The Stages of Change Model

The Stages of Change model comprises five primary stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. A sixth stage, Termination, is often included but is less applicable to adolescent substance use due to the chronic nature of substance use disorders. The fluidity of these stages, with possible progression and regression, underscores the importance of continuous assessment and individualized intervention strategies.

1. Precontemplation: Adolescents in this stage are not considering change, either due to denial of the problem, lack of awareness, or perceived invulnerability. This stage is particularly challenging as adolescents may not perceive their substance use as problematic, or they may resist change due to peer influence and a desire for autonomy.
2. Contemplation: At this stage, adolescents acknowledge the potential risks associated with their substance use but are ambivalent about change. They may weigh the pros and cons of their behavior, often resulting in prolonged deliberation. This stage is critical for clinicians to build rapport and enhance motivation through motivational interviewing, a technique that helps resolve ambivalence by eliciting the adolescent’s own reasons for change.
3. Preparation: Adolescents in the preparation stage have made the decision to change and are planning to take action in the near future. At this point, specific goals and strategies for change should be developed collaboratively between the clinician and the adolescent. Interventions might include the development of coping strategies, addressing environmental triggers, and fostering supportive relationships that encourage sobriety.
4. Action: This stage involves the implementation of change, where the adolescent actively alters their behavior and environment to reduce or eliminate substance use. Clinicians play a crucial role in supporting adolescents during this stage by providing ongoing reinforcement, addressing challenges and setbacks, and ensuring that the strategies devised in the preparation stage are effectively employed.
5. Maintenance: In the maintenance stage, the focus shifts to sustaining the changes made during the action stage and preventing relapse. Adolescents are at risk of relapse due to the persistent nature of cravings, social pressures, and emotional triggers. Long-term success in this stage often requires continued counseling, participation in support groups, and ongoing monitoring by healthcare providers.

Clinical Application

Effective utilization of the Stages of Change model in adolescent substance use requires a thorough assessment of the adolescent’s current stage, followed by the implementation of stage-appropriate interventions. Physicians and counselors must be adept at identifying the subtle indicators of each stage and tailoring their approach to match the adolescent’s readiness to change.

1. Assessment and Rapport Building: Initial assessment should focus on understanding the adolescent’s perception of their substance use, their readiness to change, and any co-occurring mental health issues. Building rapport is essential, as adolescents are more likely to engage in treatment when they feel understood and respected. Tools such as the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) can be used to gauge the adolescent’s stage of change.
2. Motivational Interviewing: Motivational interviewing is particularly effective in the precontemplation and contemplation stages. This client-centered, directive method facilitates the exploration of ambivalence and strengthens the adolescent’s intrinsic motivation for change. Key techniques include expressing empathy, developing discrepancy between the adolescent’s goals and their current behavior, rolling with resistance, and supporting self-efficacy.
3. Tailored Interventions: Interventions should be stage-specific. For example, adolescents in the precontemplation stage may benefit from psychoeducation and discussions about the consequences of substance use, while those in the preparation stage might require help with developing actionable plans and identifying triggers. In the action stage, clinicians should focus on skill-building and problem-solving to navigate real-world challenges.
4. Relapse Prevention: Maintenance strategies should incorporate relapse prevention techniques, such as cognitive-behavioral therapy (CBT), which helps adolescents identify and challenge cognitive distortions that could lead to relapse. The use of contingency management, where positive behaviors are reinforced through rewards, has also shown efficacy in maintaining long-term sobriety.

Conclusion

The Stages of Change model offers a comprehensive framework that enables clinicians to deliver personalized care in the treatment of adolescent substance use. By aligning interventions with the adolescent’s stage of change, physicians and counselors can more effectively support the adolescent’s journey toward recovery. Continued research and training in the application of this model are essential to improving outcomes in this vulnerable population.

References

1. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
2. DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3-24). Springer US.
3. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.
4. Moyer, V. A., & US Preventive Services Task Force. (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 159(3), 210-218.
5. Wagner, E. F., & Ingersoll, K. S. (2013). Beyond cognitions: Broadening the treatment of adolescent alcohol and drug use. In E. F. Wagner & H. B. Waldron (Eds.), Innovations in adolescent substance abuse interventions (pp. 171-188). Elsevier.
6. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334.
7. Liddle, H. A., & Dakof, G. A. (1995). Efficacy of family therapy for drug abuse: Promising but not definitive. Journal of Marital and Family Therapy, 21(4), 511-543.
8. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33(3), 511-525.
9. Kaminer, Y., & Godley, S. H. (2010). Adolescent substance use disorders: Developmental considerations. In Y. Kaminer & K. C. Winters (Eds.), Clinical manual of adolescent substance abuse treatment (pp. 1-24). American Psychiatric Publishing.
10. Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. Guilford Press.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Theoretical Framework and Application of MI in Adolescence

Motivational interviewing was developed by Miller and Rollnick in the early 1980s as an approach to address ambivalence in clients with alcohol use disorders. Rooted in humanistic psychology, particularly the work of Carl Rogers, MI emphasizes empathy, respect for autonomy, and the therapeutic alliance. MI operates on the premise that behavior change is more likely when individuals feel they are in control of their decisions and are supported in exploring their reasons for change. This approach aligns well with the developmental stage of adolescence, characterized by an increased desire for autonomy and identity exploration.

Adolescents often present with ambivalence about changing their substance use behaviors. On one hand, they may recognize the negative consequences associated with their use, while on the other, they may view substance use as a means to achieve social acceptance or cope with stress. MI is particularly suited to addressing this ambivalence, as it provides a non-confrontational space for adolescents to express their thoughts and feelings, ultimately helping them to articulate and strengthen their motivation for change.

Efficacy of MI in Treating Adolescent Substance Use

The efficacy of MI in treating adolescent substance use has been supported by a growing body of research. Meta-analyses have demonstrated that MI is associated with small to moderate reductions in substance use among adolescents, with some studies indicating that MI may be particularly effective when used in combination with other therapeutic approaches, such as cognitive-behavioral therapy (CBT) (Barnett et al., 2012; Jensen et al., 2011). The adaptability of MI across diverse settings, including primary care, schools, and juvenile justice facilities, further underscores its utility in addressing adolescent substance use (Hettema et al., 2005).

One of the strengths of MI lies in its ability to engage adolescents who may be resistant or avoidant to treatment. Traditional approaches that emphasize confrontation and directive advice are often met with resistance, particularly among adolescents who may perceive such tactics as threats to their autonomy. In contrast, MI’s emphasis on collaboration and respect for the adolescent’s perspective fosters a sense of empowerment, making it more likely that the adolescent will engage in the treatment process (D’Amico et al., 2015).

Mechanisms of Change in MI

The mechanisms through which MI effects change in adolescent substance use are multifaceted. Central to MI is the concept of change talk, or the client’s verbal expressions that favor movement toward change. Research has shown that the frequency and strength of change talk during MI sessions are predictive of subsequent behavior change (Moyers et al., 2007). By eliciting and reinforcing change talk, clinicians can help adolescents build a stronger commitment to change.

In addition to change talk, the therapeutic alliance in MI is another key mechanism of change. The quality of the relationship between the adolescent and the clinician has been consistently linked to positive outcomes in substance use treatment (Karno & Longabaugh, 2005). MI’s focus on empathy, active listening, and unconditional positive regard contributes to the development of a strong therapeutic alliance, which in turn enhances the likelihood of successful outcomes.

Implementation and Integration into Practice

For physicians and counselors working with adolescents, the integration of MI into clinical practice requires both skill development and ongoing supervision. Training in MI typically involves workshops, role-playing, and feedback, with an emphasis on developing proficiency in MI techniques, such as reflective listening, summarizing, and eliciting change talk (Miller & Rollnick, 2013). Additionally, ongoing supervision and fidelity monitoring are essential to ensure that MI is being delivered as intended and to maintain clinician competency over time.

Physicians, in particular, may find MI to be a valuable tool in brief interventions during routine clinical encounters. Given the limited time available in most medical settings, MI’s brevity and focus on specific behavior change goals make it an efficient approach for addressing substance use. Moreover, the incorporation of MI into primary care settings has been shown to enhance patient engagement and improve outcomes in adolescent substance use (D’Amico et al., 2015).

Challenges and Considerations

Despite its demonstrated efficacy, the implementation of MI in adolescent substance use treatment is not without challenges. One significant barrier is the variability in clinicians’ adherence to MI principles, which can impact treatment outcomes. Additionally, the effectiveness of MI may be influenced by the adolescent’s readiness to change, with those at higher stages of readiness potentially deriving greater benefit from MI (Prochaska & DiClemente, 1983). Furthermore, while MI has been shown to be effective across diverse populations, cultural factors should be considered when applying MI in different contexts, as cultural values and norms can influence the adolescent’s perceptions of substance use and change.

Conclusion

Motivational interviewing represents a promising approach to addressing substance use among adolescents. Its emphasis on autonomy, empathy, and the therapeutic alliance makes it particularly well-suited to the developmental needs of adolescents, who may be ambivalent about change. While challenges exist in its implementation, MI’s adaptability and evidence base make it a valuable tool for physicians and counselors working to reduce substance use in this vulnerable population. Continued research and training efforts are essential to maximize the potential of MI in adolescent substance use treatment.

References

1. Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational interviewing for adolescent substance use: A review of the literature. Addiction Research & Theory, 20(4), 329-342.
2. D’Amico, E. J., Miles, J. N. V., Stern, S. A., & Meredith, L. S. (2015). Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment, 50, 46-53.
3. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.
4. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. Journal of Consulting and Clinical Psychology, 79(4), 433-440.
5. Karno, M. P., & Longabaugh, R. (2005). What do we know? Process analysis and the search for a better understanding of Project MATCH’s anger-by-treatment matching effect. Journal of Studies on Alcohol, 66(5), 644-652.
6. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
7. Moyers, T. B., Martin, T., Houck, J. M., Christopher, P. J., & Tonigan, J. S. (2007). Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment, 32(2), 197-206.
8. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
9. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334.
10. Wagner, E. F., & Ingersoll, K. S. (Eds.). (2012). Motivational interviewing in the treatment of psychological problems. Guilford Press.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Vista Hill Native American SmartCare Program

This said, the following discussion of the ‘ordinary’ challenges of the adolescent phase of development may offer some hope about their intrinsic resiliency— while the risks and dangers have been seriously elevated, teens’ intrinsic adaptability can be expected to assist most of them in handling risks and dangers safely and, with that, there is reason for hope that they can and will find opportunities for growth even in the face of adversity.

No phase of parenting evokes as much consternation and concern as the adolescent years of transitions, and this is with good cause. It is a time of dramatic change for the teen — there are enormous challenges to deal with: body changes, increased and complex social pressures, changes in mood and thinking, changing sexual awareness, and an adult world that may be seem and even be more distressed or confounded as the teens themselves may be, about how to handle all the transition and new concerns.

All these changes and the multiple challenges of growing up come with risk and vulnerability, and as a society, there is and also has been a widely-held view that “adolescence” equals “trouble”.   Fortunately, this view is more myth than fact, as the vast majority (albeit not all) of teens manage their adolescent transitions relatively smoothly and progress into young adulthood without permanent damage or harm to themselves or to others.  Keeping this in mind can assist parents and others position themselves to better support healthy outcomes for their teens and young adults.

For sure, the dangers and risks are great and many: drinking, smoking, reckless driving, injury from risky sports, drugs (illegal and legal), pregnancy, STDs, school failures, runaways, antisocial behaviors, and on and on and on. Teens with pre-existing problems and those with families in distress are particularly vulnerable.  But, again, most teens—through good fortune, attentive and balanced parenting, and/or support from peers, teachers and other adults in the community, go through their growing pains and development safely.

Taking risks is an essential part of the adolescent process, even as it may take the breath away and test the patience of the best of parents and providers.   It can be exquisitely challenging for parents, teachers and other adults to provide a balance of support and corrective guidance so that teens make wiser choices at they push into new areas of living and experimentation.  An appreciation for most young persons’ judgment and resilience can be helpful in finding a helpful posture in relating to them and helping them in their growth and development.   Fear driven and negative approaches with teens most often fail, while positive Involvement, encouragement, and engagement between an adolescent and his/her parent(s) and other adults is one of the best preventive tools.

When in doubt or in the face of persistent problems, consultation with a mental health professional is a wise intervention.  For those seeking further information the following references may be of benefit.

References:

“Your Adolescent: Emotional, Behavioral, and Cognitive Development from Early Adolescence Through the Teen Years – David Pruitt, MD & the American Academy of Child & Adolescent Psychiatry, Harper Collins Press, 2000

“The Romance of Risk: Why Teens Do the Things They Do”, Lynn Ponton, M.D.; Basic Books, 1998

A recent randomized control trial highlighted the role for Escitalopram in helping teenagers with generalized anxiety (Strawn et al, 2020). Interestingly, the study also found that certain genetic factors may impact effectiveness of the medication. This highlights the clear role for SSRIs in anxiety management, as well as possible future directions for tailoring psychiatric treatment. Other reviews of anxiety treatment highlight that SSRIs can be effective for multiple anxiety disorders (Generalized anxiety, social anxiety, panic disorder and others), and in general can take up to 8 weeks to take full effect (Kodish et al., 2011).

A proposed dosing strategy for adolescents with anxiety

Sertraline – start at 25 mg and increase by 25 mg every 1-4 weeks, targeting symptom remission. Typically response occurs between 100 – 150 mg, but can occur at lower doses. Sometimes doses up to 200mg may be used, provided the medication is tolerated.

Fluoxetine – start at 10 and increase by 10 mg – every 1-4 weeks, targeting symptom remission. Typically response occurs between 20 – 40 mg, but can occur at lower doses. Rarely doses up to 60 mg may be used, provided the medication is tolerated.

Escitalopram – start at 5 – 10 and increase by 5 – 10 mg – every 1-4 weeks, targeting symptom remission. Maximum dose is 20 mg, higher doses are not recommended due to QTC prolonging risks.

For referrals or psychopharm guidance

• SmartCare for Families : 858-956-5900
• SmartCare for Providers : 858-880-6405
• Psychologytoday.com
• County Sevices
  • https://www.optumsandiego.com/content/dam/san-diego/documents/socdirectory/SBC_DBH-SUDRS_Provider_Directory_English.pdfIpser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2.Strawn JR, Mills JA, Schroeder H, Mossman SA, Varney ST, Ramsey LB, Poweleit EA, Desta Z, Cecil K, DelBello MP. Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. J Clin Psychiatry. 2020 Aug 25;81(5):20m13396. doi: 10.4088/JCP.20m13396. PMID: 32857933; PMCID: PMC7504974.
  • Kodish, I., Rockhill, C., & Varley, C. (2011). Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues in clinical neuroscience, 13(4), 439–452.

Additional issues arise with the prevalence of youth presenting with complex clinical presentations with multiple co-morbidities, varying symptomatic profiles over the course of time, and innumerable stressors impacting them during their years of growth and development. In the face of these challenges, there are often pressures for physicians and other prescribers to seek clinical benefit through the use of more than one medication— sometimes this makes perfect sense (as with the concurrent use of stimulants and α-agonists) but sometimes it may be a sign of a prescriber being stretched or overwhelmed. While the rationale for using polypharmacy can often be quite substantial, there are obvious concerns about problems emerging— current trends, discussed below, highlight the importance for providers using a cautious and thoughtful approach to using multiple medication treatments in the population.

In a recently published article in JAMA Pediatrics (C. Zhang, MPH, and colleagues) reported on findings of a retrospective analysis of prescriptions detailing the increase in psychotropic polypharmacy over the course of the past 15 years, from 1999 through 2015.

With a definition of polypharmacy being the use of two or more psychotropic medications, there has been a substantial increase in youth being prescribed multiple medications for behavioral health concerns. Medication classes included in the study included stimulants, antidepressants, mood stabilizers, antipsychotics, anxiolytics, sedatives, and α-agonists.

Among the findings of the study:

1. ADHD:   Not surprisingly, the largest cohort of youngsters being treated with multiple medication were those who carried a diagnosis of ADHD (80%) as this is among the most common disorders in the population and one that is often associated with co-occurring behavioral concerns.
2. Diagnosis: There have been increased rates of diagnosing mood disorders (anxiety and depression) and Autism Spectrum Disorder.
3. Antipsychotic agents: Prescriptions for antipsychotics in youth prescribed multiple psychiatric medications doubled from the first to the third time periods, rising from 38% of youth in 1999-2005 to 75% between 2011 and 2015.
4. α-agonists (guanfacine and clonidine) show significant increased rates of use
5. Mood Stabilizers: In contrast, there was a significant decline in mood stabilizer use (from 61% of youth between 1999 and 2004 to 38% of youth between 2011 and 2015).
6. Antidepressants:   Still frequently prescribed, but with a modest decrease in use noted
7. Three or more medications:   Broken into five year segments (1999-2005; 2005-2010, 2011-2015) their study demonstrated a greater than doubling (~ 210%) from the first time segment to the second with a subsequent increase for the third at ~130% over the 2005-2010 segment– all told the number of youth receiving multiple medications increased just shy of threefold.
8. Racial disparities: the use of polypharmacy is significantly higher in youth of color – this, as with other issues of racial disparity is an arena of concern and one for further inquiry and sensitivity.

Some Practical Guidelines:

Dr. Oliver Wendall Holmes Sr. (1809-1894) who lived and worked in a different era, is reported to have said that ‘if all the medications in our pharmacopeia were to be dumped into the oceans, it would be all the worse for the fishes and all the better for mankind’.

We live in a different era with quite a bit more science and far better tools at our disposal, so that, in the face of rapid changes in practice patterns as described in the referenced study, it can be all too attractive to get on a “Medications are (or Polypharmacy is) Bad” soap box. But we know that proper medication regimes can be life enhancing and at times lifesaving for many.

The following guidelines are suggested

1. Prescribe with care, basing treatment on clarity of diagnosis and with full consideration of the potential complexities of each individual.
2. Seek to coordinate care with a qualified and clinically astute therapist who can address psychosocial issues with the youth, the family and with school and community partners and one that is committed to ongoing dialogue about the patient.
3. If you are prescribing, see your patient frequently enough to monitor their progress and assess for ongoing or newly developing concerns.   Be clear in your own mind what symptoms are being targeted with medications you are prescribing and monitor for efficacy and side effects with regular contacts.
4. When clearly indicated, titrate dosing to optimize response and accept polypharmacy approaches if they make sense— but keep it simple and avoid the temptation to simply add medications when things are not getting better.
5. Sometimes careful and thoughtful de-prescribing makes more sense than ramping up dose of adding extra agents. Discontinuing a medication can often be more difficulty to do, but if an agent has not shown evidence of efficacy or benefit, removing it from the treatment regimen should seriously be considered.
6. Utilize both clinical inquiry and screening tools to monitor progress and/or lack thereof.   Encourage parents and patients to call you if they have concerns.
7. Consult with a peer or colleague in your practice to seek input and learn collaboratively. When in doubt, refer to a trusted consultant – what you learn will help with your current patient and will enhance your comfort and capacity to address similar issues with other patients in the future.

References:

Characteristics of Youths Treated With Psychotropic Polypharmacy in the United States, 1999 to 2015

Chengchen Zhang, MPH¹; O’Mareen Spence, MPH, PhD¹; Gloria Reeves, MD²; et al; Susan dosReis, PhD¹;

JAMA Pediatr. Published online November 2, 2020. doi:10.1001/jamapediatrics.2020.4678

Brunette MF, de Nesnera A, Swain K, et al.: Public-academic partnerships: a program to improve the quality of antipsychotic prescribing in a community mental health system. Psychiatric Services 62:1004–1006, 2011

Parameters 3.8 for Use of Psychotropic Medications in Children and Adolescents; Los Angeles County Department of Mental Health, July 15, 2020 (revised)   http://file.lacounty.gov/SDSInter/dmh/1071988_Paremeters3.8ForUseOfPsychotropicMedicationInChildrenAndAdolescents.pdf

Less is known about the impact of the pandemic in teenagers who in most communities, have, along with the rest of society have been affected by social distancing and various quarantine orders (Richter, 2020). While the limitations placed by the pandemic may increase parental observation, other risks increase including increased exposure to virtual platforms of all sorts and more pervasive contact and exposure to family, with both positive and negative impacts.

Dumas, Ellis and Litt have explored post-Covid use patterns in adolescents in Canada and they report that teens continue to use in social settings (including in person, in virtual interactions, as well as alone).   They have further reported that there are increasing rates of alcohol and marijuana consumption, solitary use that seems correlated with increased fear about the pandemic, and an increase exposure to parental substance use as well as an increase in substance use with parents (Dumas et al., 2020). More research is needed in the United States, however, substance use patterns are likely shifting in similar ways, and, as a significant element of the stress occurring from the pandemic, adolescent substance abuse needs to be on healthcare providers’ radar as a significant challenges for our youth.

What can be done in the primary care setting? As with all risk factors and behavioral issues that can be impacted through encounters with primary care providers, inquiring about and showing concern for risk behaviors can have positive impact.   So minimally, in contacts with teens and their parents, and especially important in these times, it is good to ask about substances and seek to identify both those at risk and those already in potential trouble.   The act of inquiring (regardless of one’s level of suspicion about a particular patient) and having a brief discussion(s) about the risks and dangers of substance use can be quite beneficial – for the patient, for the parent and, as a piece of public health messaging, for their peers.

More formally, use of screening tools can be an important augmentation of such inquiries and educational discussions. The CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) is an effective evidence-based screening tool for youth 12-21.   Having patients and families complete the screening in itself highlights the health concern with substance use and a positive finding can present a meaningful segue to begin a discussion about the need for further intervention.  http://crafft.org/

A referral for therapy is a good place to start. For families with commercial health insurance, a referral to a SUD counselor or a generalist mental health therapist will have some experience in providing evidence -supported interventions for substance use, including motivational interviewing and as needed potential referral for more intensive services. The County of San Diego has multiple programs for the MediCal and the uninsured population, that provide substance abuse interventions, ranging from early intervention activities on to more intensive programs for those with moderate and severe substance abuse challenges.

Regardless of the referrals and interventions made, follow up on patients with substance use issues in the primary care setting is warranted—whether as part of an active monitoring program (i.e., lab testing for ongoing use) or simply as a reinforce of the on ongoing potential health concern.

San Diego County Adolescent Substance Abuse Resources: https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/bhs/homepage/BHS_SUD_Brochures/BHS%20AOD%20Adolescent%2008-01-17_FINAL.pdf

National Institute on Alcohol Abuse and Alcoholism: https://www.niaaa.nih.gov/

Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/find-treatment

Smartcare: http://www.smartcarebhcs.org/ :

Dumas, T. M., Ellis, W., & Litt, D. M. (2020). What Does Adolescent Substance Use Look Like During the COVID-19 Pandemic? Examining Changes in Frequency, Social Contexts, and Pandemic-Related Predictors. Journal of Adolescent Health, 67(3), 354–361. https://doi.org/10.1016/j.jadohealth.2020.06.018

Richter, L. (2020). The Effects of the COVID-19 Pandemic on the Risk of Youth Substance Use. Journal of Adolescent Health, 67(4), 467–468. https://doi.org/10.1016/j.jadohealth.2020.07.014

Spagnolo, P., Montemitro, C., & Leggio, L. (2020). New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders—The Perfect Storm. American Journal of Psychiatry, appi.ajp.2020.2. https://doi.org/10.1176/appi.ajp.2020.20040417