Evidence-based assessment/Rx4DxTx of SubstanceUse

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Resources for the Assessment and Treatment of Substance Use Disorder in Adolescents[edit | edit source]

Substance use disorder (SUD) is understood as the consistent and persistent use of substances to the detriment of the individual's livelihood and wellness. SUD can have serious mental, physical, and social ramifications if not properly addressed. Though SUD can develop at any age, it is especially important to analyze in adolescents, given rising substance use prevalence in that age group and poor prognosis associated with early-onset SUD.[1][2] A study by The National Comorbidity Survey-Adolescents discovered that, of the more than ten thousand adolescents examined, there was an 11% lifetime prevalence of use of substances for those between the ages 13 and 18.[3]

This paper is intended for clinicians and lay people to gain a deeper understanding of SUD in adolescents, particularly relating to alcohol, marijuana, nicotine, and opioids. Smoking, drinking, and illicit drug use are several among a list of substances that cause concern among U.S. adolescents for their prevalence rates[4], while alcohol, marijuana, and nicotine are the most commonly used by this age demographic nationally.[5] Each of these substances can have adverse, long-lasting effects if not managed properly, resulting in seriously compromised lifelong wellbeing.[6]

This article explores SUD's prevalence and reviews diagnostic criteria in relation to adolescence, including a synopsis of changes in SUD classification between the DSM-IV and DSM-5 and discussion of ICD-11 and the Research Domain Criteria (RDoC) system as a basis for research related to substance use. Effective assessment and consideration of co-occurring disorders are covered as well. Although the prognosis of SUD varies by an individual's environment and circumstances, a modal developmental course for SUD is discussed. Finally, a curated list of nationally recognized resources, including hotlines, clinics, and informational sites, is provided, along with an example of a compilation of local resources in North Carolina to illustrate how national resources might be augmented with local ones to provide a more effective continuum for education and intervention.

By addressing these aspects of adolescent SUD, the research team offers a broader view of prevalence in the United States, key warning signs and comorbidities, and a thorough examination of possible assessments and treatments for adolescents with SUD.

Diagnostic Criteria[edit | edit source]

Diagnostic and Statistical Manual of Mental Disorders[edit | edit source]


Substance use disorder is defined in the most recent edition of the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders (5th ed.) as “a problematic pattern of substance use leading to clinically significant impairment or distress”.[7] The DSM-5, like the ICD-11, lacks any developmentally-specific or age-specific considerations in the diagnostic criteria specific to adolescent presentation of SUD.[7]

Substances recognized by the DSM-5 for SUD can be separated into groups. Depressants include alcohol, cannabis, inhalants, opioids, and sedatives, hypnotics, or anxiolytics.[8][9] Stimulants cover tobacco and caffeine, among others.[8][9] Hallucinogens are also recognized as a separate class.[8][9] Finally, a category of "other or unknown substances" is recognized.[8] To warrant a diagnosis of SUD, at least two of the eleven criteria outlined in the table below must be met in a period of one year.[7] These eleven criteria can be understood as indicators of physical and psychological substance dependence, loss of control of usage, prioritization of substance use above most everything, risky use, and specific consequences of substance use.[7]

DSM-5 Criteria Example
Craving or a strong drive for substance use Craving a cigarette upon waking up
Desire or unsuccessful attempts to decrease substance use Flushing all prescription painkillers in the house, then buying more later that night
Unintended increase in amount or period of time of substance use Planning to have one drink at a casual party but instead having eight
Substance use interfering with ability to meet school, home, or work obligations Coming to school high from smoking marijuana and failing all final exams
Significant time spent acquiring, using, or recovering from use of the substance Drinking for hours each night and laying in bed for hours the next morning with a hangover
Continuance of substance use even when usage causes or worsens interpersonal problems Getting dumped by a significant other due to constant angry behavior when drunk
Tolerance, either increased amount of substance used to get the same effect or decreased effect with continued use of the same amount of the substance Smoking a joint and realizing the buzz lasts a much shorter amount of time than when you started the habit six months ago
Withdrawal, either withdrawal symptoms or taking the substance to relieve or avoid withdrawal symptoms Going on a long family vacation without access to opioids and experiencing insomnia, sweating, aches, dilated pupils, and vomiting
Continued substance use despite a physical or psychological problem that was probably caused or worsened by substance use Continuing opioid use despite self harm and suicidal ideations that follow opioid use
Substance use in situations where it could cause physical harm Driving friends to McDonalds after smoking marijuana every Friday night
Giving up or cutting back on social, occupational, or recreational activities due to substance use Quitting the school basketball team because the sport requires regular drug testing
DSM-5 Criteria for Substance Use Disorder[8] with Examples

The DSM-5 outlines specifiers for severity, remission, and environment. The severity specifier adds a dimensional component to the diagnosis of SUD based on the number of the 11 DSM-5 criteria that are met. The presence of two or three criteria indicates mild SUD, four to five indicates moderate SUD, and six or more indicates severe SUD.[7] Remission specifiers give context to SUD that has not been active for some length of time. “In early remission” is specified if criteria have not been met in the past three months but have been met at some point in the past 12 months, with the exception of craving, and “in sustained remission” is indicated if the criteria have not been met for the past year.[7] To provide more context around someone who is in treatment, the environment specifier “In a controlled environment” indicates that the person does have access to any substances because they are currently residing in a restricted environment, such as a rehabilitation center.[7]

While the DSM-IV operated with a class of Substance-Related Disorders, the DSM-5 class was revised to Substance-Related and Addictive Disorders, which includes gambling disorder.[10] Moreover, the DSM-5 consolidated substance abuse and substance dependence, which were separate in the DSM-IV, into one set of criteria for a diagnosis of SUD.[11] In addition to these structural changes, criteria-level changes were made. DSM-5 added the criterion of craving, and it removed DSM-IV criterion of recurrent substance-related legal problems.[10][11] These changes came from an analysis of 39 studies totaling over 200,000 subjects which plotted criterion severity against how well a criterion discriminates between subjects of high or low severity.[11] Ultimately, a pattern emerged such that substance abuse and substance dependence criteria were related to severity, with the exception of the legal issues criterium and the addition of craving criterium.[11] Further, the legal issues criterium displayed low endorsement and poor discrimination.[10] The addition of the craving criterion also helped to improve cross-classification system continuity, as this criterion was already used in the ICD-10.[10] Additionally, a threshold of two criteria to receive a diagnosis was set given the urgency of early intervention for successful treatment outcomes.[11] Given findings that increasing number of criteria was associated with increasing consequences of the disorder, current nosologies designate severity as mild, moderate, or severe based on the total count of criteria present.[11] A study estimating the impact of diagnostic criteria changes on diagnoses of SUD found that using DSM-IV criteria tends to underestimate SUD prevalence compared to DSM-5 criteria.[10] Particular substances such as alcohol, hallucinogens, and prescription painkillers were at the highest risk of this misclassification, likely due to the addition of the craving criterion in the DSM-5.[10]

International Classification of Diseases[edit | edit source]

World Health Organization logo

The International Classification of Diseases (ICD) is a global diagnostic system under the World Health Organization oriented around clinical use and scientific validity used to categorize and diagnose disorders.[9] The ICD-11 first segments these disorders by the substance used. [12] Specified substances include all substances recognized by the DSM-5 and additional substances of synthetic cannabinoids, cocaine, synthetic cathinones (bath salts), MDMA, dissociative drugs, and non-psychoactive substances.[13] After the substance itself is specified, the ICD-11 categorizes the disorder as either harmful use or dependence.[12] Harmful use could constitute physical or mental harm to oneself (ex: injuries sustained from car crash while driving high) or to another (ex: PTSD developed by victim of drug-induced rage).[12] Dependence, the more severe diagnosis, is characterized primarily by impaired control over substance use and a strong drive to use the substance.[12] Finally, a harmful use disorder is categorized as episodic or continuous. To qualify as episodic use, the substance use and symptoms must be present over the past year.[14] In cases of heavy use, with near-daily use and symptoms, the disorder is classified as continuous use.[13]

Diagnosis ICD-11 Description
Harmful pattern of use of alcohol, episodic A pattern of episodic or intermittent alcohol use that has caused damage to a person’s physical or mental health or has resulted in behavior leading to harm to the health of others. The pattern of episodic alcohol use is evident over a period of at least 12 months.
Harmful pattern of use of cannabis, continuous A pattern of continuous (daily or almost daily) cannabis use that has caused damage to a person’s physical or mental health or has resulted in behavior leading to harm to the health of others. The pattern of continuous cannabis use is evident over a period of at least one month.
Nicotine dependence, current use Current nicotine dependence with nicotine use within the past month.
Opioid dependence, current use Opioid dependence, with use of an opioid within the past month.
ICD-11 Diagnoses of Substance Use Disorder[13]

A major strength of the ICD-11 is the ease of interfacing with a diverse range of clinical and healthcare settings. The ICD-11 is widely accepted by hospitals, practitioners, and insurance companies both in the US and abroad for physical and mental health disorders.[15] Aside from the high-level benefit of ease of use, the differentiation of disorder by substance class allows for specification in substance-specific medical interventions and treatment of withdrawal symptoms. Moreover, segmenting diagnoses as harmful use or dependence provides an opportunity to tailor level of intervention to pattern of use, allowing for early intervention at a crucial stage of harmful use or more intensive levels of intervention for dependence.[12] However, the ICD-11, similar to the DSM-5, lacks any adolescent-specific criteria or diagnoses for SUDs.

Research Domain Criteria[edit | edit source]

A visual representation of the RDoC framework. Link to original work

Developed by the National Institute of Mental Health in 2009 for research rather than clinical use, the Research Domain Criteria (RDoC) is a system rooted in neuroscience to understand classification of mental disorders from a dimensional perspective.[16][17] Although traditional diagnostic systems focus on symptoms and clinical presentation, the RDoC pays special attention to biological mechanisms on multiple levels of analysis.[16][18] The RDoC outlines major transdiagnostic neurobiological and observable behavior domains.[16] For each domain, RDoC organizes a matrix of operational definitions, with the goal of understanding links between different levels of analysis extending from genes to molecules, cells, circuits, and physiological systems, up to observable behaviors and subjective experiences usually assessed by self-report. RDoC also seeks to organize operational definitions of different domains at the level of animal models and laboratory tasks for use with humans (which it refers to as "paradigms").

Regarding substance use disorder, at least three of these domains are clearly implicated: cognitive systems, positive valence, and negative valence.[19][20] The cognitive systems domain covers executive functioning and preoccupation with obtaining or using substances, while the positive valence domain includes reward pathways, and the negative valence domain involves general negative emotional and stress responses. [19] These three domains meet in the model of addiction such that individuals who are more sensitive to rewards are at risk of initial substance use, which can be heightened to heavier use by cognitive systems and negative valence systems such as negative affect (the "self-medication" hypothesis, where substance use may serve to reduce negative valence subjective states, such as anxiety), or withdrawal (which also increases negative affect).[21][22]

The RDoC was developed as a tool for researching domains and functions based on neurobiological phenomena, but it has been proposed that it be adapted for assessment of substance use disorder. Although intended to be transdiagnostic, the original formulations did not specifically have addictions disorders in mind, and it is not clear whether RDoC domains currently provide comprehensive coverage of the constructs and systems important to understanding substance use.[22] The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is exploring the development of an "Alcohol Addiction RDoC" (AARDoC) to address some of these concerns. The Addictions Neuroclinical Assessment (ANA) grew out of this initiative. The ANA assesses the RDoC domains relevant to addiction (cognitive--specifically focusing on executive function, positive valence--specifically on incentive salience, and negative valence--specifically negative affect as a part of withdrawal) through an amalgam of self-report questionnaires, various behavioral tasks, and neuroimaging (including fMRI) which amounts to approximately a 10 hour comprehensive battery.[19] Though the ANA is a recent development, it has shown promising validity in measuring negative valence in men and women seeking treatment for alcohol use disorder.[23] Future research will focus on if the ANA can be used to effectively specify treatment based on measurements of these domains.[23] Currently, however, the RDoC remains predominantly used in research settings rather than clinical settings.[16][24]

Prevalence[edit | edit source]

Trends in substance use over time can be assessed using an annual survey by Monitoring the Future, which measures the substance use of 8th, 10th, and 12th graders in a nationally-representative sample. In 2018, the survey sample included 44,500 students in 392 schools across the US.[25] Annual use of alcohol or any illicit drug in adolescents in 2018 was 27.1%, up from 24.9% in 2008.[25] The most common substance used each year was alcohol, with a prevalence of 36.1% in 2018, down from 48.7% in 2008.[25] Following alcohol in prevalence is marijuana, with an annual prevalence of 24.3% in 2018, up from 21.5% in 2008.[25] For all of these categories, prevalence increased as grade level increased.[25] By the age of 18, nearly 20% of all respondents had experienced SUD.[26]

Nicotine vaping is on the rise among adolescents

Nicotine use was reported for 8th, 10th, and 12th graders across different substances. Cigarette use in the past 30 days was 4.6% in 2018, down from 12.6% in 2008.[25] Smokeless tobacco use in the past 30 days was 3.4% in 2018, down from 4.9% in 2008.[25] Nicotine vaping data was only collected beginning in 2017, with a 30 day prevalence of 14.2% in 2018, up from 7.5% in 2017.[25] 30 day use of large cigars, flavored little cigars, regular little cigars, and tobacco using hookah have all been trending down in the past few years, with 30 day prevalence in 2018 of 3.2%, 5.5%, 3.4%, and 2.7%, respectively.[25]

Past year prevalence of substance misuse and substance use disorder was measured in adolescents ages 12 to 17 by the Substance Abuse and Mental Health Services Administration's 2018 National Survey on Drug Use and Health. Annual opioid misuse was 2.8%, down from 3.9% in 2015.[27]

Past year prevalence of substance use disorder was reported by substance for adolescents ages 12 to 17. For any alcohol or illicit drug SUD, prevalence was 3.7% in 2018, down significantly from 5.0% in 2015.[27] SUD specific to alcohol was 1.6% in 2018, significantly less than 4.9% in 2008.[27] Prevalence of SUD specific to marijuana was 2.1% in 2018, which is a significant decrease from 3.4% in 2008.[27] For SUD specific to opioids, prevalence was 0.4% in 2018, which is not significantly different than 0.5% in 2015.[27]

Substance Past Year Prevalence of Substance Usage Past Year Prevalence Diagnosis of Substance Use Disorder
Alcohol 36.1%[25] 1.6%[27]
Marijuana 24.3%[25] 2.1%[27]
Opioids 2.8%[27] 0.4%[27]
Past Year Prevalence of Substance Usage and Diagnosis of SUD in Adolescents by Substance, 2018

Substance use and SUD prevalence differs significantly across gender, race, ethnicity, and sexual orientation. In early adolescence, females have higher rates of substance use than males.[28] However, by mid-adolescence and early adulthood, males surpass females in substance use.[29] Differences by race and ethnicity also emerged, such that Hispanics had the highest rate of substance use in early adolescence, but Caucasians had the highest rate by mid-adolescence.[29] Regarding sexual orientation, a meta-analysis found that sexual minority adolescents have a higher prevalence of SUD than heterosexual adolescents, such that on average, the odds of SUD for a sexual minority youth is 190% more than their heterosexual counterpart.[30]

Beyond the baseline rate of SUD in the general population, it is helpful to know rates of SUD across diverse settings. A study from 2001 in California assessed past year prevalence rates of SUD in adolescents across five clinical settings. In formal alcohol and drug sectors of care, 42.6% of participants reported SUD in the past year.[31] Juvenile justice settings had a 36.9% prevalence rate.[31] In mental health care settings, prevalence was 22.9%.[31] Public school services for adolescents with severe emotional disturbance had a prevalence rate of 16.0%.[31] Child welfare settings had a prevalence rate of 11.0%.[31] A review found that homeless adolescents were at a particularly elevated risk of SUD.[32] Settings with higher prevalence of SUD may benefit from more widespread or comprehensive SUD screening or assessment.

Comorbid Disorders[edit | edit source]

Adolescent substance use disorder and mental health information. Link to original content

Approximately 60% of adolescents with SUD satisfy diagnostic criteria for one or more co-occurring psychological disorders.[33] A review found that the most common comorbidity for adolescents was a category of disruptive behavior disorders including oppositional defiant disorder (ODD) and conduct disorder (CD). The median prevalence of comorbidity of ODD and CD was 46.0%.[33] There is some evidence that there is a cyclical relationship between substance use and behaviors associated with conduct disorders, such that one issue increases the other and vice versa, leading to increasing severity of both issues over time.[34] Depression was also common, with a median comorbidity rate of 18.8%.[33] Comorbid attention deficit hyperactivity disorder (ADHD) had a prevalence of about 12.3%, however, it is important to note that this may be partially explained by the high degree of correlation between ADHD and ODD/CD.[34]

Prevalence of substance misuse among adolescents is highest for those with prior anxiety disorders (such as generalized anxiety disorder, panic disorder, and post-traumatic stress disorder) and behavior disorders (such as ADHD, CD, and ODD).[35] 17.3% of adolescents with prior anxiety disorders experienced alcohol misuse and 20% experienced drug misuse.[35] For adolescents with prior behavioral disorders, 15.6% experienced alcohol misuse and 24% experienced drug misuse.[35]

SUD is also associated with suicide in adolescents.[34] Teenagers with SUD are about three times more likely to attempt suicide than their counterparts who do not use substances.[34] The issue of suicide is particularly relevant to adolescents, because it is the third leading cause of death in Americans ages 10 to 19.[34]

Comorbid Disorder Prevalence Prevalence in SUD Clinical Setting
Any Comorbid Disorder 60.0%[33] 73.0% - 75.6%[36]
Conduct Problems (CD/ODD) 46.0%[33] 55.7% - 58.6%[36]
Depression 18.8%[33] 32.7% - 36.2%[36]
ADHD 12.3%[33] 45.3% - 48.2%[36]
Rate of SUD Comorbid Disorders in Adolescents

Comorbidities are typically more common in clinical settings for the treatment of SUD.[36] Individuals in SUD treatment settings under age 15 had a prevalence for any mental health problem of 73.0% and those ages 15-17 had a prevalence of 75.6%.[36] Prevalence of conduct problems in this population was 58.6% for those under age 15 and 55.7% for ages 15-17.[36] ADHD had a prevalence for under age 15 and age 15-17 of 48.2% and 45.3%, respectively.[36] Depression prevalence was 32.7% for those under 15 years old and 36.2% for those ages 15-17.[36] The high prevalence of comorbid disorders in clinical settings for the treatment of SUD highlights the need for comprehensive assessment of mental illness.

Prognosis or Developmental Course[edit | edit source]

Substance use and abuse prevalence rises throughout adolescence and reaches a peak in early adulthood.[1] Developmental stage is important in understanding SUD, as substance use among adolescents manifests differently than among adults. Moreover, adolescence is a time of intense change within the individual and their social networks; these processes and interactions increase both opportunities and motives for substance use and experimentation.[37] Adolescent substance use and risks are shaped by legal and logistical barriers to obtaining substances which can increase risk of binge use, increased sensitivity to peer influence, and still-developing brains that make substance use at this age particularly dangerous.[34] For example, because a minor cannot purchase alcohol, adolescents drink less frequently than adults yet are more likely to engage in binge drinking with peers.[34] Binge drinking is a high-risk activity, as it may lead to neurological damage or accidental injury/death.[34]

Early onset substance use, defined as use prior to age 14-15 for alcohol and 16 for marijuana, is associated with a higher risk of chronic SUD.[2] This subgroup of early substance users splits into an adolescent-limited course and a chronic course with high risk for SUD throughout adulthood.[2][38] Those with comorbid disorders and certain temperament characteristics, such as behavioral disinhibition, are at higher risk for developing a chronic course of SUD.[2]

Factors associated with better treatment outcomes and positive prognosis include completion of treatment, high motivation to abstain, low substance use when commencing treatment (i.e., milder presentation), and more social support from non-using family and friends.[2][39] Course and outcome are influenced by factors such as co-occurring disorders, racial and ethnic background, and gender.[40]

There are also various predictors of poor outcomes of adolescent SUD. A comprehensive review of the role of personality traits found that impulsivity is a key predictor of negative outcomes in individuals with substance use disorder.[41] Substance dependence during adolescence also predicts a poor prognosis.[42] Moreover, substance use early in life is a predictor of increased use of heavier, more intense substances in the future.[43] Predictors of substance use have been demonstrated to differ across race as well, where lower distress tolerance was significantly related to higher past year alcohol use among Caucasian adolescents but had no significant relationship among African-American adolescents.[44]

Relapse rates are high for adolescents who have received outpatient treatment for SUD; one study found a six-month relapse rate of 66% and a median time to relapse of 54 days without any significant difference by demographic factors or comorbid disorders.[45] A large review showed six-month relapse rates at 62% and one-year relapse rates at 68%.[39] Reported reasons for relapse differ between adolescents and adults: adolescents tend to attribute relapse to social situations and peer use, while adults attribute relapse to coping with negative emotions.[2] However, relapse for cigarette use is an exception: teens attribute use to compulsion rather than peer pressure.[2] Recovery is not guaranteed with any initial intervention, and often those with SUD will require numerous attempts to overcome SUD before long-term success is achieved.[46]

Evidence-Based Assessment[edit | edit source]

This section is intended to provide an assessment model for clinicians who may not be specialized in substance use disorder. For clinicians who are specialized in substance use disorder, this resource kit may be more applicable.

Screening measures for Substance Use Disorder
Questionnaire/Interview Age Range Administration/ Completion Time Qualifications to Give Assessment Substance(s) Assessed Purpose of Assessment Cost PDF/Link
Problem Oriented Screen Instrument for Teenagers (POSIT) Adolescents 20-30 mins None Needed Any Treatment Planning Free Link Here

Info Here

Problem Oriented Screen Instrument for Parents (POSIP) Adults 10-15 mins None Needed Any Treatment Planning Free Link Here

Info Here

Screening to Brief Intervention (S2BI) 12-17 5 mins None Needed Alcohol, Marijuana, Tobacco, Others Initial Screening Free Link Here

Assessment Here

Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) 12-17 5 mins None Needed Alcohol, Tobacco, Others Initial Screening Free Assessment Here

Online Assessment Here

Teen Addiction Severity Index (T-ASI) Adolescents 20-45 mins Professional Any Treatment Planning, Assess Treatment Free Link Here

English Assessment

Time Line Follow-Back (TLFB) Adolescents 10-15 mins Minimum Training Alcohol, Tobacco, Others Treatment Planning, Assess Treatment Free Link Here
Rutgers Alcohol Problems Index and Marijuana Adolescent Problem Inventory (RAPI/MAPI) Adolescents 10 mins None Needed Alcohol, Marijuana Treatment Planning Free RAPI Link


GAIN-SS (Global Appraisal of Individual Needs-Short Screener) Adolescents, Adults 5 minutes Minimum Training Any Initial Screening $100 for 5 years of all GAIN measures Link Here
GAIN-I (Global Appraisal of Individual Needs-Initial) Adolescents, Adults 60-120 mins Minimum Training Any Diagnosis, Treatment Planning, Assess Treatment $100 for 5 years of all GAIN measures Link Here
Drinking Motives Questionnaire (DMQ) Any 10 mins None Needed Alcohol Treatment Planning Free Link Here
Comprehensive Marijuana Motives Questionnaire (CMMQ) Any 10 mins None Needed Marijuana Treatment Planning Free Link Here
The Contemplation Ladder Any 5 mins None Needed Any Treatment Planning, Assess Treatment Free Link Here
The Readiness Ruler Any 5 mins None Needed Any Treatment Planning, Assess Treatment Free Link Here
Urine Drug Screen Any 10 mins Trained Collector/ Certified


Marijuana, Opiates, Others Initial Screening, Treatment Planning, Assess Treatment Varied N/A
CRAFFT (Car, Relax, Alone, Friends/Family, Forget, Trouble) Adolescents 5 mins None Needed Any Initial Screening Free Link Here

Info Here

Alcohol Use Disorders Identification Test (AUDIT) Adults,

Adolescents 14-18

5 mins None Needed Alcohol Initial Screening Free Link Here

Assessment Here

While assessments are often used as screeners or diagnostic tools, they can also be helpful tools throughout treatment. The integrative Evidence-Based Assessment (EBA) model is a framework for using clinical psychological assessments at all stages of clinical care: for prediction, prescription, and process.[47] With "prediction" of adolescent substance disorder, consistent use of brief screeners for substance use in mental health and medical care settings can catch substance use that would otherwise go undetected, allowing for early intervention and treatment implementation.[48][49] In the absence of these screeners, clinical judgement alone underestimates adolescent substance use and often doesn't identify the problem until late-stage behavioral issues become apparent.[50] With "prescription," assessments can help a clinician determine the best treatment plan for an adolescent with a substance use disorder, considering the individual holistically. In this vein, assessments can help the clinician determine the substance use severity, motivation for the substance use,[51] and the adolescent's readiness for change,[52] while also considering caretaker reports, toxicology testing, and external school, medical, and legal reports.[49] After developing a treatment plan in collaboration with the adolescent based on the comprehensive evaluation, assessments should be continuously used throughout the treatment to gauge the "process," allowing for the treatment plan to adapt as needs change and for outcome goals to be measured.[47]

There are many options for evidence-based screeners for initial assessment of adolescent substance use. These validated screeners assess substance use along a continuum based on frequency and intensity of use.[50] Screening to Brief Intervention (S2BI) asks about the frequency of use in the past year of eight types of substances (tobacco, alcohol, marijuana, illegal drugs like cocaine or ecstasy, non-prescribed prescription drugs, misuse of OTC medication, inhalants, and herbs or synthetic drugs) with six frequency responses ranging from "never" to "daily".[53] The Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) asks about the individual's and their friends' substance use in the past year, along with one's individual frequency of use in the past 30, 90, and 365 days.[54] The [[wikipedia:Global_Appraisal_of_Individual_Needs#Family_of_assessments |Global Appraisal of Individual Needs]] Short Screener (GAIN-SS) is a broader assessment, looking at four subscales for internalizing disorders, externalizing disorders, substance use disorder, and crime/violence. This can be helpful in determining comorbid disorders, in addition to substance use issues. The substance use items focus on the frequency of usage, priorities of substance use, and problems related to substance use.[55] The [[CRAFFT Screening Test |CRAFFT]] screener is an acronym for Car, Relax, Alone, Friends/Family, Forget, Trouble. This screener asks about frequency of substance use and identifies problems associated with substance use related to the dimensions represented by the acronym.[56][57] [[w:Alcohol Use Disorders Identification Test |Alcohol Use Disorders Identification Test]] (AUDIT) specifically screens for risky drinking, asking questions about frequency of use, alcohol dependence, and alcohol-related problems. While the screener was created for adults, research supports its use for adolescents ages 14 to 18 as well.[58]

If substance use is indicated in a brief screener, further assessment can help a clinician gain insight on the severity of the substance use, along with other individual and environmental characteristics that can aid and inform the optimal treatment plan. The Problem Oriented Screening Instrument for Teenagers (POSIT) is a longer screener with 139 items that explores an adolescent's current functioning, focusing on substance use, physical and mental health, family and peer relations, educational and vocational status, social skills, recreational activities, and aggressive/criminal behavior.[59] The Problem Oriented Screening Instrument for Parents (POSIP) is the parental version of the POSIT, asking similar questions from the caregiver's perspective.[59] The Teen Addiction Severity Index (T-ASI) is a semi-structured interview that assesses the adolescent's functioning across seven domains: substance use, school, vocation, family, legal status, peer relationships, and mental health status. Each domain is rated from one to five in terms of both perceptions of impairment and need for treatment.[60] The [[wikipedia:Global_Appraisal_of_Individual_Needs#Family_of_assessments |Global Appraisal of Individual Needs]] Initial (GAIN-I) is a [[w:Semi-structured interview |semi-structured diagnostic interview]] that can help diagnose substance use disorder and can be used to inform treatment placement and planning along with outcome monitoring. The GAIN-I focuses on the same four subscales as the GAIN-SS: substance problems, internal mental distress, behavior complexity, and crime/violence.[61] If a clinician specifically wants to know more about an adolescent's alcohol related problem behavior, the The Rutgers Alcohol Problems Index (RAPI) is an 18 item questionnaire that asks about the frequency of issues like going to school drunk, avoiding responsibilities, and blacking out.[62] Similarly, the 23 item Marijuana Adolescent Problem Inventory (MAPI) assesses problem behavior related specifically to cannabis use.[63]

The Readiness Ruler is a tool to assess readiness for change. Link to original study

In addition to the assessing severity of use and problems functioning, learning about the adolescent's context of substance use, motives for substance use, and readiness to change their behavior can help inform treatment planning and assess ongoing treatment.[49] The Time Line Follow-Back (TLFB) is a calendar-based method of reporting substance use in the past month.[64] This assessment not only gives information on the frequency and severity of use but can also highlight the contexts in which the adolescent tends to use the substance and illuminate patterns of their use.[65][66] The Drinking Motives Questionnaire Revised (DMQ-R)[67] and Comprehensive Marijuana Motives Questionnaire (CMMQ)[68] assess the adolescent's reasons for substance use. The DMQ-R looks at four main motives for alcohol use: drinking to be social, drinking to cope, drinking to enhance positive emotions, and drinking to conform with peers.[67] The CMMQ looks at 12 main motives for cannabis use: enjoyment, conformity, coping, experimentation, boredom, alcohol, celebration, altered perception, [[w:Social anxiety |social anxiety]], relative low risk, [[w: Sleep |sleep/rest]], and availability.[68] In both measures, "using to cope" was associated with more negative consequences, as was "using to sleep/rest" for the CMMQ.[67][68] To assess motivation to change substance use behavior at the onset or during treatment, clinicians can use the Contemplation Ladder[69] or the Readiness Ruler[70]. The Contemplation Ladder has 11 "rungs" that range from statements of no desire to change, to ambivalence, to taking action[69][71] The Readiness Ruler is a visual scale from one to ten with similar markers along the continuum of change.[70][72] These tools can help the clinician gauge the adolescent's feelings about treatment and desire or resistance to changing their substance use.

In addition to self-report and interview assessments, toxicological tests of urine, blood, or hair are recommended to detect substance use at the onset of and throughout treatment.[42] However, a negative test does not necessarily mean the adolescent is not using drugs, as drugs only temporarily remain in urine and results can vary based on the type of substance and frequency of use.[42] While some studies have found self-report measures to be highly correlated with urine tests,[73][74] others have found self-report measures to be inconsistent with urine tests, with some adolescents who report substance use having negative [[w:Clinical urine test |urinalysis]] and other adolescents who deny substance use having positive urinalysis.[75][76] Therefore, the results from multiple types of assessments should be considered by the clinician. Adolescents may under-report or deny use in a clinical setting due to fear of negative ramifications like legal repercussions or parental consequences.[76] In addition to supplementing adolescent self-report by cross-referencing with parental-reports and biological testing, validity of adolescent self-report can be improved by building rapport with motivational interviewing techniques[77] and by discussing confidentiality guidelines and limitations prior to assessment.[48]

Evidence-Based Treatment[edit | edit source]

Determining the optimal treatment for adolescent substance use disorder requires careful consideration of multiple factors. According to the American Society of Addiction Medicine (ASAM) criteria, clinicians should consider the patient on six dimensions to approach their treatment planning from a holistic perspective. These include the individual's addiction history, severity, and withdrawal potential, their physical health/medical conditions (including STIs, HIV, and pain), their mental health, their readiness to change, their risk of relapse, and their recovery situation/support.[78] With these factors in mind, the clinician can determine the best intensity of treatment for the patient on the continuum of care options, ranging from brief intervention, to outpatient services, to intensive outpatient services, to residential/inpatient services, to medically managed intensive inpatient services.[78] Adolescents should be treated in the least restrictive care setting that still provides necessary care and a safe environment.[78] While more intensive residential programs may be needed in more serious cases, outpatient therapy is the most common treatment for adolescents and can foster generalization of treatment gains.[42] There is not a "one-size fits all" treatment for adolescent substance disorders, and the best treatment varies based upon the type of substance and the adolescent's particular needs and problems. These needs will likely change over time and treatment should be continually assessed and adapted through a continuing care approach.[79]

The least intensive of the ASAM criteria levels of care is early intervention.[78] This is often implemented through a brief intervention delivered by a primary care provider or other medical professional. This brief intervention is a short conversation between the provider and patient that is tailored to the severity of substance use that the patient disclosed on a screener assessment. The focus should be on preventing, reducing, or stopping substance use. The provider should give clear advice to abstain from the substance, information on negative effects of usage, and discuss a plan to stop usage that emphasizes individual strengths and positive behaviors of the patient that will help them abstain.[50] Specific training guidelines by the American Academy of Pediatrics for primary care providers on how to deliver a brief intervention for adolescent substance misuse can be found here.

Components of comprehensive drug use treatment. Link to original content

For adolescents who need more than a brief intervention, the next level of care according to ASAM criteria is outpatient therapy.[78] This treatment may consist of many different elements and forms of therapy in order to address the multiple needs of the adolescent around their substance usage including family therapy, individual behavioral therapy, support groups, medication, and legal services. Given high comorbidity rates among adolescents with SUD, co-occurring disorders should be screened for in all SUD treatment settings. Along with the SUD, these co-occurring disorders must be appropriately addressed with evidence-based methods in order for the adolescent to return to developmentally-appropriate functioning.[42] Throughout treatment, drug usage should be continuously monitored as relapse is common and recovery is a long term process.[79] The treatment should be abstinence-based with a focus on motivation, family engagement and support, skills-building and relapse prevention, co-occurring disorder treatment, multi-system intervention, and completion of treatment and follow-up.[42][39] Ensuring that services that are developmentally, culturally, and gender-appropriate is also necessary when determining treatment for adolescent substance use.[79]

In general, the most efficacious therapies for adolescent substance use disorder are family-based ecological treatment, cognitive behavioral therapy (individual, group, and family), motivational enhancement treatment with CBT, or some combination of all three therapies.[79] Family therapy is important as family relationships and context are important risk factors for adolescent SUD and families can institute important environmental changes.[42] Cognitive behavioral therapy helps the adolescent anticipate their problems and enhance their self-control. They work on recognizing cravings and situations that are high-risk for their substance use and building adaptive coping skills and strategies to avoid or manage them. Developing buy-in to therapy is crucial to treatment completion and relapse prevention, especially since adolescents rarely self-refer and instead are typically pressured or forced into treatment by a caregiver.[80] Motivational Enhancement Treatment can help drive treatment compliance and retention in adolescents with SUD by helping them increase their motivation for recovery and build a plan for change.[42][39][79] In addition to these therapies, twelve-step groups such as AA or NA have been shown to be a beneficial as supplemental or continuing treatment.[42] Similarly, building peer support systems of non-users can be a driver of sustained behavior change and help prevent relapse.[42][39]

There are many forms of evidence-based family therapy for adolescent substance use disorder. Family Behavior Therapy focuses on the substance use issues along with other simultaneous problems including conduct disorders, depression, mistreatment, and family conflict. The therapist meets with the adolescent and one of their caregivers and helps them create behavioral goals for substance abstinence and build new skills to cope with co-occurring issues. The therapy also utilizes contingency management and allows the patients to contribute to the treatment planning.[81][79] Brief Strategic Family Therapy focuses on identifying and changing family patterns that are thought to continue or worsen adolescent substance abuse and conduct problems. The approach of BSFT is flexible and can be adapted to many settings and modalities of treatment from outpatient therapy to being a part of a residential program or continual care plan.[46][79]

Pharmacological treatments

Other forms of family therapy are more comprehensive and community based, addressing the influence of school, peers, and community in the treatment.[79] Since family, school, and peer systems significantly shape adolescent behavior and exert considerable structure and control on their lives, aligning these systems with recovery-focused goals can be highly influential to decrease instances of relapse and to address and overcome trauma that might be a root cause of the substance abuse.[29] One of these types of comprehensive substance abuse treatments that works with the adolescent and their family is Multisystemic Therapy (MST). MST is especially helpful for adolescents who display antisocial behavior along with their substance use. The intensive treatment occurs in natural environments in patient's home, school, and/or community and addresses individual factors, family conflict, peer influence, school issues, and neighborhood cultural influences on drug use.[79] MST has high retention rates and has been found to significantly reduce substance use for at least six months after treatment. [82][83] Multidimensional Family Therapy (MDFT) considers adolescent drug use through the lens of multiple interconnected networks of the individual, family, peer group, and community. The therapist works with the individual to build important developmental skills for problem solving, decision making, and communication along with vocational skills. They work to increase desirable behavior and decrease drug use and other problem behaviors across many different settings with multiple strategies. Parallel sessions with the caregiver focuses on examining parenting styles and negotiating developmentally appropriate levels of control and influence. [79][84][85]

While pharmacological treatment is often a significant component of treatment for adult substance use disorder, there are limited addiction medications that are approved by the FDA for people under 18. Currently, over-the-counter nicotine chewing gum, lozenges, and skin patches are the only FDA approved medications for adolescent substance users and should only be used with physician consultation.[79] Recent research suggests that buprenorphine, a prescription medication for treating opioid addiction, may be effective for adolescents 16 and older, but the medication has not yet been approved by the FDA.[86][87] Other medications for treating opioid, nicotine, and alcohol substance use disorder are currently being researched to determine their safety for adolescent populations.[79]

Resources[edit | edit source]

The goal of this section is to illustrate a range of informational and clinical resources, using internet searches as the point of entry. Smartphone and internet searches are the main way that the general public looks for information and treatment options. The reliance on internet search is likely to be even more true for information-seeking related to substance use, because of factors such as the comorbidity described above and the splitting of services into separate silos for general health, mental health, and substance use. Additionally, the high level of stigma around the topic of of substance misuse makes the privacy of online searches particularly well-suited for initial information gathering.[88]

Online search is also a primary strategy for health professionals.[89][90][91] The value of online search for professionals is accentuated with regard to substance misuse due to the fragmentation of services combined with the value of integrated care models for addressing the multiple needs of many people.[92] Online searches for resources also are a key component of "foregrounding" information gathering as providers start their practices, relocate to a new area, or seek to support patients who themselves are relocating or inquiring about resources for friends and family in other geographic locations.

This section combines two different approaches. One is to focus on high quality and nationally accessible sources, such as content from federal agencies and national hotlines. The other is to seek local resources along a continuum of care, which is crucial for finding and identifying services such as individual counseling, support groups, and intensive-outpatient, partial hospital, inpatient, and residential programs. The full continuum of services may not be available at all geographic locations. We use a relatively resource-rich location as an example to show possibilities, so that gaps in offerings will be easier to identify in other settings.

National resources[edit | edit source]

In the event of a life-threatening emergency, immediately call 911, which is available throughout the United States and Canada. Similar emergency services are available in many other countries. An individual in crisis looking for immediate support may also either call a crisis support line at 1-800-273-8255 or text START to 741-741 to talk to a trained call operator anytime in a free, confidential setting.[93] An individual with suicidal thoughts seeking immediate support can call the National Suicide Prevention Lifeline at 1-800-273-TALK.[93] In the United States, a national three-digit prevention hotline will launch in 2022.[94]

An Alcoholics Anonymous chip representing six months sober

National resources are available to provide information hubs on SUD for adolescents and their support systems. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) website is an easily accessible resource that provides confidential and free information services for individuals and family members facing substance use disorder. Moreover, SAMHSA National Helpline is available 24/7 at 1-800-662-4357. Furthermore, the Society for Adolescent Health and Medicine (SAHM) offers a plethora of resources for young adults to find resources pertaining to SUD. From the Partnership for Drug-Free Kids, a resource aimed at assisting families and individuals with SUD, to the Kelty Mental Health Resource Centre, which offers information on SUD and comorbid disorders, there are many ways to find help at the national level. Likewise, NIDA for Teens is a website covering national research findings related to SUD.

National resources are available to locate treatment options for adolescents with SUD. Higher Ed allows for drug rehab searches by state or city and details service options, level of care, treatment type, payment type, clients served, and contact information for each resource.[95] The SAMHSA website also provides information on thousands of state-licensed providers who specialize in treating substance use disorder, addiction, and mental illness.[96] People seeking help can use the Substance Abuse Treatment Facility Locator and the Opioid Treatment Program Directory features and filter by location, treatment type, age, and language.[96] Search results include extensive details on each treatment program.[96] To find a psychiatrist that treats adolescents, the American Academy of Child and Adolescent Psychiatry's Psychiatrist Finder is available.

For those in recovery, national support groups might be a beneficial way to further one's rehabilitation journey; Alcohol Anonymous and Narcotics Anonymous offer support to adolescents and young adults, and meetings nearby can be found on their respective websites. SMART Recovery is also a resource that teens can utilize to access self-empowering support, in person meetings, and a powerful online community. These models started as face-to-face group meetings, and developed into national networks that people could use to find meetings when traveling or relocating. In response to the COVID-19 pandemic and social distancing policies, these organizations have rapidly developed videoconferencing models for their meetings that further increase accessibility for many people.[97]

Resource Type Phone Contact
Crisis Support Line Crisis 1-800-273-8255
Crisis Support Text Line Crisis Text START to 741-741
National Suicide Prevention Lifeline Crisis 1-800-273-TALK
SAMHSA National Helpline Informative 1-800-662-4357
Society for Adolescent Health and Medicine Informative --
Partnership for Drug-Free Kids Informative --
Kelty Mental Health Resource Centre Informative --
NIDA for Teens Informative --
SAMHSA Substance Abuse Treatment Facility Locator Treatment Locator --
SAMHSA Opioid Treatment Program Directory Treatment Locator --
Higher Ed Treatment Locator --
AACAP Psychiatrist Finder Treatment Locator --
Alcohol Anonymous Support Group --
Narcotics Anonymous Support Group --
SMART Recovery Support Group --
National Resources

Local resources[edit | edit source]

Local resources that offer evidence-based treatment for adolescent SUD often can be compiled from these national search engines. At a local level, there could be a multitude of resources to connect adolescents with SUD to professionals who can provide evidence-based treatment, but they may not be immediately obvious, and quality of services can be highly variable. It is important to carefully assess each local resource to determine which best meets the specific needs of the individual adolescent. Then, relevant treatment programs can be contacted to initiate assessment and treatment.

To illustrate how these local resources can be collected and presented in a relatively research-rich location, an example for the Research Triangle Park, North Carolina is analyzed. For assistance in finding the best treatment options locally in North Carolina to fit the specific needs of an individual adolescent, Easterseals provides a CARES program found at their website.[98] This service connects a family in crisis with a qualified staff member who personally assists the family in finding comprehensive clinical services and appropriate care.[98] Around Research Triangle Park, North Carolina, options for various levels of outpatient care are available for adolescents with SUD at universities such as Duke University and The University of North Carolina at Chapel Hill and their respective medical centers and campuses. These local programs are strongly rooted in evidence-based approaches and accept insurance; however, they lack the ability to handle higher levels of care.[99][100] An option for drug and alcohol addiction treatment for adolescents offering higher levels of care located in Raleigh, North Carolina is Triangle Springs. This facility offers detox services, inpatient treatment, outpatient treatment, an alumni support group, and a 24/7 confidential helpline. A compilation of local resources in a table can be a helpful tool for adolescents and their support system to start to seek assessment and treatment for SUD.

Treatment Program Evaluation Offered Level of Care Therapeutic Modality Insurance Accepted Address Phone Number
UNC Adolescent Substance Abuse Service No
  • Outpatient
  • Family Therapy
  • Motivational Interviewing
  • Cognitive Behavioral Therapy
  • Dialectical Behavioral Therapy
Yes 101 Manning Dr

Chapel Hill, NC 27514

Carolina Behavioral Care Yes
  • Outpatient
  • Anger management
  • Brief intervention
  • Cognitive behavioral therapy
  • Dialectical behavioral therapy
  • Relapse prevention
  • Substance use counseling approach
  • Trauma-related counseling
Yes 4102 Ben Franklin Blvd

Durham NC 27704

Duke CAST Yes
  • Intensive Outpatient
  • Outpatient
  • Drug Education and Counseling
  • Family Systems Therapy
  • Motivational Interviewing
  • Cognitive Behavioral Therapy
  • Psychoeducation
  • Social support network
Yes 2301 Erwin Rd

Durham, NC 27705

UNC Horizons Program Yes
  • Outpatient
  • Residential
  • Anger management
  • Cognitive behavioral therapy
  • Contingency management/motivational incentives
  • Dialectical behavior therapy
  • Motivational interviewing
  • Matrix Model
  • Relapse prevention
  • Substance use counseling approach
  • Trauma-related counseling
Yes 410 N Greensboro St, Carrboro, NC 27510 919-966-9803
Triangle Springs Yes
  • Educational Programs
  • Intensive Outpatient
  • Partial Hospitalization Program
  • Inpatient
  • Detox
  • Alumni Support Program
  • Virtual Adolescent Program
  • Cognitive Behavioral Therapy
  • Didactic Behavioral Therapy
  • Mindfulness
  • Motivational Training
  • Family counseling
  • Holistic therapies
  • Group therapy
Yes 10901 World Trade Blvd

Raleigh, NC 27617

Sample of Local Resources: Research Triangle Park, North Carolina

Conclusion[edit | edit source]

Summary[edit | edit source]

This research paper investigated substance use disorder in adolescents through studies conducted in the United States. By analyzing differences in diagnostic criteria between the DSM-IV and DSM-5, as well as the ICD-11, we have outlined some of the common indicators of SUD as well as common misclassifications. Intended primarily for medical and mental health professionals with limited knowledge of SUD, the prevalence of substance use and SUD among adolescents was presented, particularly for the substances alcohol, nicotine, marijuana, and opioids, as were common comorbid disorders. Some common comorbidities with SUD include ODD/CD, depression, and ADHD.[36] The developmental course of SUD was found to be highly dependent on many specific factors related to the individual, and thus the age of onset, temperament, and comorbidities, among others, affected the prognosis of SUD and influenced the type of assessment and treatment offered to the individual. Numerous assessments for SUD in adolescents exist, and it is important for clinicians to consider cost, accessibility, and type of substance use/abuse when determining which assessment is needed in the context of a specific individual at a certain point in time. Likewise, evidence-based treatments, including individual, family, and community therapy are available and can offer relief to those with SUD.

A plethora of resources, both national and local, are readily available through simple internet searches that locate websites and phone lines to provide further context around preemptive risks and warning signs of SUD development, anonymous crisis support, how and where to receive support, and treatment clinics open to new patients.

Having a deeper understanding of what SUD is and how it affects adolescents is an important first step in reducing the prevalence of SUD, negating the long-term consequences of addiction, and preparing for unexpected but relevant issues that could exacerbate mental health disorders that heighten the risk of substance use disorder in adolescents.

Limitations[edit | edit source]

While this paper is a general overview of adolescent substance use disorder diagnosis, assessment and treatment, this review is limited in scope to a United States context. Developmental norms for adolescents and clinical concepts of substance misuse vary across cultures and countries. Similarly, context is key to determining the best treatment plans; there is no one-size-fits-all for substance use disorder. Age of onset of use, type of substance, co-occurring disorders, social determinants of health, and frequency and quantity of use can all drastically affect patient needs and outcomes in ways that are not fully covered in the scope of this paper. An additional limitation to this paper is variation between states in the US on legal issues such as disclosure of medical records or the right for minors to consent to substance use treatment. Determining if, when, and how to break confidentiality to inform parents depends on the context, clinical judgements, and the minor consent laws of the specific state.[101] Also, this paper is intended for medical and mental health professionals with little experience with substance use disorder. Therefore, this paper may be less relevant for the general public or medical and mental health professions well-versed in substance use disorder.

Future Directions[edit | edit source]

Future directions for research in this field include cross-comparisons of trends in different countries as well as with research conducted in different languages. Furthermore, including life-course trajectory perspectives is essential for understanding later-life treatment outcomes and potential interventions. This paper provided a broad overview of many substances, yet much remains unknown about what roles specific substances may play and how different substances may interact with one another. Future work should determine similarities and differences in how specific substances help maintain addiction and interact with comorbid mental health disorders.

Future reviews on adolescent substance use disorder could also focus on the effect of widespread crises such as natural disasters, social unrest, and pandemics. Current research on COVID-19 has suggested increased isolation during the pandemic has heightened risks associated with SUD, such as stress, fear, and anxiety, as well as reducing the potential for intervention and treatment.[102] For example, in the cases of [[w:Opioid overdose |opioid overdose]], there is a lower probability of someone being in proximity who could administer live-saving measures like [[w:Naloxone |naloxone]].[103] However, recent research on bipolar disorder suggests that COVID-19 presents both challenges, such as [[w:Social stigma |stigma]], interruption of treatment, stress, and medical risks, as well as opportunities, such as increased [[w:Resilience |resilience]] and adaptations of mental health treatment delivery, for those with [[w:Bipolar disorder |bipolar disorder]].[104] As the COVID-19 global pandemic continues, more research on how these impacts specifically impact adolescents with SUD can help to increase understanding of the role that external forces have on adolescents with substance use disorder.  

Additional Information[edit | edit source]

Acknowledgements[edit | edit source]

The author team wants to acknowledge the assistance of Eric A. Youngstrom, PhD, for his guidance and feedback in the creation of this paper.

Conflict of Interest[edit | edit source]

The research team does not have any conflicts of interest to declare.

Ethics statement[edit | edit source]

There are no primary results from human or animal subjects research presented in this paper.

Ways of sharing information from this article[edit | edit source]

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