Substance Use Disorders

Fast facts

• Many young people experiment with alcohol and substance use, and the majority will not go on to have long term difficulties.
• Alcohol (binge drinking) is the most common form of problematic substance use in New Zealand.
• Cannabis is the most common illicit substance used by New Zealand young people.
• Effective interventions include motivational approaches, CBT, and family and systemic therapies, with multi-modal interventions indicated for severe or longstanding difficulties.

Interventions that work – at a glance

This table represents a compilation of information from several different sources (Fonagy et al. (2015), The Matrix (2015), Matua Raki (2014), NICE (2007) and Dunnachie (2007) and is designed to provide an overview only. Directly consulting these sources will provide considerable additional information. The Evidence Based Interventions (EBI) page has more detail on these categories.

The fine print

1. Combined, brief CBT and motivational approaches (such as motivational interviewing) are more effective than when each is used alone (Fonagy et al., 2015). Many of these interventions take place in groups, and limited evidence suggests this is an effective mechanism, though results have been contradictory at times and concerns remain that the group setting may exacerbate difficulties, as young people may influence each other unhelpfully (Fonagy et al., 2015).
2. Family and/or systems approaches are effective (Bukstein et al., 2005) and can also be combined with brief CBT and motivational techniques (Fonagy et al., 2015; The Matrix, 2015). The goals of family approaches include providing psychoeducation, assisting the family to continue efforts to support the young person to engage with effective treatment, assisting parents to implement or re-establish consistent limit-setting behaviour and careful monitoring of the young person’s activities, and supporting effective communication within the family (Bukstein at al., 2005).
3. It is not known whether adolescent 12-step programmes are effective, as there are few studies, and the results have been unclear (Fonagy et al., 2015). 
4.  Interventions such as Multi-Systemic Therapy (MST), Multi-Dimensional Family Therapy (MDFT), Functional Family Therapy, or the Adolescent Community Reinforcement Approach (A-CRA): Each of these treatment programmes is effective (The Matrix, 2015), but more rigorous research is required, as is research into which (if any) of these programmes are more effective than others – existing research has explored their effectiveness with different groups of young people and in different settings, making comparison difficult (Fonagy et al., 2015).
5. While anti-craving medications may be safer to use than aldehyde dehydrogenase inhibitors for alcohol use disorders in adolescents, there is not enough evidence to recommend these as a standalone treatment for young people (Fonagy et al., 2015).
6. NICE guidelines recommend that a series of motivational interviews should to be offered by practitioners trained in motivational approaches (NICE, 2007).

Description and demographics

Many substances, when taken in excessive quantities, can result in harm or adverse outcomes. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) explains that the substance-related disorders include the following classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, and tobacco. The “use disorders” in DSM-5 (alcohol use disorder, cannabis use disorder, opioid use disorder, etc.) also include gambling, and potentially internet gaming disorder (Fonagy et al., 2015), but these difficulties are not the focus of this report. These “use disorders” are deemed to be mild, moderate or severe, according to how many of 11 particular criteria are met. The criteria include such things as cravings, time spent obtaining the substance or recovering from its use, impact on work or school roles, continuing to use despite social and interpersonal problems resulting from use, tolerance and withdrawal (American Psychiatric Association, 2013). Co-morbidity is a key issue, with ADHD, anxiety and mood disorders often occurring alongside substance use issues (Fonagy et al., 2015). Adult diagnostic criteria are broadly valid for children and adolescents, but levels of substance use that may be considered less severe in adults may actually be associated with serious developmental, academic or social consequences in children and adolescents (Fonagy et al., 2015). 

In terms of treatment, a distinction needs to be made between two groups of young people – those who experiment with substance use and develop difficulties, and the minority who are at high risk of chronic dependence on substances (Fonagy et al., 2015). The smaller group, who are at higher risk of longer-term difficulties, are likely to require ongoing therapeutic input, and assessment and support around coexisting mental health issues, which are more likely to be present (Fonagy et al., 2015). A large New Zealand study suggested that around 11% of high school students use substances at levels that are likely to cause current harm and longer term difficulties (Fleming et al., 2014). Around 20% of Māori students’ description of their substance use placed them in the same category, with Pacific students around 8%, and Asian students around 3% (Fleming et al., 2014). This study did not include young people who were in alternative education or not in education at all, and as such may underestimate the rate of problematic substance use (Fleming et al., 2014). In New Zealand, binge drinking is the most common form of problematic substance use (Fleming et al., 2014; Fergusson & Boden, 2011a). In terms of illicit substances, cannabis is the most common substance used by adolescents in New Zealand (Fergusson & Boden, 2011b). 

Treatment goals may include complete abstinence, controlled use, or harm reduction / minimisation (Matua Raki, 2014), with goals selected in partnership with young people and families.

Kaupapa Māori services have been developed in partnership in New Zealand (see report by Matua Raki, 2012), in order to deliver alcohol and drug intentions in a culturally sensitive and appropriate manner.

References

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association.
• Bukstein, O. G., & the Work Group on Quality Issues. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders. Journal of the American Academy of Child and Adolescent Psychiatry 44(6), 609–621.
• Dunnachie, B. (2007). Evidence-based Age-appropriate Interventions – A guide for child and adolescent mental health services (CAMHS). Auckland: The Werry Centre for Child and Adolescent Workforce Development.
• Fergusson D., & Boden, J. (2011a). Alcohol Use in Adolescence. In: P. Gluckman & H. Hayne (Eds.). Improving the Transition: Reducing Social and Psychological Morbidity During Adolescence. Office of the Prime Minister’s Science Advisory Committee, 257-271
• Fergusson D., & Boden, J. (2011b). Cannabis Use in Adolescence. In: P. Gluckman & H. Hayne (Eds.). Improving the Transition: Reducing Social and Psychological Morbidity During Adolescence. Office of the Prime Minister’s Science Advisory Committee, 257-271
• Fleming, T., Lee, A.C., Moselen, E., Clark, T.C., Dixon, R., & The Adolescent Health Research Group (2014). Problem substance use among New Zealand secondary school students: Findings from the Youth’12 national youth health and wellbeing survey. Auckland, New Zealand: The University of Auckland.
• Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What Works for Whom? A critical review of treatments for children and adolescents (2^nd Ed). New York: Guilford.
• The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.
• Matua Raki (2012). Maori and Addiction Treatment Services: A paper prepared for the national committee on addiction treatment. Wellington: Matua Raki.
• Matua Raki (2014). A Guide to the Addiction Treatment Sector in Aotearoa New Zealand. Wellington: Matua Raki.
• National Institute for Health and Care Excellence (NICE) (2007). Substance misuse interventions for vulnerable under 25s. NICE Public Health Guidance 4.
• The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.