Drug Abuse Treatment

Research Findings from September, 2004 Director's Report

This section lists selected summaries from NIDA funded research projects that investigate the child and adolescent drug abuse treatment. The summaries provided were selected from recent issues of the Director's Report to the National Advisory Council on Drug Abuse. For a more comprehensive listing of NIDA funded projects see the Director's Report.

Impact of Childhood Treatment of Anxiety on Later Drug Abuse

This study evaluated outcomes in 86 individuals who had received cognitive behavioral treatment for anxiety disorders in childhood an average of 7.4 years earlier. Based on diagnostic interviews, the authors conclude that a good number of the participants maintained gains in terms of reduced anxiety several years later. They also found that those who responded more positively to the initial treatment had less drug involvement, and fewer drug-related problems, than those who responded less positively. However, this is not a randomized trial, and it is not clear whether the treatment itself was related to the differences in outcome, or whether other characteristics rendered some children at risk for poor outcomes in both arenas. Thus, while this study suggests that treatment of childhood psychiatric conditions holds potential for reducing later drug abuse, further work is needed to confirm this finding. Kendall, P.C., Safford, S., Flannery-Schroeder, E, and Webb, A. Child Anxiety Treatment: Outcomes in Adolescence and Impact on Substance Use and Depression at 7.4-Year Follow-Up. Journal of Consulting and Clinical Psychology, 72, pp. 276-287, 2004.

Bupropion SR in Adolescents with Comorbid ADHD and Nicotine Dependence: A Pilot Study

Investigators at the Medical University of South Carolina conducted an open-label pilot study designed to examine the feasibility and preliminary tolerability of bupropion SR in adolescents with nicotine dependence. Sixteen adolescents were enrolled in the study. Eleven of the 16 participants also had comorbid ADHD. Two brief smoking cessation counseling sessions were also delivered. Over the course of treatment, a significant decrease in the average number of cigarettes smoked and carbon monoxide levels was found. There was no significant change in ADHD symptoms during the study. The investigators conclude that bupropion SR along with brief counseling may be safe and potentially efficacious for adolescents with nicotine dependence with and without ADHD. Smoking cessation trials in adolescents need to focus on strategies to increase retention for optimal effects. Upadhyaya, H.P., Brady, K.T. and Wang, W. J. Am. Acad. Child Adolesc. Psychiatry, 43(2), pp.199-205, 2004.

Treatment of Adolescent Smokers with the Nicotine Patch

This study examined the effects of the nicotine patch on craving and withdrawal symptoms, safety, and compliance among adolescents. The secondary goal was to conduct a preliminary investigation of the effectiveness of the nicotine patch in helping adolescents quit smoking. The study design was a double-blind, placebo-controlled, randomized trial of the nicotine patch. The intervention also provided intensive cognitive-behavioral therapy and a contingency-management procedure. Participants (n=100) attended 10 treatment visits over 13 weeks. Compared with the placebo patch group, the active nicotine patch group experienced a significantly lower craving score and overall withdrawal symptom score (p=.011 and p=.025, respectively), as well as a time trend toward lower scores (p<.001) in craving only. Moreover, the nicotine patch appeared safe for adolescents to use. No differences by treatment group were found in experiencing adverse events, except that the participants in the placebo patch group reported more headaches than those in the active nicotine patch group. As another measure of safety, the overall mean salivary cotinine levels were significantly lower at 1, 6, 8, and 10 weeks post quit (all p<.05) compared with baseline levels, although these results were confounded by dropouts. Additionally, a significant number of participants were compliant with using the nicotine patch daily. Finally, point prevalence (7-day and 30-day abstinence rates) and survival analysis of participant abstinence indicated no significant differences between treatment groups. The results of this study suggest that the nicotine patch is a promising medication and a larger clinical trial of the nicotine patch among adolescents is warranted. Hanson, K., Allen, S., Jensen, S. and Hatsukami, D. Treatment of Adolescent Smokers with the Nicotine Patch. Nicotine. Tob. Res., 5, pp. 515-526, 2003.

A Randomized Controlled Trial of Pemoline for Attention-Deficit/Hyperactivity Disorder in Substance-Abusing Adolescents

In adolescents with substance use disorder (SUD), comorbid attention-deficit/hyperactivity disorder (ADHD) is associated with greater severity of substance abuse, conduct problems, and worse treatment outcomes. Although many controlled trials have established the efficacy of psychostimulants, including pemoline, for ADHD in children and adolescents, none have been conducted in adolescents with SUD. This randomized, placebo-controlled trial, conducted between 1996 and 2000, evaluated the safety and efficacy of pemoline on substance abuse and conduct problems. Sixty-nine adolescents (aged 13-19) with conduct disorder (CD), SUD, and ADHD were recruited from the community and randomly assigned to a 12-week clinical trial of pemoline (n = 35) or placebo (n = 34), titrated over 4 weeks to a single morning dose of 75 to 112.5 mg as tolerated. Results showed that pemoline had greater efficacy than placebo for ADHD as determined by significantly more Clinician's Global Impression-Improvement (CGI-I) ratings of 1 (very much improved) or 2 (much improved) at the study endpoint (n = 69; p <.05). There was also greater reduction in ADHD severity on the parent-rated Conners Hyperactivity-Impulsivity scale in pemoline-treated study completers compared to placebo-treated completers (pemoline, n = 17; placebo, n = 16; p <.01), but no difference between groups in the intent-to-treat analysis (n = 68; p <.13). Substance use did not decline in either group, and there was no difference between groups in baseline to study endpoint change in substance use or CD symptoms. Overall, pemoline was well tolerated, demonstrating a good safety profile and no elevation in liver enzyme levels. The results suggest that pemoline was efficacious for ADHD but did not have an impact on CD or substance abuse in the absence of specific treatment for SUD. Riggs, P.D., Hall, S.K., Mikulich-Gilbertson, S.K., Lohman, M., and Kayser, A. A Randomized Controlled Trial of Pemoline for Attention-Deficit/Hyperactivity Disorder in Substance-abusing Adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 43, pp. 420-429, 2004.

Family-Based Therapy was Shown to be More Effective Than Peer-Group Therapy in Treating Urban Adolescent Substance Abuse

A randomized clinical trial evaluated a family-based therapy (Multidimensional Family Therapy, MDFT; Liddle 2002a) and a peer group therapy with 80 urban, low-income, and ethnically diverse young adolescents (11 to 15 years) referred for substance abuse and behavioral problems. Both treatments were outpatient, relatively brief, manual-guided, equal in intervention dose, and delivered by community drug treatment therapists. Results indicated that the family-based treatment (MDFT, an intervention that targets teen and parent functioning within and across multiple systems on a variety of risk and protective factors) was significantly more effective than peer group therapy in reducing risk and promoting protective processes in the individual, family, peer, and school domains, as well as in reducing substance use over the course of treatment. Liddle, H.A., Rowe, C.L., Dakof, G.A., Ungaro, R.A. and Henderson, C.E. Family-based Therapy was Shown to be More Effective than Peer-group Therapy in Treating Urban Adolescent Substance Abuse. Journal of Psychoactive Drugs, 36(1), pp. 49-63, 2004.

DSM-IV Criterion for Cannabis Tolerance is Limited as an Indicator of Dependence in Adolescents

The usefulness of the Diagnostic and Statistical Manual's (4th ed.; DSM-IV; American Psychiatric Association, 1994) tolerance criterion as an indicator of dependence has been debated. The authors of this study evaluated the performance of DSM's cannabis tolerance criterion, operationally defined as a percentage increase in quantity needed to get high, in distinguishing adolescents with and without cannabis dependence. Two samples of adolescent cannabis users (ages 12-19) provided data (ns = 417 and 380). Tolerance, defined as a percentage increase (median increase = 300% and 175%, respectively, in the samples), had only moderate overall sensitivity and specificity in distinguishing those with and without cannabis dependence. Results suggest limitations of the DSM-IV, and recommend a change-based operational definition of tolerance in adolescents. Chung, T., Martin, C.S., Winters, K.C., Cornelius, J.R., and Langenbucher, J.W. Limitations in the Assessment of DSM-IV Cannabis Tolerance as an Indicator of Dependence in Adolescents. Experimental Clinical Psychopharmacol, 12(2), pp. 136-146, 2004.

Medical Provider Referrals of Adolescents to Substance Abuse and Mental Health Treatment

This study examines the factors related to referrals of adolescents with substance use disorders to substance abuse or mental health treatment by their medical providers. Administrative and chart review data from the membership of a large private health maintenance organization (HMO) were collected from a probability sample of 400 adolescents, ages 13-18, who were diagnosed with a substance use disorder in 1999. Logistic regression analyses examined referral to substance abuse treatment and referral to mental health treatment in the aggregate and stratified by gender. Documented use of both alcohol and another illicit drug, and legal problems increased likelihood of referral to substance abuse and mental health treatment, whereas diagnoses of alcohol and marijuana use disorders decreased likelihood of referral to substance abuse treatment. Mental health diagnoses played a limited role in both types of referrals, although specific psychosocial problems were associated with increased likelihood of referrals. Treatment history and location of first mention of problem were significant predictors of referral. There were no gender differences in referral rates to either substance abuse or mental health treatment; however predictors of referral differed by gender. These findings extend our knowledge about factors that influence clinicians' treatment referrals of adolescents with substance abuse diagnoses and have implications for influencing clinician referral behavior within health plans. Scott, M., Parthasarathy, S., Kohn, C., Hinman, A., Sterling, S. and Weisner, C. Medical Provider Referrals of Adolescents to Substance Abuse and Mental Health Treatment. Ment Health Serv Res, 6(1), pp. 47-60, March 2004.

Elevated Post Treatment Relapse Rates Among Recovering Youth with ADHD

Researchers used a sample of 220 adolescent drug abusers in treatment to estimate the degree to which probable ADHD status increases the odds of post treatment alcohol, marijuana, and other drug relapse during the first 6 months following discharge. Drug abusing youth with probable ADHD status exhibited 2.5 times the risk of post treatment alcohol relapse when compared to youth without probable ADHD status, while controlling for demographics, pretreatment conduct-disordered behavior, pretreatment alcohol use frequency, and treatment factors. A significant crude association between probable ADHD status and other drug relapse was not maintained when adjusted for pretreatment conduct-disordered behavior, pretreatment other drug use frequency, or treatment factors. The findings suggest that standard treatment approaches that do not directly address comorbid disorders may result in elevated post treatment relapse rates among recovering youth with ADHD. Latimer, W.W., Ernst, J., Hennessey, J., Stinchfield, R.D. and Winters, K.C. Relapse Among Adolescent Drug Abusers Following Treatment: The Role of Probable ADHD Status. Journal of Child and Adolescent Substance Abuse, 13, pp. 1-16, 2004.