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Prognosis and Developmental Course Edits
Substance use and abuse prevalence rises throughout adolescence and reaches a peak in early adulthood. Developmental stage is important in understanding SUD, as substance use among adolescents manifests differently than among adults. Adolescents have legal and logistical barriers to obtaining substances, increased peer influence, and still-developing brains that make substance use at this age particularly dangerous. For example, since a minor can't purchase alcohol, making it difficult to obtain, adolescents drink less frequently than adults but are more likely to engage in binge drinking with peers. Binge drinking is a high-risk activity, as it may lead to neurological damage or accidental injury/death.

Early onset of substance use, defined as prior to age 14-15 for alcohol and 16 for marijuana, is associated with a higher risk of chronic SUD. This subgroup of early substance users splits into an adolescent-limited course and a chronic course with high risk for SUD throughout adulthood. Those with comorbid disorders and certain temperament characteristics, such as behavioral disinhibition, are at higher risk for developing a chronic course of SUD.

Factors associated with better treatment outcomes and a more positive prognosis are completing treatment, motivation to abstain, low substance use upon commencing treatment, and social support from non-using family and friends. There are also various predictors of poor outcomes of adolescent SUD. A key development in the literature comes from a comprehensive review that focused on personality traits. This review found that impulsivity is a key predictor of negative outcomes in individuals with substance use disorder. Adolescent substance dependence is another predictor of poor prognosis. Moreover, substance use early in life is a predictor of increased use of heavier, more intense substances in the future.

Relapse rates are high for adolescents who have received outpatient treatment for SUD; one study found a six-month relapse rate of 66% and a median time to relapse of 54 days without any significant difference by demographic factors or comorbidities. A large review showed six-month relapse rates at 62% and one-year relapse rates at 68%. Reported reasons for relapse are different for adolescents than adults; adolescents tend to attribute relapse to social situations and peer use, while adults attribute relapse to coping with negative emotions. However, relapse for cigarette use is an exception, and is attributed to compulsion rather than peer pressure.

Introduction
Research has recently been advancing regarding Substance Use Disorder (SUD) in adolescents since they are most prone to beginning to use substances which seriously compromise their lifelong wellbeing. It is crucial to synthesize recent findings and better understand SUD in this age group since smoking, drinking, and illicit drug use are among top drivers of morbidity and mortality among adolescents. Furthermore, SUD affects millions of people around the world, and its disastrous outcomes often affect more than just the individual abusing; as found in the Briefing on Substance Use Treatment and Recovery in the United States Executive Summary, substance use and abuse can manifest in any and all communities, in a wide range of age groups (although some are at higher risk), and can have negative outcomes in public sectors, from businesses to jails, hospitals to individual families. Another worrying aspect of substance abuse is that often many go untreated for their illness, leading to losses in economy, productivity, and lives. In the United States itself, drug overdoses are one of the highest causes of death, and are therefore a cause for major concern in the realm of public health. Furthermore, Mack et al. found that both urban and rural areas are hard hit by substance misuse, with increases seen in each region between 2012 and 2014, though higher instances of use and fatalities were seen in heavily populated metropolitan areas as opposed to rural landscapes. Unfortunately, some areas and demographics of people are less able to seek treatment, as well, leading to inconsistencies in healthcare provided to people in need. With limited resources for treatment services, particularly in rural areas as opposed to urban, a need for more attention to these areas that are lacking is necessary.

Copious amounts of clinically-useful research have been published recently that expand on fundamental understandings of SUD in youths; however, the traditional research-to-practice gap in mental health persists. Essentially, an abundance of research is produced quicker than can be consumed, critically evaluated, and implemented by psychological practitioners. Therefore, this article seeks to narrow that gap by providing a comprehensive overview of research in SUD in youths to inform clinicians. This overview includes diagnostic criteria, prevalence, comorbidities, assessment tools, treatments, and a special focus on the interaction with sleep and diet. While it is impossible to put all information that a clinician could require into one article, this article is a step towards providing a strong and accessible foundation for time-limited clinicians to keep up with current relevant research and stay well-informed of the most important pillars for helping youths with SUD.

Diagnostic Criteria
Substance-use disorder is defined in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed.) as “a problematic pattern of substance use leading to clinically significant impairment or distress” with at least two of eleven criteria present during one year. Those eleven criteria represent indicators of substance abuse and substance dependence, which can be physical or psychological. Physical dependence, which includes tolerance and withdrawal, has consistently strong empirical support dating back to early studies of SUD. Further diagnostic criteria includes the use of drugs/illicit substances for periods longer than planned and the need to continue using the substance at high cost to the individual - to the point where obtaining the drug is what the user’s day revolves around. Additional grouping criteria for SUDs includes social impairment, “risky use” that puts the life of the user in danger, and “pharmacological criteria,” exhibited by higher tolerance of the substance. Interestingly, there are no developmentally-specific or age-specific considerations in the diagnostic criteria that apply specifically to children or adolescents.

The DSM-5 outlines specifiers related to remission, environment, and severity. “In early remission” is specified if criteria have not been met in the past three months but have been met at some point in the past twelve months, with the exception of the craving, and “in sustained remission” is indicated if the criteria have not been met for the past year. “In a controlled environment” indicates that the person does have access to substances due to residing in a restricted environment, such as a rehabilitation center. Presence of two or three criteria indicates mild severity, four to five indicates moderate severity, and six or more indicates severe severity.

The DSM-5 marked a significant departure from the DSM-IV along the lines of substance-related disorders by consolidating substance abuse and substance dependence into SUD upon recommendation from the DSM-5 Substance-Related Disorders Work Group. After reviewing the DSM-IV criteria, the Work Group also successfully advocated for an addition of the criterium related to craving and removing the criterium related to recurrent substance-related legal problems. These decisions came from an analysis of 39 studies including over 200,000 subjects where the researchers plotted criterion severity against how well a criterion discriminates between subjects of high or low disorder severity. Ultimately, they found a pattern that substance abuse and substance dependence criteria were related with the exception of the legal issues criterium and the addition of craving criterium, resulting in the above-mentioned changes.

Other changes discussed included the threshold of two criteria to receive a diagnosis, which was agreed to be sufficient given the urgency of early intervention for successful treatment outcomes. Given findings that increasing number of criteria was associated with increasing consequences of the disorder, it was decided to indicate severity simply as mild, moderate, or severe based on criteria count. Consistent with the goals of simplicity and usefulness, the physiological specifier was dropped and remission specifiers were restructured. Although the DSM-5 had an overall goal to highlight biomarkers when possible, they were excluded from SUD because studies showed that biomarkers of SUD were not yet sufficiently reliable or valid. Future DSM editions may attempt to include these as more research and precise technology further study biomarkers.

Prevalence
There is a shortage of strong epidemiological data specific to youth SUD, with more focus on substance use itself. Data from large national surveys indicate that adolescents ages twelve to seventeen had a prevalence in 2010 of 7.0% for SUD and 6.0% for any alcohol disorder. This marked a major decrease since 2003, with prevalence of 7.3% and 4.6%, respectively. On a broader scale, it is believed that opioid abusers specifically amount to around 32.4 million people across the world.

Cross-sectional and longitudinal studies with nationally-representative samples show evidence of higher prevalence rates of substance use and misuse among females, Hispanics, veterans, and older adolescents. However, an annual report that monitors adolescent drug use since 1975 notes that the gender and race/ethnicity gap in drug use has narrowed over time. Nevertheless, because differences do persist, a potential cause for this pattern being cultural stereotypes of genders, puts into focus the necessity of carefully choosing messages released to the public.

Likewise, people in regions harder hit by economic difficulty are more likely to engage in abuse of illicit substances, as many find the outlet of drugs and other harmful activities to help curb the stress experienced by everyday life. Lastly, though youths who were found to already have substance abuse disorders by the time they were 18 were fairly common, a study by Langford et al. found that the numbers of young adults who continued suffering from SUDs into early adulthood and beyond decreased. One potential theory for this pattern is the occurrence of more and greater responsibilities as one matures, which create situations for the individual that compels him/her to seek treatment for SUDs. Therefore, it is important for clinicians to remember that anyone can have SUD, regardless of demographic characteristics.

In a national sample of over 40,000 adolescents ages twelve to seventeen, 22% used alcohol, 12% marijuana, 4% other illicit drugs, and 11% prescription drugs, with prevalence rates increasing as age increased. In light of the current opioid crisis, it is important to examine rates of opioid misuse among adolescents. Prescription opioid misuse was 3.52% and prescription opioid use disorder 0.52%, with higher rates among those with lower family incomes.

Common Comorbidities
SUD is often co-occurring with other disorders. Comorbidities are also believed to develop more often early in the developmental trajectory of the individual, usually due to trauma, and result in higher anxiety and greater stress over the lifetime – risk factors for SUD. About 70% to 80% of youth in treatment for SUD have comorbid mental disorders. Common comorbid mental disorders in adolescents with SUD include suicidal ideations or behaviors, internalizing disorders such as depression and  anxiety, and externalizing disorders such as  oppositional defiant disorder,  attention deficit hyperactivity disorder, and  conduct disorder. Further common comorbidities include bipolar disorder, eating disorders, and schizophrenia, showing especially often as heightened aggression and violence in young males. Internalizing, as compared to externalizing, disorders had greater comorbid correlation. There is some evidence that there is a cyclical relationship between substance use and behaviors associated with conduct disorders, such that one issue increases the other and vice versa, leading to increasing severity of both issues over time. Further, since SUD is a risk for suicide in adolescents, it is a driver of the third leading cause of youth death and merits major intervention.

SUD has been classified as an externalizing disorder. The high prevalence of comorbidities can be explained by the internalizing-externalizing transdiagnostic factor model. This emerging model is more aligned with the Research Domain Criteria rather than the DSM, as it focuses on a dimensional, biologically-based model of mental illness rather than a categorical, symptom-based approach. This approach suggests shared underlying processes and pathways between SUD and the comorbid externalizing disorders. However, it does not account for comorbid internalizing disorders. This phenomenon is best explained empirically by a combination of shared genetic and social risk factors and a direct causal relationship from SUD to depression and anxiety. While this is significant, it does not clarify the mechanisms of the causal relationship. Fergusson et al. proposed socioeconomic drift or neurochemical changes resulting from substance use as potential mechanisms subsequently leading to internalizing disorders.

Unique to SUD are associated physical and medical conditions in adolescence, including automobile accidents, physical and sexual violence, overdose, sexually transmitted diseases, and asthma. These physical health issues are increased by the direct negative effect of substance use on physical health and the indirect effect of increased risky behavior. These issues represent a major consequence of the disorder on adolescent morbidity and mortality.

Prognosis or Developmental Course
Life course and development plays a strong influence on the manifestation of SUD and its effects by way of biological and cognitive, identity and relationships, and achievement and responsibility pathways. Adolescents have legal and logistical barriers to obtaining substances, increased peer influence, and still-developing brains that make substance use at this age particularly dangerous. For example, adolescents drink less frequently but are more likely to binge drink due to access to alcohol, and thus are at high risk of neurological damage or accidental injury/death. Substance use continues to rise and peaks in early adulthood, when emergency department visits due to illicit drug use are highest, general health deterioration heightens, and pregnancies of mothers who use substances are at high risk. Among older adults, substance use declines. Most illicit drug use lessens, but opioids, alcohol, tobacco, and marijuana are still used, leading to increased chronic health problems, internalizing disorders, insomnia, and dementia. Therefore, across the lifespan different biological, psychosocial, and social location factors shape distinct presentations of substance use, mental illness, and physical condition.

Regarding prognosis, it has been difficult to predict who will benefit from treatment. Because substance abuse does have the potential for so many (and varied) comorbidities, as well as incorporates many types of substances that can be abused, it is important that treatments and interventions to prevent SUD before it further progresses be considered heavily in treatment programs for best prognoses. Furthermore, treatments for people with comorbidities should not focus on a single problem at a time, but should, instead, incorporate new treatment plans that address issues in tandem, in order to have the most positive outcome for the disorder, though this can be tricky to attempt. For example, in one study within six months 66% of adolescents had relapsed, with a median time to relapse of 54 days and no significant difference in relapse status or time to relapse by demographic factors or comorbidities. A review shows six-month relapse rates at 62% and one year at 68%. The same review notes factors associated with better treatment outcomes as finishing treatment, low substance use when commencing treatment, and social support from non-using family and friends. Nevertheless, according to the DSM-5, the typical prognosis for those with SUD is positive; only the severest of cases have more questionable long-term repercussions.

A key development in the literature comes from a comprehensive review that cleverly focused on personality traits. This review found that impulsivity is a key predictor of negative treatment outcomes in individuals with substance use disorder. Additionally, while many adolescents with SUD recover, those who progress into adulthood often experienced dependence as an adolescent. Lastly, many who suffer from SUDs are unable to seek care; thus greater emphasis should be placed on ensuring that specialty care for the individual is available, as well as on the healthcare system at large, to ensure that no patients fall through the cracks. Especially since some studies have found that use of substances in early life is a predictor of increased use of heavier, more intense substances in the future, it is necessary that those who need treatment seek it, quickly. More research is needed on factors influencing prognosis and course of SUD in adolescents.

Evidence-Based Assessment
As substance use still has a perceived stigma in culture, as well as potential legal ramifications for the use of particular substances, the approach to assessing the presence of SUD in a patient must be handled with care. Particularly because the topic is so personal and because specific answers are often expected (usually in the negative in relation to usage), the approach to assessment must be finely tuned to the situation and patient.

Multiple levels of evidence-based assessment of SUD exist for adolescents. The common CRAFFT screening test is a brief six item screening, often used in primary care settings. It has proven to be a valid instrument to assess risk. Given the high prevalence of SUD in adolescents and that fewer than 25% of pediatricians are comfortable assessing and referring adolescents for substance use issues, CRAFFT could be a simple yet effective way to identify from the general population those adolescents who need more comprehensive assessment without demanding too much time, money, or expertise from the primary care system. Another option includes Self-Administered Questionnaires (SAQ), as they were found to be more likely to get the most accurate results needed for assessments as compared to interviewer administered questionnaires; however, these results require further testing, as other studies have shown that the opposite is true, and that teens referred for treatment in particular, were more likely to answer more truthfully when an interviewer posed the questions. Other lengthier but more comprehensive screening options include Personal Experience Screening Questionnaire (PESQ) which screens for the need for further drug use assessment, Drug Use Screening Inventory - Adolescent (DUSI-A) which screens for severity of involvement with and consequences of drug use, and Problem Oriented Screening Instrument for Teenagers (POSIT) which looks at problems and needs in multiple areas, including substance use. Likewise, McNeely et al. developed the TAPS Tool to help assess, accurately, the recent usage and current risk level of developing specific substance abuse disorders. More recently, evidence shows validity in differentiating clinically important adolescent substance use for an electronic assessment of annual use frequency for eight commonly-abused substances.

Beyond screening, assessment should quantify substance use, effects on functioning, and decide if criteria for a DSM disorder is met. This requires information gathered from multiple sources (i.e. teachers, parents, physicians, social workers), since the adolescent is unlikely to be forthcoming about substance abuse. Severity ratings such as Adolescent Drug Abuse Diagnosis (ADAD), Adolescent Problem Severity Index (APSI), Teen Addiction Severity Index (T-ASI), and Comprehensive Addiction Severity Index - Adolescents (CASI-A) are empirically supported, as are structured interviews like Adolescent Diagnostic Interview (ADI). The Addiction Severity Index (ASI), renowned as the one of the most popularly used substance abuse assessment tools today, in both clinical and research settings, involves semi-structured interviewing to learn about the patient in multiple areas, and thus is one assessment method which should not be overlooked. For SUD in particular, best practice is to conduct toxicology reports pre, throughout, and post treatment, which allows for tracking progress and confirming self-reports.

Evidence-Based Treatment
Although relapse is common, treatment is proven to be better than no treatment for adolescents with SUD, especially treatment specific to SUD. Unfortunately, only 10% of adolescents with SUD receive any treatment. This is potentially related to the shortage of adolescent-specific treatment in substance abuse treatment, as only 29% of facilities can accommodate adolescents. Taken together, these factors suggest that specific SUD treatment for adolescents is crucial, but significant barriers to access prevent such treatment.

Looking at therapeutic modalities, the gold-standard evidence-based treatment for adolescents is family therapy,  while  cognitive-behavioral therapy and  community reinforcement are also supported empirically. An overview of systematic reviews found that school and family-based substance abuse interventions had the most efficacy for adolescents. twelve-step groups such as AA or NA are shown to be a beneficial as supplemental or continuing treatment. The trend towards emphasizing family and school may be particularly salient to adolescents because they are not yet fully independent and these systems create structure and exert control in their lives. Since these systems shape adolescent behavior significantly, aligning them with recovery-focused goals have potential to be highly influential, helping to decrease instances of relapse and to address and overcome trauma that might be a root cause of the substance abuse.

Many other forms of therapy are also acceptable and evidence-proven ways to help combat substance abuse, including experiential therapy, which uses hands on approaches to engaging in new tasks – like art or music, dialectical behavioral therapy (DBT), which focuses on developing mindfulness and control of emotions, and eye movement desensitization and reprocessing (EMDR), which is a psychotherapeutic therapy that allows the patient to work through past, negative experiences.

Best-practice treatment plans for SUD should be abstinence-based with focus on motivation, family engagement/support, skills-building and relapse prevention, co-occurring disorder treatment, multisystem intervention, and completion of treatment and follow-up. Family therapy is key because family relationships and context are important risk factors for adolescent SUD, and because families can institute environmental change. Similarly, building peer support systems of non-users is a driver of sustained behavior change since adolescent substance use is often related to peers. Moreover, since youths rarely self-refer and instead are typically pressured or forced into treatment by a caregiver, developing buy-in is crucial to treatment completion and relapse prevention. Motivational interviewing drives treatment compliance and retention in adolescents with SUD.

As for treatment setting, adolescents should be treated at the lowest appropriate level of care so as to foster generalization. This level of care, ranging from twelve step groups to outpatient, intensive outpatient, and residential care, should be the least restrictive option that still provides necessary care and a safe environment. Additionally, given high comorbidity rates in adolescent SUD, co-occurring disorders should be screened for in all SUD treatment settings. These disorders must be appropriately addressed with evidence-based methods in order for the adolescent to return to developmentally-appropriate functioning. In summary, treatment for SUD in adolescents should be comprehensive and evidence-based.

Sleep
The link between SUDs and sleep issues is increasingly being researched. Substance abuse and sleep are suggested to have a bidirectional relationship, such that early sleep pattern and duration can be a risk factor for SUD and that substance use is associated with sleep issues. While the mechanism for the former is still being researched, it has been suggested that erratic sleep/wake behaviors are associated with lower behavioral inhibition, which is a risk for SUD. More recent research suggests that childhood sleep issues predict early-onset SUD only for boys. Additionally, a few possible mechanisms for the relationship between SUD and sleep issues exist in the literature. Mechanisms could include the effect of alcohol consumption on decreasing nighttime melatonin, or the physiological effect of withdrawal on waking up during sleep, sleep arousal, lower sleep duration, increased  REM sleep, and decreased  slow wave activity.

These findings have important implications for SUD interventions in adolescents. First, sleep difficulties need to be addressed through CBT or medication in order to prevent self-medication in the form of substance abuse. These early sleep interventions could decrease the risk and incidence of SUD in adolescents. Second, the sleep disturbances resulting from discontinuing substance use must be anticipated, treated, and monitored as part of the SUD treatment process, which would eliminate a barrier to long-term recovery. This step could prevent relapses in people entering or completing treatment.

Diet
Substance use has a connection to health and diet of those who suffer from SUD. One study by Kovacs et al. found that, in the long term, the health of the individual played a role in the likelihood of developing SUD. This does not come as a surprise - previous discussions of the role of health have been discussed – but it is necessary to note as a confound. For example, when people deal in negative ways with their emotions or hard life circumstances, they are more likely to turn to illicit substances. When that person already receives less than the recommended physical activity daily and feels depressed because of their body image, for instance, then the likelihood of using substances to cope increases.

Further studies found that when people had higher Body Mass Index (BMI) – which is often a result of non-healthy diets – the individual experienced more dissatisfaction. However, when they turned to addictive substances, including alcohol, their chances of increasing their BMI increased, and thus the cycle of helplessness and displeasure with the current situation was exacerbated, continuing the cycle of abuse.

However, when people lived healthier lives, their overall satisfaction with life increased, and so their dependence on foreign substances to increase their mood decreased. In fact, Kovacs et al. found that a controlled diet drastically decreased the chances of smoking and served as a protective measure for other aspects of health and the avoidance of illicit substances.

Resources
In the event of a life-threatening emergency, immediately call 911. An individual in crisis looking for immediate support can call the crisis support line to talk to a trained call operator in a free, confidential setting anytime at 1-800-273-8255, or text START to 741-741. An individual with suicidal thoughts seeking immediate support can call the National Suicide Prevention Lifeline at 1-800-273-TALK.

A multitude of resources exist to connect adolescents with SUD to professionals who can provide evidence-based treatment. In the Triangle area of North Carolina, options for various levels of outpatient care are available for adolescents with SUD at universities such as  Duke University and  University of North Carolina. These local programs are strongly rooted in evidence-based approaches and accept insurance; however, they lack the ability to handle higher levels of care. For higher levels of care such as residential programming and detox, traveling farther to an option such as Caron Teens Program in PA is a strong option. Although a distance away, this 90+ day long-term program is nationally-renowned and evidence-based with the capacity to focus on SUD while treating co-occurring disorders and supporting the adolescent holistically in a gender-specific, teen-only environment. This program accepts major insurances, and has options for continuing care to prevent relapse. More information on these treatment programs can be found in the following table. For assistance finding the best treatment options locally in North Carolina to fit specific needs of a youth, Easterseals has a CARES program found at their website. This service connects a family in crisis with a qualified staff member who personally assists the family in finding comprehensive clinical services and appropriate care. Nationally, search engines such as Higher Ed allow for drug rehab searches by state or city and detail service options, levels of care, treatment type, payment type, clients served, and contact information for each result. The US government also provides a search engine that filters by location, treatment type, age, and language. Search results include extensive details on each treatment program. The same group also offers a hotline 1-800-662-HELP to match with people with national SUD treatment options. Help is available to adolescents with SUD, both in North Carolina and nationally.