Description of the condition
Several studies have demonstrated that adolescent (less than 18 years old) substance abuse is a serious and growing problem (Altobelli 2005).
In Europe, the estimate of lifetime prevalence of use for young adults 15 to 34 years old is of 32.5% for cannabis, 6.3 % for cocaine, ranging from 0.7 % to 13.6 % in different countries, 5.5 % for amphetamines, ranging from under 0.6 % to 12.4 %; most countries reported estimates in the range of 2.1 to 5.8 % for ectasy and from 0.1 % to 5.4 % for LSD. National estimates vary widely between countries in all measures of prevalence. Opioids, mainly heroin, were cited as the primary drug by more than 200,000 clients reported entering specialist drug treatment in 29 European countries in 2010, or 48 % of all reported treatment entrants (EMCDDA 2012).
In Europe in 2011, the European School Survey Project on Alcohol and Other Drugs (ESPAD) collected data on substance use of more than 100,000 15 to 16-year-old European students from 36 countries. Nearly one in three (29%) students in the ESPAD countries perceived cannabis to be (fairly or very) easily available. On average, 18% of students have tried illicit drugs at least once during their lifetime. Most of them (17%) have used cannabis while 6% reported experience with drugs other than cannabis. After cannabis, amphetamines and ecstasy are in second position, each being mentioned by 3% of the students. Lifetime use of cocaine, crack and LSD or other hallucinogens was reported by fewer students (2%) and the rates for heroin and GHB were even lower (1%). Use of cannabis in the past 12 months was 13%, while use in the past 30 days was claimed to be 7% (ESPAD 2012).
In the USA, recent household survey data indicate 9.5 % of youths aged 12 to 17 were current illicit drug users. This rate was similar to the rates of current illicit drug use in 2005 to 2011, but it was lower than the rates from 2002 to 2004. In addition, 7.2 % of youths aged 12 to 17 were current users of marijuana, 2.8 % were current non medical users of psychotherapeutic drugs, 0.8 % were current users of inhalants, 0.6% were current users of hallucinogens, and 0.1 % were current users of cocaine (SAMHSA 2013).
In the USA after 1992, the proportion of young Americans with lifetime use of any drugs rose considerably to a recent high point of 55% in 1999; it then declined gradually to 47% in 2007 through 2009, and stands at 49% in 2012. The annual prevalence of heroin use among 12th graders fell by half between 1975 and 1979, from 1.0% to 0.5%. The rate then held amazingly steady until 1994. Use rose in the mid and late 1990s, along with the use of most drugs; it reached peak levels in 1996 among 8th graders (1.6%), in 1997 among 10th graders (1.4%), and in 2000 among 12th graders (1.5%), suggesting a cohort effect. Since those peak levels, use has declined, with annual prevalence in all three grades fluctuating between 0.7% and 0.9% from 2005 through 2011. Use has declined some in the past two years; in the three grades combined, the 2011 to 2012 decline from 0.7% to 0.6% was significant (Monitoring the Future 2013).
In 2010, most Australians aged 14 years and over (60%) had never used an illicit drug. However, around 15% had used one or more illicit drugs in the past 12 months. Cannabis was the most common illicit drug used recently (10.3%), followed by ecstasy (3.0%) and amphetamines and cocaine (each used by 2.1% of people). Many people who used an illicit drug in 2010 also used other drugs, illicit or licit ( AIHW 2011).
Patterns of drug use have changed over time. An analysis of treatment entry data between 2000 and 2009 showed a decrease in drug injection among primary heroin clients in all European countries (from 58 % to 36 %), particularly in western Europe (EMCDDA 2012). In addition, among opioid users entering treatment in outpatient settings since 2009, those smoking the drug outnumbered those injecting it (EMCDDA 2012).
Description of the intervention
Numerous medications have been successfully used in the treatment of adolescents with a broad array of psychiatric disorders (Hunt 1990; Kaminer 1995). In contrast, medications have been infrequently used in treating substance abuse disorders among adolescents, nevertheless they have generally been shown to be a promising component of such interventions (Kaminer 1995).
The scientific literature examining effective treatments for opioid dependent adults clearly indicates that pharmacotherapy is a necessary and acceptable component of effective treatments for opioid dependence. Nevertheless, when young people must be treated, it probably is necessary to monitor the interventions in order to adapt them to this specific population. Different pharmacological agents have been used as detoxification agents to ameliorate withdrawal symptoms, however, the rate of completion of detoxification tends to be low, and rates of relapse to opioid use following detoxification are high (Gossop 1989; Vaillant 1988). Methadone may still be the medication that is most widely used but buprenorphine is seen as having some advantages for adolescents because of its excellent safety profile and the absence of long-term complications (Levy 2007; Smith 2012). Younger patients who present for treatment of drug dependence often have a shorter history of drug use than treatment-seeking adults. Treatment early in the course of the disorder presents the opportunity to prevent co-morbidities associated with drug use, including acute and chronic medical conditions, and psychiatric and social complications (Levy 2007).
How the intervention might work
Managed withdrawal, or detoxification, is not in itself a treatment for dependence (Lipton 1983; Mattick 1996) but detoxification remains a required first step for many forms of longer-term treatment (Kleber 1982). Withdrawal symptoms, particularly drug craving, may continue to be experienced for weeks and even for months after detoxification, and the period of recovery from dependence is typically influenced by a range of psychological, social and treatment- related factors.
Why it is important to do this review
We did not find any reviews in the published literature that assessed the effectiveness of detoxification treatment for adolescents. Many other Cochrane systematic reviews have been published on the effectiveness of various detoxification treatments: methadone (Amato 2013), buprenorphine (Gowing 2009), alpha2-adrenergic agonists (Gowing 2014), opioid antagonists with minimal sedation (Gowing 2009b) and under heavy sedation (Gowing 2010), psychosocial combined with detoxification treatment (Amato 2011) and one review comparing inpatient versus outpatient settings for opioid detoxification (Day 2005), but none address the question of the effectiveness of treatments for adolescents.