Treating substance abuse is difficult whether the patient is young or old. Although one might hope that the shorter period of abuse seen in teens would make the disorder less entrenched, the data shows otherwise: addiction is a stubborn disorder with a long term, relapsing, and remitting course (Simkin DR and Grenoble S, Child Adolesc Psychiatric Clin North Amer 2010;19(3):591–608). Treatment needs to address the complex needs of the adolescent patient: identification and treatment of comorbid psychiatric disorders, behavioral interventions, family and environmental supports, individual therapy, and at times, medication.
Adolescents with substance use disorders often struggle with skill deficits (eg, social, academic) that may need to be addressed, as well as other adversities. We need to remember to treat the whole patient, not just the substance abuse. Don’t forget to screen for common diseases associated with drug abuse, including hepatitis, HIV, and tuberculosis, and educate your patient on how to avoid the risky behaviors that lead to them.
We should monitor for drug use throughout treatment (urine screens, for example), but don’t get frustrated if the tests sometimes come out positive. Relapse is the rule for substance abuse treatment. Instead of the “detox-and-done” approach, plan on a long treatment course with frequent assessments and revisions of the overall treatment plan as the needs of the adolescent change. Use the adolescent’s need for autonomy and get the patient involved in planning contingencies for relapse and identifying treatment goals. Make small steps into victories, even if the adolescent is not voluntarily seeking treatment. Many people who abuse substances do not tolerate failure, so relapses (and “failures” of any kind) need to be reframed and normalized.
Medications have been helpful in adults and in what few studies of adolescents that have been done. If you think that a medication might help, the table “Medications for Substance Abuse in Adolescents” summarizes the available evidence.
Table 2: Medications for Substance Abuse in Adolescents
There are currently no drugs FDA-approved for treatment of marijuana dependence. There have been small pilot studies of buspirone (Buspar), divalproex (Depakote), the Parkinson’s disease drug entacapone (Comtan), gabapentin (Neurontin), mirtazapine (Remeron), and the oral tetrahydrocannabinol Dronabinol. A small randomized controlled trial showed benefit for N-acetylcysteine (Acetadote).
Medications for cocaine dependence have not been well-studied in adolescents. Amphetamine (Adderall), baclofen (Gablofen, Lioresal), desipramine (Norpramin), and methylphenidate (Ritalin, Concerta) have shown some success in treating adults with cocaine dependence.
Studies have been small and meta-analyses have not detected any effect of medications for smoking cessation in adolescents, however buproprion (Wellbutrin, Zyban); the nicotine replacements, Commit, NicoDerm CQ, Nicorelief, Nicorette, Nicotrol, and Thrive; and varenicline (Chantix) are FDA-approved for adults.