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Drug and Substance Use in Adolescents

By Sharon Levy, MD, MPH, Assistant Professor of Pediatrics;Director, Adolescent Substance Abuse Program, Harvard Medical School;Boston Children's Hospital

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Substance use among adolescents ranges from sporadic use to severe substance use 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 share a social experience or feel part of a social group

  • To relieve stress

  • To seek new experiences and take risks

  • To relieve symptoms of mental health disorders (eg, depression, anxiety)

Additional risk factors include poor self-control, lack of parental monitoring, and various mental disorders (eg, attention-deficit/hyperactivity disorder and depression). Parental attitudes and the examples that parents set regarding their own use of alcohol, tobacco, prescription drugs, and other substances are a powerful influence.

According to national surveys, the proportion of high school seniors who report lifetime abstinence from all substances has been steadily increasing over the past 40 yr. However, at the same time, a broad range of more potent and dangerous products (eg, inhalable alcohol, pure tetrahydrocannabinol [THC], synthetic cannabinoids, prescription opioids) have become available. These products put adolescents who do initiate substance use at higher risk of developing both acute and long-term consequences.

Specific Substances

Alcohol

Alcohol use is 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, and adolescent drinkers may have significant alcohol toxicity. 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. 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.

Tobacco

Rates of tobacco use among adolescents fell dramatically in the 1990s and 2000s but have now plateaued. The CDC reports that in 2015, about 11% of high school students reported current cigarette use (smoked in the previous 30 days), down from 27.5% in 1991; only about 2% report smoking every day. However, 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. About 7 to 8% of 9th graders report smoking regularly (1).

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 7.3% of high school students use smokeless tobacco; this rate has remained relatively constant since 1999. 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 US, but use has increased among middle and high school students since 1999. The percentage of people > 12 yr who smoke cigars has declined.

Electronic cigarettes (e-cigarettes, e-cigs, vapes) have become increasingly popular among adolescents over the past several years, especially among adolescents of middle and upper socioeconomic status. Current e-cigarette use among middle and high school students has increased markedly from 4.5% in 2013 to 13.4% in 2014, and 24.1% in 2015 according to the CDC. About 45% of high school students have tried e-cigarettes. Electronic cigarettes do not contain tobacco but rather heat liquified nicotine into vapor that can be inhaled. Because there are no combustion products of tobacco, these products do not cause most of the adverse health consequences of smoking. However, nicotine is highly addictive, and nicotine toxicity is possible. E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine, but their effect on the rate of adult smoking is unclear. There are a number of other ingredients in e-cigarettes, some of which may be toxic. The long-term risks of e-cigarettes are unknown (1).

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).

Other substances

Use of other substances among adolescents remains a serious problem. The Youth Risk Behavior Surveillance nationwide survey of high school students done annually by the CDC reported that in 2015 the prevalence of current marijuana use among high school students was 21.7% (which is below the peak rate of 25.3% in 1995) and about 39% reported having used marijuana one or more times in their life. In 2010, the rate of current marijuana use surpassed the rate of current tobacco use for the first time.

In the same survey, the following percentages of high school students reported using illicit substances one or more times in their life:

Prescription drugs particularly abused include opioid analgesics (eg, oxycodone), stimulants (eg, ADHD drugs such as methylphenidate or dextroamphetamine), and sedatives (eg, benzodiazepines).

Nationwide, 1.8% of students had used a needle to inject any illegal drug into their body one or more times during their life (1).

General reference

Diagnosis

  • 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

Screening adolescents for substance use

Clinicians should screen for use of tobacco, 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.

There are a number of different screening tools. Some are brief and can be administered verbally; these may be helpful for identifying at-risk adolescents who might benefit from more detailed investigation. Other tools are more comprehensive paper or digital questionnaires that provide more information but require more time when administered by clinicians. Patient literacy may be an issue with a self-administered screening tool (eg, paper or digital questionnaire in office).

Alcohol screening

For alcohol screening, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed a guide that suggests beginning with two screening questions. The questions and interpretation of answers vary by age (see Table NIAA Alcohol Screening Questions for Children and Adolescents).

NIAA Alcohol Screening Questions for Children and Adolescents

Age Group*

1st Question

2nd Question

Interpretation

Risk Levels by Age

Elementary school (typically 9–11 yr)

Do you have any friends who drank any drink containing alcohol in the past year?

In the past year, have you ever had more than a few sips of any drink containing alcohol?

Friends: Any drinking heightens concern

Patient: Any drinking highest risk

≤ 11 yr: Any drinking highest risk

Middle school (typically 11–14 yr)

Do you have any friends who drank any drink containing alcohol in the past year?

In the past year, on how many days have you had more than a few sips of any drink containing alcohol?

Friends: Any drinking heightens concern

Patient: Any drinking moderate to highest risk depending on age and number of days

≤ 11 yr: Any drinking highest risk

12–14 yr: Moderate risk 1-5 days; highest risk > 5 days

High school (typically 14–18 yr)

In the past year, on how many days have you had more than a few sips of any drink containing alcohol?

If your friends drink, how many drinks do they usually drink on an occasion?

Patient: Low, moderate or highest risk depending on age and number of days

Friends: Binge drinking (3–5+ drinks) heightens concern

14–15 yr: Moderate risk 1-5 days; highest risk > 5 days

16 yr: Moderate risk 6–11 days; highest risk > 11 days

17 yr: Moderate risk 6–24 days; highest risk > 24 days

18 yr: Moderate risk 12–52 days; highest risk > 52 days

*School level is used because risk increases on transition to a higher level.

NIAA = National Institute on Alcohol Abuse and Alcoholism.

For moderate- and highest-risk patients, ask about

  • Drinking patterns: Usual and maximal consumption

  • Problems caused by or risks taken due to drinking: Missing school, fights, injuries, car crashes

  • Use of other substances: Any other things taken to get high

The NIAA guide also provides useful strategies to address problems that are discovered.

The CRAFFT questionnaire is another validated screening tool that has been widely used. 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

General substance screening

Because the CRAFFT questionnaire does not screen for tobacco use, provide information on frequency of use, or discriminate between drug and alcohol use, other screening tools have been developed.

The Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) and the Screening to Brief Intervention (S2BI) tools cover a broad range of substances and provide brief clinical guidance on how to respond to screening results. These tools will soon be available online.

Drug testing

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. However, the decision not to drug test should not prematurely terminate assessment for a possible substance use disorder or a mental health disorder. Adolescents with nonspecific signs of a substance use disorder or a mental health disorder should be referred to a specialist for a complete evaluation.

Treatment

  • 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 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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Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • DEXEDRINE
  • COMMIT, NICORETTE, NICOTROL
  • CONCERTA, RITALIN
  • OXYCONTIN