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 Table of Contents    
CLINICAL PRACTICE GUIDELINES  
Year : 2019  |  Volume : 61  |  Issue : 8  |  Page : 333-349
Clinical practice guidelines on assessment and management of substance abuse disorder in children and adolescents


1 Director and Consultant Psychiatrist, Gaur Mental-Health Clinic, Ajmer, Rajasthan, India
2 Director and Consultant Psychiatrist, Gautam Hospital & Research Centre, Jaipur, Rajasthan, India
3 Additional Professor, Department of Psychiatry, PGIMER, Chandigarh, India
4 Senior Resident DM, Child and Adolescent Psychiatry, PGIMER, Chandigarh, India
5 Assistant Professor, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India

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Date of Web Publication14-Jan-2019
 

How to cite this article:
Gaur N, Gautam M, Singh S, Raju V V, Sarkar S. Clinical practice guidelines on assessment and management of substance abuse disorder in children and adolescents. Indian J Psychiatry 2019;61, Suppl S2:333-49

How to cite this URL:
Gaur N, Gautam M, Singh S, Raju V V, Sarkar S. Clinical practice guidelines on assessment and management of substance abuse disorder in children and adolescents. Indian J Psychiatry [serial online] 2019 [cited 2019 Sep 20];61, Suppl S2:333-49. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/8/333/250049





   Introduction Top


Today's youth are tomorrow's future and hence it is very important to formulate the clinical practice guidelines for substance abuse disorder in children and adolescents. The previous guidelines were published in 2008, so it was of paramount importance to update the scientific information to guide management in recent times.

According to the Census of India, 2011, adolescents (10–19 years) constitute one-fifth (20.91%) of the Indian population. The first nation-wide survey on children (5–18 years) conducted under the auspices of the National Commission for Protection of Child Rights (2013) at 135 sites across 27 states and 2 union Territories provides us with significant insights as to the magnitude and pattern of drug menace in this age group. Most children had used any one or more of the substances in their lifetimes with tobacco and alcohol leading the charts followed by cannabis, inhalant, opioids, sedatives, and heroin/smack; and there is progression from licit to illicit substances. The mean age at onset was 12.3 years with increasing age associated with increased use of illicit drugs. The type of substance preference varies in different geographical regions. Out-of-school and street children have an earlier onset and more dysfunction and almost half of them are working in unskilled jobs. It is to be noted that among these more than two-third had never sought treatment.

The presentation of substance use problem differs in adults and adolescents as shown in [Table 1]. It is quite reasonable to say that adolescents will have much better prognosis if evidence-based treatment programs are designed keeping in mind these very fundamental differences and needs in mind.
Table 1: Clinically significant differentiating characteristics of adolescent substance abusers from adult substance abusers

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Before implementing the current guidelines in toto, one should be acutely aware of the fact that evidence regarding substance use disorder (SUD) in adolescence is nonexisting (India in general and Indian children and adolescents in particular). Though we may speculate that cultural and ethnic factors may influence the treatment process and outcomes, the evidence related to this aspect is lacking.

The primary goal (both in short-term and long-term) of SUDs management in adolescents is to achieve and maintain abstinence from substance use. While trying to achieve the ultimate, harm reduction may be an intermediate implicit (never explicit) goal of treatment. The treatment goal should not only include substance control but a range of rehabilitative measures too. This will not only improve psychosocial functioning but will also help in achieving improved outcomes in terms of achieving and maintaining abstinence.


   Methodology Top


Review articles and various guidelines published till 2018 were searched. A thorough search in Google, Google scholar, and PubMed was made with search words/phrases such as Management/treatment/intervention of substance/alcohol/tobacco/cigarette/inhalant/opioids/heroin/stimulants/benzodiazepines/use/abuse/addictions in children and/or adolescence with special emphasis for articles published after 2010.

General considerations for the management of substance use disorders in children and adolescents

  • Ethical considerations specific to children and adolescents need to be considered
  • Setting for the treatment needs to be decided based on clinical features


    • Inpatient treatment should be reserved for patients with severe dependence, longer duration of use, multiple failed abstinent attempts in the past, significant health complications, concurrent use of multiple other substances, substantial problems at home or school, absent/minimal family support, distance from care providers, and familial issues that interfere with care process
    • In outpatient treatment, frequency and duration of sessions may vary depending on patient characteristics and individualized goals.


Management can be conceptualized into

  • Short-term and long-term
  • Pharmacological and nonpharmacological.


Short-term

  • Assessment: A detailed work up of patients with elaborate history of substance use and its medical and psychological complications needs to be done. History about family, school, work, sexual, living conditions, temperament, comorbid conditions such as attention deficit/hyperactivity disorders (ADHD) and conduct disorder needs to be taken. General physical examination, systemic examination, and a mental state examination need to be done covering assessment of behavior, speech, affect, thought, and perceptual disturbances. Cognitive functions such as consciousness, orientation, memory, intelligence, abstract thinking, and judgment need to be checked. Motivation to quit substance, to be assessed by Diclemente and Prochaska's stages of change and finally insight of patient about his problems needs to be assessed. The motivational interviewing technique can be used while eliciting history to enhance person's motivation
  • Screening to be done based on clinical pointers for suspected substance use, marked decline in upkeep, absenteeism or truancy from school, decreasing school performance, impairment in cognitive function (like attention or memory), or recent change in behavior.
  • Diagnosis should be established as per ICD-10 classificatory system
  • Investigation: Apart from routine investigation, urine screening for other substance use, serology for viral markers in case of high risk behaviors and other special investigation as per associated physical comorbidities can be considered. It helps to have baselines investigations for comparison with follow-up investigations as well as to choose medication for treatment (especially liver and renal function tests). They can also help in facilitating a change in behavior or for influence them to consider referral for treatment.
  • General substance withdrawal rating pro forma and rating scale of substance and/or behavior-related problems in terms of (health, education, finance, legal, sexual, family, and social) are helpful for problem severity assessment, making decision with regard to treatment and assessing the progress of treatment
  • The developmental appropriateness is a prerequisite for the instruments before applying them to adolescents. No psychometric instrument has been demonstrated to be consistently culture sensitive across all ethnicities but, at the same time, existing data fail to indicate any such need
  • Appropriate consultation with medical specialist as and when required
  • The management of intoxication, withdrawal and dependence of substance has a general application of both pharmacological and nonpharmacological measures in combination (though specificities exist for individual substance use as per the properties of the substance).


Long-term

  • Once stabilized from acute crisis (intoxication/withdrawal symptoms), it is essential to have a prophylaxis for lapse and relapse in long-term
  • Harm minimization is also an important concept if complete abstinence is in question for long-term
  • Prophylaxis mainly is talked in sense of pharmacological treatment like naltrexone (NTX) for opioids and disulfiram (DSF)/NTX for alcohol
  • Nonpharmacological measures, where available, may be considered as a part of long-term treatment and prophylaxis involving relapse prevention counseling or therapy, group sessions, family sessions
  • A special emphasis is given to formal engagement of patient into treatment net as long as possible considering the chronic nature of SUDs with high rates of relapse
  • Hence, active surveillance strategy should be implemented with help sought from psychiatric social worker where available, to ensure regular follow-ups enabling long-term engagement and better outcomes
  • The evidence-based regarding pharmacotherapy of SUD in children and adolescents is scanty. Therefore, any use of medications in this population is subject to clinical judgment and psychosocial treatments should be given a priority over them wherever and whenever feasible.


Nonpharmacological measures also emphasize on wide range of services

  • Psychoeducation of patient and family with special emphasis on harm minimization. For example, not to use inhalants when no one is around, or in a enclosed space, or when required to drive after use of inhalant, or while smoking/ being near a lit cigarette or flames, or when have accrued significant physical exertion.
  • Brief interventions (BI): A common approach to the delivery of BIs is the FRAMES model developed by Miller and Sanchez based on the motivational interviewing style. FRAMES is an acronym for the elements of behavioral intervention, and includes providing feedback, encouraging the patient to take responsibility, advising to make change to behavior, discussing a menu of options for change, providing empathy for the condition of the patient, and supporting self efficacy for effecting the change.
  • Motivation enhancement treatment: This Miller and Rollnick model utilizes specific interviewing techniques to help the patient work through ambivalence and move to the stage of contemplation. An empathetic nonconfrontational relationship is formed in which reflection and reframing help the patient to explore the pros and cons of substance-using behavior. Self-efficacy is enhanced as the patient is helped to realize his or her capacities and options while recognizing that it is the patient's decision whether to change. Motivational interviewing involves 1–2 sessions with adolescents as an interim step before a more comprehensive cognitive-behavioral therapy (CBT) program
  • Relapse prevention therapy (RPT): RPT has been shown to improve the outcomes in SUD. There are three primary areas of focus in RPT: (1) coping skills training, (2) cognitive therapy interventions, and (3) behavioral techniques/lifestyle changes. Two models are available: Marlott's and Gorski's CENAPS Model of RPT. RPT is to be done postdetoxification
  • CBT-based approaches: Both individual and group CBT has been shown to be effective in cases of SUD that include alcohol, cannabis, stimulants, and nicotine
  • Group therapy and 12-step programs: Lately, reports about Group therapy and 12-step programs that are commonly used with adolescents are warranting caution. Group therapies may inadvertently reinforce deviant behavior through the peer networks developed during such sessions. Also, teens and adolescents may not be suitable for 12 step programs due to developmental characteristics and diagnostic issues pertaining to alcohol use disorders among adolescents.
  • Supportive psychotherapy: May be considered for patients for whom CBT is not feasible
  • Contingency management (CM) interventions/motivational incentives: It includes voucher-based reinforcement and prize incentives approaches. It incorporates providing patients tangible rewards in order to enhance positive behaviors like remaining abstinent to substances. It has been shown to be effective in alcohol, stimulants, opioids, marijuana, and nicotine dependence
  • Community reinforcement approach plus vouchers: This outpatient therapy utilizes a range of familial, social, vocational and recreational reinforcers and pertinent material incentives to make substance use less rewarding than non-drug use lifestyle. This intensive program is geared towards cocaine and alcohol users.
  • The matrix model: In this approach, a structure is provided for engagement in treatment of stimulant users and helping them to achieve abstinence.
  • Family systems approach: Effective since family-related factors play a significant role in adolescent SUD. Despite various approaches tested specifically in adolescents like the multisystemic therapy, brief strategic family therapy, multidimensional family therapy and functional family therapy; high attrition among adolescents remains a problem.
  • Psychosocial interventions:


    • Aid in engagement of the patient and involvement of the family
    • School-based: Emphasis is placed on re-entry into school and addressing school re-adjustment issues
    • Activity- and engagement-based approaches: This utilizes activity-based methods for engaging children into the treatment process, and has been utilized for homeless street children
    • Life skill-based approaches: This includes activities which cater to money management, intended to enable children to be cognizant of alternate/healthy ways of spending money.
    • Residential rehabilitation: This might be more relevant for chronic inhalant users who use this substance heavily and where other treatment options have not worked well.
    • Vocational rehabilitation: for street children for effective schooling and employment opportunities.


Treatment of comorbid conditions

  • ADHD, conduct disorder, oppositional defiant disorder and learning disorders need to be addressed to improve short- and long-term outcome of the management plan
  • Induced psychiatric disorders usually remit with cessation of substance use, and specific psychotropic medications are usually not required (except when symptoms pose a threat to self or others, or the symptoms are severe).


Special consideration for management of alcohol use disorders

A majority of the teenagers who use alcohol are either experimenters or intermittent users. Some of them are regular users. They seldom come into contact with de-addiction services (except when they encounter an acute health event like accident under intoxication). Generally, adolescents coming in contact with the health-care services are those who are alcohol abusers or binge drinkers, and they do not have long enough duration of alcohol use to qualify for alcohol dependence. The identification of binge-drinkers or high-risk drinkers is important as it will help us to identify the target population requiring intervention [Table 2] and [Table 3].
Table 2: Binge drinking in adolescents

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Table 3: Age at onset of past year risk-drinking

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It is to be noted that the term AUD as has been used in this document to encompass intermittent binge drinking, hazardous drinking, and chronic alcohol abuse and dependence. Following laboratory investigations are carried out to screen for biomarkers and to assess liver functioning at baseline and follow-up [Table 4] and [Table 5].
Table 4: Laboratory testing in alcohol use disorder assessment

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Table 5: Alcohol and other drugs assessment tools

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Assessment questionnaires, inventories, and scales

A comprehensive diagnostic approach for alcohol problems may cover physiological, behavioral, psychological and social aspects of the patient. The predictors and facilitators of relapse may be assessed, along with the strengths and deficits of the individual and the individual's readiness to change.

Treatment strategies for alcohol dependence

The treatment/intervention plan will depend upon the stage and or severity of alcohol use and severity of withdrawal symptoms. Most evidence indicate efficacy of psychosocial measures with pharmacotherapy as an adjunct modality.

A medication-assisted treatment for AUDs has several benefits.

It prolongs the periods of abstinence, thereby enhancing the coping mechanisms that facilitate long term recovery. It may also help to prevent occurrence of relapse from a lapse. It may help in reducing the protracted withdrawal, and may help the brain to re-adapt to a non-alcoholic state. Such medication assisted treatment may support the effects of psychosocial treatment and sustain the gains made with intervention. And of course, pharmacological treatment may be quite beneficial in the management of withdrawals.

Acute stage management-alcohol withdrawal syndrome

Mainstay: Benzodiazepines (BZD) remain the cornerstone of pharmacotherapy during acute stage alcohol detoxification, withdrawal symptom management, and prevention of complications such as delirium tremens and seizures. The choice of type of BZD depends on the severity of withdrawal symptoms and status of liver function. Long-acting BZDs such as chlordiazepoxide and clonazepam are preferred. If liver function is compromised medium-acting BZD such as oxazepam and lorazepam should be used depending on availability.

Adjunct (as and when clinically indicated): Nutritional deficiencies are seen commonly in subjects of AUD for a variety of reason and must be addressed to improve the overall prognosis such as thiamine, magnesium, and multivitamins supplementation.

Maintenance stage

Psychosocial intervention is the mainstay of the treatment. On a case to case basis, medication may be used intermittently or for long durations, with interventions that help change certain lifestyles to maintain recovery. The use of adjuvant pharmacotherapy is recommended for those with moderate-to-severe dependence postalcohol withdrawal. Adjuvant pharmacotherapy is also suitable for children and adolescents with mild dependence who have either not responded to initial attempts to attain abstinence or have specifically requested it.

Medications commonly used are DSF, acamprosate, NTX, and nalmefene [Table 6].
Table 6: Medications in alcohol pharmaco prophylaxis - clinical considerations

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The choice depends on individual patient profile.

  1. Deterrent/alcohol-sensitizing drug – DSF helps in decreasing impulsive or situational use of alcohol. It inhibits alcohol dehydrogenase in liver and dopamine β-hydroxylase in brain. The first action results in high levels of acetaldehyde that causes an unpleasant physical reaction (known as DSF-ethanol reaction, DER) within 15–30 min and lasts several hours or days (if DSF being taken for long). The severity of DSF will depend on the dose of DSF and blood alcohol concentration. DSF has potentially serious adverse reactions and there are higher chances of DER in children and adolescents as they may succumb to peer pressure easily while being on DSF. Therefore, its use requires great caution. Its use should be restricted to highly motivated patients only, with ingestion under direct supervision and regular specialist monitoring. In patients committed to complete abstinence it might benefit with more total days of abstinence, reduced weekly drinking, and lower levels of gamma-glutamyltransferase (a marker of liver injury due to heavy alcohol use). Regular monitoring through clinical supervision and laboratory testing should be done once decision to start DSF is taken in consent with patient and/or guardians [Table 7]


  2. DSF should be continued for a duration till the treatment goals have been achieved in terms of long term stable abstinence. Duration of supervised therapy probably determines the duration of abstinence to alcohol after termination of disulfiram.

  3. Anticraving agents


    1. NTX – This opioid antagonist reduces relapse to heavy drinking by inhibiting alcohol-induced dopamine release in the reward circuitry. It lessens craving, blocks pleasurable effects and reduces urges to drink. Before the initiation of NTX therapy, rule out use of recent opioids lest it may precipitate unpleasant withdrawal symptoms. NTX therapy gives better results in those where individuals have


      • Good motivation and ready for supervised medication
      • A history of opioid abuse/dependence and are seeking treatment for AUDs
      • Intense alcohol cravings during treatment
      • More somatic complaints
      • A family history of alcohol dependence
      • Asp40 variant of OPRM1 (μ opioid receptor) on genotyping.


      NTX should be continued for a minimum period of 3 months to 1 year. It is not associated with withdrawal symptoms on discontinuation, hence no taper off required. Patients should continue NTX despite having a lapse/relapse as it may reduce the severity of the relapse

    2. Acamprosate – Through its action on glutamatergic pathways, acamprosate reduces symptoms of postacute (protracted) withdrawal, as features of impaired sleep or mood instability may elicit a relapse to drinking. There are several advantages of using acamprosate:


      • No clinically significant drug-drug interactions
      • Safe in cases of severe hepatic failure
      • Safe in patients receiving concomitant opioid maintenance therapy
      • No interaction with any other medication used in alcohol detoxification
      • Extremely safe; no overdose risk up to 56 g
      • Adverse effects-mild and transient.


    3. Nalmefene – An opioid antagonist, it may be an option for patients who do not tolerate NTX or who do not respond to that drug. In a limited number of studies on adult subjects, nalmefene has been shown to have some impact in decreasing the total daily alcohol intake and number of heavy drinking (more than 60 and 40 g of pure alcohol per day for men and women, respectively) days. It may help alcohol dependent individuals to reduce the risk status of drinking, improving the health outcomes potentially


    4. It has been approved in the European Union in 2013 for this indication in adults. Interesting to note is that it can be used as needed if the patient perceives a risk of drinking, giving more autonomy and flexibility to the patient, thus ensuring their active involvement in the treatment process.

    5. Under trial (clinical/preclinical) – Include baclofen, ondansetron, topiramate, ondansetron-topiramate combination, varenicline, gabapentin, and prazosin. There is not enough evidence at present to recommend them in AUDs.
Table 7: Laboratory monitoring of disulfiram therapy

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Psychosocial measures

One needs to consider the developmental stage and developmental processes while planning intervention for adolescents. Most mild cases of AUD are effectively dealt with interventions aimed at bringing motivation to change, strengthening support system, and developing life skills. Evidence-based approaches for adolescent AUD problems include:

  • Family system approach
  • BI
  • Motivational Enhancement Therapy (MET)
  • Cognitive-behavioral skills.


Special population

Pregnancy – The nutritional needs during pregnancy are 10%–30% greater than normal; food intake needs to increase by as much as 140% to cover the needs of both mother and the fetus. The management should preferably be psychosocial along with enhanced nutrition in case of continuation of pregnancy.

Pharmacological measures should only be used strictly under addiction specialist only when, in the judgment of the physician, the probable benefits outweigh the possible risks.

Psychiatric comorbidity – Adolescents who meet the criteria of SUD, 60% also meet the criteria of a psychiatric disorder. Therefore, addressing a co-occurring psychopathology is equally important in dealing with AUD as it is related with better abstinence rates than treatment of AUD alone. Common comorbidities include (but not limited to) attention-deficit/hyperkinetic disorder, conduct disorder, anxiety, depression, and posttraumatic stress disorder.

The AUD management has been summarized in [Figure 1].
Figure 1: Algorithm for management of alcohol use disorder

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Special consideration for management of cannabis use disorder

The use of cannabis in some parts of the world is on rise and there is no reason to believe that the same is not true for India. About 10%–30% of those who ever use cannabis develop a cannabis-use disorder within a decade. Among the adolescents, the frequency of cannabis use may be a better predictor of cannabis use disorder than duration of use. It is used as bhang, ganja, hashish, hash oil, or synthetic cannabinoids. Synthetic cannabis is either smoked or used as tea. It is known by various street names such as K2, Skunk, Synthetic, etc. Some users claim that synthetic cannabinoids are much stronger in effect than cannabis and the withdrawals are also more severe.

With time the perception that cannabis use poses a significant risk of negative consequences has decreased. This is despite the fact (as per US data) that the average potency of delta-9-tetrahydrocannabinol in seized marijuana has increased from 3% in 1992 to 11% in 2010. The increase in potency coincides with an increase in treatment admissions for marijuana use disorders. This is pertinent to think about in counseling parents, who, recalling their own past experiences with marijuana, do not consider it likely that it could be harmful to their children. Another challenge is the lack of standardization in dose, potency, or chemical constituency of cannabis.

The changing cannabis use patterns among adolescents carry grave significance to public health as it is associated with hazardous behaviors such as drug peddling, violence, drunk driving, all forms of abuse (physical, sexual, and emotional), and future development of SUD.

Many cannabis users do not consider their cannabis use problematic, and hence their readiness to quit this substance might be low. The withdrawal effects of marijuana are relatively mild as compared to substances like opioids and alcohol. Also, many cannabis users espouse the goal of moderating, rather than quitting altogether.

A typical cannabis withdrawal begins within 24–48 h of abstinence; peak within 4–6 days, and last from 1 to 3 weeks, although significant individual differences occur in withdrawal expression [Table 8].
Table 8: Pretreatment assessment and categorization of intoxication and withdrawal

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The management of cannabis intoxication, withdrawal and dependence is a work in progress and further research exploring better clinical practices is the need of the hour. Currently, there are no “recommended” treatment approaches for cannabis use disorders. Most adolescents do not need specific medication for cannabis cessation, and non-pharmacological approaches like enhancing coping and providing information may suffice.

Pharmacotherapy of cannabis withdrawal syndrome and cannabis use disorder (CUD) is mostly symptomatic. Short term symptomatic medication like diazepam (up to 40 mg per day in 4 divided doses for about a week), metoclopromide (for nausea), and olanzapine (up to 10 mg per day in 2 divided doses for about a week for agitation) can be given in individual cases.

Psychotic symptoms should be managed with an antipsychotic medication for up to 2 weeks. If the symptoms are severe or persistent for longer than this, detailed psychiatric evaluation should be undertaken. The sleep disturbance should be managed without medications.

For cannabis use disorders, no pharmacological treatment has been shown to be efficacious for prophylaxis. Drugs such as buspirone, bupropion, and NTX are commonly used in CUD.

Psychosocial treatments, such as MET, CBT (i.e., coping skills training), and CM, as well as family-based treatments and mindfulness meditation have been carefully evaluated and have demonstrated enthusiastic results.

[Figure 2] summarizes the management of CUD.
Figure 2: Management of Cannabis use disorder

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Special consideration for management of Inhalants use disorder

IUD is more common in lower socioeconomic status, street children, school dropout, conduct disorder, and low parental supervision. Effects are that of CNS depression. Intoxication occurs rapidly and it is comparatively of short duration (3–6 h). Withdrawal from inhalants generally does not require medical attention. However, medical evaluation and/or care should be provided for an adolescent who is pregnant, has a pre-existing medical condition (including seizures), or has considerable physical discomfort.

Inhalant intoxication

  • Basic supportive care
  • Use of sedatives should be avoided
  • Appropriate consultation with pulmonologist/ENT for (cough, wheezing, dyspnea, emphysema, and pneumonitis), cardiologist for (dysrhythmias, hypoxic-induced heart block), neurologist for (encephalopathy, cerebellar ataxia, neuropathies, white matter degeneration/atrophy, and  Parkinsonism More Details), dermatologist for (burns, contact dermatitis, perioral eczema) may be required. Complications, if any, must be using appropriate therapeutic intervention/ referral to suitable facility
  • The adolescent can be discharged from care with a guardian when the symptoms of inhalant intoxication wane within a period of 4 to 6 hours, with observation continued at home till 24 h.


Inhalant withdrawals

The management is either short-term or long-term, and pharmacological and/or nonpharmacological.

Short-term

Withdrawal symptoms are often mild. They may extend for a period of up to 2 to 5 days. Detoxification consists of basic supportive care and symptomatic medical management. Apart from a case series of baclofen, no specific pharmacotherapy has been used to manage inhalant withdrawal.

Long-term

As there is no evidence for any effective pharmacoprophylaxis, it is important to keep patient under active follow-up with regular urine screening for substance use and regular brief sessions enquiring patient's motivation and emphasizing on principles of relapse prevention counseling.

Nonpharmacological interventions

Psychoeducation of patient and family with special emphasis on harm minimization like not to use inhalants

  • When alone or in secretive, enclosed spaces
  • When smoking or near a lit cigarette or flames
  • When there is physical exertion and
  • Several hours before driving.


  • Motivation enhancement treatment
  • RPT
  • CBT-based approaches
  • Supportive psychotherapy (where CBT is not feasible)
  • CM
  • Psychosocial intervention:


    • Patient engagement and family involvement
    • School re-entry and school readjustment
    • Activity and engagement-based approaches
    • Life skills-based approaches.


  • Residential rehabilitation: This might be more relevant for chronic inhalant users who use this substance heavily and where other treatment options have not worked well.
  • Vocational rehabilitation: for street children for effective schooling and employment opportunities can be used.


Special populations

Psychiatric comorbidity: conduct disorder, oppositional defiant disorder and learning disorders should be addressed to improve short and long-term outcome of management plan.

Inhalant induced psychiatric disorders usually remit with cessation of substance use, and specific psychotropic medications are usually not required (except when symptoms pose a threat to self or others, or the symptoms are severe).

Special consideration for management of tobacco use disorder

Salient features:

  • Gateway substance - 90% of adult smokers smoked their first cigarette before the age of 18 years
  • Addressing adolescent cigarette use should encompass primary prevention and smoking cessation.
  • Treatment of tobacco use disorders should be individualized for the adolescent, This should be based upon smoking patters, concomitant medical conditions, and preferences of the individual.
  • Most patients are managed at outpatient setting of various specialties and inpatient management for tobacco use is rare except for admissions for treatment of various other medical or psychiatric disorders including inpatient treatment of other substance use
  • For adolescent smoking cessation, behavioral treatments are the main treatment recommended at present.


Pharmacotherapy

  • Before opting for pharmacotherapy in teens, a number of factors are to be considered such as efficacy, side effects, cost, and ease of use
  • There are no medications investigated specifically for adolescent smoking cessation
  • There are medications for the purpose of smoking cessation in adults that include Nicotine Replacement Therapies (NRT) delivered in the form of a patch, inhaler, lozenge, gum or nasal spray, as well as bupropion sustained-release (SR) and varenicline
  • Studies in adolescent age group are starting to emerge but are lagging behind adult population.


Nicotine replacement therapy [Table 9]
Table 9: Nicotine dosage forms and doses

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  • Studies evaluating efficacy of NRT in adolescent group has shown mixed results. To date, no adverse effects with NRT were noted
  • The only form of NRT that has been studied and have shown benefit is the nicotine patch. The patch may be helpful to some adolescent smokers but relapse after treatment is common. Smoking while using the patch may increase risk of adverse effects
  • As, there is lack of data for this age group, data from adult recommendations are often used in routine clinical practice. The NRT dosing is based upon the severity of tobacco use. The outcomes of NRT are better when the dose and duration are adequate. NRT can be initiated even when the individual has not fully decided on quitting tobacco. The quit date is prior to beginning NRT. Optimal duration of treatment is 3 months


Those who smoke less than 10 cigarettes per day are not suitable for NRT.

Combination of patch and another NRT modality (like gum or lozenge) may be more effective than a single approach.

Nonnicotine pharmacotherapy

  • Varenicline, bupropion, nortriptyline and cytosine are studied in adults but convincing data on adolescents are lacking
  • Varenicline is not approved in adolescent population and very few studies have evaluated its use in this age group. Its use is restricted because of serious neuropsychiatric adverse effects like agitation, hostility, suicidal ideation and depressed mood
  • Bupropion SR use has shown mixed results in efficacy when used in combination with NRT and tobacco cessation counseling in adolescence
  • Bupropion may increase suicidal ideation, particularly so in adolescents with depression
  • Hence, mental health should be closely monitored in adolescents who are being given these medications.


Long-term

  • Behavioral counseling and long-term follow-up increases the abstinence rate
  • The treatment of comorbid psychiatric disorders such as ADHD and conduct disorder increases the abstinence rates in long-term.


Special consideration for the management of opioid use disorder

  • Despite increasing trends toward use of opioids in adolescent age group, they still do not receive adequate treatment due to restrictions on use of pharmacotherapy in this age group
  • There is increasing use of injectable opioids in adolescence with associated increase in HIV, hepatitis C, and other blood-borne infectious diseases
  • In India, among the intravenous drug users (IDU), opioids are the most commonly injected drugs
  • Clinical opiate withdrawal scale (COWS) might come handy in determining the severity of withdrawal and start and monitoring of pharmacotherapy
  • Apart from routine investigation, viral markers for high risk sexual behaviors and urine screening to confirm opioid use and to look for other substance use are required to plan the individualized management.


Opioid intoxication

Look for a triad of (i) coma/unconsciousness, (ii) severely depressed respiration, and (iii) pinpoint pupils.

Management: In cases of suspected opioid intoxication, airways should be made clear and breathing ensured (supported as required). Initially 0.8mg/70kg naloxone dosing should be given, and the dose may be repeated every 2 to 3 minutes till 10 mg. If no response, alternative cause/substance is to be considered.

Opioid dependence: Detoxification (withdrawal management)

The choice of treatment needs to be made on a case-by-case basis.

  1. Clonidine-based symptom management


    • Reserved for mild cases and in whom long-term prophylaxis is planned with an opioid antagonist like NTX
    • It requires careful monitoring of side effects like hypotension
    • Sedative-hypnotics or anxiolytics for sleep difficulties and or anxiety, antiemetics for nausea and vomiting, NSAIDS for muscle cramps, antispasmodic for gastrointestinal cramping and adequate hydration or oral rehydration solution for loose stools may be required
    • When withdrawal symptoms are severe and clonidine-based management is planned it is preferable to have inpatient management
    • Patients suffering from mild withdrawal or some with moderate symptoms may respond to clonidine alone. Observe for 45 min the diastolic blood pressure after an initial test dose of 0.1 mg (oral/sublingual) and if no orthostatic hypotension is evident, then doses of 0.1–0.2 mg should be administered orally every 4–6 h.


  2. Agonist agent-based symptom management:


    • It is treatment of choice for detoxification in adults, but in children and adolescence, both buprenorphine and methadone are used with caution considering poor tolerability.


Buprenorphine

  • It is a partial opioid agonist, that is administered sublingually. It is available in either plain form, or in combination with naloxone. Naloxone is added to formulation to prevent diversion to injecting drug use of buprenorphine, as naloxone is not absorbed sublingually, but purportedly exerts opioid antagonist effect when injected.
  • For detoxification, dose calculation is symptom-based and later once symptoms are managed adequately, dose is tapered-off gradually
  • Buprenorphine dosing should not start until at least 6 h after the last heroin dose or 24–48 h after the last methadone or other longer acting opioid dose, till the adolescent is not showing signs of opioid withdrawal, or the COWS score <6. If dosed too early, precipitated withdrawal may occur
  • Buprenorphine may be appropriate treatment for adolescents with short addiction histories, and who have histories of opioid abuse and addiction and multiple relapses but who are not currently dependent on opioids
  • It may be preferred to methadone because of the relative ease of withdrawal from buprenorphine treatment
  • Longer buprenorphine taper-off over 4–8 week has better outcomes in terms of abstinence and treatment retention, than shorter taper regimen.


Methadone

  • Not a first-line treatment, it is to be used under expert guidance only. Methadone based withdrawal management should be done in the inpatient setting only.


Symptomatic medications: May be helpful. Include

  • Benzodiazepine (e.g., Diazepam 5–10 mg QID prn) for a maximum of 7–10 days
  • Metoclopramide 10–20 mg TDS prn for nausea
  • Simple analgesia (e.g., paracetamol, NSAIDs)
  • Antidiarrheal (e.g., loperamide).


Long-term management

The duration of maintenance therapy varies from case to case basis anywhere between 6 and 24 months or more depending on the clinician's assessment.

Opioid antagonist treatment (naltrexone)

  • Criteria for using opioid antagonist treatment include:
  • Comparatively brief duration of opioid use, good motivation, absence of injecting drug use, less severe dependence, good social supports and good premorbid social and occupational functioning.
  • As an opioid antagonist, it can precipitate sudden withdrawal symptoms in a patient who recently used opioids
  • Therefore, clinicians should only administer NTX 3–6 days after the most recent use of short-acting opioids (e.g., most short-acting prescription opioids or heroin) and 7–10 days after the most recent use of long-acting opioids (e.g., most long-acting prescription opioids, buprenorphine, or methadone)
  • NTX prescription is to be preceded by a urine drug screen
  • First oral dose is administered under direct supervision in the clinic and monitored (60 min) for signs of withdrawal. Naloxone challenge test is also used before starting NTX
  • NTX is taken orally either 50 mg daily or 100 mg - 100 mg –150 mg three times a week
  • Advantages of NTX are: User does not perceive any particular drug effect, no potential for abuse, and nonaddictive
  • Also available as extended-release intramuscular once-a-month injection (Vivitrol) in some countries. It has not been evaluated in adolescents
  • Before starting injectable NTX, an opioid-free period of a minimum of 7–10 days is recommended to avoid precipitating withdrawal.


Injectable NTX may be more suitable for those individuals living in correctional facilities, or those with HIV and willing to abstain from opioids. Several clinical conundrums and knowledge gaps make use of injectable NTX difficult - for exampe, transitioning to NTX, duration of treatment, pain management, risk of opioid overdose, cost factors and pragmatic efficacy.

Opioid agonist maintenance treatment/opioid substitution treatment

  • In government run centers in India, opioid-substitution treatment includes dispensing an opioid-agonist agent along with nonpharmacological measures such as group meetings, role plays, and psychoeducational meetings held at weekly follow-up visits
  • Not all adolescents who have used opioids need to be commenced on opiate replacement therapy
  • Risk of toxicity and overdose, especially with methadone which is highest in the first 14 days of treatment
  • Criteria for determining suitability for opioid substitution therapy include long-duration opioid users, severe dependence, high risk of relapse, willing to comply with the requirements, harm reduction strategy in someone with HIV- or HBV-positive status with IDU.


The specific objectives of agonist-maintenance treatment include reduction of harmful and illicit drug use, reduction of risk of transmission of blood borne infections, reduction of medical morbidity and risk of overdose, reduction of criminality, enhancement of social and occupational functioning and integration with families.

Nonpharmacological

  • Psychoeducation
  • Motivation enhancement treatment
  • RPT
  • Emphasis on concept of harm reduction
  • Psychosocial intervention in the form of school or educational and vocational rehabilitation.


Special consideration for management of sedative and hypnotics use disorder

Medications included in the category of sedatives and hypnotics are of three types: barbiturates, BZD and “Z-drugs” (zolpidem, zopiclone, eszopiclone, and zaleplon). A knowledge of t1/2 of BZDs is important before embarking on related problems [Table 10].
Table 10: Diazepam equivalent dosage of other benzodiazepines

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Benzodiazepine intoxication

  • These are in line with the guidelines applicable to adults as there is no specific recommendation in adolescent population
  • Supportive measures are important. Gastric lavage is not usually recommended unless suspected of other lethal co-ingestant
  • Flumazenil, a competitive benzodiazepine receptor antagonist can be used in acute severe intoxication at doses of 0.1–0.3 mg over a period of 30 s. Additional boluses are often required (as the duration of action of flumazenil is shorter) until consciousness is established or a maximum dose (2–5 mg), as applicable to adults, is reached.


Benzodiazepine dependence

  • Adolescents mostly use BZD for recreational purpose. A few misuse the prescription dose and increase on their own and continue using benzodiazepine for a duration and manner long enough to result in dependence
  • Initial attempts should be gradual and slow dose reduction with watch for any seizure episode or agitation
  • If difficulty is seen with tapering the short acting benzodiazepine, then it can be substituted with the equivalent dose of long acting benzodiazepine and then gradual taper can be attempted
  • Antidepressants, melatonin and at times valproate, carbamazepine, and quetiapine are also used to aid in taper-off along with the use of nonpharmacological measures such as psychoeducation, sleep hygiene, and CBT. Valproate should be initiated at a dose of 125 mg/day and escalated to 750 to 1200 mg/day (in q. i. d. divided doses) as rapidly as tolerated
  • In groups with polysubstance abuse and high-dose benzodiazepine use for recreational purpose caution should be exercised for risk of seizures and gradual dose reduction should be done with long acting benzodiazepine in an inpatient setting.


Barbiturate use disorders:

  • It needs a special consideration due to its high dependence potential and narrow therapeutic window. Data are very scarce in adult population and not available in adolescent population
  • For the management of intoxication, there is no specific antidote and focus is mainly on supportive measures. For management of barbiturate dependence, principle is same as with BZD though it is more advisable to treat under inpatient setting. Nonpharmacological management as mentioned for other SUD is equally important in this group as well.


Special consideration for management of stimulant use disorder

  • Literature on guidelines of these disorders is very scarce due to rarity in cases seen in India. These are frequently part of illegal rave parties. Commonly available drugs are amphetamine-type stimulants, gamma-hydroxybutyrate (GHB/gamma butyrolactone), and cocaine
  • The management of intoxication is basically supportive care as there is no specific antidote [Table 11]. Heavy GHB use requires an inpatient management and can be managed with low-to-moderate dose long-acting benzodiazepine with close medical observation. Withdrawal symptoms are managed based on the symptom presentation with use of sedatives, antipsychotics, and valproate. Once stabilized, role of psychosocial intervention becomes important. This group requires extensive rehabilitation plan. Special emphasis is made on retaining patients under active follow-up with the help of psychosocial workers and continuing RPT [Table 12]
  • Other than routine investigations, following may be required:
  • Table 11: Short-term acute management

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    Table 12: Planned detoxification and long-term management

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    • Urine drug screen (for cocaine request plasma benzoylecgonia, the demethylated metabolite of cocaine, as cocaine itself has a variable and short half-life).
    • ECGs: to exclude arrhythmias in toxicity
    • Cardiac enzymes, troponin levels-where ischemic heart disease is suspected (cocaine)
    • CPK to exclude rhabdomyolysis
    • Chest X-ray where indicated
    • Computed tomography or magnetic resonance imaging head: if indicated, for example, to exclude cerebrovascular accidents.


”Street drugs” and psychotropics

It is important to know the interaction as psychotropics are often used in the management of the problems associated with the use of street drugs [Table 13].
Table 13: Pharmacodynamic interactions between street drugs and psychotropics

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   Conclusion Top


SUD treatment in adolescents remains an enigma. Multiple barriers to treatment include low motivation to change, stigma, desire for self reliance, perception of lack of treatment services and consideration that treatment is not necessary.

As limited evidence suggests only modest efficacy across treatments, clinicians should choose evidence-based interventions, they are familiar with and feasibility of its implementation to optimize outcomes. It is likely that treatments may have differential impacts on the different substance users. Psychosocial interventions remain the mainstay of management despite high nonresponse and relapse rates (70%), with adjunct pharmacotherapy. SUD runs a chronic course hence participation in aftercare services after an acute treatment schedule should be encouraged as it is related to improved outcomes.

In sum, treatment should be individualized, taking into consideration what the adolescent and family are able to do and trying to optimize outcomes by choosing among interventions. We need more research and clearer understanding of how to cater to the needs of the adolescents coming from different setting and backgrounds. Future efforts should aim towards developing models of intervention that address the prevention as well as amelioration of substance use disorders.[18]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Navendu Gaur
Gaur Mental-Health Clinic, Ajmer, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_581_18

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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