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Treatment Outcome for Adolescents Abusing Alcohol and Cannabis: How Many 'Reliably Improve'?   Back Bookmark and Share
Bobby Smyth,Alan Kelly,J Barry,Walter Cullen,C Darker

BP Smyth1,2, A Kelly2, J Barry2, W Cullen3, C Darker2

1Addiction Service, Bridge House, Cherry Orchard Hospital, Dublin 10

2Department of Public Health and Primary Care, Trinity College Dublin

3 UCD Health Sciences, Belfield, Dublin 4


Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p=0.004), only four (11%) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p<0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.



Half of Irish 16 year-olds report alcohol use in the past month and 18% report lifetime cannabis use.1 Cannabis has become the dominant drug leading to referrals into adolescent addiction treatment services in the past decade.2,3 Motivation among adolescent treatment attenders tends to be poorer than among adults.4,5 In large clinical trials examining treatment of adolescent cannabis use, interventions tend to yield reductions in days of drug use of 25-38%.6,7 Heterogeneity in treatment interventions and in measured outcomes makes it difficult to provide succinct comment on outcome of adolescent alcohol use disorders8,9 Some interventions show no change, while others report up to 50% abstinence at three months.9 As abstinence is rarely sustained in adolescents, harm reduction approaches have been proposed.10,11 It has been argued that evaluations of addiction treatments should measure the proportion of patients who achieve reductions in substance use which are of clinical and statistical importance, but fall short of abstinence. To achieve this, Marsden et al propose more widespread use of statistical methods to measure the proportion of patients who achieve reliable change in their substance use.12 The aim of this study was to assess the three-month outcomes for patients presenting with high risk alcohol and high risk cannabis abuse following attendance at a specialist outpatient treatment service for adolescents.


The study setting was a specialist outpatient treatment service for adolescents experiencing substance use problems. The treatment provided included individual counselling and family therapy. While abstinence is encouraged, it is not a compulsory goal. Involvement of parents in assessment and treatment is encouraged but not mandatory. While treatment is tailored to the individual's needs, a basic treatment episode involves about six sessions over two months, with family input into two or three of these. Therefore, for the purposes of this study, we viewed patients who left treatment in an unplanned manner prior to their sixth appointment as having had an 'inadequate dose of treatment'. Psychiatric treatment is offered where comorbidity is identified.

Teenage patients from Dublin were eligible to participate. A baseline clinical assessment (T1) was completed and this was repeated after three months (T2). A Research Ethics Committee approved the study. We utilised a before and after comparison of scores on related measures from T1 to T2. The primary outcome measure was the number of days consuming alcohol and/or cannabis in the previous month, as assessed by the Maudsley Addiction Profile (MAP).13 We used the ASSIST which provides estimates of substance-related risk.14 It generates a separate score for each substance being used. We utilised the recently recommended lower, and more age appropriate, cut-offs for adolescents to identify those with high risk use.15 The SOCRATES assesses an individual's motivation to change their substance use, examining alcohol and drugs separately, and includes subscales of Problem Recognition and Taking Steps.16 As data on days and quantity of use were highly skewed, we utilised the Related Sample Wilcoxin Signed Rank Test.

'Regression to the mean’ complicates assessment of behaviour change in simple pre/post study designs. Therefore, it is useful to determine the proportion of patients who achieve a 'reliable change' in their baseline substance use.12 Hageman & Arrindell provide details of the computation involved in identifying individuals who have reliably improved, reliably deteriorated or remained unchanged.17 The calculations are contingent on estimating an appropriate standard error of the difference (T2 minus T1) from which the required 95% confidence interval for the difference is obtained. The standard error of the difference is derived from the standard deviation of the T1 scores for all participants and the known reliability of the test instrument.17 Outcomes for substances other than alcohol and cannabis were not examined as small patient numbers greatly limited the utility of any analysis.


There were 143 consecutive eligible patients, of whom 35 did not enter the study (16 patients refused, 14 cases unable to obtain consent from a parent and 5 cases unclear). The demographic details of the 108 participants are presented in Table 1. Past month criminal activity was reported by 51%, with drug selling (30%) and shoplifting (22%) being most common. Table 2 presents information on substances used and proportions using these individual substances in a high risk manner. Excluding tobacco, 49 (45%) patients were identified as having 'high risk' use of more than one substance. Motivation to ‘Take Steps' and ‘Problem Recognition’ were low or very low among the majority of high risk users of each individual substance apart from high risk opioid users. Among those reporting both high risk use of alcohol and high risk drug use, ‘Problem Recognition’ and ‘Taking Steps' subscale scores were each significantly higher regarding the drug problem compared to the alcohol problem (p=0.01).

The median number of appointments attended by patients was seven (Inter-Quartile range [IQR], 5-12). The median number of appointments attended by parents was three, and in 34% of cases parents did not attend any clinical appointments. We conducted follow-up interviews with 87 (81%) participants. The followed-up group did not differ in socio-demographic, substance use or treatment characteristics. Among those identified as high risk drinkers, alcohol was their most problematic substance in just 52% of cases based upon ASSIST scores. Among these high risk drinkers, we had follow-up information in 35 (83%) cases. The median days of use reduced from 12 (IQR 6-15) at baseline to 7 (IQR 4-14) (p=0.004). The mean days dropped by 27%, from 11 days per month to 8 days. There was also a significant reduction in the number of standard drinks per month (p=0.007), reducing from a median of 120 (IQR 0-240) to 60 (IQR 24-105).

Calculation of the reliable change index for alcohol indicated that a change in days of use per month of seven or greater was reliable. Only four (11%) of the high risk drinkers were abstinent at follow-up, but a further five (14%) were reliably improved. One person had reliably deteriorated while 25 (71%) were unchanged. Among high risk cannabis users, we had follow-up information on 55 (71%) people. The median days of use reduced from 25 (IQR 15-30) at baseline to 15 (IQR 4-30) and this was statistically significant (p<0.001). The mean days dropped by 32%, from 22 days per month to 15 days. Calculation of the reliable change index for cannabis indicated that a change in days of use per month of nine or greater was reliable. Six people (11%) were abstinent at follow-up and a further 20 (36%) had reliably improved. There were four (7%) patients who reliably deteriorated, while 25 (45%) were unchanged. We grouped together the 26 (47%) high risk cannabis users who were either abstinent or reliably improved to generate a "good outcome group" and the remaining high risk cannabis users were categorised as a "poorer outcome group". There was no statistically significant difference between these groups in terms of gender, referral source, baseline criminal activity, baseline motivation, family involvement in treatment or dose of treatment. A similar examination of outcome for high risk drinkers was not undertaken due to small numbers.


Consistent with other Irish treatment settings, polysubstance use was the norm.3 Motivation was very poor when compared to adult treatment-attending groups.16 Motivation regarding alcohol problems was particularly poor. Where drug and alcohol problems co-occurred, patients were more motivated to address the drug problem. This highlights the complexity of motivation in real world clinical settings, where patients are very motivated to make some changes while being unmotivated to address other issues. Unfortunately, given the interconnections between alcohol and drug use, a disinterest in addressing problem drinking may impede progress in tackling drug use.18 Although high risk drinkers reduced their days of drinking and total monthly alcohol consumption, the magnitude of improvement was quite modest. Pharmacological agents to treat alcohol use disorders were not prescribed to this patient group, but some have argued that there is a growing role for these in adolescents.9

Only one in nine high risk drinkers achieved abstinence. This illustrates again the elusive nature of this goal in adolescents with significant substance use disorders.19,20 Our alcohol outcomes are probably poorer than those reported in international, mainly American, studies.8,9 The cultural context of youth drinking is very different in Ireland, as we have a lower legal drinking age, a decline in actual age of drinking onset, increased adult drinking, and unhealthy drinking is the norm.21,22 This 'wet' society may impact negatively on the ability of Irish adolescents to recognise their own unhealthy drinking and to change it when they do. Although only one in nine of the high risk cannabis users were abstinent at follow-up, a further one third achieved substantial reductions in their cannabis use. Across the group of high risk cannabis users, the mean days used per month fell by 32% and seems acceptable, falling within the range of other international outcomes.6,7 The most comprehensive outcome evaluation of adolescent cannabis dependence was the CYT study, a RCT which compared five outpatient treatment approaches.4 The adolescents in our study were older, less likely to be in education and reported more frequent alcohol and cannabis use at baseline. In the CYT study, almost one quarter of participants were "in recovery" at three month follow-up but the reduction in mean days of cannabis use was almost identical to that seen here.7 A recently published large Dutch CBT group therapy study demonstrated that the mean days use per month dropped 27% to 15 days cannabis use per month.6

Our study did not identify any patient or treatment adherence characteristics significantly associated with better treatment outcome, but it had limited power to do so. Other studies have found that baseline mental health problems, lower motivation and low treatment adherence are associated with poorer outcome2 and greater family input improves outcomes.24 The limitations of this study include the fact that the treatment intervention was not manualised. For ethical and practical reasons there was no control group in this study. Consequently, it is not possible to determine whether this treatment was better than no treatment. However, the use of the reliable change methodology compensates for this deficiency to some extent, by identifying the magnitude of change that is likely to be independent of 'regression to the mean'.12 Although changes in substance use were reliant upon self report, there is a high concordance between self-reported drug use and toxicology in young people.25 As the vast majority of the participants fell into the poor motivation category, this reduced our power to detect possible significant associations between motivation measures and outcome. The time gap to follow-up of three months may have been too short for some patients to make substantial changes to their substance use.

As motivation tends to be quite low, especially for alcohol use disorders, services should assess it at the outset of treatment and target poor motivation where it does exist. Although the average reductions in substance use were modest, and broadly in line with international studies, the proportion of patients who achieved abstinence was low. It is important that patients, parents, referrers and funders of adolescent drug and alcohol services have realistic expectations of treatment.

Correspondence: B Smyth

Addiction Service, Bridge House, Cherry Orchard Hospital, Dublin 10

Email: [email protected]


The study was funded in part by the Alcohol Implementation Group of the HSE. We are grateful to the clinical team in YoDA who assisted with the completion of this project, in particular to P James, A Campbell and T Kearns.


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