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Drug and Substance Use in Adolescents

By Sharon Levy, MD, MPH, Harvard Medical School;Children's Hospital, Boston

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Substance use among adolescents ranges from experimentation to severe substance use disorders (see Substance-Related Disorders). The consequences range from none to minor to life threatening, depending on the substance, the circumstances, and the frequency of use. However, even occasional use can put adolescents at increased risk of significant harm, including overdose, motor vehicle crashes, violent behaviors, and consequences of sexual contact (eg, pregnancy, sexually transmitted infection).

Adolescents use substances for a variety of reasons:

  • To escape from perceived pressures (eg, from parents or peers)

  • To challenge authority

  • To seek thrills and take risks

Additional risk factors include poor self-control, lack of parental monitoring, and various mental disorders (eg, attention-deficit/hyperactivity disorder [see Attention-Deficit/Hyperactivity Disorder (ADD, ADHD)] and depression [see Depressive Disorders in Children and Adolescents]). Parental attitudes and the examples that parents set regarding their own use of alcohol, tobacco, prescription drugs, and other substances are a powerful influence.

Specific Substances


Alcohol use is extremely common and is the substance most often used by adolescents. By 12th grade, > 70% of adolescents have tried alcohol and nearly half are considered current drinkers (having consumed alcohol within the past month). Heavy alcohol use is also common. Nearly 90% of all alcohol consumed by adolescents occurs during a binge, putting them at risk of accidents, injuries, unwanted sexual activity and other bad outcomes.

Society and the media portray drinking as acceptable or even fashionable. Despite these influences, parents can make a difference by conveying clear expectations to their adolescent regarding drinking, setting limits consistently, and monitoring. On the other hand, adolescents whose family members drink excessively may think this behavior is acceptable. Some adolescents who try alcohol go on to develop an alcohol use disorder (see Alcohol Use Disorders and Rehabilitation). Known risk factors for developing a disorder include starting drinking at a young age and genetics. Adolescents who have a family member with an alcohol use disorder should be made aware of their increased risk.


Rates of tobacco use among adolescents fell dramatically in the 1990s and 2000s but have now plateaued. The majority of adults who smoke cigarettes begin smoking during adolescence. If adolescents do not try cigarettes before age 19, they are very unlikely to become smokers as adults. Children as young as age 10 may experiment with cigarettes. Nearly one fifth of 9th graders report smoking regularly.

The strongest risk factors for adolescent smoking are having parents who smoke (the single most predictive factor) or having peers and role models (eg, celebrities) who smoke. Other risk factors include

  • Poor school performance

  • High-risk behavior (eg, excessive dieting, particularly among girls; physical fighting and drunk driving, particularly among boys; use of alcohol or other drugs)

  • Poor problem-solving abilities

  • Availability of cigarettes

  • Poor self-esteem

Adolescents may also use tobacco in other forms. About 3.3% of people 18 and older and about 7.9% of high school students use smokeless tobacco. Smokeless tobacco can be chewed (chewing tobacco), placed between the lower lip and gum (dipping tobacco), or inhaled into the nose (snuff). Pipe smoking is relatively rare in the United States, but use has increased among middle and high school students since 1999. The percentage of people over age 12 who smoke cigars has declined.

Parents can help prevent their adolescent from smoking and using smokeless tobacco products by being positive role models (that is, by not smoking or chewing), openly discussing the hazards of tobacco, and encouraging adolescents who already smoke or chew to quit, including supporting them in seeking medical assistance if necessary (see Smoking Cessation : Cessation in children).

Other substances

Marijuana use (see Marijuana (Cannabis)) is on the rise and recently surpassed tobacco use. Prescription drugs, particularly opioid analgesics, anti-anxiety drugs, and stimulants, and OTC drugs, mainly dextromethorphan (which is present in many cough suppressants), are now misused by adolescents more than any other substances other than alcohol and marijuana. Inhalant use (see Volatile Solvents) is also a problem, particularly among young adolescents. Many of these psychoactive substances are addictive, and delaying the onset of substance use from adolescence into adulthood may prevent the acute problems associated with substance use and decrease the lifetime risk of developing a substance use disorder.

Other abused substances include amphetamines and methamphetamines, cocaine, anabolic steroids, opioids, and so-called date rape drugs and club drugs (eg, methylenedioxymethamphetamine [MDMA, or Ecstasy], ketamine, and gamma hydroxybutyrate [GHB]). In 2007, about 47% of 12th graders had used these other substances at some time in their life.

About 2% of 12th graders have used anabolic steroids (see Anabolic Steroids) in their lifetime. Although steroid use is more common among athletes, nonathletes are not immune. Use of anabolic steroids is associated with a number of adverse effects, including premature closure of the growth plates, resulting in permanent short stature. Other adverse effects are common to both adolescents and adults.


  • Clinical evaluation, including routine screening

Behaviors that should prompt parental concern for possible substance abuse include

  • Finding drugs or drug paraphernalia

  • Erratic behavior

  • Depression or mood swings

  • A change in friends

  • Declining school performance

  • Loss of interest in hobbies


Clinicians should screen for use of alcohol and other drugs at every health maintenance visit and also should advise both adolescents and parents about safely using and monitoring OTC and prescription drugs.

The CRAFFT questionnaire is one validated screening tool. Adolescents with ≥ 2 positive answers require further evaluation. Clinicians ask adolescents whether they do or have done the following:

  • C: Ride in a Car driven by someone (including themselves) who is “high” or has been drinking alcohol or using drugs

  • R: Drink alcohol or use drugs to Relax, feel better about themselves, or fit in

  • A: Drink alcohol or use drugs while they are Alone

  • F: Forget things they did while drinking or using drugs

  • F: Are ever told by family members or Friends that they should drink less or use drugs less

  • T: Get into Trouble while drinking or using drugs

Drug testing

Drug testing (see Drug Testing) may be useful but has significant limitations. When parents demand a drug test, they may create an atmosphere of confrontation that makes it difficult to obtain an accurate substance use history and form a therapeutic alliance with the adolescent. Screening tests are typically rapid qualitative urine immunoassays that are associated with a number of false-positive and false-negative results. Furthermore, testing cannot determine frequency and intensity of substance use and thus cannot distinguish casual users from those with more serious problems. Clinicians must use other measures (eg, thorough history, questionnaires) to identify the degree to which substance use has affected each adolescent's life. Given these concerns and limitations, it is often useful to consult with an expert in substance abuse to help determine whether drug testing is warranted in a given situation.


  • Behavioral therapy tailored for adolescents

Typically, adolescents with a moderate or severe substance use disorder are referred for further assessment and treatment. In general, the same behavioral therapies used for adults with substance use disorders (see Overview of Substance-Related Disorders) can also be used for adolescents. However, these therapies should be adapted. Adolescents should not be treated in the same programs as adults; they should receive services from adolescent programs and therapists with expertise in treating adolescents with substance use disorders.

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