CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines on Assessment and Management of Substance
Abuse Disorder in Children and Adolescents
Navendu Gaur1, Manaswi Gautam2, Shubhmohan Singh3, V. Venkatesh Raju4, Siddharth Sarkar5
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1
Director and Consultant Psychiatrist, Gaur Mental-Health Clinic, Ajmer, 2Director and Consultant Psychiatrist, Gautam Hospital &
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Research Centre, Jaipur, Rajasthan, 3Additional Professor, Department of Psychiatry, 4Senior Resident DM, Child and Adolescent
Psychiatry, PGIMER, Chandigarh, 5Assistant Professor, Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
INTRODUCTION
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
Address for correspondence: Dr. Navendu Gaur,
Gaur Mental‑Health Clinic, Ajmer, Rajasthan, India.
E‑mail: navmang@gmail.com
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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.
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
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
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Gaur N, Gautam M, Singh S, Raju VV,
Sarkar S. Clinical practice guidelines on assessment and
management of substance abuse disorder in children and
adolescents. Indian J Psychiatry 2019;61:333-49.
S333
 Gaur, et al.: Substance abuse in children and adolescents
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
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clinical features
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• 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
Table 1: Clinically significant differentiating characteristics of adolescent substance abusers from adult substance
abusers
Briefer history of substance involvement
Higher chances of episodic substance use than chronic daily
use
Less incidence of progressive disorder, medical complications,
and other consequences of protracted use
Experimentation with varied types of substances, and
consequently having more complicated withdrawal patterns
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• 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
More often associated with co‑occurring psychiatric comorbidity, family
disruption, academic problems, problem behaviors, deviance, and peer drug use
Higher occurrence of improvement by early adulthood without formal intervention
or treatment
Confrontation‑of‑denial approaches to treatment are less successful
Developmental changes may exacerbate the effects of psychotropics
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 Gaur, et al.: Substance abuse in children and adolescents
• 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
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patient into treatment net as long as possible considering
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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
Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019
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
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 Gaur, et al.: Substance abuse in children and adolescents
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
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short‑ and long‑term outcome of the management plan
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• 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 [Tables 2 and 3].
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 [Tables 4 and 5].
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.
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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].
The choice depends on individual patient profile.
a. 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
Table 2: Binge drinking in adolescents
Boys Girls
Age (years) Number of drinks* Age (years) Number of drinks*
9-13 3 9-17 3
14-15 4
16+ 5
*Within 2 h and achieving a BAC of 80 mg%. BAC – Blood alcohol concentration
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 Gaur, et al.: Substance abuse in children and adolescents

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

Highest‑risk Moderate‑risk
Age (years) Approximate number of days child drank (past year) Age (years) Approximate number of days child drank (past year)
≤11 1 12-15 1
12-15 6 16-17 6
16 12 18 12
17 24
18 ≥52
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Table 4: Laboratory testing in alcohol use disorder assessment

To detect recent alcohol intake Breath analysis
BAC
Urine metabolites of alcohol (not required routinely)
Biomarkers for AUD CDT ‑ chronic alcohol consumption
AST and GGT ‑ recent significant consumption
To identify alcohol‑related damage CBC: MCV
Vitamin deficiencies
Hepatorenal testing
Others Ultrasonography: To assess hepatorenal status
Fibroscan: Early diagnosis of alcoholic cirrhosis
ECG: Especially if malnourishment and mineral deficiencies and before initiation of drug therapy
BAC – Blood alcohol concentration; CDT – Carbohydrate deficit transferrin; AST – Aspartate aminotransferase; GGT – Gamma glutamyltransferase;
CBC – Complete blood counts; MCV – Mean cell volume; ECG – Electrocardiography; AUD – Alcohol use disorder

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]
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.
b. Anticraving agents
i. 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
ii. 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.
iii. 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

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 Gaur, et al.: Substance abuse in children and adolescents

Table 5: Alcohol and other drugs assessment tools

Name Authors Details Remarks
Screening only
CRAFFT Knight et al., 6‑item Screens for both alcohol and drugs
2002 Interview Brief screen for primary care professionals
Public domain Developmentally appropriate
AUDIT Saunders JB, 10‑item Developed by WHO
et al., 1993 Internationally validated with a wide range of populations, including
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adolescents
Developed for screening in primary care medical settings
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PESQ Winters, 1992 40 items Indicates need for further assessment of SUDs
Self‑report
ADI Harrell AV and 24‑item Assesses alcohol use in adolescents with psycho‑emotional‑behavioral
Wirtz PW, 1994 Self‑report problems
Identifies those who need further alcohol evaluation or treatment
Defines the type of drinking problem
Can help develop treatment plans and recommendations
RAPI White H and 18 items Assess adolescent problem drinking and related negative consequences
Labouvie E, Self‑report Usable in both clinical and nonclinical population
1989 Public domain
POSIT Rahdert, 1991 139 item Functioning measured in 10 domains
Self‑report “Red flag” items signal the need for further
assessment
CAST Legleye et al., 6‑item Assess the frequency of the following events throughout an individual’s
2007 lifetime: Seemingly nonrecreational use (smoking alone or before
midday), memory disorders, being encouraged to reduce or stop using
cannabis, unsuccessful attempts to quit, and problems linked to cannabis
consumption
SASSI‑A 100 items Identifies those with high probability of having SUD
Self‑report Identifies those unwilling or unable to admit substance abuse
GAIN‑short screen Dennis, 1998 20 items Documents SUD and other psychiatric diagnoses; placement criteria;
Self‑report health, mental distress and environment; and service use outcomes
A brief version allows for screening
An outcome version provides information about critical outcome variables
Comprehensive assessment
ADI Winters and Structured interview Assesses symptoms associated with SUDs
Henley, 1993 Obtains diagnoses, substance use history, and psychosocial functioning
CDDR Brown Items vary Current and lifetime measures of 4 alcohol‑ and other drug‑related
et al.,1998 Structured interview domains
Public domain
ADAD Friedman and 150 items Assess substance use and other life problems
Terras, 1989 Structured interview Assist with treatment planning
Public domain Assess changes in life problem areas and severity over time
APSI Metzger et al., 85 items Provides severity ratings on multiple
1991 Interview domains of functioning
Public domain For use in non‑juvenile justice settings, such as treatment facilities, mental
health agencies, or schools
CASI‑A Meyers et al., Semi‑structured interview 12-18 years
1995 Assess substance use, substance abuse and dependence symptoms, and
related problems
Assists with referral and treatment decisions
Problem identification and for monitoring treatment outcome
PRQ Cady et al., 25‑item Adolescents’ perceptions of the seriousness of alcohol/drug involvement
1996 self‑report and motivation for drug use change and readiness for treatment
GAIN Dennis et al., 1606‑item Documents SUD and other psychiatric diagnoses; placement criteria;
1998 Self‑report/structured health, mental distress and environment; and service use outcomes
interview A brief version allows for screening
An outcome version provides information about critical outcome variables
DUSI‑A Tarter and 159 items Documents the level of involvement with a variety of drugs
Hegedus, 1991 10 domains Quantifies severity of consequences associated with drug use
Self‑report
TASI Kaminer et al., 154 items Provides severity ratings on multiple domains of functioning
1993 Semi‑structured interview Used in those with substance abuse, psychiatric and co‑occurring
Public domain disorders

Contd...

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 Gaur, et al.: Substance abuse in children and adolescents

Table 5: Contd...
Name Authors Details Remarks
PEI Winters et al., 276 items Informs substance use frequency and severity, personal and environmental
1989 Self‑report risk factors, problem screening, and faking
12-18 years
AUDIT – Alcohol use disorders identification test; PEI – Personal experience inventory; TASI – Teen‑addiction severity index; DUSI‑A – Drug use screening
inventory‑ adolescents; GAIN – Global appraisal of individual needs; PRQ – Problem recognition questionnaire; CASI‑A – Comprehensive adolescent severity
index for adolescents; APSI – Adolescent Problem Severity Index; ADAD – Adolescent drug abuse diagnosis; PESQ – Personal experience screening
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questionnaire; ADI – Adolescent Drinking Index; RAPI – Rutgers Alcohol Problem Index; ADI – Adolescent diagnostic interview; POSIT – Problem‑oriented
screening instrument for teenagers; GAIN – Global appraisal of individual needs; CDDR – Customary drinking and drug use record; SASSI‑A – Substance abuse
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subtle screening inventory adolescent version; CAST – Cannabis Abuse Screening Test; SUD – Substance use disorder

Table 6: Medications in alcohol pharmaco prophylaxis ‑ clinical considerations

Drug Dose (mg) Pharmacokinetics Clinically significant/severe Management of adverse effects Significant drug‑drug
adverse effects interactions
Disulfiram Initial: 250- 80%-95% of oral Common=Drowsiness, nausea, Skin: Anti‑histamines Avoid in patient who
500 mg/d, dose absorbed; vomiting, acneiform eruptions Psychosis: Dose reduction or are or were recently
started 12-24 binds irreversibly Rare=allergic dermatitis, fatal discontinuation; adjust dosage of on amprenavir,
h of alcohol to ALDH hepatitis (may occur many anti‑psychotic drug ritonavir, sertraline,
abstinence for months after stopping DSF or Fatal hepatitis/peripheral neuritis/optic metronidazole,
1-2 week without prior liver disease), neuritis: Discontinue DSF paraldehyde, alcohol,
Maintenance: peripheral/optic neuritis, or alcohol‑containing
125-250 mg/d encephalopathy, psychosis preparations (e.g.,
DER Mild: Reassurance, oral fluids cough syrups, tonics);
Mild (BAC 5 to 10 mg/100 mL) Mod‑severe: Restore blood pressure also patients exposed to
Moderate (BAC 50 mg/100 mL) and treat shock; administer oxygen ethylene dibromide or
Severe (BAC 125 to or carbogen (95% O2 + 5% CO2), IV its vapors (e.g., in paint,
150 mg/100 mL) vitamin C (1g), ephedrine sulfate, or IV paint thinner, varnish,
antihistamines, dopamine infusion shellac) or using
If no response, then Fomepizole (4-methyl products that contain
pyrazole): 15 mg/kg IV single dose alcohol (e.g., vinegars,
sauces, aftershave
lotions, liniments)
Acamprosate 333 mg 2 tab Oral bioavailability Uncommon: intestinal cramps, Self‑limiting or discontinuation of drug Increase in serum levels
t.i.d. 11%; renal headache, flatulence, increased of naltrexone
excretion as such. or decreased libido, insomnia,
Before initiation anxiety, muscle weakness, nausea,
and during itchiness, dizziness
follow‑up: Renal Most common: Diarrhea Treat with loperamide or Bismuth
function tests subsalicylate
(urea, electrolytes, Loperamide: 6-8 years, 20-30 kg: start 2
and serum mg PO x1, then 1 mg PO after each loose
Creatinine) to rule stool; Max: 4 mg/day
out severe renal 8-11 year, 30-40 kg: Start 2 mg PO x1,
impairment then 1 mg PO after each loose stool;
Max: 6 mg/day ≥12 year: Start 4 mg PO
x1, then 2 mg PO after each loose stool;
Max: 8 mg/day
Dietary changes
Dose reduction or discontinuation, if persists
Suicidal ideation (less common Contact doctor immediately
but serious) Monitor for onset or worsening of
depression
Discontinue acamprosate
Naltrexone 12.5-25 mg Near complete Nausea, vomiting, diarrhea, Nausea: Take with meals rich in complex Opioid containing
od×1-2 weeks; oral absorption constipation, stomach ache, loss sugars cough/cold/
initiated and hepatic of appetite Simultaneous simethicone or bismuth antidiarrhials: Reduced
3-7 days of metabolism to subsalicylate (1 tbsf) effect
abstinence; active metabolite Reduce dose/stop for 3-5 days than restart Opioid analgesia
maintenance 6‑β‑naltrexol at lower dose requires dose escalation‑
dose 50 mg od (t1/2=13 h) risk of prolonged
respiratory depression

Contd...

Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019 S339

 Gaur, et al.: Substance abuse in children and adolescents

Table 6: Contd...
Drug Dose (mg) Pharmacokinetics Clinically significant/severe
adverse effects
Hepatotoxicity (abdominal
pains that last more than a few
days, fatigue, nausea, weakness,
fever, light‑colored stools, dark
tea‑colored urine, yellowing of
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Management of adverse effects Significant drug‑drug
interactions
In healthy: LFT (i.e., ALT, AST, GGT, Thioridazine:
BR) at baseline and then at 1/3/6 month Somnolence, lethargy
and yearly thereafter NSAIDS: Raised AST/
More frequently if: Baseline LFT high, ALT if dose of NTX
history of liver disease, concurrent >100 mg

sclera or skin) hepatotoxic drug, NTX >50 mg/day, AST/

ALT >5 × normal
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Discontinue NTX
Overdose Symptomatic supportive care
Precipitated opioid withdrawal Discontinue NTX, supportive care,
symptomatic medications to manage
withdrawal symptoms (clonidine,
antispasmodics, antidiarrheals)
Nalmefene 18 mg OD t1/2=13.4 h; slower Most common: Nausea Mostly self‑limiting Not suitable for patients
preferably 1-2 h onset and longer Very common insomnia, Dose reduction required only if severe requiring opioid
before alcohol duration of action dizziness, headache; No risk of hepatic impairment analgesia
intake; if started than naltrexone liver toxicity No requirement to monitor LFT Interaction with
to drink before inducers and inhibitors
the day’s dose, of the UGT2B7 enzyme
then take as
soon as possible
IV – Intravenous; BAC – Blood alcohol concentration; LFT – Liver function tests; NTX – Naltrexone; AST – Aspartate aminotransferase; ALT – Alanine transaminase;
ALDH – Alcohol dehydrogenase; PO – Per oral

has been shown to have some impact in decreasing Special population

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
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.
iv. 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.
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.
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.
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

S340 Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019

 Gaur, et al.: Substance abuse in children and adolescents

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.
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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

With time the perception that cannabis use poses a cannabis use disorder (CUD) is mostly symptomatic.
significant risk of negative consequences has decreased.
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Short term symptomatic medication like diazepam (up

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 Clinical assessment

increase in potency coincides with an increase in treatment

admissions for marijuana use disorders. This is pertinent to AUDIT
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 SCORE > 07 SCORE 03-06 SCORE < 03

is the lack of standardization in dose, potency, or chemical

constituency of cannabis.
Diagnostic evaluation & Brief intervention &
No intervention
treatment intervention periodic evaluation
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 Assess physical
N
Progression of AUD
emotional), and future development of SUD. dependence

Y
Many cannabis users do not consider their cannabis
use problematic, and hence their readiness to quit this Y
Out-patient management
substance might be low. The withdrawal effects of marijuana Mild

are relatively mild as compared to substances like opioids N

and alcohol. Also, many cannabis users espouse the goal of
moderating, rather than quitting altogether. Out-patient Hospitalization &
detoxification detoxification

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
Community Psychosocial
withdrawal expression [Table 8]. intervention ± drug
Long-stay rehabilitation

prophylaxis
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 Figure 1: Algorithm for management of alcohol use disorder

Table 7: Laboratory monitoring of disulfiram therapy

When What
Before starting DSF Breath or blood alcohol tests (if clinically indicated to confirm abstinence)
To confirm abstinence LFT: AST, ALT, GGT, Alkaline phosphatase, LDH, BR, ALB, PT
To determine baselines after stabilization Complete blood count, routine chemistries (if clinically indicated)
KFT: BUN, Cr
Pregnancy test (girls)
After DSF initiation LFT: AST, ALT, GGT, BR
At 2 weeks Pregnancy test (girls)
monthly (or more frequently) × 6 month ECG
every 3 months thereafter KFT: BUN, creatinine
Monthly Urine toxicology screen: Perform only when concern exists about unreported alcohol or drug use
As clinically indicated
DSF – Disulfiram; AST – Aspartate aminotransferase; ALT – Alanine transaminase; GGT – Gamma glutamyltransferase; ECG – Electrocardiography;
LDH – Lactate dehydrogenase; BUN – Blood urea nitrogen; LFT – Liver function tests; PT – Prothrombin time; ALB – Albumin; BR – Bilirubin; Cr – Creatinine

Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019 S341

 Gaur, et al.: Substance abuse in children and adolescents

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
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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

psychiatric evaluation should be undertaken. The sleep The management is either short‑term or long‑term, and
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disturbance should be managed without medications. pharmacological and/or nonpharmacological.

For cannabis use disorders, no pharmacological treatment Short‑term

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.
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),
dermatologist for (burns, contact dermatitis, perioral
eczema) may be required. Complications, if any, must
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.

Table 8: Pretreatment assessment and categorization of intoxication and withdrawal

Intoxication Withdrawal
Acute Chronic Pathological Chronic user
Euphoria, anxiety, relaxation, sensory stimulation, greater appetite Weight gain, lethargy, Psychosis, dysphoric mood (anxiety,
Pupillary constriction, nystagmus, diplopia, conjunctival injection, gynecomastia, reactive delirium, irritability, depressed
photophobia, temporary bronchodilatation, autonomic dysfunction airway disease, panic, mood, restlessness),
(tachycardia, hypertension, orthostatic hypotension) amotivational syndrome, flashbacks insomnia, EEG changes
lower sperm count

S342 Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019

 Gaur, et al.: Substance abuse in children and adolescents
History & Clinical assessment
Intoxication Withdrawal
Assess severity Reassurance
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Acute Chronic Pathological
Reassurance and - Discontinue Cannabis Anxiolytics,
observation - Symptomatic Neuroleptics
Enrol in psychosocial therapy
Figure 2: Management of Cannabis use disorder
• 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
Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019
• 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]
• 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
S343
 Gaur, et al.: Substance abuse in children and adolescents

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
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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.

• Behavioral counseling and long‑term follow‑up 1. Clonidine‑based symptom management

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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.
• 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.

Management: In cases of suspected opioid intoxication, Buprenorphine

airways should be made clear and breathing ensured • It is a partial opioid agonist, that is administered sublingually.
(supported as required). Initially 0.8mg/70kg naloxone It is available in either plain form, or in combination with

Table 9: Nicotine dosage forms and doses

NRT preparation
Nicotine gum/
lozenge 2 mg, 4 mg
Nicotine patch 21 mg,
14 mg, 7 mg
Nicotine Inhaler
10‑mg cartridge delivers
4 mg of nicotine per spray
Nicotine
Nasal spray
Recommendations (in adults) Studies in adolescence
<25 cig=2 mg every 1-2 hourly >25 cig=4 mg every 1-2 h (maximum: 24 gums/day) Gums ‑ yes
Duration: 12 weeks Lozenges ‑ No
Week 1-6:1 piece every 1-2 h; week 7-9: 1 piece every 2-4 h
Week 10-12: 1 piece every 4-8 h
>10 cigarettes/day d: 21 mg/day; <10 cigarettes per d: 14 mg per day Yes
Duration: 10-12 week
Week 1-6:21 mg/day or 14 mg/day; week 7-9: 14 mg/day or 7 mg/day
Week 10-12: 7 mg/day
Usual: 6-16 cartridges per day Initially: 1 cartridge every 1-2 h No
Duration: 12-24 week
Taper in last 6-12 week
1 spray (1 mg nicotine) in each nostril Yes
Initial treatment is 1-2 doses per h, as needed
Typical dosing is 8-40 doses/d
Duration : 12-24 weeks

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 Gaur, et al.: Substance abuse in children and adolescents
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
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6 h after the last heroin dose or 24–48 h after the last
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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
Indian Journal of Psychiatry, Volume 61 (Supplement 2), January 2019
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
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 Gaur, et al.: Substance abuse in children and adolescents
• 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
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Medications included in the category of sedatives and
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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].
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.
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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:
• 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].
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 Gaur, et al.: Substance abuse in children and adolescents

Table 10: Diazepam equivalent dosage of other benzodiazepines

Hypnotics Equivalent doses (diazepam 5 mg) Approximate t½ (h)
Ultra‑short acting benzodiazepines (t1/2 <4 h)
Triazolam 0.25 mg 1-3 h
Midazolam 15 mg 1-3 h
Short‑acting benzodiazepine (t1/2 6-12 h)
Oxazepam 15 mg 4-15 h
Temazepam 10 mg 5-15 h (10 h)
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Intermediate‑acting benzodiazepine (t1/2 12-24 h)

Lorazepam 1 mg 12-16 h
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Bromazepam 3 mg 20 h
Alprazolam 0.5 mg 6-25 h
Flunitrazepam 1 mg 20-30 h
Clobazam 10 mg 17-49 h
Long‑acting benzodiazepines (included effects of active metabolites) (t1/2 >24 h)
Clonazepam 0.5 mg 22-54 h
Diazepam 5 mg 20-80 h
Chlordiazepoxide 10 mg >50 h
Flurazepam 15 mg >50 h
Nitrazepam 5 mg 16-48 h
Z‑drugs
Zolpidem 10 mg 2.4 h
Zopiclone 7.5 mg 5.2 h
Zaleplon 10 mg 1.5 h

Table 11: Short‑term acute management

ATS MDMA Cocaine Management of complications of
stimulant intoxications
General symptomatic and supportive measures In addition to measures In addition to earlier measures Acute rhabdomyolysis: Requires
Rehydration for ATS Chest pain: Hospitalize and urgent diagnosis and treatment
Monitor closely. Emesis or gastric lavage observe otherwise risk of renal failure
Acidification of urine if MDMA toxicity from Hypertension: Use Chest pain: Admit. Risk is highest in
If agitation, sedate with benzodiazepines oral intake, is alert and alpha‑blocker (phentolamine) the 1st h after the use. Monitor with
If extreme agitation or violence, give diazepam IV has taken MDMA less or a combined alpha and serial ECGs, cardiac enzymes and
If on parenteral benzodiazepines, ICU setting is than 4 h previously beta‑adrenergic blocker troponin levels at least 12 h
preferable Correct fluid and (e.g., Labetalol) Administer sublingual glyceryl
In addition, a sedating antipsychotic agent electrolyte imbalance, Avoid β‑blockers as they trinitrate for chest pain and treat as for
(e.g., olanzapine or quetiapine) may be required. particularly exacerbate cocaine‑induced the myocardial infarction but note that
Avoid phenothiazines as they lower seizure hyponatremia coronary artery vasoconstriction cocaine has local anesthetic effects
threshold Avoid calcium‑channel blockers Avoid beta blockers
Close Monitoring for depression and suicidality (increased seizure risk) Avoid aspirin if cerebral hemorrhage
Protection from risk of self‑injury is suspected
ATS – Amphetamine‑type stimulants; MDMA – Methylenedioxy‑methamfetamine; ICU – Intensive care unit ECG – Electrocardiography; IV – Intravenous

CONCLUSION relapse rates (70%), with adjunct pharmacotherapy. SUD runs

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
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.

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 Gaur, et al.: Substance abuse in children and adolescents

Table 12: Planned detoxification and long‑term management

Psychoeducation about withdrawal symptoms and their time course, and reassurance
Elective detoxification
Home: Most cases may be managed in a supportive home environment
Ambulatory: In this, patient visits the hospital on a daily basis
Hospitalization: Severe dependence with medical or psychiatric complications, or having a lack of supportive home environment
A supportive safe, quiet, and nonthreatening environment is essential for rest and sleep
Other aspects of management
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Adequate diet
Short‑term benzodiazepines for insomnia and agitation, e.g., diazepam 20-40 mg in 4 divided doses
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If psychosis, use anti‑psychotics

Craving management: Advise 3 Ds
Delaying the decision to use or not for 1 h
Distracting oneself with some activity during this hour
Decide whether it is worth using after the hour is up
Treat co‑morbid psychiatric disorders. Increased risk of suicide if preexisting depression. Suicide risk assessment should be undertaken regularly, if
indicated
Role of antidepressants
Indicated if preexisting comorbid depression and are administered 4-6 weeks following
abstinence
Tricyclic antidepressants may place the patient at risk of toxicity overdose if the patient is suicidal. May cause CNS depression if combined with other
antidepressants
SSRIs may cause the serotonin syndrome if combined with stimulants
Long‑term
Psychosocial measures: As discussed under general consideration for management of SUD
Pharmacotherapy
Psychostimulant replacement therapy. Includes dexamphetamine, methylphenidate and phentermine
Disulfiram. Attenuate cocaine high thus decreasing desire to use more cocaine
Modafinil and bupropion can be given a trial
CNS – Central nervous system; SSRIs – Selective serotonin reuptake inhibitors; SUD – Substance use disorder

Table 13: Pharmacodynamic interactions between street Financial support and sponsorship

drugs and psychotropics
Cocaine, Amphetamine, Ecstasy, MDA, 6-APB
General Stimulants (cocaine can be sedative in higher doses)
considerations Arrhythmia possible
Cerebral/cardiac ischaemia with cocaine‑ may be fatal
Hyperthermia/dehydration with ecstasy
Older Antipsychotics reduce the psychotropic effect of almost
antipsychotics all drug of abuse by blocking dopamine receptors and
hence patients may take excess doses to get a high
EPS may be more common in those who have taken
ecstasy
Cardiotoxic or very sedating antipsychotics should be
possibly avoided
Atypical Antipsychotics may reduce craving and cocaine‑induced
antipsychotics euphoria
Olanzapine may worsen cocaine dependency
Clozapine may increase cocaine levels but diminish
subjective response
Antidepressants Avoid TCAs (arrhythmia risk)
MAOIs contradicted (hypertension)
SSRI antidepressants are generally ineffective at
attenuating withdrawal effects from cocaine
SSRIs may increase cocaine levels, especially
fluoxetine
Risk of serotonin syndrome with concomitant use of
SSRIs, cocaine or other stimulants (especially MDA
and 6-APB)
SSRIs may enhance subjective reaction to cocaine
SSRIs – Selective serotonin reuptake inhibitors;
MDA – Methylenedioxyamphetamine; 6-APB – 6-(2-aminopropyl) benzofuran;
TCA – Tricyclic antidepressants; MAOIs – Monoamine oxidase inhibitors;
EPS – Extra pyramidal symptoms
Nil.
Conflicts of interest
There are no conflicts of interest.
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