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Drug and Substance Use in Adolescents

By

Sharon Levy

, MD, MPH, Harvard Medical School

Last full review/revision Jul 2022| Content last modified Jul 2022
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Substance use among adolescents ranges from sporadic use to severe substance use disorders Substance Use Disorders Substance use disorders are a type of substance-related disorder that involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant... read more . The acute and long-term consequences range from minimal 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 Violence Adolescence is a time for developing independence. Typically, adolescents exercise their independence by questioning or challenging their parents' (or guardians') rules, which at times leads... read more , and consequences of sexual contact (eg, pregnancy Contraception and Adolescent Pregnancy Many adolescents engage in sexual activity but may not be fully informed about contraception, pregnancy, and sexually transmitted infections, including hepatitis C and HIV infection. Impulsivity... read more , sexually transmitted infection Overview of Sexually Transmitted Infections Sexually transmitted infections (STIs), also termed sexually transmitted diseases or STDs, can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and... read more ). Substance use also interferes with adolescent brain development in a dose-dependent fashion. Regular use of alcohol, cannabis (marijuana), nicotine, or other drugs during adolescence is associated with higher rates of mental health disorders, poorer functioning in adulthood, and higher rates of addiction.

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)

According to US national surveys, the proportion of high school seniors who report lifetime abstinence from all substances has been steadily increasing over the past 40 years. However, at the same time, a broad range of more potent, addictive, and dangerous products (eg, prescription opioids, high-potency cannabis products, fentanyl, e-cigarettes) has become available. These products put adolescents who do initiate substance use at higher risk of developing both acute and long-term consequences.

The COVID-19 pandemic had a mixed impact on adolescent substance use. During stay-at-home periods, rates of initiation decreased, but rates of heavy use increased because some adolescents increased their substance use as a mechanism for coping with stress. All substance use, inhalational substance use in particular, increases the risk of infection and also the risk of severe disease. Thus, interventions that reduce substance use are an important part of a COVID-19 mitigation strategy.

Specific Substances

The substances that are used most by adolescents are alcohol, nicotine (in tobacco or vaping products), and cannabis.

Alcohol

Alcohol use is common and is the substance most often used by adolescents. The Monitoring the Future Survey on Drug Use reported that in 2021 by 12th grade, 54% of adolescents have tried alcohol, and nearly 26% are considered current drinkers (having consumed alcohol within the past month) ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ). Heavy alcohol use is also common, and adolescent drinkers may have significant alcohol toxicity Alcohol Toxicity and Withdrawal Alcohol (ethanol) is a central nervous system depressant. Large amounts consumed rapidly can cause respiratory depression, coma, and death. Large amounts chronically consumed damage the liver... read more . 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. A binge is defined as a pattern of alcohol consumption that raises the blood alcohol level to 80 mg/dL (17.37 mmol/L). The number of drinks that constitute a binge depends on age and sex and can be as few as 3 drinks within 2 hours for younger adolescent girls.

Society and the media portray drinking as acceptable, fashionable, or even as a healthful mechanism for managing stress, sadness, or mental health problems. 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 Alcohol Use Disorders and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more . 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

The majority of adults who smoke cigarettes began 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 ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ).

Rates of combustible tobacco use among adolescents fell dramatically in the 1990s and 2000s and continue to decline. The Monitoring the Future Survey reported that in 2021, about 4.1% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991 and from 5.7% in 2019; only about 2% report smoking every day.

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 substances)

  • Poor problem-solving abilities

  • Availability of cigarettes

  • Poor self-esteem

Adolescents may also use tobacco products in other forms. About 2% of high school students are current users of smokeless tobacco ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ); this rate has declined over the past 10 years. 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. The percentage of people > 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 Smoking Cessation Most smokers want to quit and have tried doing so with limited success. Effective interventions include cessation counseling and drug treatment, such as varenicline, bupropion, or a nicotine... read more ).

Electronic cigarette products (vaping products)

Electronic cigarettes (e-cigarettes, e-cigs, vapes) use heat to volatilize a liquid containing the active ingredient, typically nicotine or tetrahydrocannabinol (THC). Electronic cigarettes initially entered the market as alternatives to smoking for adult smokers, and initial models were not used much by adolescents. They have since morphed into "vapes," which are highly attractive to and have become increasingly popular among adolescents over the past several years, especially among adolescents of middle and upper socioeconomic status. Current e-cigarette use (nicotine vaping, not counting other substances) among 12th graders increased markedly from 11% in 2017 to 25.5% in 2019. According to the Monitoring the Future Survey, in 2021 e-cigarette use decreased to 19.6%, and about 40.5% of 12th graders tried e-cigarettes (nicotine and other substances), which is a decrease from 45.6% in 2019 ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ).

Electronic cigarettes cause different adverse effects compared to smoking Chronic effects of smoking Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more . Other chemicals contained in vaping products can cause lung injury, which can be acute, fulminant, or chronic and, in its most severe form, lethal. In addition, these products can deliver very high concentrations of nicotine and THC. THC and nicotine are highly addictive, and 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. Other potential long-term risks of e-cigarettes are also unknown ( 2 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ).

Cannabis (marijuana)

The Monitoring the Future Survey reported that in 2021 the prevalence of current cannabis Marijuana (Cannabis) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent... read more use among high school seniors was 19.5%, which is a decrease from 22.3% in 2019. About 38.6% of high school seniors reported having used cannabis one or more times in their life ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ). In 2010, the rate of current cannabis use surpassed the rate of current tobacco use for the first time.

Other substances

Use of substances other than alcohol, nicotine, and cannabis during adolescence is relatively rare.

In the 2021 Monitoring the Future Survey, the following percentages of 12th grade students reported using illicit substances one or more times in their life ( 1 Specific substances references Substance use among adolescents ranges from sporadic use to severe substance use disorders. The acute and long-term consequences range from minimal to minor to life threatening, depending on... read more ):

Specific substances references

Screening for Substance Use Disorders in Adolescents

  • Clinical evaluation, including routine screening

  • Screening questions and drug testing

Some behaviors should prompt parents, teachers, or others involved with an adolescent to be concerned about a possible substance use disorder. Other behaviors are nonspecific, for example

  • Erratic behavior

  • Depression or mood swings

  • A change in friends

  • Declining school performance

  • Loss of interest in hobbies

Adolescents who exhibit any of these behaviors should have a full medical evaluation for mental health and substance use. Substance use disorders should be considered as possible causes of these behaviors even if screening is negative. Substance use disorders are diagnosed based on clinical criteria Diagnosis Substance use disorders are a type of substance-related disorder that involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant... read more .

Screening adolescents for substance use

Screening for use of tobacco, alcohol, and other drugs is a standard part of health maintenance. Adolescents and their parents can benefit from advice about safely using and monitoring over-the-counter and prescription drugs. Universal substance use screening can normalize discussions about substance use, reinforce healthy behaviors and choices, identify adolescents at risk of problematic substance use or of a substance use disorder, guide interventions, and identify adolescents in need of referral for treatment.

There are a number of different validated screening tools. The National Institute on Drug Abuse (NIDA) has two such electronic screening tools available for use with patients ages 12 to 17, the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) tool and the Screening to Brief Intervention (S2BI) tool. Each screening tool may be either self-administered by the patient or administered by a health care professional. Self-administration is recommended because it is preferred by adolescents. The tools begin with questions about frequency of use of tobacco, alcohol, and cannabis in the past year. A positive answer prompts questions about additional types of substance use. The tools triage adolescents into one of three risk categories for a substance use disorder: no reported use, lower risk, and higher risk. Based on the results, the tools offer an action plan based on guidance derived from expert consensus. Although times may vary based on method of administration and number of follow-up questions, these tools can typically be completed in under 2 minutes.

The CRAFFT questionnaire is an older, validated screening tool for alcohol and drug use. Because the original CRAFFT questionnaire does not screen for tobacco use, provide information on frequency of use, or discriminate between drug and alcohol use, it is no longer widely used and other screening tools have been developed, including the updated CRAFFT 2.1+N questionnaire, which does have a question about use of tobacco and nicotine.

Alcohol screening

For more specific and comprehensive 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 NIAAA Alcohol Screening Questions for Children and Adolescents NIAAA Alcohol Screening Questions for Children and Adolescents NIAAA Alcohol Screening Questions for Children and Adolescents ).

Table

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

Drug testing

Drug testing Drug Testing Drug testing is done primarily to screen people systematically or randomly for evidence of use of one or more substances with potential for abuse. Testing is done in the following: Certain groups... read more may be useful to identify substance use 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 (including at-home 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 use disorders 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 of Drug and Substance Use in Adolescents

  • Behavioral therapy tailored for adolescents

Typically, adolescents with a moderate or severe substance use disorder are referred for further assessment and treatment, often by a behavioral health specialist, or, in some cases, to a specialty substance use disorder treatment program. In general, the same behavioral therapies used for adults with substance use disorders Treatment Substance use disorders are a type of substance-related disorder that involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant... read more 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.

Drugs that are used to treat withdrawal symptoms resulting from stopping the use of nicotine, THC, and other substances are available for adolescents and can be prescribed by a primary care provider.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

Drugs Mentioned In This Article

Drug Name Select Trade
COMMIT, NICORETTE, NICOTROL
ACTIQ, DURAGESIC, SUBLIMAZE
OXYCONTIN
CONCERTA, RITALIN
DEXEDRINE
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