If the adolescent has a comorbid disorder for which medication is being considered (e.g., ADHD, major depression), abstinence is ideal before initiating medication for comorbidity. However, abstinence is not a realistic goal for many adolescent patients. Clinicians must therefore weigh the risk of potential drug–medication interactions against the risk that the untreated psychiatric illness will thwart treatment engagement or precipitate early dropout. Once the adolescent is engaged in substance abuse treatment, both urine drug screening and self-report should indicate either abstinence or significant reduction in substance use, although it is often necessary to tolerate some ongoing alcohol or cannabis use. The mental health professional or psychiatrist should then develop a plan for regular drug abuse monitoring (e.g., urine toxicology, breath alcohol) and for information exchange regarding compliance with substance treatment, urine toxicology results, target symptom response, and emergence of adverse side effects. When initiating medications, the patient should be compliant with at least weekly therapy sessions. Our clinical experience suggests benefit from motivational enhancement therapy coupled with CBT and an empathic, encouraging therapeutic style. Such an approach typically leads to successful medication stabilization for comorbidity during the first month of treatment. Early treatment of a psychiatric disorder can be critically important in facilitating treatment engagement and retention during the initial months of substance abuse treatment.

The following principles also may be helpful when using medications to treat comorbid disorders concurrently with substance dependence. First, when medication is indicated, consider medications with good safety profiles, low-abuse liability, and once-per-day dosing, if possible. Second, use a single medication if at all possible. Third, provide the patient and family with education about the potential for adverse interactions of medications with substances of abuse and the need for abstinence or reduced substance use to ensure safety and efficacy. Fourth, establish mechanisms to closely monitor medication compliance (initially weekly), adverse effects, target symptom response, and ongoing substance use (using both self-report and urine drug screening). Fifth, monitor compliance with regular substance treatment (generally, individual or family counseling at least weekly) and regular urine drug screening (if not the primary substance abuse treatment provider). Sixth, monitor patient treatment motivation and target symptom response as well as behavior changes and psychosocial functioning throughout treatment. If substance abuse or target symptoms of the comorbid disorder do not significantly improve within the first 2 months after initiating treatment, or if there is evidence of escalation in drug abuse or clinical deterioration, consider several options. First, evaluate the medication efficacy and change the medication. Second, reassess the diagnostic formulation (e.g., bipolar vs. unipolar depression). Third, increase the treatment intensity (frequency or level of care). Adherence to these principles should facilitate pharmacotherapy in adolescents who frequently have comorbid Axis I psychiatric disorders with their substance dependence. Medications primarily targeted at the substance dependence, such as bupropion or NRT for nicotine dependence, might also be considered, but behavior treatments should be tried first for most adolescents with primary substance dependence and no other Axis I psychopathology.

This theory comes from epidemiological research that has examined the patterning of alcohol and other drug use progression among adolescents. However, recently this theory has become a battleground for those both for and against the decriminalization of marijuana. The theory is based on the delineation of four stages in the sequence of involvement with drugs. The original findings suggested that surveyed adoles

cents engage in use of either alcohol or cigarettes (as legal and culturally accepted drugs) then progress to marijuana, and then on to other illicit drugs, such as heroin and cocaine. The legal drugs are necessary intermediates between nonuse and marijuana. Thus, the use of tobacco, alcohol, and marijuana by adolescents was viewed as a crucial step, or “gateway,” to the use of other illicit drugs (Kandel, 1975). However, opponents of this theory suggest that, if there were a risk factor that was common to both marijuana and other drugs, it could easily account for the relationship between both marijuana and other drug use. Examples of a theorized “third factor” include the genetic predisposition to drug use, a predisposition toward adolescent risk behavior in general, or shared opportunities to obtain both marijuana and other drugs (Morral, McCaffrey, & Paddock, 2002). Nonetheless, surveys of American high school students suggest that by 12th grade, 37% of students have tried marijuana, whereas 0.9% have tried heroin and 4.8% have tried cocaine (Johnston, O'Malley, & Bachman, 2002b). The discrepancies in these prevalence rates indicate that although hard drug users may have started with marijuana, it is clear that marijuana use does not invariably progress to adolescent use of hard drugs.

A less controversial aspect of this theory deals with age of initiation of experimentation with drugs of abuse (whether it is alcohol, tobacco, marijuana, or hard drugs), and the timing of stages of regular use and problematic involvement. The literature converges around the observation that the earlier the onset of substance use, the greater the likelihood of problematic involvement (Choi, Gilpin, Farkas, & Pierce, 2001; Choi, Pierce, Gilpin, Farkas, & Berry, 1997; Kandel & Logan, 1984; Schuckit & Russell, 1983; Yamaguchi & Kandel, 1984b). For this reason, substantial effort has been placed on prevention interventions that delay the initiation of initial substance exposure.

Problem behavior theory is an influential conceptual framework for understanding not only substance abuse but a wide variety of other types of risky adolescent behaviors (Jessor & Jessor, 1977). The theory proposes that there exists a syndrome of adolescent problem behaviors that may co-occur within the same individual (Jessor, 1991). For example, those who experiment with substance use also tend to engage in risky sexual practices and illegal behavior. These adolescent problem behaviors include

These deviant behaviors are thought to emanate from a single underlying factor (perhaps of genetic origin) that may exist prior to adolescence, resulting in a general syndrome of deviance. The risky behaviors may also be adaptive to the extent that they serve a social or maturational goal, such as separating from parents, achieving adult status, or gaining peer acceptance, and these behaviors may help an adolescent cope with failure, boredom, social anxiety or isolation, unhappiness, rejection, and low self-esteem. One example of a risk behavior syndrome is an adolescent's reported use of substances as a means of gaining social status and acceptance from peers and, at the same time, enhancing mood and feelings of low self-worth (DuRant, 1995; DuRant, Getts, Cadenhead, Emans, & Woods, 1995). Thus, this theory posits that substance abuse for some adolescents may be a maladaptive means to cope with the stresses and social pressures that are characteristic of the adolescent stage of development. This theoretical perspective suggests that prevention interventions that offer alternative means of coping and social adaptation might reduce adolescent substance use behavior.

Patterson's theory was originally proposed to explain the development of juvenile delinquency, and however consistent with the observation