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Substance Use and Abuse in Adolescents

By

Sharon Levy

, MD, MPH, Harvard Medical School

Last full review/revision Sep 2020| Content last modified Sep 2020
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Substance use among adolescents ranges from experimentation to severe substance use disorders. All substance use, even experimental use, puts adolescents at risk of short-term problems, such as accidents, fights, unwanted sexual activity, and overdose. Substance use also interferes with adolescent brain development. Adolescents are vulnerable to the effects of substance use and are at increased risk of developing long-term consequences, such as mental health disorders, underachievement in school, a substance use disorder, and higher rates of addiction, if they regularly use alcohol, marijuana, nicotine, or other drugs during adolescence.

In modern Western society, substance use is an easy way for adolescents to satisfy the normal developmental need to take risks and seek thrills. Not surprisingly, substance use is common as adolescents get older, and about 70% of adolescents will try alcohol before high school graduation. However, recurring or ongoing substance use is much less common. Even occasional substance use is risky and should not be trivialized, ignored, or allowed by adults. 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 12th graders who report they have not used any substances in their lifetime has been steadily increasing over the past 40 years. However, at the same time, a broad range of more potent and dangerous products (such as prescription opioids, high-potency marijuana products, and fentanyl) has become available. These products put adolescents who do start using substances at higher risk of developing both short- and long-term consequences.

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

Alcohol Use in Adolescents

Alcohol is the substance most often used by adolescents. About 70% of 12th graders report having tried alcohol, although only 55% say they have ever been drunk. About 50% of 12th graders have consumed alcohol in the past month and are considered current drinkers. Heavy alcohol use is also common, and nearly 90% of all alcohol consumed by adolescents occurs during a binge. A binge is defined as consuming 3 to 5 standard drinks (depending on gender and age) within 2 hours or less. However, because adolescents often drink alcohol directly from the bottle or pour their own drinks, a drink for them may be larger than a "standard" drink for adults. Binges put adolescents at risk of accidents, injuries, unwise or unwanted sexual activity, and other unfortunate situations. For these reasons, adolescents should be discouraged from drinking.

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. 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 Use in Adolescents

Rates of tobacco use among adolescents fell dramatically in the 1990s and 2000s and continue to decline. The National Institute on Drug Abuse at the National Institutes of Health (NIH) survey reported that in 2019, about 5.7% of 12th graders reported current cigarette use (smoked in the previous 30 days), which was down from 28.3% in 1991 and from 7.6% in 2018. Only about 2% of 12th graders reported smoking every day. 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.

The single strongest risk factor for adolescent smoking is

  • Having parents who smoke

Other risk factors often associated with starting smoking during childhood include

  • Peers and role models (such as celebrities) who smoke

  • Poor school performance

  • Other high-risk behavior (such as excessive dieting, particularly among girls; physical fighting and drunk driving, particularly among boys; or use of alcohol or other substances)

  • Poor problem-solving abilities

  • Availability of cigarettes

  • Poor self-esteem

Adolescents may also use tobacco in other forms. About 3.5% of high school students use smokeless tobacco, and 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 dip), or inhaled into the nose (snuff). Pipe smoking is relatively rare in the United States. 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 Cessation in children and adolescents).

Electronic Cigarettes (Vaping Products)

Electronic cigarettes (e-cigarettes, e-cigs, vapes) are battery-operated devices that use heat to turn a liquid into a vapor that can be inhaled. These liquids typically contain nicotine, which is the active ingredient in tobacco, or tetrahydrocannabinol (THC), which is the active ingredient in marijuana. Both nicotine and THC are addictive. (See also Vaping.)

Electronic cigarettes initially entered the market as nicotine cessation devices for adult smokers. 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 social and economic status. According to the NIH survey, current e-cigarette use (nicotine vaping, not counting other substances) among 12th graders increased markedly from 4.5% in 2013 to 25.5% in 2019. About 45.6% of 12th graders have tried e-cigarettes (nicotine and other substances).

Unlike regular cigarettes, electronic cigarettes do not have tobacco and do not burn anything, which means they also do not have the combustion products of burning tobacco (tar, carbon monoxide, and other toxins), which are responsible for many of the negative health effects caused by smoking, including lung cancer and chronic obstructive pulmonary disease (COPD). However, other chemicals contained in vaping products can cause lung injuries. Lung injuries can be sudden, severe, or long-lasting and, when most severe, lethal. In addition, these products can deliver very high concentrations of nicotine and THC. THC and nicotine are highly addictive, and toxicity is possible. Secondhand vapor from e-cigarettes contains nicotine or the other active ingredients.

E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine, but their effect on the rate of adult smoking is unclear. The long-term risks of e-cigarettes are not currently known.

Marijuana

The NIH survey of high school students reported that in 2019 22.3% of high school students were current marijuana users, which is an increase from 20.6% in 2009. About 43.7% of high school students 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.

The most significant increase in marijuana use is in THC vaping. The number of 12th graders who reported vaping THC increased from 4.9% in 2017 to 14% in 2019 (see also vaping products).

Other Substances

Use of substances other than alcohol, nicotine, and marijuana during adolescence is less common.

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

Prescription drugs that are particularly abused include opioid (narcotic) pain relievers, antianxiety drugs, and stimulants (such as methylphenidate and similar drugs used for attention-deficit/hyperactivity disorder).

Although anabolic steroid use is more common among athletes, non-athletes are not immune. Use of anabolic steroids is associated with a number of side effects. A problem specific to adolescents includes premature closure of the growth plates at the ends of bones, resulting in permanent short stature. Other side effects are common to both adolescents and adults.

Nonprescription, over-the-counter (OTC) drugs that are commonly misused include cough and cold drugs that contain dextromethorphan. OTC cough and cold drugs are widely available and are considered safe by many adolescents and now serve as gateway drugs.

Even young adolescents may try drugs, with some reporting drug use as early as age 12. Many adolescents who experiment with OTC, prescription, and other substances go on to develop substance use disorders.

Diagnosis

  • A doctor's evaluation, including routine screening and sometimes a drug test

Behaviors that should prompt parents to discuss their concerns with their child and doctor include

  • Finding drugs or drug paraphernalia (such as vapes, pipes, syringes, and scales)

  • Erratic behavior

  • Depression or mood swings

  • A change in friends

  • Declining school performance

  • Loss of interest in hobbies

During routine health care visits, parents should expect their child’s doctor to screen their child for substance use by asking confidential questions about tobacco, alcohol, and other drug use. Doctors can help assess whether an adolescent has a substance use disorder and implement an appropriate intervention or make a referral.

A drug test may be a useful part of an assessment but has significant limitations. Results of a urine test may be negative in adolescents who use drugs if the drug has been cleared from the body before the test is done, if a drug not included on a standard testing panel has been used, or if the urine specimen has been contaminated. Sometimes, drug test results are positive in adolescents who have not used drugs (false positive). Even a true-positive test does not indicate how often and how heavily a drug is used and thus cannot distinguish casual use from more serious problems.

Given these limitations, a doctor with expertise in this area should determine whether a drug test is needed in a given situation, and parents should respect their doctor’s advice. When parents demand a drug test or demand information that would break their child’s confidentiality, they may create an atmosphere of confrontation and accidentally make it difficult for a doctor to obtain an accurate substance use history and form a trusting relationship with their child.

Treatment

  • Therapy tailored for adolescents

If the doctor thinks the adolescent has a substance use disorder, a referral for further assessment and treatment may be needed. In general, the same treatment used for adults with substance use disorders can also be used with adolescents. However, the treatment should be tailored to the adolescent's needs. Adolescents should receive services from adolescent programs and therapists with expertise in treating adolescents with substance use disorders. In general, adolescents should not be treated in the same programs as adults.

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.

  • Al-Anon Family Groups: Access to resources and support for families and friends of alcoholics

  • Alcoholics Anonymous (AA): An international fellowship of nonprofessional men and women who support each other to confront and overcome a drinking problem

  • American Lung Association: Resources about how to prevent children from smoking and how to help those that smoke to quit

  • Narcotics Anonymous (NA): Support resources and a recovery program for people who are addicted to drugs or alcohol

  • National Institutes on Drug Abuse: Agency within the U.S. National Institutes of Health that has information specific to children and adolescents about how drugs affect their brain, facts about widely used drugs, and links to related content

  • Substance Abuse and Mental Health Services Administration: Agency within the U.S. Department of Health and Human Services that leads public health efforts to reduce the impact of substance abuse and mental illness on America's communities

Drugs Mentioned In This Article

Generic Name Select Brand Names
DELSYM
CONCERTA, RITALIN
ACTIQ, DURAGESIC, SUBLIMAZE
COMMIT, NICORETTE, NICOTROL
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