence on alcohol and other drugs when diagnosed according to DSM-III criteria. These diagnostic systems do not take into account the social and developmental consequences, e.g. impact of substance dependence on adolescent social relationships, achievement of young adult roles, separation and individuation from family and physical change (Kelter et al., 1992; Edwards and Peters, 1994; Martin et al., 1995; Ellickson et al., 1996; Peters, 1996). Instruments to measure problems related to alcohol use are not relevant to young people (Drummond, 1990). Thus lack of tight criteria impedes an understanding of which populations of young people are being treated, and hinders generalisability of the results of any outcome studies. While the HAS report (Health Advisory Service Report, 1996) description highlights and clarifies a very complex area, the lack of standardisation in population definition in the studies described and quoted remains, still leaving us with a major problem regarding how representative these problems are in terms of the nature and extent of polysubstance abuse.

8.2. Outcome measures The range and diversity of outcome measures, particularly if main outcomes are not specified initially, are the source of additional difficulties. Again, standardisation of these (and other relevant assessment) characteristics, is important. As has been alluded to throughout the review, substance misuse in young people is associated with problems in personal development, psychiatric comorbidity (especially suicide, depression and conduct disorder), physical and sexual abuse, criminal activity, prostitution, homelessness, truancy and unemployment, family disintegration and social deprivation. Poor general health, particularly as a result of intoxication and withdrawal, is common. Thus, instruments which incorporate assessment of these multiple aspects of the adolescent’s life should be developed and ap-

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plied. The Comprehensive Addiction Severity Index for Adolescents (CASI-A), as described by McLellan and colleagues (Meyers et al., 1995) in the contribution on ‘Assessment’, is one such method. The adolescent relapse coping questionnaire also highlights differences between adults and teenagers (Myers and Brown, 1996). The HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents (Gowers et al., 1996) measures global outcome. Major outcome measures must focus on substance use, severity of dependence, physical and psychological aspects, relationships, legal, scholastic, vocational, recreational and housing problems.

8.3. Accessing the target population– lack of age specific ser6ices in the United Kingdom The evolution of a number of different services, e.g. old age psychiatry and geriatric medicine, is a useful model. As the needs of the patient population are often very different an expertise in dealing with a seemingly diverse pattern of needs begins to take shape. The rationale underpinning this view is that patients who are experiencing similar problems feel more comfortable and accepted in an environment geared to their needs. Providers become experienced in the nature of the problems and build up a cohesive service. This then provides a model of ‘good practice’. Teenagers require a somewhat different constellation of multi-disciplinary provision compared to children and adults. This requirement stems from ethical and legal reasons, as well as developmental factors (Kandel et al., 1978; Kandel and Andrews, 1987). The knowledge and experience of community paediatricians, addiction specialists, child and adolescent psychiatrists sit comfortably with those of youth workers, psychologists, community drugs workers, paediatric nurses, counsellors, education welfare officers and social workers. To my knowledge, there are only three designated services in the UK at the present time. These are substance misuse community services with a degree of input from addiction and other medical specialists and professionals. National Health Service inpatient facilities are non-existent, though there are a couple of private or voluntary agency residential services. This constitutes a major difficulty in establishing a research base, where compared with other areas there is a trend to multi-site studies with large sample sizes. Development of services as models of good practice would provide more information on the accessibility of the service, the nature and extent of drug, alcohol and related problems, engagement and retention in treatment, definition of treatment needs as well as the efficacy of treatment interventions. Pilot studies might do well to evaluate treatment outcome of individual treatment packages in designated

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services. If this facilitates improvement in key indicators of health, social stability as well as substance use, this would provide a basis for larger studies where patients could be randomly allocated to specific treatment programmes.

8.4. Sample size, random assignment and double blind procedures In the only designated service in the UK, 30 patients were being prescribed methadone at any one time (Crome et al., 1998). If the numbers seen there are any indication of the extent of the opiate problem, between 1–2% of the teenage population are using heroin in a dependent manner. Severe alcohol problems (with attendant risks), likewise, are estimated to affect about 5% of the adult population, and about 1–2% of adolescents (Anderson et al., 1993; Central Statistical Office, 1995; Graham, 1996; Health Advisory Service Report, 1996). If services were orientated to young people, it appears likely that greater numbers would be recruited to treatment. The integrity of random assignment and double blind procedures are also important, especially, though not only, in pharmaceutical drug trials. This too, as mentioned in the British Association for Psychopharmacology Consensus Statement, is more costly than adult trials. However, it may come to pass that parents and users will themselves insist on improved monitoring procedures.

8.5. Adult inter6entions restructured or inno6ations? What has been described thus far is primarily a restructuring of interventions, aimed initially at adults, within a multi-disciplinary framework oriented at young people. While implementing and adapting such adult interventions appear to be worthwhile at the clinical level–apart from the evaluations described earlier–there has been no rigorous evaluation of restructuring. So, what constitutes innovative treatment for adolescents and which interventions and models of service delivery ‘work’ for young people require investigation. Peer and parental pressures, academic achievement, self esteem, wider social relationships and socio-economic status are elements which contribute to careers in substance use. These should be considered when interventions, services and indeed prevention opportunities (as discussed in Section 9), are being organised.

8.6. Costs and cost effecti6eness No research on the financial costs to society of young substance users is available. The immediate, let alone longer-term costs, of a young person being involved in a life of substance use and all the attendant social and

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medical problems, have not been assessed (Doyle et al., 1994). Given the scale of the problem within the wider community, this seems a worthwhile avenue to explore. The topic of cost and cost effectiveness is very complex, controversial, and uncertain at this stage (Maynard et al., 1987; Finney and Monahan, 1995). Briefer interventions, if inappropriate, though cheaper at the outset, may incur greater future health service (and other) costs. The short-term strategy of cost minimisation versus cost containment in the longer term is perhaps nowhere more germane than in the case of young substance abusers (Coyle et al., 1997).

where parents are using drugs may be at social disadvantage as a consequence of this habit (Hawkins et al., 1992). Prevention in treatment seeking populations is important as findings also suggest that delaying the onset of substance use might mitigate the development of substance dependence, offending behaviour, psychological problems and enhance educational and employment opportunities (Fergusson et al., 1994; Fergusson and Horwood, 1997).

10. Conclusions–the future health of the nation

10.1. General themes about treatment 9. The prevention intervention connection Though this is beyond the scope of this review, no discussion on treatment of substance misuse can afford to ignore the contribution of the prevention dimension and the role specialist services might play in targeting young substance misusers. In what way can individual treatment approaches be part of the comprehensive public health approach (Babor, 1995; World Health Organisation, 1995; Smart et al., 1996; Wagenar et al., 1996; Rigotti et al., 1997)? What role do the specialist services have in the design, implementation and evaluation of prevention programmes, especially in high risk (e.g. treatment seeking) populations (Foxcroft et al., 1997)? The association between familial variables and adolescent substance use and misuse has been the subject of substantial investigation (Quinn et al., 1988; Whipple and Noble, 1991; Schuckit and Smith, 1996; Schuckit et al., 1996). Characteristics that buffer children from risk include parental warmth, parent-child attachment, parental support of child competencies and positive parent-child interaction and communication (Rutter, 1990; Richter et al., 1991; Cohen et al., 1994; Bauman and Ennett, 1996; Miller, 1997). Parental attitudes favourable to substance misuse, parental substance misuse, parents involving children in their own drug use, family conflict and poor family management practices are conducive to adolescent substance use and misuse (Fergusson et al., 1994; Sayette et al., 1994; Curran and Chassin, 1996). Targeting those at risk, e.g. substance misusers with young children, can assist in facilitating positive relationships and skills in dysfunctional families. Adolescents who choose to become involved with substance users constitute a high risk group (e.g. low commitment to school, poor scholastic achievement, early and persistent behavioural difficulties and childhood adversity) which may be susceptible to therapeutic interventions (Duncan et al., 1994). Risk factors may have an additive effect because families

Most young people do reduce or cease using substances without the intervention of treatment services. Also, individuals with substance problems demonstrate the capacity for change, despite very severe dependence and complex social problems (Crome et al., 1996, 1998; Crome, 1999). Moreover, there is no single treatment approach for addiction, nor are the particular components of treatment which yield beneficial results identifiable (Hubbard et al., 1989; Ghodse, 1997). However, engaging patients in a long-term relationship is important in improving outcome. Treatment is associated with reduced substance use, injecting behaviour and related physical and psychological well being. Cost effective minimal interventions may produce significant health gain. However, intensive treatment for severe problems should be an option as it can be associated with improvement, as may a combination of psychological and pharmacological treatments as part of a cohesive treatment package (Kranzler et al., 1995).

10.2. Specific needs of young people Most authors have stressed the need for greater attention to the specific needs and specialised treatment units for young people with problematic substance use. Some effort has been directed toward the implementation of effective interventions be they suitable assessment tools, psychological techniques and pharmacotherapies embedded in relevant programmes. There are questions and concerns about the capacity of these interventions to contain the extent of substance problems in the community (Wright and Pearl, 1995). While it is tempting to propose one set of interventions that work for a heterogeneous range of adolescents, this is clearly untenable. In addressing the problems of which interventions work for which young people, their personal, social, psychiatric, medical, educational or employment prospects, potential and problems require an individualised approach.

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10.3. Joint commissioning and joint pro6ision Furthermore, while there is some limited evidence regarding the effectiveness of interventions for young people, the conjoint development of pilot services and evaluation of outcome have to take priority over a descriptive approach. While the development of each service will itself be constrained by the allocation of scarce resources, e.g. level of training of personnel, professional affiliations, time, quality of interagency liaison and types of problems.

10.4. Early inter6ention is better than cure If there is little provision for the evaluation of earlier specialist interventions in young people in need, their pathway into a chronic disorder with attendant social, physical and psychological difficulties may well be unnecessarily hastened (Edwards et al., 1993; Holder and Edwards, 1995). The benefits of reduction in substance use, improved health and social functioning as well as diminished threats to public health and safety should not be minimised as decisions regarding allocation of resources are made. New funding for the future health of the nation is key.

Acknowledgements The expert secretarial assistance of Sharon Finney and Valerie Waldron are acknowledged.

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