NEW YORK – When evaluating adolescents with substance use disorder (SUD), paying attention to frequently occurring comorbid conditions, such as attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder, is essential for developing a successful treatment plan, according to an expert summary of current strategies that was presented at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.

“If you see SUD in a juvenile, think psychopathogy,” reported Dr. Timothy Wilens, chief of the division of child and adolescent psychiatry, Massachusetts General Hospital, Boston. Citing a series of studies published over the past 20 years, he said that the proportion of patients with SUD and overlapping psychopathology “is approaching 90%.”

The most significant predictor of SUD is conduct disorder whether or not it is linked to ADHD, according to Dr. Wilens. He emphasized the risk of SUD, which can range from a mild form consisting of intermittent use of alcohol or drugs to a severe form consisting of functional impairment and substance dependence, exceeds 80% in children and adolescents with a history of conduct disorder. ADHD specifically can be diagnosed in about 50% of children with SUD.

Overall, the presence of ADHD, mood disorders such as depression or anxiety, posttraumatic stress disorder (PTSD), and bipolar disorder all double the risk of SUD in children and adolescents. In most but not all cases, SUD should be treated first. According to Dr. Wilens, SUD can complicate efforts to treat comorbid psychopathology, particularly if pharmacologic agents such as stimulants are part of the therapy. One exception is bipolar disorder.

Bipolar disorder “is a different story. When I have bipolar kids who are using, I blast through the substance use,” said Dr. Wilens, referring to his strategy of treating this condition either first or in conjunction with treatment of SUD. While he indicated that control of bipolar disorder might be more important for achieving control of SUD than the other way around, he also cited data demonstrating a favorable influence of lithium relative to placebo on alcohol- or marijuana-associated SUD in adolescents. In another study of adolescents with SUD, quetiapine plus topiramate was associated with a significant reduction in marijuana use when compared with quetiapine and placebo.

In adolescents, marijuana is the most common form of SUD. Although alcohol is involved in about 70% of cases of SUD in adults, marijuana is also the most common type of SUD in the pediatric population, according to Dr. Wilens. Although the use of opioids has been trending upwards over the last 10 years in all age groups, use remains relatively low in children and adolescents. Still, 40% of adolescents reported narcotics to be fairly easy or very easy to obtain in a recent survey cited by Dr. Wilens.

“Most are getting the narcotics from family or friends,” reported Dr. Wilens, noting that these are too often found in the bathroom medicine cabinet. He suggested that parents could reduce risk of adolescent use of narcotics by either throwing away spare pills or putting them in a place where they are less likely to be found.

In a treatment plan for adolescents, harm reduction is the first concern, but Dr. Wilens also counseled that reasonable goals and a collaborative approach to treatment should be introduced long before a “tough love” strategy that includes total abstinence. In children with moderate to severe SUD, Dr. Wilens suggested that clinicians should work to define triggers and then negotiate reasonable strategies to change behavior.

In motivated children, one strategy is “sobriety sampling.” In this approach, the patient is challenged to abstain from substance use for a finite period, such as a month. According to Dr. Wilens, “kids often realize that they feel better,” which is a critical step toward success in avoiding triggers.

There are a number of psychotherapies, such as cognitive behavioral modification, and psychopharmacologic strategies, such as N-acetyl cysteine (NAC) and buspirone, associated with success in treating SUD, but dedicated treatment facilities may be the right answer when clinicians do not have the time or experience to provide care. Dr. Wilens suggested that a national treatment facility locator developed by the Substance Abuse and Mental Health Services Administration may be helpful. The locator tool can be found online (www.findtreatment.samhsa.gov).

One reason to treat SUD in adolescents is that the problem, if untreated, is likely to persist. Data suggest that 50% of adults with SUD developed this condition before the age of 18. For many patients, success in treatment will depend on strategies that ultimately addresses both SUD and the frequently occurring comorbid conditions. Overall, Dr. Wilens recommended a systematic but not a rigid approach.

“The ultimate goal of harm reduction is abstinence, but we are not saying you are a failure if you did not just stop,” Dr. Wilens said. Although a “tough love” approach may have value in some patients “it is not an first, second, third, fourth, or fifth intervention. It may be one, but it’s down the line.”

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In adolescents, treat substance use disorder before ADHD