Chapter 5: Adolescent Substance Abuse

Substance abuse tends to be a chronic, progressive disease. Initiation of substance use is becoming such a common feature of an American adult that many authorities call it normative behavior. At this stage, substance use is typically limited to experimentation with tobacco or alcohol (so-called gateway substances). During adolescence, young people are expected to establish an independent, autonomous identity. They try out a variety of behaviors within the safety of families and peer groups. This process often involves experimentation with psychoactive substances, usually in culturally acceptable settings. Continuation of substance abuse, however, is a nonnormative risk behavior with the potential to compromise adolescent development.

The American Psychiatric Association has outlined criteria to judge the severity of substance use disorders (SUD). The most recent version, DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), has moved from the previous terms “substance abuse” and “substance dependency” to mild, moderate, and severe SUD. There are 11 features described in DSM-5. Patients with mild SUD have two or three features, whereas those with moderate have four or five features without loss of control or compulsive features. Patients with severe SUD have more than six features, including loss of control or compulsive features.

Common physiologic effects and symptoms of intoxication (which can occur at any stage of substance use) and withdrawal (a symptom of dependency) for the major classes of substances are shown in Tables 5–1 and 5–2.

The best current source of information on the prevalence of substance abuse among American adolescents is the Monitoring the Future study (2019), which tracks substance abuse-related behaviors in a sample of 44,500 8th, 10th, and 12th graders in the United States. This study probably understates the magnitude of the problem of substance abuse because it excludes high-risk adolescent groups—school dropouts, runaways, and those in the juvenile justice system. Two other periodic surveys are the Youth Risk Behavior Survey (biannual) of students in grades 9–12 and National Survey of Drug Use and Health that is a home-based computer-assisted interview of individuals 12 years or older. Substance abuse among American youth rose in the 1960s and 1970s, declined in the 1980s, peaked in the 1990s, and has declined in the early 2000s. The most important finding to emerge from the most recent Monitoring the Future survey (2018 data) is the dramatic increase in vaping by adolescents. Vaping of three specific substances, nicotine, marijuana, and flavoring, is a relatively new phenomenon that substantially increased in 2018; the Monitoring the Future study registered some of the largest absolute increases in vaping of all three of these substances that this survey has ever tracked for any substance. Vape devices and electronic cigarettes (e-cigarettes) have rapidly become the most common tobacco products used by youth, driven in large part by marketing and advertising by e-cigarette companies. E-cigarettes are battery-operated devices designed to heat liquid into an aerosol that users inhale. The aerosol can contain nicotine, glycerol, propylene glycol, formaldehyde, cadmium, benzoic acid, lead, cannabis, chromium, nickel, different flavors and other chemicals. Pod-based e-cigarettes that use a salt-based nicotine made popular by Juul Labs have added to the availability of this product. Given that nicotine is involved in most vaping and that nicotine is a highly addictive substance, this presents a serious threat to all of the hard-won progress in adolescent substance abuse that has been made in recent decades.

The Monitoring the Future survey and others show that alcohol is the most frequently abused substance in the United States. Experimentation with alcohol typically begins in or before middle school. It is more common among boys than girls. It is most common among whites, less common among Hispanics and Native Americans, and least common among blacks and Asians. Almost two-thirds (59%) of adolescents consume alcohol before graduating from high school. Approximately one-tenth (9%) of eighth graders and 46% of high school students report being drunk at least once in their life. Marijuana is the most commonly used illicit drug in the United States. First experiences with marijuana and the substances listed in Table 5–2 typically occur during middle or early high school. The lifetime prevalence of marijuana use reported by 12th graders in 2018 was 29.7%. Daily use of marijuana increased until 2011 and has decreased since, with 3% of high school seniors being a daily or near daily user. Synthetic marijuana, often called spice and K-2, was scheduled by the Drug Enforcement Agency in 2011. Despite this intervention, annual synthetic marijuana use remains unchanged at 11.5% making, it the second most widely used class of illicit drug use after marijuana. In the most recent Monitoring the Future survey, there was little change in daily and annual marijuana prevalence rates and annual use of any illicit drug. The annual prevalence of marijuana use has held quite steady for several years, at 36%. In the past decade, lysergic acid diethylamide (LSD), methamphetamine, and cocaine use has decreased. Recently, ecstasy use has increased after a steady decline of several years.

Increasing opioid use has been another important trend in the United States. This issue encompasses a range of behaviors, from opioid misuse (defined as taking a prescription opioid in ways not prescribed by a physician) to use of illicit opioids (such as heroin) or synthetic opioids (such as fentanyl). Initiation of opioid misuse commonly occurs with prescription opioids, and among those with a history of heroin use, most report first opioid exposure having been a prescription opioid. Youth usually acquire opioids from family or friends or they consume opioids prescribed to them for medical indications. Dental visits are a leading source of opioid prescriptions to youth, and use of these prescriptions may be associated with an increased risk for of subsequent opioid use and abuse. In one study, 1 in 10 high school seniors reported nonmedical use of prescription opioids, and almost half (45%) used opioids to “relieve physical symptoms” in the past year. Although Vicodin use decreased among 12th graders to 2.9% in 2016, it remains one of the most widely used illicit drugs.

In the past 10 years, there has also been an increase in the recreational use of other prescription medications and over-the-counter (OTC) cough and cold medications among adolescents. Overall, the psychotherapeutic drugs (amphetamines, sedatives, tranquilizers, and narcotics other than heroin) make up a large part of the overall US drug problem. Medication used in the management of chronic pain, depression, anxiety, and attention-deficit/hyperactivity disorder can all be drugs of abuse.

Studies indicate that variations in the popularity of a substance of abuse are influenced by changes in the perceived risks and benefits of the substance among adolescent users. For example, the use of inhalants was rising until 2006, when both experience and educational efforts resulted in a perception of these substances as being “dangerous.” As the perception of danger decreases, old drugs may reappear in common use. This process is called “generational forgetting.” Currently, uses of LSD, inhalants, and ecstasy all reflect the effects of generational forgetting. Legalization of marijuana in certain states in the United States may increase the scope and breadth of the substance abuse problem. A recent study has shown an increase in medical marijuana use among adolescents in substance abuse programs. The American Academy of Pediatrics (AAP) has reaffirmed its position against the legalization of marijuana and its opposition to “medical marijuana”; it offers recommendations to protect children and adolescents in states that have legalized marijuana for medical or recreational purposes.

Supplement Use & Abuse

Use of supplements or special diets to enhance athletic performance dates to antiquity. Today, many elite and casual athletes use ergogenic (performance-enhancing) supplements in an attempt to improve performance. The most popular products used by adolescents are anabolic-androgenic steroids, steroid hormone precursors, creatine, human growth hormone, diuretics, and protein supplements. Anabolic-androgenic steroids increase strength and lean body mass and lessen muscle breakdown. However, they are associated with side effects, including acne, liver tumors, hypertension, premature closure of the epiphysis, ligamentous injury, and precocious puberty. In females, they can cause hirsutism, male pattern baldness, and virilization; in boys, they can cause gynecomastia and testicular atrophy. Creatine increases strength and improves performance in brief, high-intensity exercises but can cause dehydration, muscle cramps, and has potential for renal toxicity. Human growth hormone may increase lean body mass and decrease fat mass but has limited effect on strength and athletic performance. Potential risks include coarsening of facial features and cardiovascular disease. Strength athletes (ie, weight lifters) use protein powders and shakes to enhance muscle repair and mass. The amount of protein consumed often greatly exceeds the recommended daily allowance for weight lifters and other resistance-training athletes (1.6–1.7 g/kg/day). Excess consumption of protein provides no added strength or muscle mass and can provoke renal failure in the presence of underlying renal dysfunction. The AAP cautions against the use of performance-enhancing substances.

As the use of supplements and herbs increases, it is increasingly important for pediatric care providers to be familiar with their common side effects. The Internet has become a source for information about and distribution of these products. The easy accessibility, perceived low risk, and low cost of these products significantly increase the likelihood that they will become substances of abuse by adolescents.

Use and abuse of alcohol or other mood-altering substances in adolescents in the United States are tightly linked to adolescents’ leading causes of death, that is, motor vehicle accidents, unintentional injury, homicide, and suicide. Substance abuse is also associated with physical and sexual abuse. Drug use and abuse contribute to other high-risk behaviors, such as unsafe sexual activity, unintended pregnancy, and sexually transmitted disease. Adolescents may also be involved with selling of drugs.

Risks associated with tobacco, alcohol, and cocaine are listed in Table 5–2. The use of e-cigarettes has been documented to lead to harmful health effects on the heart, lungs, and blood vessels. Nicotine also alters adolescent brain chemistry, making adolescents vulnerable to addiction and other substance use. Use by adolescents can lead to their becoming nicotine dependent, increasing their risk of developing mental health problems. The American Psychological Association notes that nicotine-dependent smokers are up to eight times more likely to develop psychotic disorders, depressive disorders, anxiety, and delirium than smokers who are not dependent on nicotine or those who have never smoked. As e-cigarettes have been used for only a decade, their long-term harms are unknown. Also, less well-known are the long- and short-term adolescent morbidities connected with the currently most popular illicit drugs, marijuana, and synthetic marijuana. The active ingredient in marijuana, δ-9-tetrahydrocannabinol (THC), transiently causes tachycardia, mild hypertension, and bronchodilation. Regular use can cause lung changes similar to those seen in tobacco smokers. Heavy use decreases fertility in both sexes and impairs immunocompetence. It is also associated with abnormalities of cognition, learning, coordination, and memory. It is possible that heavy marijuana use is the cause of the so-called a motivational syndrome, characterized by inattention to environmental stimuli and impaired goal-directed thinking and behavior. Early and frequent use of marijuana during adolescence, compared with occasional use or nonuse, has been associated with development of a higher incidence of psychiatric problems. Analysis of confiscated marijuana recently has shown increasing THC concentration and adulteration with other substances.

Evaluation of the impact of legalization of marijuana on the adolescent and pediatric population has just begun. One observation has been a decrease in perceived harmfulness of marijuana. Adolescents often see nothing wrong with their marijuana use; on contrary; they may believe it has medical and therapeutic use. Additionally, pregnant adolescents tend to use marijuana 1.8 times more often than nonpregnant adolescents. They also use it more compared to pregnant adults. Presence of cannabis products in the home has contributed to an increase in exposure and accidental consumption by younger children. A study in Colorado after marijuana legalization showed an increase in hospitalizations associated with marijuana-related codes from 274 (2010) to 593 (2015) per 100,000 and a fivefold increase in mental health emergency room visits with marijuana-related codes. Calls to emergency rooms related to marijuana exposure increased by 79.7%. As more states legalize marijuana, it will be important to continue to assess potential consequences. Many of the issues related to legalization of marijuana are detailed in the AAP technical report (reference below), and different medical marijuana policies among US states are outlined on the AAP website (reference below).

The popularity and accessibility of ecstasy is again increasing among adolescents. Chronic use is associated with progressive decline of immediate and delayed memory, and with alterations in mood, sleep, and appetite, that may be permanent. Even first-time users may develop frank psychosis indistinguishable from schizophrenia. Irreversible cardiomyopathy, noncardiogenic pulmonary edema, and pulmonary hypertension may occur with long-term use. Acute overdose can cause hyperthermia and multiorgan system failure.

Prenatal and environmental exposure to abused substances also carries health risks. Parental tobacco smoking is associated with low birth weight in newborns, sudden infant death syndrome, bronchiolitis, asthma, otitis media, and fire-related injuries. Maternal use of marijuana during pregnancy is associated with an increased risk of sudden infant death syndrome. In utero exposure to alcohol may produce fetal malformations, intrauterine growth restriction, and brain injury.

Initially, most adolescents use mood-altering substances intermittently or experimentally. The challenge to pediatric health care providers is to recognize warning signs, identify potential abusers early, and intervene in an effective fashion before acute or chronic use produces morbidity. The prediction of progression from use to abuse is best viewed within the biopsychosocial model. Substance abuse is a symptom of personal and social maladjustment as often as it is a cause. Because there is a direct relationship between the number of risk factors listed in Table 5–3 and the frequency of substance abuse, a combination of risk factors is the best indicator of risk. Even so, most teenagers with multiple risk characteristics never progress to substance abuse. It is unclear why only a minority of young people exhibiting the high-risk characteristics listed in Table 5–3 go on to abuse substances, but presumably the protective factors listed in Table 5–3 give most adolescents the resilience to cope with stress in more socially adaptive ways. Being aware of the risk domains in Table 5–3 will help physicians identify youngsters most apt to need counseling about substance abuse.

Office Screening

The AAP recommends Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a universal framework for identifying substance use during routine health supervision visits. The three main goals of the integrated, algorithm-based SBIRT screening are to determine whether teens have used any alcohol or drugs; to determine where adolescents are on the substance use spectrum; and finally, for the health care provider to initiate a brief discussion with their teenage patients about substance use and provide them with education, advice, and referrals within a motivational interviewing model.

An important goal of this framework is to identify the range of youth substance use from abstinence to risky substance use to that rising to the level of a SUD. Given the high incidence of substance abuse and the subtlety of its early signs and symptoms, a general psychosocial assessment is the best way to screen for substance abuse among adolescents. In an atmosphere of trust and confidentiality, physicians should ask routine screening questions of all patients and be alert for addictive diseases, recognizing the high level of denial often present in addicted patients. Clues to possible substance abuse include truancy, failing grades, problems with interpersonal relationships, delinquency, depressive affect, chronic fatigue, recurrent abdominal pain, chest pains or palpitations, headache, chronic cough, persistent nasal discharge, and recurrent complaints of sore throat. Substance abuse should be included in the differential diagnosis of all behavioral, family, psychosocial, and medical problems. A family history of drug addiction or abuse should raise the level of concern about drug abuse in the pediatric patient. Possession of promotional products such as T-shirts and caps with cigarette or alcohol logos should also be a red flag because teenagers who own these items are more likely to use the products they advertise. Pediatricians seeing patients in emergency departments, trauma units, or prison should have an especially high index of suspicion.

In the primary care setting, insufficient time and lack of training are the greatest barriers to screening adolescents for substance abuse. Brief questionnaires can be used if time does not allow for more detailed investigation. A screening instrument that has been rigorously studied in primary care settings is the CAGE questionnaire. CAGE is a mnemonic derived from the first four questions asked of patients regarding their substance use: the need to cut down, annoyance if asked about it, feeling guilty about the use, and the need of the drug/alcohol as an eye opener. A score of 2 or more is highly suggestive of substance abuse. Although constructed as a screening tool for alcohol abuse in adults, the CAGE questionnaire can be adapted to elicit information about use of other mood-altering substances by pediatric patients and their close contacts (eg, parents and older siblings). Clinicians may find it helpful to use such questionnaires to stimulate discussion of the patient’s self-perception of his or her substance use. For example, if an adolescent admits to a previous attempt to cut down on drinking, this provides an opportunity to inquire about events that may have led to the attempt. Unfortunately, despite guidance to screen adolescents for substance abuse, recent studies demonstrate that clinicians generally do not regularly ask/advise adolescents about substance use.

Utilizing the SBIRT framework, pediatricians should focus their brief intervention on reducing risks associated with ongoing substance use and motivational interviewing to engage youth in treatment for their SUD. This patient-centered strategy of harm reduction focuses on the risk behaviors identified during intake and aims to meet youth where they are, recognize their inherent strengths and motivation to be well, respect their rights, and create a personalized health promotion strategy in collaboration with the youth. Providers provide education, advice, and referrals within a motivational interviewing model. The Harm Reduction Coalition (https://harmreduction.org) has numerous resources that can be applied in the primary care setting.

Diagnosis

When the psychosocial history suggests the possibility of substance use, the primary tasks of the diagnostic interview are the same as for the evaluation of other medical problems (Table 5–4).

First, specific information about the extent and circumstances of the problem is gathered. Eliciting information through multiple-choice questions is a useful technique. For example, “Has anything really good ever happened to you when you are high? Some of my patients like to get high because they feel good; others find it helps them relax and be sociable with friends; and some find it helps them forget their problems. Are any of these things true for you?”

Second, the provider should determine why the patient has progressed from initiation to the continuation or maintenance phase of substance abuse. The cause may be different at different periods of development. Although peer group characteristics are one of the best predictors of substance use among early and middle adolescents, this is not so among older adolescents and young adults.

Although few children and adolescents will have been abusing substances long enough to have developed overt signs and symptoms, it is important to look for them on physical examination. Positive physical findings can be a tool to penetrate a patient’s denial and convince him or her of the significance of alcohol or drug use.

Comorbidity

Comorbidities, especially other psychiatric disorders, are common among substance-abusing patients (Table 5–5). Affective disorder, anxiety disorder, and mania are most strongly associated with alcohol and drug dependence. Attention-deficit/hyperactivity has also been closely linked with adolescent substance abuse. Adolescents with depression are likely to use drugs in an attempt to feel pleasure, but this type of self-medication may exacerbate their underlying condition. Although it is often difficult to determine which diagnosis is primary, it is important for pediatric health care providers to recognize the possibility of a comorbid condition and provide appropriate treatment. Finally, in addition to identifying psychiatric comorbidities, it is imperative that providers look for medical conditions that mimic symptoms of drug withdrawal or intoxication.

Pharmacologic Screening

The use of urine and blood testing for detecting substance abuse is controversial. The consensus is that pharmacologic screening should be reserved for situations in which behavioral dysfunction is of sufficient concern to outweigh the practical and ethical drawbacks of testing. The AAP recommends testing under certain circumstances (eg, an inexplicably obtunded patient in the emergency department) but discourages routine screening for the following reasons: (1) voluntary screening is rarely truly voluntary owing to the negative consequences for those who decline to participate; (2) infrequent users or individuals who have not used substances recently may be missed; (3) confronting substance-abusing individuals with objective evidence of their use has little or no effect on behavior; and (4) the role of health care providers is to provide counseling and treatment, not law enforcement, so drug testing should not be done for the purpose of detecting illegal use. If testing is to be performed, the provider should discuss the plan for screening with the patient, explain the reasons for it, and obtain informed consent. The AAP does not consider parental request and permission sufficient justification for involuntary screening of mentally competent minors. It also opposes widespread drug testing in schools because of a lack of solid evidence for its effectiveness.

If testing is to be performed, it is imperative that it be done accurately and that the limitations of testing be understood. Tests range from inexpensive chromatographic spot tests, which can be performed in the office, to gas chromatography and mass spectrometry, which require specialized laboratory equipment and are usually reserved for forensic investigations. Most commercial medical laboratories use the enzyme multiplication immunoassay technique, in which a sample of the fluid to be tested is added to a test reagent containing a known quantity of radiolabeled index drug. If the index drug is present in the patient’s urine or serum, it competes with the radiolabeled drug for binding sites on the test kit antibody. The unbound or excess drug can then be quantified with a spectrophotometer. Most of the commonly abused mood-altering substances, with the exception of solvents and inhalants, can be detected by this method.

Interpretation of results is complicated by false positives resulting from antibody cross-reactions with some medications and substances (Table 5–6) or from a patient’s passive exposure to illicit substances. The most common cause of false-negative tests is infrequent use. Table 5–7 shows the duration of detectability in the urine after last use by class of substance and duration of use. Detectability ranges from a few hours for alcohol to several weeks for regular marijuana use. False-negative results can also occur if the patient alters or adulterates the test specimen. Some of the commercial products used to adulterate samples include glutaraldehyde, nitrite, pyridinium chlorochromate, peroxidase, and peroxide (stealth). Household products such as bleach, vinegar, Visine^® eye drops (for marijuana), strong alkali drain cleaners, and detergents are also used. Teenagers should be advised that, despite street lore, ingesting these compounds is an ineffective and potentially dangerous way to prevent drug detection in the urine. Close observation during collection and testing the temperature, specific gravity, and pH of urine samples may detect attempts at deception.

Home drug-testing products are available for parents and can be procured via the Internet; however, these products have limitations and potential risks. The AAP recommends that home (and school-based) drug testing not be implemented until the safety and efficacy of these procedures can be established. It further recommends that parents be encouraged to consult the adolescent’s primary care provider rather than relying on home drug-testing products.

Office-Based Treatment

The AAP recommends that all children and adolescents receive counseling about the dangers of substance use and abuse from their primary care providers. By offering confidential health care services and routinely counseling about the risks associated with drug abuse, primary care providers can help most patients avoid the adverse consequences of experimentation with mood-altering substances. However, more intervention is required for youngsters in environments where substance abuse is regarded as acceptable recreational behavior. Counseling strategies appropriate for patients who wish to change their behavior may be ineffective for patients who do not consider use of mood-altering substances to be a problem. It may therefore be preferable to begin discussions about treatment by helping youngsters consider alternative ways of meeting the needs that substance use is currently addressing. The clinician in this way may help the patient devise alternatives that are more attractive than substance use. Brief interventions for adolescents have yielded some improvement among high-risk youth. However, few substance-abusing teenagers will choose to quit because of a single conversation, even with a highly respected health care provider. The message is most effective when offered repeatedly from many sources—family, peers, guidance counselors, and teachers. Motivational interviewing and computer-facilitated screening and brief advice for substance-abusing teens have shown promise.

Assessment of the patient’s readiness to change is a critical first step in office-based intervention. Clinicians should consider the construct presented in Table 5–8. In theory, individuals pass through this series of stages in the course of changing problem behaviors. To be maximally effective, providers should tailor their counseling messages to the patient’s stage of readiness to change.

Once it has been established that a patient is prepared to act on information about treatment, the next step is to select the program that best fits his or her individual needs. Most drug treatment programs are not designed to recognize and act on the individual vulnerabilities that have predisposed the patient to substance abuse. When programs are individualized, even brief (5- to 10-minutes) counseling sessions may promote reductions in cigarette smoking and drinking. This strategy appears to be most effective when the health care provider’s message is part of an office-wide program so that the entire staff reinforces the cessation message with every patient.

Smoking Cessation in Pediatrics

Although more than half of adolescents who smoke regularly say they want to quit and have tried to quit, only a minority report that they have been advised or helped to do so by a health care provider. Practitioners unfamiliar with approaches to smoking cessation may feel that smoking cessation interventions are time consuming, not reimbursable, and impractical in a busy office. An easy guideline for health care providers is the “five A’s” for tobacco cessation (Table 5–9), published by the Public Health Service and endorsed by the AAP.

Smoking cessation is a process that takes time. Relapse must be regarded as a normal part of quitting rather than evidence of personal failure or a reason to forgo further attempts. Patients can actually benefit from relapses if they are helped to identify the circumstances that led to the relapse and to devise strategies to prevent subsequent relapses or respond to predisposing circumstances in a different manner.

Nicotine is a physically and psychologically addictive substance. Providers should be aware that adolescents may not exhibit the same symptoms of nicotine dependence as adults and that dependence may be established within as little as 4 weeks. Replacement therapy improves smoking cessation rates and may relieve withdrawal symptoms. Both nicotine gum and transdermal nicotine patch replacement therapies are recommended for teens. Those who are not comfortable prescribing and monitoring nicotine-replacement therapies should limit their involvement with patients who smoke to those who do not exhibit signs of nicotine dependency (eg, patients who smoke less than a pack of cigarettes a day or do not feel a craving to smoke their first cigarette within 30 minutes after waking). Patients who exhibit nicotine dependency can be referred to community smoking cessation programs, including “smoking quit lines.” In addition to nicotine-replacement therapies, sustained-release forms of the antidepressants bupropion, clonidine, and nortriptyline have been shown in randomized trials to help smokers quit and to decrease relapse rates fivefold.

The AAP and the World Health Organization recommend against the use of e-cigarettes as a cessation aid or nicotine dependence treatment for adolescents. Public policy recommendations include support for legislation (regulation of all tobacco products and adequate funding of tobacco control), continued education of clinicians, research and evaluation of e-cigarette use, dissemination of effective tobacco-control messaging, increase in taxation on tobacco products, and ban of all flavored products.

Referral

There is no consensus about which substance-abusing patients can be adequately treated in the office, which require referral, and which require hospitalization. Factors to be considered prior to referral are summarized in Table 5–10. When doubt exists about the seriousness of the problem or the advisability of office management, consultation with a specialist should be sought.

Although most primary pediatric providers will not assume responsibility for the treatment of substance-abusing youngsters, clinicians can be instrumental in motivating patients to seek treatment and in guiding them to appropriate treatment resources. Substance-abusing teenagers are best treated in teen-oriented treatment facilities. Despite the similarities between adult and adolescent substance abuse, adult programs are usually developmentally inappropriate and ineffective for adolescents. Many adolescents are concrete thinkers, and their inability to reason deductively, especially about emotionally charged issues, makes it difficult for them to understand the abstract concepts (such as denial) that are an integral component of most adult-oriented programs. This invariably frustrates counselors who misinterpret lack of comprehension as resistance to therapy and concrete responses as evidence of deceit.

Treatment programs range from low-intensity, outpatient, school-based student-assistance programs, which rely heavily on peers and nonprofessionals, to residential, hospital-based programs staffed by psychiatrists and other professionals. Outpatient counseling programs are most appropriate for motivated patients who do not have significant mental health or behavioral problems and are not at risk for withdrawal. Some investigators have raised the concern that in pediatric settings, users who lack significant mental health or behavioral comorbidities may actually experience a strengthening of the drug subculture by associating in group therapy with users who have a greater burden of comorbidities. More intensive day treatment programs are available for those who require a structured environment. Inpatient treatment should be considered for patients who need medical care and detoxification in addition to counseling, education, and family therapy.

Finally, special dual-diagnosis facilities are available for substance-abusing patients who also have other psychological conditions. These patients are difficult to diagnose and treat because it is often unclear whether their symptoms are a consequence of substance use or a symptom of a comorbid psychological disorder. Recognition of such disorders is critical because they must be treated in programs that include psychiatric expertise.

Approaches to the treatment of substance abuse in children and adolescents are typically modeled after adult treatment programs. Key elements of an effective adolescent drug treatment program include assessment and treatment matching, a comprehensive and integrated treatment approach, family involvement, a developmentally appropriate program, engagement and retention of teens, qualified staff, gender and cultural competence, continuing care, and satisfactory treatment outcomes. Several studies of adolescent substance abuse treatment programs have shown that many do not adequately address all of the important components of therapy.

Prevention of substance abuse has been a public health priority since the 1980s. Pediatric health care providers are important advocates and educators of the community and government on developmentally appropriate programs. Primary-level programs focus on preventing the initiation of substance use. The Drug Awareness and Resistance Education (DARE) program is a familiar example of a primary prevention program that attempts to educate elementary and middle school students about the adverse consequences of substance abuse and enable them to resist peer pressures.

Secondary-level programs target populations at increased risk for substance use. Their aim is to prevent progression from initiation to continuance and maintenance, relying on individualized intervention to reduce the risk and enhance protective factors listed in Table 5–3. This approach enables the provider to focus scarce resources on those who are most likely to benefit from them. Alateen, which supports the children of alcoholic parents, typifies secondary level prevention.

Tertiary-level prevention programs target young people who have been identified as substance abusers. Their aim is to prevent the morbid consequences of substance use. One example is the identification of adolescents who misuse alcohol and drugs at parties and providing them with a safe ride home. Because prevention is more effective when targeted at reducing the initiation of substance use than at decreasing use or associated morbidity, tertiary prevention is the least effective approach.

Very few population-based programs undergo rigorous scientific evaluation, and few programs have been shown to be effective. Although tertiary prevention programs are the least effective approach, it is the consensus among drug educators that primary prevention programs, such as D.A.R.E., also have limited effect. Parents and others should understand that most adolescents who abuse alcohol and drugs do not do so just for the high. Rather, these behaviors are often purposeful, developmentally appropriate coping strategies. To the extent that these behaviors meet young people’s developmental needs, they are not apt to be abandoned unless equally attractive alternatives are available. For example, even though many teenagers cite stress and anxiety as reasons for smoking, teen-oriented smoking cessation programs rarely address the young smoker’s need for alternative coping strategies by offering stress management training. Similarly, for the youngster growing up in an impoverished urban environment, the real costs of substance abuse may be too low and the rewards too high to be influenced by talk and knowledge alone. It is unreasonable to expect a talk-based intervention to change attitudes and behaviors in a direction that is opposite to that of the child’s own social milieu. The efficacy of the most promising prevention models and interventions is apt to decay over time unless changes in the social environment provide substance-abusing children and adolescents with realistic alternative ways to meet their developmental needs.

Web Resources

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