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

Abstract

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 thirteen original principles; condenses the eight original modalities into five 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.

Introduction

An estimated 2.2 million, or 8.5% of U.S. adolescents aged 12-17 met criteria for a substance use disorder (SUD) in 2021.¹ The majority of adults who develop SUDs first use psychoactive substances during adolescence.^2,3 By the 12^th grade, nearly 1 in 3 (32.6%) adolescents report using substances in the past year.⁴ Substance use during adolescence is associated with increased risk of lower academic performance, development of mood disorders, social difficulties, and even illness and death.^5-7 Adolescent substance use is a risk factor for suicidality and has potential to cause overdose and death in this population.^8,9 Despite the elevated risk for long-term negative physical, mental health, and psychosocial outcomes,^6,7,10,11 few adolescents with SUDs receive specialty care.¹² In 2021, only 3.5% of adolescents reporting a illicit drug or alcohol use disorder in the past year received treatment,¹ due in part to the lack of resources and provider expertise to identify and address substance use in this population.^13,14

In 2014, the U.S. National Institute on Drug Abuse (NIDA) released the, “Principles of Adolescent Substance Use Disorder Treatment: A Research Based Guide,” which identified thirteen principles aligned with existing evidence for assessment, treatment, and continuing care services for SUDs.¹⁵ Winters et al. (2018)¹⁶ further expanded these principles with additional guidance for adolescents, including summaries of evidence-based practices for adolescents recommended in the previously mentioned NIDA publication. This publication was chosen for updating due to its focus on adolescents and its contributions to operationalizing the NIDA Principles of Substance Use Disorder Treatment. This review meaningfully builds on that formative work by Winters et al. by including newer research related to evidence-based principles and practices. We also offer (1) updated recommendations for public policy changes aligned with the extant research to optimize widespread dissemination and implementation of evidence-based practices into routine services for adolescents with SUDs,^17,18 and (2) research priorities to address gaps in the current evidence base.

Methods

We conducted a focused literature review that iteratively expanded on Winters et al. (2018)¹⁶ to identify the latest research pertaining to adolescent substance use services. In the process of this review, we created a detailed table outlining key articles that informed the revisions made within each “principle” or “practice” subsection. This rapid interpretive review process was more appropriate for our purposes than a full systematic review.¹⁹ We searched the Cochrane, MEDLINE-PubMed, and PsychInfo databases for relevant published studies that provided new information on adolescent substance use assessment, treatment, and/or aftercare services with an additional focus on updated implementation evaluation and outcomes associated with SUD-focused national initiatives since the 2018 paper. Studies had to be relevant to care provided in the United States for individuals ages 17 and younger. Please see Supplement 1 for details of the search strategies. Findings from the literature search were incorporated into updates of the 13 principles and five practices through group discussion among the authors, all of whom are experts in adolescent SUD service delivery and/or implementation.

Results

We present updates to the 13 identified treatment principles and five of the eight treatment practices presented in the prior review.⁸ For all principles and practices described in this review, harm reduction strategies and resources are an integral component of an effective approach. Harm reduction recognizes people have varied motivations for using substances, and may not desire or need abstinence to function well.²⁰ The goal of professional services should therefore be to promote healthy functioning and minimize harms from substance use if/when the adolescent engages in it. Such approaches promote better outcomes for youth with SUDs or at risk, especially when tailored to patterns of use, types of substances used, and other socio-behavioral norms in this age group.²¹ Furthermore, three treatment practices were not included as distinct practices in this review (12-Step, Therapeutic Community, and Electronic-based Strategies) because they were integrated within the other sections. For example, digital interventions for prevention, early intervention, and adolescent SUD treatments have been studied across various platforms including web, game, mobile, computer/tablet-based, and virtual reality forums.²²

Service Principles

The following revised principles (Table 1) highlight key pillars of assessment, treatment, and aftercare services for adolescent substance use. Principles are listed with the goal of providing recommendations for future research and funding opportunities to support implementation of effective interventions tailored to this population.

Table 1.

Adolescent Substance Use: Principles of Effective Care

Principle	Description	Policy Supports Needed	Updates from Original Review16
1. Identify and address substance use as young as possible	Identifying and addressing adolescent substance use as soon as possible is important due to the negative effects of exposure on development. Adults with SUDs often report using substances as adolescents or young adults.	Creation of developmentally appropriate and non-carceral substance use service systems in all states; integrated with education, mental health and primary care.	Discussion of the negative effects of early substance exposure on overall development. Newer approaches to screening.
2. Adolescents do not have to be addicted to benefit from a substance use intervention	Youth benefit from intervention at early stages of developing substance use problems. Consideration is needed for patterns of use more frequently observed in adolescents, such as binge-drinking and cannabis use, even when there is no diagnosed use disorder.	Invest in effective early intervention services, such as following up screening and assessment with brief intervention immediately when warranted. Do not require a formal SUD diagnosis for reimbursement.	Emphasis on potential benefits of brief intervention.
3. Substance use screening, comprehensive assessment, and treatment can be conducted across various settings	Schools (including remote learning), primary care offices, emergency room settings, and general mental health settings provide opportunities for screening and comprehensive assessment to determine if an adolescent is using substances and if intervention is warranted. SUD treatment can be delivered across settings including home and schools.	Investment in screening and comprehensive assessment to address substance use, development of scales that address confidentiality and disclosure of substance use results in minors; and dissemination and incentivization of screening and assessment in youth.	Outline of settings that provide additional screening opportunities and expanded possibilities for treatment delivery beyond medical visits.
4. Sensitive issues should be addressed and confidentiality maintained when possible	Maintaining confidentiality with respect to sensitive issues (e.g., substance use, mental health, trauma history) is important in the therapeutic setting. However, mandated reporting in cases of abuse/neglect or notification of acute safety issues to a caregiver is legally required. Confidentiality may be further compromised by procedures for consent or electronic care records.	Development and promotion of strategies for balancing adolescent confidentiality with family involvement; and investment in research to identify guidelines for confidentiality related to substance use and related behavioral issues.	Discussion of need for confidentiality in electronic health records, and issues with managing confidentiality and consent in screening and treating adolescent populations.
5. Treatment should be tailored to the adolescent’s needs	Many developmental factors need to be considered when creating a treatment plan for an adolescent including cognitive maturity, adolescent-specific challenges to recovery (e.g., peer, family and school issues), and inclusive services.	Invest in research to develop and implement guidelines for treatment levels of care and best practices that align with levels.	Developmental period and other adolescent-specific factors when creating treatment plans.
6. Treatment should not focus on just substance use	Treatment should incorporate other needs, such as co-occurring mental health disorders, housing, medical, social, and legal issues, as well as be provided through a lens of harm reduction without focus only on abstinence or sobriety.	Invest in research on treatments for co-occurring disorders and holistic programs that address psychosocial needs; support treatment focused on a harm reduction approach	Inclusion of harm reduction principles in the consideration of nontraditional treatment approaches.
7. Adolescents presenting with concerning substance use should be tested and treated for sexually transmitted infections (STIs) and hepatitis B and C and should be offered contraceptive resources and STI preventative care	Adolescent substance use increases risk for sexually transmitted and bloodborne diseases (e.g., human immunodeficiency virus, hepatitis B and C) and pregnancy. Treatment can help decrease high-risk behaviors thereby reducing the likelihood of infection and unintended pregnancies.	Clinics that serve adolescents need supports for STI screening and referral for appropriate treatment, as well as preventive care and contraception.	Principle focuses on testing for STIs , pregnancy, and other bloodborne diseases as part of reducing additional high risk behaviors for adolescents struggling with substance use.
8. Behavioral therapies are an essential part of SUD treatment	Substance use behaviors can be understood and treated using the same learning principles as any other human behavior. Behavioral therapies help build motivation to change by providing incentives for treatment goals, teach skills to address factors such as cravings or contextual antecedents, and identify positive and rewarding activities.	Support research examining dissemination and implementation of evidence-based therapies and evaluation of treatment sustainment and fidelity in routine care settings; financially support the adoption and use of evidence-based therapies in community treatment settings.	Less emphasis on abstinence and 12-Step-Based treatment for youth. Inclusion of contingency management.
9. Family and community support are important features of treatment	Most evidence-based services for adolescent substance use involve family members and individuals in the youth’s community. These services try to improve family communication and provide the adolescent with support.	Reorganize substance use services (and how they are funded) to make involvement of family and other supports central.	Update on necessary policy changes for provider reimbursement to offer family- and community-based services.
10. Mental health conditions need to be addressed to effectively treat substance use	Adolescents with a substance use disorder often have co-occurring mental health conditions. Simultaneous integration of treatment is crucial for successful outcomes.	Support elimination of siloes between mental health and substance use services. Consider integration requirements for access to federal and state funds. Evaluate current efforts underway to integrate behavioral health care to meet the needs of adolescents.	Identification of racial and ethnic disparities around access co-occurring disorder treatment. Emphasis on need for integration of services.
11. External pressures may influence an adolescent’s involvement in treatment	Most adolescents with an SUD do not think they need treatment and rarely seek services. The juvenile justice system has become a primary de facto system for engaging youth in substance use services, but early interventions that bypass justice involvement would have lower risks of harm.	Support lowering the age of consent for substance use services and make the services easily accessible, non-punitive, and confidential.	Greater emphasis on approaches to address barriers in accessibility and interfacing with the juvenile justice system. Greater emphasis on youth autonomy rather than pressuring them to engage in treatment.
12. Substance use should be monitored during treatment and inform adaptations made to treatment programming	It is important to monitor an adolescent’s substance use while in treatment and identify return to use early. The return to use could indicate that treatment should be intensified or altered to better meet the adolescent’s needs.	Support development and dissemination of pragmatic methods for monitoring treatment progress.	Focus on the need for continued development of adolescent progress monitoring tools.
13. Having a continuing care plan with ongoing recovery monitoring and support is important	Matching the duration of treatment with adolescents’ needs can help avoid unnecessary costs and repeat treatment episodes. Even those adolescents who do not complete treatment can benefit from ongoing continuing care monitoring and recovery support, and re-intervention if needed.	Permit reimbursement for continuing care and recovery support services; invest in research to further explore patient level of functioning matching to optimal monitoring and support duration.	Discussion around the barriers for continuing care monitoring.

Note: Adapted from: Winters et al., 2018¹⁵ and NIDA, 2014¹⁶. STI = Sexually transmitted infection; SUD= Substance use disorder.

Principle 1. Identify and address substance use as young as possible

Findings continue to strengthen the known association between younger age of substance use initiation and greater susceptibility to developing future SUDs.²³ Unfortunately, the use of standardized screening tools for identifying substance use problems in opportunistic settings such as pediatric, primary care, and school health, remains limited.²⁴ Despite the existence of well-researched and user-friendly screening tools,^25,26 a lack of provider confidence, time, and education to properly recognize and address substance use have been identified as significant barriers to the widespread dissemination of screening.^14,24 Screening for problematic substance use by non-medical professionals such as probation officers, coaches, teachers, and school counselors may reach a greater number individuals.²⁷ However, there are limitations to using non-clinical staff to conduct screening or low intensity interventions. Training on how to appropriately handle any safety concerns, mandated reporting issues, and when and how to involve family in discussions around risky behaviors would be necessary. Clear and practical decision guidelines for navigating challenging situations may mitigate some of these potential issues.

Investing in early intervention services including brief interventions in schools, health clinics and other settings may provide long-term health and cost benefits. A commonly cited challenge to adopting screening and brief intervention is lack of reimbursement, with primary care physicians requesting increased funds to provide these services.^14,28 Studies have demonstrated that the cost of screening and brief intervention is returned by decreasing inpatient treatment and emergency room visits costs in the adult population.^29,30 Newer digital technologies are also being developed to increase accessibility to prevention strategies and early intervention.²²

Principle 2. Adolescents do not have to be addicted to benefit from a substance use intervention

SUDs are defined on a continuum and adolescents with levels of use not yet meeting threshold for a use disorder can still benefit from intervention. A brief intervention, such as personalized feedback through a motivational interviewing (MI) framework, is endorsed by the American Academy of Pediatrics and continues to be an effective tool for reducing substance use-related problems in adolescents.^31,32 Early intervention approaches organized around the Screening, Brief Intervention, Referral to Treatment (SBIRT) model have demonstrated efficacy in improving substance use outcomes and is a vehicle for increased use of screening and behavior change strategies for youth who use substances.^33-35

More formal treatment such as psychotherapeutic and pharmacologic interventions may also benefit adolescents who are engaging in risky patterns of use with less perceived harm, often associated with occasional binge drinking or (increasingly) cannabis use, or who have a history of negative consequences such as opioid overdose, regardless of official diagnosis .^36-38 Insurance and healthcare organizations could benefit youth and families by offering appropriate and timely reimbursement for early intervention services in adolescents without requiring a formal SUD diagnosis.

Principle 3. Substance use screening, comprehensive assessment, and treatment can be conducted across various settings

Substance use screening, assessment, and treatment can be performed in a variety of settings including primary care and mental health offices, emergency rooms, schools, and other community-based programs. Providing such services in different environments offers early intervention opportunities.³³ Screening results suggestive of problematic use should be followed by a comprehensive assessment.³⁹ Treatment can also be delivered in non-clinical venues such as at home, school, or virtually, all of which can be a more comfortable experience for youth.^40-42 For example, contingency management based on academic performance has demonstrated promising results in school settings for adolescents in need of substance use treatment.⁴⁰

The establishment of substance use service systems that are developmentally appropriate and integrated within educational, mental health, and primary care services is necessary to identify and provide treatment to adolescents without necessitating involvement in the justice system. For those youth who may be engaged in heavier use or already experiencing an SUD, the juvenile justice system is often a main driver of engagement in formal addiction services.^43,44 Schools that deliver screening and brief interventions may not be reimbursed for these services,⁴⁵ creating a barrier to its widespread implementation in educational settings. Allowances for schools to receive reimbursement for screening and brief intervention services would incentivize educators to play an important role in early intervention. Research is also needed into the development of comprehensive assessment instruments that can be implemented across settings including telehealth, with sensitivity to confidentiality issues posed in each setting, so practitioners have the tools to address various patterns of substance use in this population.⁴⁶

Principle 4. Sensitive issues should be addressed and confidentiality maintained when possible

Maintaining confidentiality in the discussion of sensitive issues with adolescents such as substance use, mental health, or trauma, is critical in the therapeutic setting. Adolescents can consent for their own SUD-related care in many states and are protected by federal confidentiality laws.⁴⁷ Adolescents are also more likely to discuss their substance use history if caregivers are not a part of this conversation,⁴⁸ although many service providers have these discussions with parents present.⁴⁹ The rise of the electronic health record (EHR) has created other challenges to maintaining adolescent confidentiality as caregivers may have access to this information if not properly charted or restricted from their view.⁴⁷

The development and dissemination of best practices for involving family members in services while also maintaining autonomy of the adolescent to promote self-disclosure is needed for favorable outcomes. Future research into guidelines for addressing confidentiality, particularly how to handle non-mandated-reporting health behaviors and topics that may be necessary to disclose to parents, will help providers make educated decisions about disclosing substance use.

Principle 5. Treatment should be tailored to the adolescent’s needs

Substance use treatment should be personalized to fit the needs of this age group. Developmental considerations for tailoring treatment to adolescents compared to adults need to include the following at a minimum: (1) tailoring treatment goals sensitive to the adolescent’s cognitive maturity, which trend towards concrete thinking due to still-developing abstract thinking abilities;⁵⁰ (2) addressing school–specific challenges to maintaining recovery such as academic difficulties or social environments that encourage substance use; (3) addressing parent and sibling issues; and (4) providing skills to deal with peer influences. The importance of making treatment developmentally appropriate should not be over-shadowed by the unfortunate reality that too few substance use programs provide services tailored to adolescents.¹³ For example, it is estimated that in 2020, only 23.8% of treatment programs report providing adolescent-specific programming.¹³

When specialty services are accessed, there are still disparities in the delivery of evidence-based treatment.⁵¹ For example, the use of medication for opioid use disorder in adolescents is minimal despite endorsement by medical societies.^51-53 Research on pharmacotherapy for the treatment of other substances such as alcohol, cannabis, and nicotine use is also limited in the adolescent population.⁵⁴ Policy supports are needed to fill nationwide gaps in adolescent-specific treatment and provide inclusive and culturally sensitive care.⁵⁵ Additional research is necessary to create appropriate treatment guidelines for levels of care. For example, the American Society of Addiction Medicine (ASAM) criteria’s multidimensional assessment for levels of addiction care are not well understood when applied to adolescents.^56,57 There is also a need to train additional providers to reduce stigma and use medications for addiction treatment in this population.^58,59

Principle 6. Treatment should not focus on just substance use

Adolescents with SUDs often have psychosocial challenges including higher rates of school attrition, unstable housing, neighborhood disadvantage, and poverty.⁶⁰ Legal issues are common in individuals with SUDs,⁴³ and vulnerabilities such as unstable housing increase the risk of future substance use-related problems in adolescents more than their adult counterparts.⁶¹ Comprehensive assessment of social determinants of health should be incorporated into SUD care. Access to supports to address these factors are a necessary component of treatment.

Providing supports for harm reduction training and materials are also needed to minimize negative consequences of substance use given that an adolescent may not desire or need to become entirely abstinent from substance use to function well.²⁰ To date, little is known about the prevalence of adolescent treatment programs using harm reduction approaches or abstinence-based treatment programs acknowledging realistic harm reduction goals for their clients.

Principle 7. Adolescents presenting with concerning substance use should be tested and treated for sexually transmitted infections (STIs) and hepatitis B and C and offered contraceptive resources and STI preventative care

There is a strong association between substance use and high-risk sexual behaviors such as multiple sex partners and unsafe sexual activities.^62-64 Substance use among justice-involved youth is related to HIV risk behaviors including unreliable condom use, increased number sex partners, and increased probability of contracting sexually transmitted infections (STIs).⁶⁵ Adolescents who use intravenous drugs require screening for other bloodborne pathogens including hepatitis B and C.⁶⁶ Substance use is also associated with unintended pregnancies, suboptimal pregnancy care, and negative fetal consequences.^67,68 Adolescents who screen positive for substance use must be provided STI and bloodborne infection screening/treatment and contraceptive resources or referrals.^67,68

Adolescents who use substances often do not receive appropriate access to contraceptive resources and STI preventative care such as Pap tests or human papillomavirus vaccines.⁶⁷ Provider-level barriers such as lack of training in sexual health services and patient-level barriers such as intimate partner violence and competing priorities, reduce access to and engagement in sexual health services.^67,69 SUD service environments need to be equipped to properly screen patients and provide appropriate resources or referrals for addressing STIs and contraceptive guidance. Regulatory policies should require that such services be available for all adolescent patients.

Principle 8. Behavioral therapies are an essential part of SUD treatment

Cognitive behavioral therapy (CBT) alone or in combination with motivational enhancement therapy (MET) and contingency management (CM) have strong supporting evidence for treating substance use in adolescents.^70,71 Culturally accommodated CBT programs have shown promising results in SUD treatment for youth.⁷¹ CBT plus motivation-based therapies have also demonstrated notable utility in adolescents with co-occurring disorders.^72,73 CM uses operant conditioning to modify behavior and is an effective supplement to CBT, MET, and family-based therapies as treatment for SUDs in adolescents.⁷¹

Further attention by leaders in the field is needed to increase dissemination and implementation of effective behavioral therapies into community treatment settings. Federal and state investment into the adoption and use of in-person and virtual behavioral interventions would be a strong investment to improve quality of care in community-based treatment settings.^22,74-77 Current research is being conducted to determine effective implementation strategies of evidence-based SUD treatment into community settings for adolescents.^74,78

Principle 9. Family and community support are important features of treatment

Family, peer, and community supports are a critical part of SUD treatment and aftercare. The family plays a central role in adolescent development and many protective and risk factors for substance use involve familial relations.⁷⁹ Adolescents are at greater risk of developing SUDs or misusing substances when there is peer pressure or peers who use, respectively.^80,81 Community-based recovery organizations with peer-based recovery support services are effective aids for substance use in the adult population that could be a useful service modality for adolescents. ⁸²

Family and other support systems need to play a central role in services and should be adequately reflected in federal funding. Enhanced reimbursement for evidence-based family services and creation of billing codes that incentivize family involvement would make these treatments more accessible in all age groups.^83,84 Policy-level interventions have the ability to reform SUD treatment programs to prioritize family and community level outcomes.⁸³ Programs would also benefit from the development of guidelines that outline and promote the use of family screening, family self-referral, and integrating family member self-care mechanisms into recovery support.⁸⁴

Principle 10. Mental health conditions need to be addressed to effectively treat substance use

Adolescents presenting for SUD treatment often have high rates of mental disorders.⁸⁵ Those with co-occurring disorders have unique treatment needs that may diverge from those who have SUD diagnoses alone.^86,87 The presence of co-occurring disorders is associated with high risk sexual behaviors, more frequent substance use, and suicide attempts in the adolescent population.^88-90 Treatment for co-occurring disorders is associated with better substance use outcomes compared to when treatment focuses only on substance use,⁹¹ yet most adolescents with a major depressive episode and SUD receive treatment for only one conditions.¹ Minority racial and ethnic groups with co-occurring disorders also receive treatment at a lower prevalence than White individuals regardless of age.^92,93 Service systems need to invest in the development of comprehensive programs that assess and provide treatment for co-occurring disorders and address psychosocial needs driven by social and non-social (e.g., biological) influencers on health.⁹⁴ An estimated 44.6% of facilities that offer substance use treatment do not have services tailored to those with co-occurring mental disorders ¹³

Treatment integration for co-occurring mental disorders and SUDs requires federal and state supports to remove separations between related service systems, create and enforce treatment integration requirements, and assess the progress of existing integrated services. The simultaneous treatment of co-occurring conditions is recommended,⁹⁵ yet many adolescents do not receive integrated care.^1,93 State and local policies need to be revised to eliminate obstacles to treatment access for individuals with co-occurring disorders.⁹⁶ The shift in some education programs to train service providers in integrated behavioral health is a step in the right direction, but this trend is not the norm in programs training front-line counselors. Unfortunately, the number of providers trained to treat adolescent SUDs is limited. For example, adolescent SUD treatment falls at the intersection of two subspecialties in psychiatry, and there are very few providers that have training in both areas. More addictions training in child psychiatry and allied fields (e.g., clinical psychology, social work, family medicine) is needed to expand access to specialized services tailored to the unique needs and challenges of this population ⁹⁷ Also, support and funding are also necessary to aid in the progress evaluation of integrated treatment services. Increased funding for programs for trainees that incorporate incentives such as loan forgiveness may also encourage further training in subspeciality areas.

Principle 11. External pressures may positively influence an adolescent’s involvement in treatment

An estimated 98.6% of adolescents with an untreated SUD felt they did not need substance use treatment based on a recent national survey.¹ This lack of perceived need for treatment presents a barrier to seeking care in this population. Nearly 80% of adolescents sentenced for a drug offense have an SUD,⁹⁸ at which point legal and/or family pressure can be leveraged to encourage treatment participation. However, consistent with Principles 1 and 2, earlier intervention is preferable and can facilitate the role of trusted adults to encourage the adolescent to seek treatment.

Prompt identification of SUDs with efficient entry into treatment may be impacted by the state variability that exists in age of consent and privacy protection for substance use treatment in the adolescent population.⁹⁹ Lowered age of consent to care may be helpful across all settings, and particularly in school-based programs where many youth who do not self-identify with an SUD want to speak with a counselor. School-based counselors can screen or assess for SUD issues and respond with confidential SUD counseling if the youth is at least 12.¹⁰⁰ Past research has identified some school programs reporting reductions in gender disparities among youths accessing services when compared to community specialty clinics that are typically skewed towards male patients.¹⁰⁰ The value of establishing universal confidentiality and an appropriate age for adolescents to consent for substance use treatment is worthy of federal legislative debate and inquiry, as current differences among states may be impinging on access by youth to needed resources or on professionals’ ability to collaborate (e.g., when age of consent differs for SUD vs. mental health care).

Principle 12. Substance use should be monitored during treatment and inform adaptations made to treatment programming

Treatment programs need to include mechanisms to monitor how well evidence-based practices are implemented, the frequency with which adolescents attend sessions, and the frequency of adolescents’ substance use. It is important to know whether or not services are delivered with fidelity and adherence to the model in order to provide high quality care in a way that has been tied to positive outcomes through research. Equally important is the need to determine if adolescents are responding to services by tracking attendance and substance use patterns.¹⁰¹ Treatment providers must individualize and adapt treatment plans based on this information to deliver services that match the severity of substance use symptoms, including content, in-person or remote settings, and duration of care.^101,102

Commonly used substance use monitoring instruments for adolescents such as the Timeline Followback,^103,104 Teen Addiction Severity Index,¹⁰⁵ and Comprehensive Adolescent Severity Inventory,¹⁰⁶ can be used in conjunction with urine drug screening. Drug testing can be valuable as a means to monitor for medication adherence,¹⁰⁷ evaluate for substance use in real time, and as a component of the CM treatment approach. However, care must be taken to use the results for therapeutic purposes only (e.g., they should not be shared with juvenile justice system representatives except by informed consent of the adolescent). Support for research regarding the implementation of adolescent progress monitoring tools is needed to identify the minimum necessary frequency and duration of use to balance feasibility with effectiveness. Despite their effectiveness in this population, additional support for widespread distribution of adolescent progress monitoring tools and protocols is needed.

Principle 13. Having a continuing care plan with ongoing recovery monitoring and support is important

Although the need for continuing care monitoring, recovery support, and early re-intervention is widely recognized, factors such as stigma and lack of research funding work against well-accepted continuing care protocols for SUD.¹⁰⁸ Research indicates that adolescents who do not complete the recommended course of services typically return to substance use soon after discharge. However, continuing care monitoring, support, and re-intervention has demonstrated effectiveness for youth regardless of treatment completion status.¹⁰⁹

Further funding is needed to investigate ideal care continuation planning for adolescents regardless of discharge status. For example, the adolescent ASAM criteria can benefit from rigorous testing to establish its value as a level of care system in adolescents. More detailed guidance is needed to adapt the intensity and duration of treatment and link adolescents to ongoing recovery support after any discharge status from acute care. This may help to avoid unnecessary costs, repeat treatment episodes, and increase responsiveness to a patient’s current SUD status and needs.¹⁰¹ Unlike disease management interventions in healthcare, provider reimbursement for SUD continuing care services, including peer recovery support, is almost nonexistent. Federal and state leadership is needed to implement provider reimbursement plans that incentivize continuing care services for adolescents with less symptomatic to severe SUDs and to support evidence-based models as they are developed and tested.

Evidence-Based Practices

The following revised practices for adolescent substance use services (Table 2) demonstrate the utility of evidence-based assessment, treatment, and continuing care approaches and strategies with the goal of establishing best practices for providers and service systems working with adolescents who use substances.

Table 2.

Adolescent Substance Use: Evidence Based Practices

Practices	Description	Updates from Original Review16
1. Motivational Interviewing + Screening, Brief Intervention and Referral to Treatment (SBIRT)	Motivational interviewing (MI) uses a person-centered, nonconfrontational style in assisting youth in exploration of different facets of their use patterns. SBIRT is a packaged intervention which identifies substance use and encourages treatment for those who meet criteria. Brief intervention often consists of educational services that aim to help the adolescent recognize the negative consequences of substance use.	Inclusion of SBIRT.
2. Family-based Services	Family-based approaches seek to reduce an adolescent’s use of substances and promote healthy family functioning by addressing the mediating family risk factors, such as poor family communication.	Update on evidence for effectiveness and determinants of implementation (including reimbursement).
3. Behavior Therapies: Cognitive Behavior Therapy, Contingency Management	Cognitive-behavioral therapy encourages adolescents to develop self-regulation and coping skills by teaching youth to identify stimulus cues that precede substance use, to use various strategies to avoid situations that may trigger the desire to use, and to develop skills for communication and problem-solving. Contingency management is based on operant conditioning and utilizes rewards to reinforce desirable behaviors such as treatment attendance or use reduction.	Combined behavior and cognitive-behavior into a single practice; explicit inclusion of contingency management.
4. Pharmacotherapy	This treatment approach uses medication to address various aspects of addiction, including craving reduction, abstinence-promotion, relapse prevention, and withdrawal symptom management. Buprenorphine is the only FDA approved medication to treat a substance use disorder in adolescents. Harm reduction resources such as naloxone and fentanyl test strips can be used to reduce the risk of overdose.	Emphasis on MOUD, naloxone and other harm reduction practices.
5. Continuing Care and Recovery Monitoring, Support, and Re-intervention	Encourage the use of ongoing coordination of treatment and recovery needs. Support the use of mutual support groups, peer specialists, sponsorship, clubhouse communities, and recovery schools.	Addition as a new Practice that was not discussed in Winters et al. (2018)16
Updates across all practices	N/A	Integrated three practices (12-Step, Therapeutic Community, Electronic and web-based) throughout the other practices, rather than listing separately.

Note: Adapted from: Winters et al., 2018¹⁵ and NIDA, 2014¹⁶ , Electronic and web-based therapy was removed from Winters et al., 2018¹⁵ as these therapies can be integrated with any of the evidence-based practices described above. Note: FDA= Food and Drug Administration; MI= Motivational interviewing; SBIRT= Screening, brief intervention, referral to treatment.

Practice 1. Motivational Interviewing + Screening, Brief Intervention and Referral to Treatment

Motivational Interviewing (MI) can be delivered as a combined intervention or as stand-alone components. SBIRT often using MI as its core counseling approach, has demonstrated potential to reach much of the adolescent population as it can be used in a multitude of settings.^33,110 The promotion of SBIRT has increased the use of screening, validated tools, and preventative messaging in mental health and primary care environments.³³ MI as a standalone intervention has demonstrated significant improvement in adolescent substance use outcomes.^110,111 Significant effect sizes observed post-treatment indicate MI retains effectiveness over a variety of time periods.¹¹¹ MI has also shown success with different substance use behaviors, delivery settings, and session lengths.¹¹¹ Brief intervention consists of personalized feedback aimed to create deeper understanding of the negative consequences associated with substance use and increase motivation for change. The inclusion of brief intervention strategies have been shown to improve mental health and substance use outcomes in adolescents.^113,114

Barriers to widespread implementation of MI and SBIRT remain despite a growing evidence base. Treatment providers have reported challenges including a limited time with patients, issues with confidentiality, limited knowledge of substance use screening and treatment, and reimbursement concerns.^115-117 Investments in effective implementation strategies to boost the adoption of MI are needed in settings specific to adolescents.

Practice 2. Family-based Services

As discussed in Principle 9, active involvement of family in SUD services contributes to improved outcomes.⁸⁴ Family-based therapies have a strong-evidence base and are used to target risk factors associated with substance use.¹¹⁸ Evidence-based strategies within family-based therapies often include behavioral management, parental monitoring, promotion of close and nurturing familial relationships, stress management, and encouraging self-regulation.¹¹⁹

Despite a vast literature showing that family-based services produce favorable results on adolescent substance use,¹²⁰ there are a number of barriers to widespread implementation. Reimbursement would incentivize systems to screen families and involve peer family advocates to increase engagement in care. Better systems are needed that use clinical family assessments, involve family in the delivery of intervention techniques and recovery management strategies in remote and clinic-based settings, and encourage self-care for family members who are struggling with substance use.⁸⁴ Finally, treating adolescent SUDs presents a challenge because clinicians often must navigate differences between youth and their caregivers regarding their motivations for treatment and desired outcomes. Promoting within-family alignment and shared goals requires specialized training, as described under Principle 10.

Practice 3. Behavior Therapies: Cognitive Behavioral Therapy, Contingency Management

Cognitive behavioral therapy (CBT) centers on encouraging adolescents to develop self-regulation, coping skills, communication, and problem-solving. Previous research has identified CBT as one of the most successful treatment strategies in reducing adolescent substance use and improving outcomes.^{70,71,120,121} CM, which is based on operant conditioning, uses reinforcers to promote and increase desirable behaviors such as treatment attendance or reduction of use. The approach pre-specifies desired and functionally effective behaviors, monitors the behaviors through a planned schedule, and reinforces the desired behaviors through incentives.^77,122 CM has also demonstrated favorable outcomes in treatment by reducing substance use and enhancing treatment retention.^77,122 CM is simple to teach, affordable, and can be easily integrated with other practices.⁷⁷

Programs need additional support to provide consistent and accessible behavioral interventions that are culturally sensitive. Programs should also have separate evaluation outcomes that reflect the population served, not only focusing on substance use reduction, but also functional outcomes such as school attendance and community engagement. Federal supports are needed for CM implementation into adolescent substance use treatment, similar to their adult counterparts.¹²³

Practice 4. Pharmacotherapy

Pharmacotherapy for addiction uses medication to address aspects of substance use such as craving reduction and treatment of underlying psychiatric disorders. The only addiction medication with pediatric approval by the United States Food and Drug Administration (FDA) is buprenorphine, which is approved for the treatment of opioid use disorder in individuals aged 16 and older.¹²⁴ The majority of medications for alcohol and nicotine use disorders are prescribed off-label,⁵⁴ although this is broadly true in pediatric medicine and not unique to adolescent substance use treatment.¹²⁵

Increased funding for pharmacologic research focused on adolescent substance use and FDA approvals for young populations is crucial. Support for implementation, dissemination, and training pertaining to medications like buprenorphine and other future FDA-approved treatments for adolescents is needed. Training of primary care clinicians is also necessary to effectively utilize medication for addiction treatment, including expanding virtual treatment options for adolescents with SUDs.⁴¹

Practice 5. Continuing Care and Recovery Monitoring, Support, and Re-intervention

Assertive approaches to increasing linkage to continuing care, providing ongoing support to engage in prosocial activities and relationships, and rapid initiation of services post-discharge makes a difference in preventing return to use and reducing substance use harm.^126-128 While there is greater research regarding adult involvement in mutual support groups (i.e. 12-Step), data for adolescents is encouraging. Attendance has been associated with lower rates of substance use, higher amounts of recovery capital, and reduced medical costs.¹²⁹ However, caution is warranted when referring adolescents to these groups because adolescent-focused meetings are rare and meetings populated by older adults may or may not be equally welcoming, safe, and supportive of youth. In addition, not all 12-Step concepts align with youth beliefs (e.g., accepting the need for lifelong abstinence). Other services such as recovery coaches, residences, schools, and social clubs are growing and can both support and facilitate recovery, but are less studied in this population.

Strategies such as the use of motivational incentives and automated mobile health interventions support continuous assessment to ensure patients receive adequate recovery support as their needs change over time. More rigorous research is needed on all models addressing adolescent populations. Such models include dissemination research, implementation research, and cost-effectiveness research of rapid initiation and sustained continuing care for youth transitioning from controlled environments (e.g., childcare institutions; juvenile justice detention or incarceration) to the community. Increased funding for harm reduction services will be crucial to make these resources continuously available to adolescents.

Summary

Successful management of adolescent substance use is grounded in the early identification of substance use problems and initiation of treatment to improve long-term outcomes. This article highlights the need for identifying and treating substance use as young as possible; not limiting interventions to adolescents with a current diagnosable SUD; conducting evidence-based screenings, assessments, and treatment across a wide variety of in-person and virtual settings to improve service accessibility and engagement; and recognizing the tension between benefits and risks of collaborating with other youth systems (e.g., juvenile justice, schools). There is a need for enhanced strategies to deliver effective and developmentally appropriate treatment that addresses co-occurring mental health disorders, understands the influence of legal or family pressure on treatment involvement, monitors substance use during care, and establishes continuing care plans.

Similar to the original Winters et al.,¹⁶ behavioral therapies as well as family and community supports are still essential components of adolescent SUD services. Additional state and federal funding for harm reduction services, social programs, screening, research, and other organizations working to increase access to resources for adolescents is crucial. Dissemination and implementation science offers strategies to support provider, policy, and system changes needed to increase availability of evidence-based practices for adolescents. It also highlights the need to adapt and evaluate the fit and effectiveness of each practice within local contexts to ensure culturally responsive care. Limitations of this review include potential for bias due to the manual selection process of articles to include, as well as reliance on a limited number of databases to select publications.

Needs and directions for future research include the establishment of adolescent-specific service systems outside of the justice system, development of comprehensive assessment instruments, guidelines for addressing complex confidentiality issues, implementation of progress monitoring tools, adaptive continuing care approaches, research on effective medications to treat substance use in adolescents, and investigation of recovery supports specific to adolescent groups. The use of remote, virtual interventions, and the role of self-directed web apps are emerging practices and strategies that merit research attention. Furthermore, we recommend the NIDA principles of substance use treatment should be separately updated or expanded for adults and transitional age youth,¹⁵ to highlight developmental differences and promote consistent but tailored application of principles across the lifespan.

These revised principles and practices recommend current best approaches for service providers and systems, while highlighting aspects of the standard of care for adolescents with SUDs. Evidence-based assessment, treatment, and continuing care practices are essential components of care to reduce the negative outcomes associated with substance use in youth.

Table 3.

Summary of Key Contributing Articles

Associated Principles and Practicesa	Year	Article Type	Objectives	Main Outcomes	First Author, Reference
Principle 1. Identify and address substance use as young as possible	2023	Narrative Review	Summarize digital interventions for adolescent substance use.	Urgent need for additional digital interventions that focus on prevention and harm reduction in youth.	Monarque22
Principle 2. Adolescents do not have to be addicted to benefit from a substance use intervention	2023	Narrative Review	Update on SBIRT and management of cannabis use in youth.	SBIRT can be used in multiple settings. Brief intervention has modest, short-term effects on cannabis use in youth.	Calihan130
Principle 3. Substance use screening, comprehensive assessment, and treatment can be conducted across various settings	2022	Narrative Review	Identify when and how screening and brief intervention (SBI) is being paid for, avenues for providing SBI in schools and communities, and payment strategies for sustainable SBI programs.	SBI is primarily paid through grant funds, public services, and commercial insurance. SBI is now expanding beyond healthcare-specific settings.	Reif131
Principle 3. Substance use screening, comprehensive assessment, and treatment can be conducted across various settings	2022	Narrative Review	Review best practices, evidence, and expert opinion for the use of telehealth services across diagnoses in adolescents and young adults.	Telehealth systems need to adequately address confidentiality. There is limited data on how youth engage in virtual delivery of substance use care.	Heinrich46
Principle 4. Sensitive issues should be addressed, and confidentiality maintained when possible	2022	Narrative Review	Review laws and standard practice applicable to confidentiality and consent in the treatment of adolescents.	Confidentiality laws vary by state. Adolescents are more likely to disclose when care is confidential. Involvement of caregivers is important for treatment of health issues.	Mientkiewicz132
Principle 4. Sensitive issues should be addressed, and confidentiality maintained when possible	2017	Empirical Research	Evaluate practice of Massachusetts primary care physicians following distribution of an SBIRT toolkit.	Screening practices improved, but insufficient knowledge, lack of time, and lack of staff resources were identified barriers.	Levy49
Principle 5. Treatment should be tailored to the adolescent’s needs	2020	Empirical Research	Build evidence base and guidance for adaptive protocols for adolescent substance use treatment.	Adaptive protocols outperformed the static protocols and can be used to guide level of care placement decisions based on adolescent needs.	Agniel133
Principle 5. Treatment should be tailored to the adolescent’s needs	2021	Empirical Research	Describe characteristics and outcomes of youth seen in a primary care-based outpatient program for substance use.	Retention for adolescents and young adults receiving substance use care within primary care is highest when care is flexible, anticipates treatment of co-occurring mental health disorders, and uses re-engagement strategies.	Bagley59
Principle 6. Treatment should not focus on just substance use	2018	Empirical Research	Highlight high prevalence of social determinants of health in youth seeking substance use and mental health treatment.	Treatment seeking youth have high percentage (80%) of social determinants of health concerns in at least one domain. Integrative services should be accessible to these groups.	Settipani94
Principle 6: Treatment should not focus on just substance use	2022	Narrative Review	Describe strategies for integrating harm reduction into clinical settings in ways that are developmentally appropriate for youth.	Traditional, prevention-focused strategies should not be the only options for adolescents. Patient-centered harm reduction approaches should be tailored towards adolescents.	Winer20
Principle 7. Adolescents presenting with concerning substance use should be tested and treated for sexually transmitted infections (STIs) and be offered contraceptive resources	2019	Systematic Review	Providing guidance for research, policy, and practice addressing substance use and HIV in youth involved in the justice system.	Research in this area is limited, future studies should use approaches like longer follow-up periods, biomedical HIV prevention, and implementation of evidence-based interventions.	Tolou-Shams65
Principle 8. Behavioral therapies are an essential part of SUD treatment. Practice 3. Behavior Therapies: Cognitive Behavior Therapy, Contingency Management	2019	Narrative Review	Summarize evidence-based strategies, supplemental interventions, and other improvements to treatment approaches for adolescent SUDs.	Family-based therapies and cognitive behavioral therapy are well established interventions. Exercise, yoga, and mindfulness are possible adjunctive interventions.	Fadus134
Principle 8. Behavioral therapies are an essential part of SUD treatment	2022	Empirical Research	Enhance understanding of effective financing strategies, penetration, and sustainment of evidence-based practices for adolescent SUDs.	Framework is outlined for how to compare state-versus organization-focused grants on implementation of an evidence-based behavior therapy for adolescent SUD.	Dopp74
Principle 9. Family and community support are important features of treatment	2022	Commentary	Highlight how financing issues can impede family- inclusive interventions.	Collaboration between health systems and financers is necessary to implement immediate and long-term changes in delivery and payment of SUD treatment.	Dopp83
Principle 10. Mental health conditions need to be addressed to effectively treat substance use	2021	Empirical Research	Evaluate prevalence and treatment disparities of co-occurring SUDs and major depressive disorder in adolescents.	Unmet treatment needs were significantly higher in certain minority groups and uninsured individuals. Expanded treatment services for adolescents with co-occurring conditions and increased support through funding and policy is needed.	Lu135
Principle 10. Mental health conditions need to be addressed to effectively treat substance use	2017	Narrative Review	Review research on treatments targeted to adolescents with SUDs.	The most effective programs are individually tailored and integrate services for dual diagnoses, behavioral and family-based interventions, MI, and CM.	Brewer95
Principle 11. External pressures may influence an adolescent’s involvement in treatment	2022	Narrative Review	Summarize privacy and consent laws for adolescents in each state and discuss their impact.	Consent and privacy laws are highly variable between states, and often do not reflect standards of care for youth.	Sharko136
Principle 12. Substance use should be monitored during treatment and inform adaptations made to treatment programming Principle 13. Having a continuing care plan with ongoing recovery monitoring and support is important	2021	Narrative Review	Examine evidence for continuing care for SUDs, focusing on efficacy, moderators, mechanisms of action, and economic impact.	Continuing care for adolescents with SUD has generally favorable results.	McKay137
Practice 1. Motivational Interviewing + Screening, Brief Intervention and Referral to Treatment	2023	Narrative Review	Describe the efficacy of brief interventions for adolescents with problematic cannabis use.	Brief interventions including motivational interviewing, decisional balance exercises, and goal setting can be effective when treating adolescent cannabis use if paired with referral to more services as needed.	Winters113
Practice 1. Motivational Interviewing + Screening, Brief Intervention and Referral to Treatment	2021	Empirical Research	Investigate utilization of SBIRT by U.S. pediatricians, and identify barriers associated with use in providers and practices.	Most pediatricians deliver some components of SBIRT, but confidentiality and time are common barriers to delivering the full model.	Hammond115
Practice 2. Family-based Services	2018	Systematic Review	Review evidence for outpatient behavioral treatments for adolescent substance use.	Ecological family-based treatment, and individual and group cognitive-behavioral therapy remain well-established treatment approaches. Technology-delivered assessment and direct-to-consumer marketing strategies may help to reduce the gap in treatment access.	Hogue120
Practice 3. Behavior Therapies: Cognitive Behavior Therapy, Contingency Management	2019	Narrative Review	Review the efficacy of contingency management (CM) for SUDs in youth.	CM is an effective strategy to promote abstinence and increase treatment attendance in youth with SUDs.	Stanger138
Practice 4. Pharmacotherapy	2019	Narrative Review	Evaluate the efficacy of pharmacological approaches SUDs in youth.	Buprenorphine is the only FDA approved medication for SUD in adolescents. Off label use of pharmacotherapy can be an effective way to treat SUDs in youth, but more research is needed before FDA approval can be granted for use in this population.	Squeglia54
Practice 5. Continuing Care and Recovery Monitoring, Support, and Re-intervention	2022	Empirical Research	Investigate the relationship between frequency of Volunteer Recovery Support Administration (VRSA) and remission rates for adolescent substance use.	When compared to services as usual, high adherence to VRSA encouraged higher rates of remission in adolescent groups.	Godley128

Note^{: a}The principles and practices are detailed in Tables 1 and 2, respectively. CM=Contingency management; MI= Motivational interviewing; SBIRT= Screening, brief intervention, referral to treatment; SUD= Substance use disorder.