There are currently at least 250,000 adolescents (twelve to seventeen years of age) in need of adolescent substance abuse treatment in California.
By Timmen L. Cermak, MD
Addiction medicine has long labored with a flaw at its very core – a flaw that arose from the fact that adult professionals treating adult patients originally developed the field decades ago. As a result, substance abuse has been seen as an adult disease.
In his seminal paper, “Drug Dependence, A Chronic Medical Illness”, (Journal of the American Medical Association, 2000), Thomas McLellan (immediate past deputy director of the Office of National Drug Control Policy) presented a coherent rationale for comparing treatment strategies and outcomes for addiction to those used for other chronic medical illnesses such as hypertension and diabetes. Addiction medicine primarily resonated with Mclellan’s conclusion that, “like other chronic illnesses, the effects of drug addiction treatment are optimized when patients remain in continuing care… In other words, substance abuse must be managed for the long term, not treated once like an acute illness.”
There is, however, another conclusion embedded in the concept of drug dependence as a chronic medical illness that has not yet received adequate attention. As with any chronic disease process, the treatment of drug dependence would likely be improved with early diagnosis. In fact, with substance abuse, early diagnosis may eventually be one of the essential keys to better outcomes.
A review of the data relevant to the onset of substance abuse today is enlightening. There are currently at least 250,000 adolescents (twelve to seventeen years of age) in need of substance abuse treatment in California. Only one in ten receives any treatment and only 25o/o of those receive adequate treatment. The juvenile justice system provides the greatest access to treatment, and except for twelve-step meetings (such as AA and NA), there is virtually no aftercare for adolescents in California.
CSAM views substance abuse (SA) as a disorder of the brain, with hereditary and social/experiential components placing a subset of the population at increased risk. With sufficient exposure to drugs of addiction, however, brain changes that promote dependence occur in susceptible individuals. Of all age groups throughout the life cycle, adolescents are at highest risk of experiencing brain alterations as a result of alcohol and drug use. For example, the percentage of an alcohol use disorder (AUD) within the first two years of initiating drinking is 3.7% in ages twenty-two through twenty-six; but 9.5% of 16 year-olds will demonstrate an AUD if they have initiated drinking in the previous two years. Of those adults who started drinking at 21 or older, only 2.60/o demonstrated an AUD in the previous years, while 15% of those who began drinking between 12 and 14 years of age will demonstrate an AUD in the past year.
Greater than 47 percent of adults with alcohol use before age 14later meet criteria for alcohol dependence, versus 9o percent for those who first used at age 21 or older. And more than 90 percent of adults with current substance use disorders started using before 18; half of those began before 15. But the high susceptibility to addiction is not restricted to alcohol in adolescents. Among 22 to 26-year-olds who initiated marijuana smoking in the past two years, only 3 percent exhibit cannabis dependence;while more than 16 percent of 1S-year-olds who started smoking in the past two years satisfy the diagnostic criteria for dependence.
Why are adolescents at higher risk of substance dependence than any other age group? The answer is clearly multi-factorial, but heading the list is the fact that the human brain experiences a burst of dendritic growth and an explosion of new synapses at puberty with a gradual pruning process that lasts until at least 24 years of age. The last areas of the brain to fully mature are the frontal and prefrontal areas, regions that underlie our higher-order mental capacities– the executive functions and conceptual frameworks that modulate and inhibit impulses arising primarily in the limbic system. Without these higher-order functions, adolescents have fewer resources with which to respond to the ultimately destructive demands of a reward system that has been hijacked by psychoactive drugs.
The data show that at least 50 percent of the cases of addiction we treat in adults had their onset during adolescence– when individuals’ primary care physician was a pediatrician! Addiction is a chronic medical illness of pediatric onset, and this fundamental fact still needs to be integrated into the core of addiction medicine. The fundamental fact of addiction being a childhood disease needs to become central to the thinking of every physician who comes in contact with our youth. As with all chronic medical conditions, early diagnosis is the key to more effective treatment.
And we already know that early Adolescent treatment produces a 48 percent reduction in primary drug use, a 53 percent reduction in alcohol and drug-related medical visits, and an B0% reduction in criminal activity. While increasing the availability of treatment for substance abuse for adolescents would require an economic investment, the Little Hoover Commission estimates that treatment saves $7 for every dollar spent. This figure does not take into consideration the savings beyond direct medical costs (i.e., savings to the juvenile justice system, social welfare programs, reduced crime, etc.). Neither does it take into consideration the increased productivity that accrues to society when fewer youth drop out of school and fail to contribute to an educated and skilled workforce. The investment in developing a treatment system for youth would pay dividends both financially and in terms of reducing human suffering for countless families.
Treatment for youth will be more costly than for adults for two primary reasons: (1) The level of professional training required of workers in adolescent treatment is higher than in adult treatment, and (2) the intensive phase of treatment must often last longer with adolescents than with adults. Youth treatment must address both mental health and substance abuse issues. Co-morbidity is the norm for adolescent substance abusers. Psychiatric conditions complicating the substance abuse frequently include depression, anxiety, ADHD, and conduct disorders. Family dysfunction is very common and must also be addressed. Normal developmental issues, often delayed and distorted by the substance abuse, need to be addressed during treatment. As a result, the level of professional training required of workers in adolescent treatment is higher than in adult treatment. However, while youth treatment is more costly, the benefits (both psychologically and economically) last far longer when sobriety is established early in life.Currently in California, the juvenile justice system is the main portal for entry into treatment. This is inefficient. Student Assistance Programs are afar more effective way to intervene in youth substance abuse before legal difficulties become too severe. CSAM believes that we should strive to keep youth in school and out of jail. Substance abuse is an illness, not a crime. School achievement lowers risk of substance abuse. Bringing treatment to where youth are-in the schools-rather than waiting until they have to be removed and incarcerated would facilitate early intervention and normalize recovery.
The bottom line is that parity is essential for effective treatment. Health insurance is a strong predictor of whether or not an adolescent will receive needed health care services. Currently 64 percent of adolescents 12 to 17 are covered by private health insurance; mandated parity would provide substance abuse and mental health treatment to all of them. Federal law only states that if a medical insurance plan provides coverage for substance abuse and mental health problems, it must provide benefits that are on a par with other medical benefits.
Offering full parity to all ages for substance abuse and mental health treatment would increase insurance premiums by only 0.2 percent, about $5 per year. Mandating parity only for adolescents, at a minimum, would be a relatively inexpensive method for providing a consistent source of revenue to begin building a treatment system in California designed to meet adolescents’ needs. A statewide treatment network for adolescents is required. Treating youth and their families within their environment is preferable; but sometimes individuals need to be removed from their immediate environment in order to interrupt destructive patterns of substance use and/or ongoing traumatization. Currently, only the wealthy can afford expensive out of state wilderness programs designed to remove youth from toxic environments, circumstances, and behaviors. With a statewide treatment system, similar opportunities could exist for individuals to receive residential care within California, at some safe remove from their dysfunctional environment but still close enough that family work could proceed.
ln summary, the Honorable Judge Peggy Hora of Alameda County enunciated the direction CSAM believes should be taken in California when she wrote the following: “Once an adolescent finds he or she is unable to stop using without help, then treatment should be provided on demand and in a safe environment. The stigma on seeking help must be erased so that teenagers can get the treatment they need. We need to identify children who are at risk for addiction at a much earlier age and provide the interventions they will need to avoid alcohol and other drugs.”
Timmen Cermak, MD, is president of the California Society of Addiction Medicine. He is currently in private practice in psychiatry in Mill Valley (article used with permission from the author and the Journal of the San Francisco Medical Society).
If you or someone you know is suffering with adolescent substance abuse, please call us today for help! 707-812-7772 or Contact us.
From: Grand Rounds, (Vol.5, Jan-Mar): A Quarterly newsletter for the health care professional. Santa Clara County Department of Alcohol and Drug Services.