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but their judgment and decision-makingskills are still limited. This affects their abilityto weigh risks accurately and make sounddecisions, including decisions about usingdrugs. For these reasons, adolescents area major target for prevention messagespromoting healthy, drug-free behavior andgiving young people encouragement and skillsto avoid the temptations of experimenting withdrugs.3Most teens do not escalate from trying drugsto developing an addiction or other substanceuse disorder;* however, even experimentingwith drugs is a problem. Drug use can bepart of a pattern of risky behavior includingunsafe sex, driving while intoxicated, or otherhazardous, unsupervised activities. And incases when a teen does develop a pattern ofrepeated use, it can pose serious social andhealth risks, including: school failure problems with family and other relationships loss of interest in normal healthy activities impaired memory increased risk of contracting an infectiousdisease (like HIV or hepatitis C) via riskysexual behavior or sharing contaminatedinjection equipment mental health problems—includingsubstance use disorders of varying severity the very real risk of overdose deathHow drug use can progress to addiction.Different drugs affect the brain differently, buta common factor is that they all raise the levelof the chemical dopamine in brain circuits thatcontrol reward and pleasure.The brain is wired to encourage life-sustainingand healthy activities through the releaseof dopamine. Everyday rewards duringadolescence—such as hanging out withfriends, listening to music, playing sports,*Despite popular belief, willpower aloneis often insufficient to overcome anaddiction. Drug use has compromisedthe very parts of the brain that make itpossible to “say no.”and all the other highly motivating experiences forteenagers—cause the release of this chemical inmoderate amounts. This reinforces behaviors thatcontribute to learning, health, well-being, and thestrengthening of social bonds.Drugs, unfortunately, are able to hijack this process.The “high” produced by drugs represents a floodingof the brain’s reward circuits with much moredopamine than natural rewards generate. Thiscreates an especially strong drive to repeat theexperience. The immature brain, already strugglingwith balancing impulse and self-control, is morelikely to take drugs again without adequatelyconsidering the consequences.4 If the experienceis repeated, the brain reinforces the neural linksbetween pleasure and drug-taking, making theassociation stronger and stronger. Soon, takingthe drug may assume an importance in theadolescent’s life out of proportion to other rewards.The development of addiction is like a viciouscycle: Chronic drug use not only realigns a person’spriorities but also may alter key brain areasnecessary for judgment and self-control, furtherreducing the individual’s ability to control or stoptheir drug use. This is why, despite popular belief,willpower alone is often insufficient to overcomean addiction. Drug use has compromised the veryparts of the brain that make it possible to “say no.”Not all young people are equally at risk fordeveloping an addiction. Various factors includinginherited genetic predispositions and adverseexperiences in early life make trying drugs anddeveloping a substance use disorder more likely.Exposure to stress (such as emotional or physicalabuse) in childhood primes the brain to be sensitiveFor purposes of this guide, the term addiction refers to compulsive drug seeking and use that persists even in the face of devastating consequences;it may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, FifthEdition (DSM-5, 2013). The spectrum of substance use disorders in the DSM-5 includes the criteria for the DSM-4 diagnostic categories of abuse anddependence.4 Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Adolescents Differ from Adults in Substances Most Abused8018 – 257026 rijuana 1.712.43.018.38.61012.62017.1Percent of those who received past-year treatment12 – 17Hallucinogens InhalantsSource: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.to stress and seek relief from it throughoutlife; this greatly increases the likelihood ofsubsequent drug abuse and of starting drug useearly.5 In fact, certain traits that put a personat risk for drug use, such as being impulsiveor aggressive, manifest well before the firstepisode of drug use and may be addressedby prevention interventions during childhood.6By the same token, a range of factors, suchas parenting that is nurturing or a healthyschool environment, may encourage healthydevelopment and thereby lessen the risk of laterdrug use.Drug use at an early age is an importantpredictor of development of a substance usedisorder later. The majority of those who havea substance use disorder started using beforeage 18 and developed their disorder by age 20.7The likelihood of developing a substance usedisorder is greatest for those who begin use intheir early teens. For example, 15.2 percent ofpeople who start drinking by age 14 eventuallydevelop alcohol abuse or dependence (ascompared to just 2.1 percent of those who waituntil they are 21 or older),8 and 25 percent ofthose who begin abusing prescription drugs atage 13 or younger develop a substance usedisorder at some time in their lives.9 Tobacco,alcohol, and marijuana are the first addictivesubstances most people try. Data collectedin 2012 found that nearly 13 percent of thosewith a substance use disorder began usingmarijuana by the time they were 14.10When substance use disorders occur inadolescence, they affect key developmentaland social transitions, and they can interferewith normal brain maturation. These potentiallylifelong consequences make addressingadolescent drug use an urgent matter. Chronicmarijuana use in adolescence, for example, hasbeen shown to lead to a loss of IQ that is notrecovered even if the individual quits using inadulthood.11 Impaired memory or thinking abilityand other problems caused by drug use canderail a young person’s social and educationaldevelopment and hold him or her back in life.The serious health risks of drugs compoundthe need to get an adolescent who is abusingdrugs into treatment as quickly as possible.Also, adolescents who are abusing drugs arelikely to have other issues such as mental healthPrinciples of Adolescent Substance Use Disorder Treatment: A Research-Based Guide 5

problems accompanying and possibly contributingto their substance use, and these also need tobe addressed.12 Unfortunately, less than onethird of adolescents admitted to substance abusetreatment who have other mental health issuesreceive any care for their conditions.13Adolescents’ drug use and treatment needsdiffer from those of adults. Adolescents intreatment report abusing different substances thanadult patients do. For example, many more peopleaged 12–17 received treatment for marijuanause than for alcohol use in 2011 (65.5 percentversus 42.9 percent), whereas it was the reversefor adults (see figure, page 5). When adolescentsdo drink alcohol, they are more likely than adultsto binge drink (defined as five or more drinks in arow on a single occasion).14 Adolescents are lesslikely than adults to report withdrawal symptomswhen not using a drug, being unable to stopusing a drug, or continued use of a drug in spiteof physical or mental health problems; but theyare more likely than adults to report hiding theirsubstance use, getting complaints from othersabout their substance use, and continuing to usein spite of fights or legal trouble.substance use problems often feel they donot need help, engaging young patients intreatment often requires special skills andpatience.Many treatment approaches are available toaddress the unique needs of adolescents.The focus of this guide is on evidence-basedtreatment approaches―those that have beenscientifically tested and found to be effectivein the treatment of adolescent substanceabuse. Whether delivered in residential orinpatient settings or offered on an outpatientbasis, effective treatments for adolescentsprimarily consist of some form of behavioraltherapy. Addiction medications, while effectiveand widely prescribed for adults, are notgenerally approved by the U.S. Food andDrug Administration (FDA) for adolescents.However, preliminary evidence from controlledtrials suggest that some medications mayassist adolescents in achieving abstinence,so providers may view their young patients’needs on a case-by-case basis in developing apersonalized treatment plan.Adolescents also may be less likely than adultsto feel they need help or to seek treatment ontheir own. Given their shorter histories of usingdrugs (as well as parental protection), adolescentsmay have experienced relatively few adverseconsequences from their drug use; their incentiveto change or engage in treatment may correspondto the number of such consequences they haveexperienced.15 Also, adolescents may have moredifficulty than adults seeing their own behaviorpatterns (including causes and consequences oftheir actions) with enough detachment to tell theyneed help.Whatever a person’s age, treatment is not “onesize fits all.” It requires taking into account theneeds of the whole person—including his orher developmental stage and cognitive abilitiesand the influence of family, friends, and othersin the person’s life, as well as any additionalmental or physical health conditions. Suchissues should be addressed at the same timeas the substance use treatment. When treatingadolescents, clinicians must also be readyand able to manage complications related totheir young patients’ confidentiality and theirdependence on family members who may ormay not be supportive of recovery.Only 10 percent of 12- to 17-year-olds needingsubstance abuse treatment actually receive anyservices.16 When they do get treatment, it is oftenfor different reasons than adults. By far, the largestproportion of adolescents who receive treatmentare referred by the juvenile justice system (seefigure, page 7). Given that adolescents withSupporting Ongoing Recovery—SustainingTreatment Gains and Preventing RelapseEnlisting and engaging the adolescent intreatment is only part of a sometimes long andcomplex recovery process.17 Indeed, treatmentis often seen as part of a continuum of care.When an adolescent requires substance6 Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Number of Adolescents Aged 12–17 Admitted to Publicly FundedSubstance Abuse Treatment Facilities on an Average Day, by PrincipalSource of Referral: Treatment Episode Data Set 2008*2001841501006350460JuvenileJusticeSystemSelf ProvidersSource: 2008 SAMHSA Treatment Episode Data Set (TEDS)abuse treatment, follow-up care and recoverysupport (e.g., mutual-help groups like 12-stepprograms) may be important for helping teensstay off drugs and improving their quality of life.When substance use disorders are identifiedand treated in adolescence—especially if theyare mild or moderate—they frequently giveway to abstinence from drugs with no furtherproblems. Relapse is a possibility, however, asit is with other chronic diseases like diabetesor asthma. Relapse should not be seen as asign that treatment failed but as an occasionto engage in additional or different treatment.Averting and detecting relapse involves*18OtherHealthCareProfessionalsmonitoring by the adolescent, parents, andteachers, as well as follow-up by treatmentproviders. Although recovery support programsare not a substitute for formal evidence-basedtreatment, they may help some adolescentsmaintain a positive and productive drug-freelifestyle that promotes meaningful and beneficialrelationships and connections to family, peers,and the community both during treatment andafter treatment ends. Whatever services orprograms are used, an adolescent’s path torecovery will be strengthened by support fromfamily members, non-drug-using peers, theschool, and others in his or her life.“Treatment provi

during adolescence and young adulthood.‡ By the time they are seniors, almost 70 percent of high school students will have tried alcohol, half will have taken an illegal drug, nearly 40 percent will have smoked a cigarette, and more than 20 percent will have used a prescription drug for a nonmedical purpose.1 There are many reasons adolescents