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Drug and Substance Use 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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Topic Resources

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 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). Substance use also interferes with adolescent brain development in a dose-dependent fashion. Regular use of alcohol, 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)

Additional risk factors include poor self-control, lack of parental monitoring, and various mental disorders (eg, attention-deficit/hyperactivity disorder, 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 years. However, at the same time, a broad range of more potent and dangerous products (eg, prescription opioids, high-potency marijuana products, fentanyl) has become available. These products put adolescents who do initiate substance use at higher risk of developing both acute and long-term consequences.

Specific Substances

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

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 and continue to decline. The National Institute on Drug Abuse at the National Institutes of Health (NIH) survey (1) reported that in 2019, about 5.7% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991 and from 7.6% in 2018; 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 (2).

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 in other forms. About 3.5% of high school students use smokeless tobacco; 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).

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); there is no combustion involved. 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 socioeconomic status. 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 according to a survey sponsored by the NIH (1). About 45.6% of 12th graders have tried e-cigarettes (nicotine and other substances).

Because there are no combustion products of tobacco, electronic cigarettes cause different adverse effects compared to adverse health consequences caused by smoking. However, 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).

Marijuana

The NIH survey (1) of high school students reported that in 2019 the prevalence of current marijuana use among high school students was 22.3%, 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 (1; see also vaping products).

Other substances

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

In the NIH survey, the following percentages of high school students reported using illicit substances one or more times in their life (1):

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

Nationwide, 1.5% of students had used a needle to inject any illegal drug into their body one or more times during their life (2).

Specific substances references

  • 1. Johnston LD, Miech RA, O’Malley PM, et al: Monitoring the Future national survey results on drug use 1975-2019: 2019 Overview, key findings on adolescent drug use. Ann Arbor, Institute for Social Research, University of Michigan, 2020.

  • 2. Kann L, McManus T, Harris WA, et al: Youth Risk Behavior Surveillance—United States, 2017. MMWR Surveill Summ 67(No. SS-8):1–114, 2018. doi: 10.15585/mmwr.ss6708a1

Diagnosis

  • Clinical evaluation, including routine screening

Behaviors that should prompt parental concern for possible substance use disorder 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 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, guide interventions, and identify adolescents in need of referral for treatment of a substance use disorder.

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 when possible because rates of disclosure are higher compared to verbal interview administration. The tools begin with questions about frequency of use of tobacco, alcohol, and marijuana 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).

Table
icon

NIAAA Alcohol Screening Questions for Children and Adolescents

Age Group*

1st Question

2nd Question

Interpretation

Risk Levels by Age

Elementary school (typically 9–11 years)

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 years: Any drinking highest risk

Middle school (typically 11–14 years)

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 years: Any drinking highest risk

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

High school (typically 14–18 years)

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 years: Moderate risk 1–5 days; highest risk > 5 days

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

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

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

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

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

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 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

  • 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.

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
DEXEDRINE
CONCERTA, RITALIN
OXYCONTIN
COMMIT, NICORETTE, NICOTROL
ACTIQ, DURAGESIC, SUBLIMAZE
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