Narrative review: Revised Principles and Practice Recommendations for Adolescent Substance Use Treatment and Policy.

OBJECTIVE: In 2014, the U.S. National Institute on Drug Abuse released the "Principles of Adolescent Substance Use Disorder Treatment," summarizing previously established evidence and outlining principles of effective assessment, treatment, and aftercare for substance use disorders (SUD). Winters et al. (2018) updated these principles to be developmentally appropriate for adolescents. This review builds on that formative work and recommends updated adolescent assessment, treatment, and aftercare principles and practices. METHOD: The Cochrane, MEDLINE-PubMed, and PsychInfo databases were searched for relevant studies with new data about adolescent substance use services. This article updates the 13 original principles; condenses the 8 original modalities into 5 practices; and highlights implications for public policy approaches, future funding, and research. RESULTS: Key recommendations from the principles include integrating care for co-occurring mental health disorders and SUDs, improving service accessibility including through the educational system, maintaining engagement, and addressing tension between agencies when collaborating with other youth service systems. Updates to the treatment practices include adoption of Screening, Brief Intervention and Referral to Treatment (SBIRT), investment in social programs and family involvement in treatment, expanding access to behavioral therapies and medications, increasing funding to harm reduction services, supporting reimbursement for continuing care services, and increasing investment in research. CONCLUSION: These revised principles of adolescent assessment, treatment, and aftercare approaches and practices aim to establish guidance and evidence-based practices for treatment providers, while encouraging necessary support from policymakers and funding agencies to improve the standard of care for adolescent SUD services.

Legalization and retail availability of recreational marijuana and adolescent use in schools.

Legalization of use and retail sales of recreational marijuana in U.S. states and the associated potential increase in access to marijuana and normalization of its use by adults could lead to increased use by adolescents. Studies have found that states with legal recreational marijuana have higher rates of adolescent use and frequency of use compared to states without legal use. We examined changes in student office discipline referrals (ODRs) for substance use offenses in Oregon middle and high schools before and after the legalization of recreational marijuana relative to comparison schools in other states. We found that rates of substance use related ODRs in middle schools increased by 0.14 per 100 students (30% of the mean) with legalization relative to comparison schools. This increase was moderated by the presence of a marijuana outlet within one mile of the school. We found no statistically discernible changes in high school ODRs. Marijuana use in adolescence has been linked to negative health and social consequences, including academic problems, mental health issues, and impaired driving. Potential adverse impact on adolescents and investments in school-based prevention programs could be important considerations for policymakers and public health officials when evaluating marijuana legalization.

Brief Interventions for Cannabis Using Adolescents.

This article discusses the application of brief interventions to address adolescents with a cannabis use problem. Topics include a general model of brief interventions, the outcome literature, existing brief interventions that focus on youth cannabis use, adjustments to a brief intervention when addressing cannabis, referral to treatment issues, personalizing a brief intervention, the need to address coexisting problems, and future directions.

Brief Interventions for Cannabis Using Adolescents.

This article discusses the application of brief interventions to address adolescents with a cannabis use problem. Topics include a general model of brief interventions, the outcome literature, existing brief interventions that focus on youth cannabis use, adjustments to a brief intervention when addressing cannabis, referral to treatment issues, personalizing a brief intervention, the need to address coexisting problems, and future directions.

Testing mediational processes of substance use relapse among youth who participated in a mobile texting aftercare project.

BACKGROUND: The goal of this paper is to advance the understanding of mechanisms of action involved in behavioral-driven aftercare interventions for substance use disorders (SUDs) among youth populations. This paper reports data from a study that measured the impact of an aftercare intervention on primary substance use relapse among youth who completed treatment in Los Angeles County for SUDs. The aftercare intervention, Project ESQYIR-Educating and Supporting inQuisitive Youth In Recovery, utilized text messaging to monitor relapse and recovery processes, provide feedback, reminders, support, and education among youth from SUD specialty settings during the initial 3-month period following treatment completion.Method: Mediational modeling informed by Baron and Kenny was used to examine the extent to which select recovery processes including participation in extracurricular activities and self-help, were impacted by the texting intervention, and if such processes helped sustain recovery and prevent primary substance use relapse. The data come from a two-group randomized controlled pilot study testing the initial efficacy of a mobile health texting aftercare intervention among 80 youth (Mage= 20.7, SD = 3.5, range: 14-26 years) who volunteered to participate after completing SUD treatment between 2012 and 2013.Results: Among the two recovery processes examined in the mediational modeling, only involvement in extracurricular activities mediated the effects of the texting aftercare intervention on reductions in primary substance use relapse; not self-help participation.Conclusion: Findings from this pilot study offer greater understanding about potential recovery-related mechanisms of action of mobile aftercare interventions. Mobile texting was found to promote increased engagement in recovery-related behaviors such as participation in extracurricular activities, which mediated the effects of the mobile aftercare intervention on decreasing primary substance use relapse. Findings suggest mobile approaches may be effective for increasing adherence to a wide-array of recovery behavioral regiments among youth populations challenged by complex behavioral issues.

Correlates of Perceived Harmfulness of Regular Cannabis Use among Canadian University Students Before and After Legalization.

Objective: Among a prospective sample of Canadian university students, this study aimed to: 1) document changes in cannabis use and perceived harmfulness of use before and after the legalization of recreational cannabis; 2) examine correlates of perceived harmfulness; and 3) explore changes in perceived harmfulness as a function of cannabis use patterns. Method: A random sample of 871 students at one western Canadian university were assessed pre- and post-legalization of recreational cannabis. Descriptive and inferential statistics were used to explore changes in cannabis use and perceived harmfulness. A random effects model was developed to assess whether cannabis legalization was associated with perceptions of harmfulness of regular cannabis use. Results: Twenty-six percent of the sample used cannabis during the past three months at both timepoints. The majority of the sample perceived regular cannabis use as a high-risk behaviour at each timepoint (57.3% and 60.9%, respectively). Results from the random effects model showed that after controlling for covariates, cannabis legalization was not associated with changes in perceived harmfulness. Perceptions of harm remained relatively stable regardless of cannabis use pattern. Respondents who endorsed cannabis use at both timepoints reported a significant increase in their frequency of cannabis use post-legalization. Conclusions: Legalization of cannabis for recreational use was not associated with substantive changes in perceptions of harm among post-secondary students, yet it might lead to increases in cannabis use among those who already use the substance. Ongoing monitoring of policies is needed, as are targeted public health initiatives to identify post-secondary students who are at risk for cannabis-related consequences.

Interventions for cannabis use disorder.

How to treat adults and adolescents with a Cannabis Use Disorder is a burgeoning research area. This article reviews the empirical literature pertaining to several psychosocial approaches (cognitive-behavior therapy, motivational enhancement, and contingency management), all of which are associated with favorable outcomes. We also review the emerging research on the use of pharmacotherapy, brief interventions and technology-delivered interventions, and conclude with an overview of future research needs.

Where Do Gambling Problems Fit in the Structure of Psychopathology During Emerging Adulthood?

Research suggests major mental disorders co-occur at higher than chance levels. In adult samples, a two factor structure emerges when modeling the higher order structure of psychopathology. Specifically, disorders tend to co-aggregate into two dimensions: Internalizing (depression and anxiety) and Externalizing (acting out, impulsive, and addictive) disorders. Despite this large body of evidence, few studies have integrated problem gambling into this overall model. We used confirmatory factor analysis to model how the symptom count of gambling fits into the structure of psychopathology in a large, community based young adult twin sample of men and women (age 24; N=1329). Twins were assessed via in-person, structured diagnostic interviews on disorders including: Major Depression, Phobias, Post-Traumatic Stress Disorder and Anxiety Disorders (internalizing) and Substance Use Disorders, Gambling Problems (self-report), and Antisocial Behaviors (externalizing). The data were fit to a two-factor structure, with gambling symptoms loading most highly on externalizing, rather than internalizing. The problem gambling loadings did not differ by sex. Implications of these findings suggest that during emerging adulthood gambling problems are best classified and conceptualized in the realm of externalizing disorders for both males and females. Results also suggest prevention and intervention efforts be aimed at young adults who exhibit commonly co-occurring psychopathology.

Sweetening the pot: Exploring differences between frequent gamblers who do and do not gamble under the influence of cannabis.

The legalization of recreational cannabis for adults is becoming more common across the United States of America, as well as other counties around the world. Previous research has documented shared risk factors between cannabis use and gambling. Experimental studies have shown cognitive effects of cannabis that might influence gambling behavior. The current study explored demographics, gambling behaviors, and mental health differences based on the degree to which individuals use cannabis while they gamble. Individuals (N = 805) who gambled at least weekly completed an online survey. Thirty percent reported gambling under the influence of cannabis. Of these individuals, 41% reported using cannabis 25% of the time that they gambled, 31% reported being under the influence 50% of the time when gambling, 16% were under the influence 75% of the time when gambling, and 13% reported always or almost always gambling under the influence of cannabis. Those who reported gambling while under the influence of cannabis were more likely to be younger, non-white and non-heterosexual. They also reported higher levels of psychological distress, were more likely to have had a diagnosis of ADHD and a history of treatment for gambling, substance use, or other kinds of mental health concerns. Individuals who used cannabis while gambling also reported gambling more frequently than those who did not. This study provides one of the first explorations into who uses cannabis while gambling. Future experimental studies are required to investigate the direct effects of cannabis on gambling behaviors.

The correspondence of parent-reported measures of adolescent alcohol and cannabis use with adolescent-reported measures: A systematic review.

BACKGROUND: Valid assessment of adolescent substance use is important in both research and clinical applications. However, the optimal approach to assessing adolescent use remains controversial, particularly with regard to the use of parent-reported measures. Methods: Using a systematic review of existing literature, we sought to evaluate the utility of parent measures of adolescent alcohol and cannabis use by examining their correspondence with self-report measures. Furthermore, we investigated study-related variables that may be associated with differing levels of parent-child correspondence. Relevant articles were identified using a systematic search across multiple databases. Results: The review revealed generally poor agreement between parent and adolescent reports of alcohol and cannabis use. Parents consistently underestimated use and problems associated with use when compared with adolescents. Community-based (versus clinical) samples, reporting regarding alcohol (versus cannabis), and reporting problems associated with use (versus reports of use/nonuse) were each associated with lower levels of parent-child agreement. Conclusions: Recommendations for the optimal use of parent measures of adolescent substance use are provided.

Gambling and Cannabis Use: Clinical and Policy Implications.

Eleven US States and the District of Columbia legally allow personal (i.e., recreational) cannabis use by adults, and an additional 22 states allow use of cannabis for medicinal purposes. Of these jurisdictions, only two do not have some form of legalized gambling available (https://www.casino.org/local/guide/). In contrast to this rapid increase in legally available marijuana is the limited knowledge about the intersection of cannabis use and gambling. This paper strives to define the current status of the relevant literatures and consider the implication for future gambling research. We describe the research literature on the prevalence of cannabis use and co-existing gambling problems and the effects of cannabis use on gambling-related cognitive functions and decision-making. We also discuss clinical considerations with treating problem gamblers with a cannabis use disorder. Finally, the potential implications for responsible gambling practices and policies and the most pressing gaps in the research literature are offered.

Long-Term Outcome of a Brief Intervention to Address Adolescent Drug Abuse in a School Setting.

The present study used data from a randomized controlled trial on brief interventions with adolescents to identify distinct longitudinal patterns of substance use and identify predictors, as well as outcomes associated with those use patterns. Data were originally collected for the purpose of evaluating two brief intervention conditions with adolescents who had been identified in a school setting as abusing alcohol or other drugs (total sample, N = 315). Adolescents were randomly assigned to a two-session adolescent only brief intervention (BI-A), a two-session adolescent- plus an additional parent session (BI-AP), or an assessment only control session (CON). We located 74 participants to assess them at approximately 3.5 years post-intervention. Three distinct cluster patterns were identified, including a low decreasing, moderate increasing, and high decreasing pattern of use. The low decreasing cluster was associated with the BI-A condition, mono-substance use, and comorbid anxiety symptoms at baseline. The moderate increasing cluster was associated with the BI-AP condition, polysubstance use, and comorbid conduct disorder symptoms at baseline. No variables were found to be predictive of membership within the high decreasing cluster. There were also no differences found between clusters on adjustment outcomes in young adulthood. Overall findings from this study support the long-term efficacy of a brief intervention, without parent involvement, for adolescents experiencing mild to moderate substance abuse problems. Findings also highlight the importance of early intervention and the tailoring of interventions to meet the unique needs of adolescents.

Correlates of lifetime cannabis use and cannabis use severity in a Canadian university sample.

This study aimed to broaden previous investigations of correlates of lifetime cannabis use and problematic cannabis use among post-secondary students by examining the novel and contemporary issues of medicinal use and deep inhalation practices. The sample included 2212 undergraduate and graduate post-secondary students from Alberta, Canada, who completed the University of Calgary's Campus Experience with Cannabis Survey (average age 23.2, SD = 5.2). Nine variables were entered into the binary logistic regression to examine their differentiation of lifetime users from non-users. A multiple regression model was completed with past six-month users (n = 697), where the continuous dependent variable was cannabis use severity as measured by total scores on the Cannabis Use Disorder Identification Test-Revised. Twenty independent variables were entered simultaneously. Varsity athlete status, family mental illness, severity of alcohol use, greater support for legalization and lower perceived risk associated with regular cannabis use, differentiated lifetime users from non-users. Higher rates of religiosity and living with parents or relatives were associated with lower-lifetime rates. Male gender, earlier age of first cannabis use, cannabis use motives (including coping, enhancement and expansion), past six-month medicinal use and increased frequency of deep inhalation during consumption, were found to be significant correlates of severity. Different factors seem to predict lifetime cannabis use versus severity, and these differences may help inform the development and delivery of prevention efforts. Given that medicinal use and male gender were the largest correlates of severity, populations representing these groups may benefit most from targeted education and prevention.

Parents as interventionists: Addressing adolescent substance use.

Much research and attention has focused on addressing the extremes of the adolescent substance use spectrum: either the prevention of substance use prior to its onset or the treatment of those with a substance use disorder (SUD). Little research has looked at adolescents who fall mid-continuum. Adolescents who use substances in this mild-to-moderate range may be efficiently and cost-effectively treated using brief interventions based on cognitive-behavioral (CB) and motivational interviewing (MI) strategies. Accessibility and feasibility of providing interventions may also be enhanced by training parents in application of CB and MI principles. An innovative home-based brief intervention for parents whose children engaged in mild to moderate drug abuse was developed and evaluated using a quasi-experimental design. Participants were parents and their adolescent child from the 7-county metro area of Minneapolis-St. Paul, Minnesota. Decreased substance use and increased family cohesion were the predicted outcomes of the Home Base intervention. Results suggest decreased adolescent marijuana use frequency, decreased alcohol use disorder symptomology, and increased parental happiness with their adolescent child. Alcohol and tobacco use frequency were statistically unchanged. Baseline levels of drug use severity moderated the relation between intervention and outcomes. These findings support the potential utility of this approach and also indicate the need to further develop accessible and efficient interventions for mild to moderate SUD.

Cannabis Use for Medicinal Purposes among Canadian University Students.

OBJECTIVE: The study sought to describe a Canadian sample of university students' medicinal use of cannabis, including prevalence of cannabis use disorder (CUD) and replacement of traditional treatments with cannabis. METHOD: A random sample of 4000 university students was asked to complete a cross-sectional web-based survey. The survey was completed by 2212 (average age 23.2 years, SD = 5.2 years), representing a 55.3% response rate. To be eligible, students had to be enrolled in a class on campus and were 18 years or older. RESULT: Half (52%) of respondents used cannabis at least once in their lifetime, with ∼11% reporting medicinal cannabis use. Recreational motives to use cannabis were common among medicinal users (85%), several (38%) replaced traditional medication with cannabis, and more than a third received authorization by a health care provider. Of the medicinal users, 13.6% met the criteria for CUD. Common ailments for medicinal cannabis use were anxiety, sleep problems, depression, and pain. When mental health-related categories are combined, 78.2% of medicinal users used for at least 1 mental health condition. CONCLUSIONS: Medicinal cannabis use occurs among university students. None of the ailments listed by medicinal users meet the Canadian Family Physicians prescribing guidelines, and most are not among those viewed by the National Academies of Science, Engineering, and Medicine as having strong evidence for therapeutic value. The results raise concerns for health care providers who are authorizing or counselling patients' considering medicinal cannabis.

Genetic and environmental origins of gambling behaviors from ages 18 to 25: A longitudinal twin family study.

Gambling behaviors tend to increase in prevalence from late adolescence to young adulthood, and the underlying genetic and environmental influences during this period remain largely understudied. We examined the genetic and environmental influences on gambling behaviors contributing to stability and change from ages 18 to 25 in a longitudinal, behavioral genetic mixed-sex twin study design. Participants were enrolled in the Minnesota Twin Family Study. A range of gambling behaviors (maximum frequency, average frequency, money lost, and gambling problems) were assessed at ages 18 and 25. The results of our study support the following conclusions: (a) the genetic and environmental factors impacting a range of gambling behaviors are largely similar in men and women, (b) genetic factors increase in influence from 18 to 25 (21% at age 18 to 57% at age 25), (c) shared environmental factors are influential at age 18, but tend to decrease from ages 18 to 25 (55% at age 18 to 10% at age 25), and (d) nonshared environmental influences are similarly significant and are small to moderate in magnitude at both ages. The findings add to a small yet important research area regarding determinants of youth gambling behaviors and have the potential to inform prevention and intervention efforts. (PsycINFO Database Record

Frequent Use of Khat, an Amphetamine-Like Substance, as a Risk Factor for Poor Adherence and Lost to Follow-Up Among Patients New to HIV Care in Ethiopia.

Khat, a plant native to East Africa, has amphetamine-like psychoactive constituents, and is a potential risk factor for HIV infection. Chronic use can cause cognitive impairment and other mental disorders, raising concerns about effects on retention and adherence with HIV care. During 2013-2014, 322 Ethiopian patients newly enrolled at HIV clinics in Dire Dawa and Harar were surveyed about khat use and prospectively followed for 1 year; 9% died, 18% transferred care to other clinics, and 22% were lost to follow-up (LTFU) (no clinic visit for >3 months). Of 248 patients who received a 12-month follow-up survey, 37% used khat in the year after enrollment, with a median use of 60 h in a typical month. Those using khat ≥60 h/month (median among users) were more likely than others to be LTFU (31% vs. 16%, p = .014); those using khat ≥150 h/month (upper quartile) had 44% LTFU rates versus 16% for others (p = .002). Complete 3-day adherence (taking all doses) of antiretroviral therapy was reported by 77% of those using khat ≥60 h/month versus 95% of all others (p < .001), and 67% of those using khat ≥150 h/month versus 94% of others (p < .001). In two East African cities, where khat use is common, frequent use was a significant risk factor for higher 1-year LTFU and lower self-reported antiretroviral therapy adherence among people living with HIV entering HIV care. Where khat is widely utilized, interventions to promote either nonuse or reduced use are important as part of a comprehensive HIV care package and national HIV strategies.

Prevalence and factors associated with use of khat: a survey of patients entering HIV treatment programs in Ethiopia.

BACKGROUND: Khat, a plant native to East Africa, has psychoactive constituents similar to amphetamine. Chronic khat use can lead to psychological dependence with multiple physical and mental health harms, complicating clinical management of people living with HIV. In two Ethiopian cities where khat is common, we evaluated prevalence and correlates of khat use among patients new to HIV care. METHODS: During 2013-2014, we surveyed 322 patients recently enrolled in HIV clinics in Dire Dawa and Harar about khat use, demographics, smoking and alcohol use, clinical illness, food insecurity, and social support. We analyzed factors associated with khat use in the past year, as well as heaviest use of khat (based on greatest number of hours used in a typical month). RESULTS: 242 (75%) respondents reported lifetime khat use; 209 (65%) reported khat use during the previous year. 54% of khat users started before age 19 years. Although 84% believed that using khat every day is dangerous for health if you have HIV, khat was used in the previous year a median of 5 h/days and 30 days/month; 21% said they felt a need to cut down or control their khat use but had difficulty doing so. Those using khat were more likely to report smoking (46%) and alcohol use (49%) compared to non-khat users (1 and 31% respectively). Those reporting heaviest khat use (≥180 h/typical month) were more likely to rate their health status as poor, have an underweight BMI (≤18.5 kg/m2), report more symptoms of chronic illness, and agree with more statements indicating a negative physical quality of life. In multivariate analysis, heavy users were more likely to be male, Muslim, and non-married. CONCLUSIONS: Khat use was common among HIV patients entering care, and associated with symptoms of poorer physical health. Over half started khat use when they were young. Although most believed khat is harmful for HIV patients, a number of respondents reported some difficulty controlling their drug use. In settings where khat is legal and widely utilized, developing interventions for responsible use represent an important health priority as part of comprehensive care for people living with HIV.

Decision-making style and response to parental involvement in brief interventions for adolescent substance use.

Adolescent decision making has been previously identified as risk factor for substance abuse as well as a proximal intervention target. The study sought to extend this research by evaluating the role of decision-making style in response to parent involvement in brief substance abuse interventions. Adolescents (aged 12 to 18 years; n = 259) identified in a school setting as abusing alcohol and marijuana were randomly assigned to complete 1 of 2 brief interventions (BIs), either a 2-session adolescent-only program (BI-A) or the 2-session adolescent program with an additional parent session (BI-AP). Interventions were manualized and delivered in a school setting by trained counselors. Adolescent decision-making style was evaluated at intake, and alcohol and marijuana use were evaluated at intake and at a 6-month follow-up assessment. Supporting past research with these interventions, BI-AP demonstrated overall stronger outcomes for marijuana when compared with BI-A. Across both intervention models, an adaptive decision-making style (i.e., constructive, rational) assessed at intake predicted greater reductions in marijuana use. A significant moderation effect emerged for alcohol outcomes. Adolescents with maladaptive decision-making tendencies (i.e., impulsive/careless, avoidant) demonstrated the largest benefit from the parental involvement in BI-AP, whereas those with a less impulsive style derived little additional benefit from parental involvement in regard to alcohol use outcomes. Implications for the tailoring of brief interventions for adolescent substance abuse are discussed. (PsycINFO Database Record