Adolescents receiving treatment for alcohol and drug problems differ in length, intensity and topography of psychoactive substance use compared with clinical samples of adults. The propensity of American adolescents in treatment to use multiple substances has been well documented. Between 70 and 98% of adolescents in treatment for substance abuse are polysubstance abusers (Brown, Vik & Creamer, 1989; Estroff,Schwartz & Hoffman, 1989; Smith, Schwartz & Martin, 1989). Polysubstance abuse is common among adults in treatment samples but less prevalent than among teens, ranging from 0 to 55% (Hesselbrock, Meyer & Keener, 1985; Gawin & Kleber, 1986; Sellers et al., 1991). As noted by others (e.g. Pandina, 1986) polysubstance use by adolescents complicates the diagnosis of alcohol use disorders.
Other differences in clinical samples of adolescent and adult alcohol and drug abusers can be understood as age-related characteristics (Filstead, Parella & Conlin, 1988). Due to restrictions in age range, clinical adolescent populations have an earlier onset of substance use and a shorter duration of substance use than adults entering treatment (Brown, Mott & Myers, 1990). Similarly, adolescents have less time to experience deterioration in role functioning (Blum, 1987; Obermeier & Henry, 1985) and have less time to encounter major problems related to their alcohol and drug use (Filstead et al., 1989). Despite these characteristics that may limit the manifestation of alcohol and other drug related problems, adolescents have been shown to have a rapid progression from experimentation to abuse (Brown, Mott& Stewart, 1992; Smith et al., 1989). Adolescent polysubstance abuse and early onset of drinking have also been found to be prognostic of poor adult treatment outcome (Brown, 1993; Kashani et al., 1987). An adverse impact of heavy drug use on the psychosocial and physical development of adolescents has been suggested (Brown, 1993; Brown, Myers, Mort & Vik, 1994; Newcomb & Bentier, 1988).
The diagnosis of psychoactive substance withdrawal and dependency among adolescent alcohol and drug abusers is critical to the delivery of appropriate medical and psychological services. Empirically based criteria for the diagnosis of substance withdrawal and dependency have been established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987; and DSM-IV, American Psychiatric Association, 1994). While clinical research has sought to validate DSM-III-R and DSM-IV criteria using adult populations, there is little empirical data evaluating the applicability of these criteria to adolescent populations.
DSM-III-R provides distinct criteria for withdrawal from alcohol and drugs of different classes. DSM-III-R criteria for alcohol withdrawal have been found to be essentially the same as the symptoms experienced by adult patients in substance abuse treatment, with anxiety and perceptual disturbance being high discriminators of a withdrawal syndrome (Sellers et al., 1991). The withdrawal sequelae of opiates and benzodiazapenes have been verified in numerous clinical studies (see Chiang & Goldfrank, 1990 for review).
Validity of DSM criteria for central stimulant withdrawal and the absence of criteria for cannabis withdrawal are more controversial. While it has been argued that psychological dependence and withdrawal are the only effects of central stimulant abuse (Hall, Kulig & Rumack, 1985), Dackis and Gold (1990) have shown that central stimulants cause identifiable physical addiction and withdrawal. Brower and associates found that the central stimulant withdrawal syndrome in an inpatient population was similar to DSM-III-R criteria but that an additional group of physical symptoms including muscle pains, chills and tremor were present (Brower et al., 1988). Cannabis withdrawal is not included in DSM-III-R or DSM-IV, although some research has identified a cannabis withdrawal syndrome in adults (Rohr, Skowlund & Martin, 1989; Tunving, 1985) which includes psychological and physical symptoms. Unfortunately, in these studies the effects of cannabis abuse are confounded with co-morbid mental disorders and other substance abuse.
Although empirical evidence is sparse, it is widely held that adolescents do not exhibit physical dependence in the form of tolerance or withdrawal to any substance (Blum, 1987; Bright, Hawley & Siegel, 1985). There is some evidence that adolescents in treatment for alcohol or drug problems are less likely than adults to exhibit tolerance to and withdrawal from alcohol (Filstead et al., 1988). One survey of adolescent inpatient substance abusers found that only 8% required any medical detoxification (Obermeier & Henry, 1985). In part because of the limited need for medical intervention, DSM-III-R and DSM-IV list the typical age of onset for alcohol withdrawal syndrome as in the twenties and thirties.
Prior to DSM-III-R, physical addiction to a substance, evidenced by tolerance and withdrawal, was seen as the defining feature of psychoactive substance dependence. In contrast, current conceptualizations of dependence give psychosocial and behavioral factors equal weight in defining the syndrome (Falk, 1983; Dackis & Gold, 1990). Psychoactive substance dependence has a single set of criteria in DSM-III-R and DSM-IV that are applied to any substance of abuse. These criteria include loss of control over use, behavioral tolerance, withdrawal symptoms and continued use despite deterioration in functioning across life domains. The DSM-III-R criteria have been found to describe adequately dependence in adult populations (see Nathan, 1991 for review). Continued use despite several major life problems has been identified as an important and necessary factor in dependence on central stimulants (Dackis & Gold, 1990), alcohol (Kranzler & Babor, 1990) and cannabis (Tunving, 1985).
Although adolescent abuse of psychoactive substances is widely acknowledged, transient high levels of drug and alcohol use have been considered normal for adolescents (Jessor & Jessor, 1983). Because physical addiction and major role deterioration are not often reported by teens in treatment for alcohol or drug problems (Blum, 1987), it is unclear whether adolescents can be considered dependent on psychoactive substances. In community samples dependence estimates vary among adolescents. For example, Rachal et al. (1976) identified 30% of teens as alcohol abusers in a high-school sample based on quantity and frequency of drinking. When major life problems were used as an additional criterion only 5% of teens were identified as abusers. Donovan & Jessor (1978) found, however, that psychosocial correlates of problem drinking remained the same for a community sample of adolescents whether or not quantity and frequency or life problems were used as criteria. The distinction between substance abuse and substance dependence is important for intervention with adolescents in treatment for psychoactive substance use. Kashani et al. (1987) found, in a retrospective study of adult alcoholics, that early onset of alcohol dependence predicted a poorer outcome in adulthood. Also, treatment of adolescent substance abuse is largely based on adult models that assume patients are substance dependent (Brown, Mort & Myers, 1990; Obermeier & Henry, 1985).
The majority of substance abusing adolescents in the present study reported significant withdrawal symptoms for at least two substances of abuse. The most frequent of the psychoactive substance withdrawal symptoms reported by adolescents were mood related (e.g. depression, anger and anxiety) although physiological and cognitive symptoms were also reported by a majority of adolescents. In general, adolescents met dependency criteria for at least two drugs and half also met dependency criteria for alcohol. As expected, heavier alcohol use was associated with a greater number of alcohol withdrawal symptoms and contributed to polysubstance withdrawal. Similarly, cigarette use was associated with greater withdrawal from psychoactive substances. Despite comparable drug use patterns for the males and females in our treatment sample, females reported more severe withdrawal from alcohol and other psychoactive drugs which is consistent with gender differences reported in DSM-IV for adults.
Adolescent withdrawal symptoms reported in our sample were in excess of those previously reported in the adolescent substance abuse literature (e.g. Filstead et al., 1988) and greater than expected for amphetamines, marijuana oralcohol given the relatively short duration of use. However, the fact that these adolescents, like most other current treatment samples, used more than three substances regularly during the 3 months preceding treatment may explain the variety and intensity of withdrawal symptoms reported.
Few empirical studies have been conducted on adolescent withdrawal from psychoactive substances. It has been argued that adolescents' use of amphetamines and marijuana and short duration of alcohol use should not lead to a severe withdrawal syndrome (Hall eta/., 1985). The present study raises questions about the accuracy of this prevailing view. Adolescents in this study reported frequent physiological as well as psychological symptoms that varied in severity with the level and type of substances used.
One explanation for the intensity and diversity of withdrawal reported by adolescents in our study is their level of psychoactive substance dependence. According to DSM-III-R criteria, adolescents in treatment were dependent on at least one (96%) or two (71%) substances and half (49%) met criteria for alcohol dependence. Additionally, 31% were dependent on a third drug. Because adolescents are less likely to be working, or to have formed committed relationships, than adults they have less opportunity to decline in these areas. In contrast, a majority of adolescents repeatedly drove while intoxicated and stopped or changed social or school activities because of their use indicating that substance use is replacing usually important adolescent activities. DSM-III-R criteria do not assess the impact of substance dependence on adolescent development in such areas as social relationships, achievement of young adult roles, separation or individuation from family and physical development. Our studies to date suggest that lack of control over substance use, frequency of use and reduction in academic and social activities may be the best DSM-III-R or DSM-IV indicators of dependency among adolescent substance abusers entering treatment.
Withdrawal and dependency symptoms were assessed using adolescent self-report. While adolescent self-report of alcohol and drug use has demonstrated reliability (Henly & Winters, 1989) little is known of the reliability of self-report for withdrawal and dependency symptoms among adults or adolescents. No biological measures of level of drug or alcohol use were taken; nor were adolescents observed during acute withdrawal to measure vital signs or other symptoms. Although teens were abstinent from all substances for approximately 2 weeks, structured interviews were employed and interviewers were trained to facilitate adolescent recall and to distinguish withdrawal symptoms from intoxication states, it is possible that some reported symptoms were associated with intoxication. Pre-existing psychiatric disorders were excluded based on medical chart review and clinical history but no separate structured diagnostic interview was conducted to ascertain Axis I disorders. These adolescents may have reported mood disturbances as withdrawal symptoms that were actually part of a co-morbid psychiatric condition or a substance-induced mood disorder as outlined in DSM-IV. As mentioned, the multiple substances used by this sample of adolescents affects their ability to isolate withdrawal and dependency symptoms that occurred for individual drugs. Of note, the findings that level of use of alcohol exclusively contributed to the report of alcohol withdrawal and level of use of inhalants, hallucinogens and amphetamines contributed most to report of polysubstance withdrawal supports the discriminant validity of adolescent report of substance withdrawal. Adolescents in this study used multiple psychoactive substances, primarily cigarettes, alcohol, marijuana and amphetamines.
Generalizability to other drugs is questionable. Similarly, the small number of ethnic minorities in our sample limits generalizability to a more diverse American population. The withdrawal and dependency symptoms queried in this study were based on DSM-III-R diagnostic criteria. While withdrawal symptoms from DSM-III-R and DSM-IV are comparable, some DSM-III-R dependency symptoms have been recategorized as symptoms of abuse. The most prevalent dependency symptoms reported by adolescents in our sample are consistent with both DSM-III-R and DSM-IV dependency criteria.
Despite these limitations our results have important implications for research and clinical practice with adolescents in substance abuse treatment. Research that focuses on single substances of abuse, should also take into account the effects of the other substances adolescents may be concomitantly using. Substance abusing adolescents in treatment are unlikely to be dependent on or withdrawing from a single substance. DSM-III-R and DSM-IV criteria for withdrawal from specific substances do not appear to sufficiently describe the withdrawal symptoms adolescents experience from multiple substances. Most adolescents experienced withdrawal that included physiological, psychological and cognitive disturbances but did not uniformly fit a diagnosis of alcohol or single substance withdrawal.
-Stewart, David & Sandra Brown, Withdrawal and Dependency Symptoms Among Adolescent Alcohol and Drug Abusers, Addiction, May 1995, Vol. 90, Issue 5.
Reflection Exercise #4
The preceding section contained information
about withdrawal and dependency symptoms among adolescents. Write
three case study examples regarding how you might use the content of this section
in your practice.
What was the most frequent psychoactive substance withdrawal symptoms reported by adolescents? Record the letter of the correct answer