APA Congressional Testimony on Substance Abuse Prevention and Treatment Services to Adolescents

United States Senate
Subcommittee on Substance Abuse and Mental Health Services
Hearing on:
Providing Substance Abuse Prevention and Treatment Services to Adolescents

Statement by
Sandra A. Brown, Ph.D.

Professor Departments of Psychiatry and Psychology, UCSD
Associate Chief, Psychology Service
Veterans Affairs San Diego Healthcare System
Associate Director, NIMH Child and Adolescent Services Research Center

June 15, 2004

Introduction

Recent research supported by the National Institutes of Health and other agencies is leading to a common understanding about the critical role of age of onset of addictive disorders in their course, consequences and progression. Researchers are finding that these disorders often begin during adolescence and sometimes even during childhood; therefore early intervention may prevent many of the social, behavioral, health, and economic consequences caused by alcohol and drug abuse as well as provide an opportunity to treat problems before they become full blown and damage in the lives of our youth.

Early Onset

NIAAA and NIDA-supported researchers are finding that alcohol and other drug addictions commonly start earlier than previously understood, and the earlier youth start the greater the lifetime risk for dependence. New findings regarding early patterns of abuse and dependence dramatically underscore the importance of reducing underage drinking and drug use. The age of most prevalent tobacco dependence onset is 15 and for alcohol dependence age 18 is the most common period of first diagnosis of dependence. It is now clear that most cases of alcohol dependence begin before age 25. After that age, new cases drop off precipitously. The epidemiological research message is obvious: youth is a critical window of opportunity for preventing alcohol, tobacco and other drug disorders. Previous studies have suggested that this is so, but the new research findings, corroborated by independent sources, have confirmed these findings.

Ongoing research may reveal a cause-and-effect relationship between early use and subsequent dependence, or it may reveal that common biological and environmental factors drive the risk for both use and dependence, as well as other addictive and psychiatric disorders. In either case, these new data are a powerful indicator of the need for more effective preventive interventions for youth.

Given the new epidemiologic findings, the fact that alcohol use is so widespread among children and adolescents is troubling. Alcohol is the primary substance of abuse among American children and adolescents.

47 percent of 8th graders, 67 percent of 10th graders, and 78 percent of 12th graders have used alcohol.
11 percent of 6th graders have reported binge drinking (5 or more drinks per occasion for males; 4 for females) in the past 2 weeks.
30 percent of high-school seniors have reported binge drink at least once a month.
44 percent of college students have reported binge drinking in the past 2 weeks.
23 percent have reported that they binge drink frequently.
Youth who drink alcohol before age 14 are 4 times more likely to become alcohol dependent in their lifetime than those who wait until age 21 or older.

Neurodevelopmental Studies

A series of recent studies indicate that exposure to drugs of abuse during adolescence may produce more adverse effects than exposure during adulthood in part because of the important changes occurring in the brain during adolescent development. Advances in science have now brought us to a point where researchers can use new animal models, modern brain imaging technology and other neurobehavioral assessment tools to probe the effects of alcohol, tobacco and other drugs on the developing brain and determine immediate as well as its long-term behavioral consequences.

Emerging findings from neuroimaging studies demonstrate that brain structures change during adolescence to become more specialized and efficient in their functioning. Our developmentally focused research indicates important neurocognitive disadvantages among adolescents with alcohol and drug use disorders as compared to teens without substance involvement. For example, even after three weeks of abstinence, alcohol dependent youth display a 10% decrement in delayed memory functions. Neuropsychological testing of these youth followed up to eight years demonstrates that continued heavy drinking during adolescence is associated with diminished memory of verbal and nonverbal material, and poorer performance on tests requiring attention skills. Alcohol and drug withdrawal over the teen years appears to uniquely contribute to deterioration in functioning in visuospatial tasks. Recent brain imaging studies of alcohol and drug using youth compared to youth without such experience have also shown reduced hippocampal volumes, white matter microstructure irregularities, and brain response abnormalities while performing cognitive tasks among those with early alcohol/drug exposure. Additionally, youth who have extensive experience with alcohol have increased brain response when viewing alcohol advertisements compared to other beverage advertisements.

Animal studies are consistent with the findings that alcohol or drug exposure during adolescence has more adverse consequences than delayed (adult) exposure. In these investigations, adolescent alcohol exposure is associated with more frontal lobe damage and poorer spatial memory. Further research is needed to understand how age of drinking or drug use onset and duration of abstinence at the time of assessment affect cognitive and behavioral findings. Longitudinal studies are needed to clarify neuromaturational changes associated with early alcohol and drug exposure and patterns of resiliency. Although the magnitude of effects observed in adolescents’ neurocognition is modest, the implications are major given the prevalence of alcohol involvement, and the important educational, occupational, and social transitions that occur during adolescence.

These new directions in adolescent research will help to inform us on important aspects of cognition, decision-making, motivation, emotional regulation, and risk perception during adolescence, and will help us determine how these factors play a role in the use and consequences of alcohol and drugs. Armed with new knowledge about how adolescents make decisions, control their impulses and desires, and what motivates their behavior, researchers and agencies will be poised to design better preventions and interventions to reduce alcohol, tobacco and other drug experimentation, abuse and dependence, as well as other risky behaviors. Adolescents have in common unique neurobiological and neurocognitive developmental factors that affect risk and resiliency vis-à-vis substance use. Few studies have addressed these developmentally specific neurobiological and neurocognitive mechanisms and consequences of heavy drinking/use in this group despite the importance of these for long-term development.

Vulnerability

While early initiation of substance involvement is a powerful predictor of subsequent dependence, not everyone who uses at a young age later develops abuse or dependence. Even among youth with two alcoholic parents, only about one-half become alcohol dependent. The outcome is determined largely by the interplay of environmental and genetic/biological factors.

Environmental factors have the biggest influence on whether a child first uses alcohol, tobacco or other substances. However, genetic factors have an influence on whether a child continues to use. Understanding how these factors result in initiation and continuation of use or make resolution of drinking/drug use more difficult is essential to disrupting the developmental process of addictive behavior. Thus, a focus on genetic/biological aspect of use may clarify how variations in genes result in differences in how our bodies absorb, distribute, and eliminate substances and variability in tolerance.

Binge Drinking

Binge drinking, episodes of heavy drinking (5 or more drinks for males; 4 or more drinks for females), is a problem for people in any age group, whether or not the drinker is addicted to alcohol. An alarming number of children and adolescents binge drink and that it is increasing. Drinking too much, too fast in this manner carries additional risks especially for youth. They include car crashes, injury, death, property damage, encounters with the justice system, and family, school, and workplace problems. Each drink increases the fatal crash risk more for youth than adults. At a blood alcohol level of 0.08% in every age and gender group there is at least a 11-fold increase in single vehicle fatal crash risk. Among males 16-20 at a blood alcohol level of 0.08% there is a 52-fold increase in single vehicle crash risk compared to sober drivers the same age.

Epidemiology studies have shown beyond doubt that genes play a role in risk of alcohol, tobacco and other drug dependence. Research toward discovering which genes are involved, what biochemical pathways they influence in brain cells, and how these pathways translate into specific behaviors is the next step to this line of investigation. Such findings provide information about genetic/molecular events in the brain that influence use, and provide potential targets for pharmacological intervention. For example, new findings about a naturally occurring marijuana-like substance in the brain also provide potential new molecular targets for pharmacological intervention.

Prevention of Abuse and Dependence

Prevention of alcohol and substance use problems among youth need to be understood as a continuum of services and consequently research needs to span this continuum. This continuum ranges from universal prevention (those appropriate for all children and adolescents who might use alcohol, tobacco or other drugs) to selective preventative measures for subgroups with risk factors for abuse or dependence, to indicated preventative measures for those individually at high risk for the disorder. Preventive interventions for alcohol, tobacco, and other drug use disorders and related problems can be improved through early detection and diagnosis, and through testing of new behavioral strategies at the individual, family, and community levels. Of particular interest are longitudinal data on children entering the age of risk, adolescents and young adults in high-risk environments (college and the military), youth who resolve use/problems without formal treatment, and women of childbearing age. New interventions to prevent early-onset of use can be gleaned through studies that identify developmental and environmental features as well as biological factors that stimulate or suppress addictive behavior.

It is important to evaluate prevention programs on an ongoing basis as well as disseminate research findings to communities, educators, parents, and health care providers who are the first line of defense against alcohol, drugs and other risky behaviors. Both NIAAA and NIDA offer free educational materials designed to help students learn about the impact of alcohol and drugs on the brain and body. Parents, educators, and community leaders can use these materials to help guide their thinking, planning, selection, and delivery of drug abuse prevention programs at the community level. NIAAA and NIDA also have websites that offer science-based information specifically designed for teens. The Leadership to Keep Children Alcohol-Free has recruited 33 Governors’ spouses to spearhead a national prevention campaign which influences both public policy and local practices. The Task Force on College Drinking has brought together university presidents and researchers, and is making headway in efforts to reduce the seemingly intractable problem of drinking by college students.

Clearly, alcohol and substance use disorders are the result of a complex combination of genetic and environmental interactions that influence how people respond to the substance and their initial propensity for using alcohol and drugs. Longitudinal studies of these genetic and environmental factors are crucial for understanding (1) early initiation of drinking and drug use, (2) transition to harmful use, abuse, and dependence, and (3) remission and abatement of alcohol and drug related problems in untreated populations. This is particularly critical for youth as some resolve problematic use without treatment and research in this area can teach us how to facilitate changes in alcohol and drug involvement in ways that are most developmentally appropriate and acceptable to youth. Developmentally specific research in these areas has potential to help identify mechanisms of vulnerability and protection which can be used in prevention.

Improving Effectiveness of Treatment

Findings from the National Household Survey on Drug Abuse indicate that about 10 percent of 12- to 17- year-olds (about 2.3 million) are heavy users of alcohol or drugs, yet only 187,000 (8%) received services. Although estimates of the cost-effectiveness of early intervention are speculative, research suggests that early treatment has the potential to be cost-effective, especially in comparison with incarceration or treatment for a long-term abuse problem. For instance, cost benefit research on drug and alcohol treatment generally (Office of National Drug Control Policy, 2001) suggest that the range of savings is between $2.50 and $9.60 for every dollar spent on treatment. Unfortunately, only one person in seven who would qualify for treatment was admitted to treatment in 1999 (National Institute on Drug Abuse Community Epidemiology Work Group, 1999). The proportion of youth who are admitted to treatment is even smaller.

Much progress has been made in developing behavioral/psychosocial interventions for alcohol and other substance use disorders, but much remains to be investigated. Controlled research trials provide evidence that several psychosocial treatment approaches may be effective in reducing alcohol and other drug use while also improving associated behavioral, familial, and psychosocial outcomes. These outcomes are enhanced when a combination of modalities are offered in a comprehensive, integrated treatment plan that addresses alcohol and drug abuse and a broad range of biopsychosocial problems, skills deficits, and comorbid psychiatric problems. For example, having families involved in the treatment program increases the likelihood of success in youth. Brief Strategic Family Therapy (BSFT) and Cognitive Behavioral Interventions are examples of promising youth specific treatment already in the field. The evaluation and dissemination of more evidence-based interventions in a variety of community venues, including schools, healthcare settings, and prisons, should be a high priority. Developing, evaluating, and improving efficacy and cost-effectiveness of treatments is a central goal in alcohol, tobacco and drug research. Adolescent focused treatment research lags behind adult treatment research. Studies are needed to develop and test new behavioral therapies; conduct clinical trials in existing treatment settings, examine cost-effectiveness of behavioral and pharmaceutical therapies; clarify mechanisms of action that make effective treatments successful; and conduct trials of dissemination strategies, to test how effective they are at introducing behavioral and pharmacological treatments into real-world clinical practice.

Alcohol, tobacco and other drugs affect genders and subpopulations differently, and some groups suffer more adverse effects of alcohol, tobacco and drugs than other groups. For treatment of these youth problems to be optimally effective, research to study the role of gender, ethnicity, socioeconomic status, and other variables in determining the effects of various substance abuse interventions is sorely needed. For example, we need to support studies on specific facilitators and barriers to alcohol and drug treatment in minority and rural populations.

Clearly multifaceted longitudinal research is sorely needed to fully understand the development and resolution of alcohol and drug use disorders in the context of child and adolescent development. Through such focused process research (e.g., changes in brain structure and recovery of functioning, decision making process, social and family dynamics) can improved prevention and intervention policies emerge.

References

Brown, S.A. & Tapert, S.F. (In Press). Adolescence and the trajectory of alcohol use: Basic to clinical studies. In Dahl, R.E. and Spear, L.P. (Eds.), Adolescent Brain Development: Vulnerabilities and Opportunities, Volume 1021 of the Annals of the New York Academy of Sciences.

Brown, S.A., Tapert, S.F., Granholm, E., & Delis, D.C. (2000). Neurocognitive functioning of adolescents: Effects of protracted alcohol use. Alcoholism: Clinical and Experimental Research, 24 (2): 164-171.

Tapert, S.F., Cheung, E.H., Brown, G.G., Frank, L.R., Paulus, M.P., Schweinsburg, A.D., Meloy, M.J., & Brown, S.A. (2003). Neural response to alcohol stimuli in alcohol use disordered adolescents. Archives of General Psychology, 60: 727-735.