The leading causes of morbidity and mortality among adolescents and young adults are related to alcohol, smoking, and illicit drug use. According to 2015 data from Monitoring the Future (MTF), alcohol and tobacco use are at the lowest level in the survey’s history, which dates back to 1975. From 1996 to the present, the 30-day prevalence of smoking declined by 83% and 79% in 8th and 10th graders, respectively. Seventy-five percent fewer students reported trying cigarettes in 2015 compared to 1997. Alcohol continues to be the most widely used substance in this population. In 2000, the prevalence of alcohol use in the past 30 days was 22%, 41%, and 50% among 8th, 10th, and 12th graders, respectively; the prevalence has now dropped to 10%, 22%, and 35%, respectively. Marijuana is the most widely used illicit drug with the highest prevalence rate among 12th graders at 35%; other illicit drug use declined across 8th through 12th grades from 34.1% in 1997 to 26.8% in 2015.
Substance use often begins during adolescence or earlier. Adolescents use tobacco, alcohol, and illicit drugs to deal with problems, to enhance school performance, in response to peer pressure, or in response to desires for new experiences. Adolescents are more likely to use drugs if drugs are readily available in their community, if their peer group uses drugs, or if they have a mental health diagnosis such as depression or anxiety. Biologically, the adolescent brain is more vulnerable to substance use disorders, as the prefrontal cortex, which is responsible for judgment and impulse control, is not fully developed until the mid-20s. As there is no pathognomonic clinical presentation of substance use, clinical signs of substance use vary from behavioral and medical to a mental health complaint. The signs of substance use may be as subtle as appearing withdrawn, tired, or agitated. Secondary to substance use, a decline may be seen in school or athletic performance, and changes in peer groups, engagement in illegal activities, or other high-risk behaviors may occur.
RISK FACTORS AND PROTECTIVE FACTORS
Known risk factors for the development of substance use disorder include male gender, gang involvement, academic failure, family history of a substance use disorder, use by peers, earlier age of onset, cognitive disability, and psychiatric comorbidities such as attention–deficit/hyperactivity disorder (ADHD) and depression. Many of these risk factors overlap with other problematic behaviors such as teen pregnancy, truancy, and violence. Protective factors against substance use include community involvement, healthy family and school relationships, and prosocial peers.
SCREENING FOR DRUGS OF ABUSE
The American Academy of Pediatrics recommends annual screening of adolescents for tobacco, alcohol, and illicit drug use, including sports supplements and prescription drugs. Substance use screening should be incorporated into all healthcare visits for early identification of at-risk individuals. The healthcare provider, by creating a comfortable, trusting environment and using open-ended questions, may obtain an accurate substance use history from the adolescent patient. This portion of the history should take place without a parent in the room to help preserve patient confidentiality, which is necessary to obtain a complete psychosocial history. An effective opening question is: “During the past 12 months have you consumed alcohol, smoked marijuana, or used anything to get high?” If the response is “Yes” to drug use, proceed with asking the six CRAFFT questions to help further define the pattern of substance use.
C: Have you ever ridden in a CAR driven by yourself or someone who had been using alcohol or drugs?
R: Do you ever use alcohol or drugs to RELAX or feel better?
A: Do you ever use alcohol or drugs ALONE?
F: Do you ever FORGET things you did while using alcohol or drugs?
F: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T: Have you ever gotten into TROUBLE while you were using alcohol or drugs?
If the answer is “No” to use of drugs, complete the substance use screening by asking the “Car” question. A positive CRAFFT is defined as a score of 2 or more, indicating a high risk of having a substance use disorder. If the adolescent is using drugs, inquire about onset, duration, frequency, and route of drugs used. The CRAFFT screening tool is a validated developmentally appropriate tool that can be easily administered and scored by primary care physicians. Additional validated adolescent-specific substance use screening tools include the Alcohol Use Disorders Identification Test (AUDIT) and Problem Oriented Screening Instrument for Teenagers (POSIT). Through a careful history, the healthcare provider will be able to determine the impact of drug use on the adolescent’s social life and academic performance, which are elements that can be incorporated into the treatment plan at the end of the visit. Red flags for a severe substance use disorder include daily use of a substance, CRAFFT score of 5 or higher, and memory lapses (drug-related blackouts) after substance use. A mood inventory and family history of substance use disorders are also part of the substance use history.
TESTING FOR DRUGS OF ABUSE
The most commonly used tests for drugs of abuse are qualitative tests for screening purposes and quantitative tests for confirming test results. Most laboratories perform quantitative tests using either gas chromatography or mass spectrometry. The basic test screens for amphetamine, cocaine, marijuana, opioids, and phencyclidine. The period during which a drug may be detected after use varies according to the drug used and ranges from 1 to 7 days (Table 74-1). A positive drug test simply means the patient recently used this drug (within the past 1 to 7 days) but cannot be used to determine acute drug intoxication. Acute drug intoxication is a clinical diagnosis that can be supported by a positive drug screen. Clinicians ordering drug screens should be familiar with reasons for a false-positive drug test, such as taking a fluoroquinolone antibiotic, which can cross-react with an opiate screen. Similarly a patient taking an amphetamine for ADHD will test positive for amphetamines, which may be misinterpreted as abusing amphetamines. A false-negative result may occur if the urine sample is watered down or a masking substance was added to the urine such as soap, bleach, or ammonia. If clinical findings do not correlate with drug testing results, assistance from a laboratory should be sought for further help in interpretation of the test results. Accurate test results heavily depend on method of specimen collection; direct observation of specimen collection is the ideal method.
TABLE 74-1URINE DRUG TESTING AND DURATION OF POSITIVITY ||Download (.pdf) TABLE 74-1URINE DRUG TESTING AND DURATION OF POSITIVITY
|Drug ||Duration of Positivity |
|Amphetamines ||48 hours |
|Barbiturates ||24–72 hours |
|Benzodiazepine ||72 hours |
|Cocaine ||48–72 hours |
|Ethanol ||<12 hours (not routinely tested) |
|γ-Hydroxybutyrate ||<12 hours |
|Heroin ||24 hours |
|Inhalant ||Not routinely tested |
|LSD ||Not detected in standard urine screens |
|Marijuana ||Use of 1 dose (detectable for 48 hours); 4 times per week (5 days); daily use (10 days); chronic use (21–30 days) |
|Methadone ||3 days |
|3,4- Methylenedioxymethamphetamine (MDMA) ||Failure to detect MDMA unless large doses have been ingested |
|PCP ||8 days |
A drug screen should only be performed after obtaining the adolescent’s consent, unless the patient is experiencing a life-threatening medical situation or there are legal reasons. The American Academy of Pediatrics opposes involuntary testing of adolescents for drugs of abuse. Prior to drug testing, a discussion with the patient regarding disclosure of test results to the guardian should take place. The drug test results may remain confidential if the patient chooses this route unless the drug use is posing an acute risk of harm to self or others. Home and school-based testing is not routinely recommended. Any information obtained from drug screening should be used for therapeutic rather than punitive purposes.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), defines a substance use disorder as problematic use with the presence of 2 of 11 criteria over a 12-month period. The severity of use is further defined as mild, moderate, and severe, depending on the number of symptoms present. It is important to recognize that substance use can fluctuate with relapses and cycling back and forth in severity. Drug withdrawal is a clearly defined entity associated with prolonged use; the DSM-V specifically lists symptoms of withdrawal related to the drug used. Determining the impact of substance use on the adolescent’s life is critical, as this information can help the adolescent understand the consequences of this use and the urgency and importance of participating in a treatment program as soon as possible.
Treatment recommendations for substance use disorders depend on several factors, including the presence of medical or mental conditions, developmental stage, age, gender, cultural background, readiness to change, and history of relapse. Patient and family engagement in treatment options is highly encouraged, as ultimately the adolescent must participate in the treatment program that is ideally supported by the family. Adolescents who are experimenting with drugs with no consequences or minor consequences may be briefly counseled on how to reduce and stop using drugs to avoid ongoing negative behavioral consequences utilizing motivational interviewing techniques and Prochaska and DiClemente’s stages of change model. In addition to brief office-based interventions, outpatient treatment programs are available with varying intensities of therapy, individual and/or family-based sessions using cognitive behavioral therapeutic approaches, and motivational interviewing techniques. More severe substance use disorders require residential treatment programs followed by recovery support services, which can reduce the chances of relapse.
Ethanol content is measured as “percent” (weight to volume) and in distilled beverages as “proof” units. In the United States, 1 proof means 0.5% ethanol, or twice the percent. The ethanol content varies depending on the beverage (from 3% to 60%).
Alcohol use increases through high school years. Adolescence is an entry point for developing an alcohol use disorder, given that earlier onset of using alcohol is associated with a greater risk of developing an alcohol use disorder.
Binge drinking is defined as having more than 4 to 5 drinks in one setting or achieving a blood alcohol level of 0.08% or higher. Binge drinking is increasing among high school students; two-thirds of high school students who currently drink report binge drinking more than 1 time in the past 30 days. Frequent binge drinkers are more likely to develop an alcohol or substance use disorder.
Ethanol is a central nervous system depressant with local and general anesthetic properties. Similar to other drugs of abuse, it causes the release of dopamine.
Symptoms of an acute intoxication occur at blood alcohol concentrations (BAC) between 50 and 150 mg/dL and include sleepiness, loss of social inhibitions, incoordination, depression, aggression, and euphoria. When BAC levels are above 150 mg/dL, the patient becomes lethargic, bradycardic, and hypotensive, and may have respiratory depression. Alcohol poisoning occurs with BAC around 450 mg/dL and may lead to stupor, coma, and death by respiratory depression. Adolescents who binge drink may experience a blackout, hangover, alcohol poisoning, or death. While under the influence of alcohol, adolescents experience poor judgment, which can translate into high-risk behaviors such as driving under the influence and having unprotected sex. Half of all head injuries among adolescents in the United States are associated with alcohol consumption, and a third of all fatal accidents among 15- to 20-year-olds involve alcohol.
Chronic binge drinking of alcohol can lead to liver disease, hypertension, heart disease, stroke, and various cancers including breast cancer. The adolescent brain, not being fully developed, is vulnerable to alcohol-induced brain damage and cognitive impairment. Binge drinking in this age group may lead to a reduction in brain volume, including the frontal regions, which are involved in executive function, impulsivity, and self-regulation.
In the acutely intoxicated patient, management depends on severity. Mild intoxication (<100 mg/dL of ethanol) can be managed with close observation, hydration, and analgesics. Moderate to severe intoxication (blood alcohol level [BAL] >300 mg/dL) requires provision of appropriate airway management and supportive care. Treatment for withdrawal symptoms depends on the degree of symptoms. In mild withdrawal, rest and hydration are sufficient. For severe symptoms, use of benzodiazepines may be helpful. Seizure management entails treatment with diazepam or phenytoin. Acute psychosis can be managed with haloperidol. Long-term management depends on the severity of the alcohol problem; treatment options range from brief office-based interventions to residential treatment programs.
Discussions about the hazards of alcohol use should begin in the doctor’s office as early as 9 years of age, which is when children begin to think positively about alcohol use through exposure to alcohol advertising. Healthcare providers should encourage parents to have regular conversations regarding the hazards of drinking in high school and in college. These discussions can have a powerful impact on their future drinking behaviors. Young adults who had a conversation with their parent regarding the dangers of heavy drinking before entry into college were 20 times more likely to reduce their consumption of alcohol compared to those who did not receive the parental advice.
The majority of adult smokers began smoking during adolescence. In addition to smoking cigarettes, many teens are also chewing tobacco and using hookahs and electronic nicotine delivery systems (ENDS). ENDS devices, including e-cigarettes, convert liquid nicotine into a vapor in a process known as “vaping.” More teens are now using e-cigarettes than regular cigarettes, especially 8th graders, whose past-month reported use was 3.6% using cigarettes compared to 9.5% using e-cigarettes. Smoking e-cigarettes is strongly associated with later use of cigarettes, which may reverse the downward trend in smoking that has been observed over the last decade.
Nicotine is derived from the tobacco plant. It is a natural alkaloid that acts as a central nervous system stimulant by activating the dopamine system. A single cigarette delivers about 1 mg of nicotine while smoking. Given the highly addictive nature of nicotine, experimentation can lead to heavy smoking, and addiction can occur within a period of a few weeks.
Risk factors for initiation of adolescent smoking include availability of cigarettes, friend’s smoking, smoking among family members, depression, and alcohol use.
The short-term consequences of nicotine use include euphoria, cough, bad breath, greater risk of infections, and addiction.
Nicotine, tars, and other carcinogens in tobacco products are associated with malignancies of every organ of the body. Second-hand smoke exposure is associated with more frequent ear and respiratory infections, asthma attacks, and more missed days of school.
Tobacco use disorders can be further described as mild, moderate, or severe based on number of symptoms present. Determining the severity of the disorder as mild, moderate, or severe according to the DSM-V will help guide the intensity of the behavioral therapy. Tobacco cessation advice should be tailored to the patient’s readiness to change, with the goal of moving the patient toward wanting to make a behavior change. The 5 A’s model (Ask, Advise, Assess, Assist, and Arrange) may be used to guide the counseling sessions along with close follow-up. The 6 A’s model adds anticipatory guidance to parents regarding smoking initiation and the impact of second-hand smoke in households during preventive care visits (Table 74-2). The healthcare provider should be prepared to devise a goal to reduce the frequency of smoking with a plan of action and close follow-up. Pharmacological agents such as the nicotine patch, nicotine gum, or bupropion, combined with psychological treatment, result in the highest long-term abstinence rates. During follow-up sessions, the patient should be assessed for withdrawal symptoms. Tobacco withdrawal symptoms occur in daily users who are cutting back or quitting. These symptoms include irritability, restlessness, trouble sleeping, and feeling anxious; withdrawal symptoms can cause the patient to resume smoking or revert back to the same intensity of smoking. Relapse is common, especially in the first few weeks, but diminishes considerably after 3 months of not smoking.
TABLE 74-2THE 5 A’S TO PREVENT SMOKING INITIATION OR SUPPORT SMOKING CESSATION AMONG ADOLESCENTS ||Download (.pdf) TABLE 74-2THE 5 A’S TO PREVENT SMOKING INITIATION OR SUPPORT SMOKING CESSATION AMONG ADOLESCENTS
|Intervention ||Technique |
|Ask ||For all adolescents at every visit, ask about tobacco use without the parents in the room. For pre-teen children also inquire about tobacco use in an age-appropriate manner (eg, whether they have ever “tried” smoking or thought about trying). Also inquire about tobacco use among peers, as this may predict smoking initiation. |
|Advise ||Strongly urge all tobacco users to quit in a clear, strong, personalized manner. Advise all nonusers to remain tobacco-free. |
|Advice should be |
|Clear: “I think it is important for you to quit smoking now, and I can help you.” “Cutting down is not enough.” “If you wait until you feel bad effects of smoking, it will be too late.” |
|Strong: “As your doctor, I want you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. I will help you quit.” |
|Personalized: Tie tobacco use to current and future health and athletic performance, its social and economic costs, motivation level/readiness to quit, and the impact of tobacco use on siblings and others in the household. Remind parents of their responsibility as role models. |
|Assess ||Determine the patient’s willingness to quit smoking within the next 30 days. |
|If the patient is willing to make a quit attempt at this time, provide assistance. |
|If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention. |
|If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivation intervention. |
|If the patient is a member of a special population (eg, pregnant smoker, racial or ethnic minority), consider providing additional information relevant to this population. |
|Assist ||Provide aid for the patient to quit (eg, set a quit date, provide counseling and self-help materials, refer to a quit line). |
|Arrange ||Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated. |
Healthcare providers are in a position to reduce the rate of initiation of tobacco products by screening their patients for tobacco use during every healthcare visit. Inquiring about the patient’s incentive to smoke or stop smoking will provide a basis for effective counseling. At a minimum, tobacco screening is to be incorporated into routine preventive care visits. Engaging parents in this conversation is critical as parental smoking is a key factor for initiation of smoking during adolescent years. Educating the patient that there is no safe level of tobacco use is an integral part of the prevention counseling advice.
Stressing the importance of having a smoke-free home with the parent is helpful in prevention of not only the initiation of smoking but also exposure to second- and thirdhand smoke.
Marijuana comes from the herbaceous plant Cannabis sativa, and tetrahydrocannabinol (THC) is the psychoactive ingredient. Marijuana preparations contain varying percentages of THC. Marijuana continues to be the most commonly used illicit drug, used mainly for recreational purposes, but there is growing interest in its medicinal uses for chronic pain and a few other gastrointestinal indications. Marijuana is still viewed as a “gateway drug” that may lead to other drug use during adolescence.
Marijuana may be inhaled or ingested. THC binds to two receptors, CB1 and CB2, located in the central and peripheral nervous systems. The binding of THC to these receptors releases dopamine, which is responsible for the psychoactive symptoms produced from using marijuana.
Daily users may experience hyperemesis syndrome characterized by nausea, vomiting, and abdominal pain. Shortly after using marijuana, the user will feel euphoria and an increase in heart rate, injected conjunctiva, and a dry mouth. Notable neurological symptoms from marijuana use include nystagmus, ataxia, decrease in reaction time, and short-term memory loss. As the drug wears off, the user becomes hungry and tired.
Daily users may experience a reduction in sperm count, gynecomastia, tolerance, a lack of motivation, cognitive impairments, reduction in IQ, poor school performance, and increased risk for acute adult-onset psychosis. Symptoms of chronic marijuana use are similar to a mood disorder with impairment in daily life activities.
An adolescent with a positive CRAFFT screen for marijuana should receive a brief counseling session; indications for more intense treatment are based on the duration and frequency of marijuana use. Drug treatment programs with motivational techniques and cognitive behavioral therapy have been effective in the adolescent population. The DSM-V also recognizes cannabis withdrawal, which occurs when frequent users abruptly stop using, leading to irritability, aggression, anger, and trouble sleeping.
Treatment with buspirone and gabapentin has been successful in addition to behavioral therapy. Given the high prevalence of marijuana use, healthcare providers will continue to be in a position to provide education on the short- and long-term health hazards of using marijuana to their adolescent patients.
The most commonly abused prescription pills are opioids, central nervous system depressants, and stimulants. Young adults have the highest prevalence of abusing prescription pills at 5.9%, followed by adolescents at 3%. The majority of teens report getting the prescription pills from either a relative or friend. As the prescription rate for stimulants has increased, stimulant medication abuse has similarly increased over the past decade.
Opioids fall into a natural or synthetic category and have morphine-like properties. Natural opioids include morphine, heroin, and codeine, and synthetic opioids include hydromorphine and oxycodone. Depending on the opiate used, it may be ingested, smoked, or injected. Opioids exert their effect by binding to receptors in the gastrointestinal tract and central nervous system. The main sites of action in the central nervous system are the hypothalamus, thalamus, and limbic system. Stimulants acting on the central nervous system cause the release of dopamine, which creates a feeling of euphoria.
Stimulant users experience euphoria and an increase in energy levels, but agitation and anxiety may be felt, depending on the amount of stimulant consumed. Significant behavioral changes may occur, such as auditory hallucinations and paranoid ideation, depending on the amount used. Stimulants cause elevations in heart rate and blood pressure. In contrast to the effects of stimulant use, opiates and sedatives drop the heart rate and blood pressure, and depending on the amount used, respiratory depression and death may ensue.
Given the highly addictive nature of these drugs, withdrawal symptoms occur with abrupt cessation and are a diagnosable entity in the DSM-V. Chronic opiate users struggle with constipation, chronic rhinitis, and ulceration of nasal mucosa from snorting. From intravenous drug use, skin abscesses and cellulitis can occur. Females may experience irregular menses or amenorrhea. Extensive dental decay is a notable finding in chronic methamphetamine abusers and is referred to as “meth mouth.”
The treatment for prescription pill abuse is similar to other substance use disorders and entails behavioral therapy with or without pharmacological treatment.
KE; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine
, and tobacco smoke. Pediatrics
SK. Youth marijuana use: state of the science for the practicing clinician. Curr Opin Pediatr
LM; Committee on Substance Abuse, Ammerman SD, Gonzalez PK, Ryan SA, Siqueira LM, Smith VC. Testing for drugs of abuse in children and adolescents. Pediatrics
. 2014;133(6): e1798–e1807.
JE. Prevalence and predictors of adolescent alcohol
use and binge drinking in the United States. Alcohol Res
et al; American Academy of Pediatrics, Julius B. Richmond Center of Excellence Tobacco Consortium. State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics
et al.; Cannabis Cohorts Research Consortium. Young adult sequelae of adolescent cannabis use: an integrative analysis. Lancet Psychiatry
et al. Evaluation of timing and dosage of a parent-based intervention to minimize college student's alcohol
consumption. J Stud Alcohol Drugs
U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. http://www.ncbi.nlm.nih.gov/books/ NBK99237/
. Accessed February 10, 2017.