Substance Use

Most teenagers experiment with tobacco and alcohol, and many experiment or regularly use cannabis or other substances. In the 2019 National Survey on Drug Use and Health, 15% of adolescents aged 12 to 17 years reported substance use (illicit drugs, tobacco products, or alcohol) in the past month. Substance use is not sufficient for a diagnosis of a substance use disorder (see specific diagnostic criteria below).

Monitoring the Future is an annual self-reported survey of drug use among U.S. students in the 8th, 10th, and 12th grades that provides estimates of substance use trends in adolescents. Key findings and trends among adolescents between 2011 and 2021 are summarized below.

• The percentage of adolescents reporting substance use decreased significantly in 2021, representing the largest one-year decrease in overall illicit drug use reported since the survey began in 1975.

• The 2021 survey reported significant decreases in use across many substances, including alcohol, marijuana, and vaped nicotine.

• The 2021 decrease in vaping for both marijuana and tobacco follows sharp increases in use between 2017 and 2019, which then leveled off in 2020.

(Source: Monitoring the Future 2021 Survey Results. National Institute of Drug Abuse 2021.)

Substance Use Disorders

Many adolescents use substances, but to meet criteria for a substance use disorder, adolescents must demonstrate impairment in various domains of life, including the following:

• family conflict/dysfunction

• interpersonal strife

• academic difficulties

Evaluation and Diagnosis

The Diagnostic Criteria for Substance Use Disorders (DSM-5-TR) classifies substance use disorders according to the specific substance used (e.g., alcohol use disorder, cannabis use disorder). Diagnostic criteria exist for the following specific substances: tobacco, alcohol, cannabis, opioid, phencyclidine, other hallucinogen, inhalant, sedative hypnotic or anxiolytic, and stimulant (includes cocaine). If a patient is struggling with substance use not covered in this list (e.g., anabolic steroids), the diagnosis of other (or unknown) substance use disorder can be applied. The degree of substance use disorder is marked by the number of symptoms present as follows:

• mild (2 or 3 symptoms)

• moderate (4 or 5 symptoms)

• severe (≥6 symptoms)

Risk Factors

• genetic factors

  • family history of substance use

  • genetic predispositions to affective, cognitive, and behavioral dysregulation

• family-related factors

  • parental substance use

  • poor parent-child relationships

  • low perceived parental support

  • poor communication

  • poor parental supervision and management of the adolescent’s behavior

• psychological factors

  • childhood sexual abuse or other traumatic events

  • cultural factors (media promotion of substance use)

• mental illness in the adolescent

  • particularly disruptive behavior disorders; mood and anxiety disorders

• developmental issues of puberty

  • identity formation

  • feeling invulnerable

  • issues of autonomy

  • peer influences/peer pressure

Screening

All older children and adolescents should be screened for substance use with validated screening tools or history. Screening questions should focus on specific substance(s) used, quantity and frequency, adverse consequences of use, and the youth’s attitude toward and understanding of use.

The CRAFFT screening tool, a brief set of structured screening questions, is commonly used. It consists of six questions and applies to alcohol or other drug use.

(Source: Adolescent Screening, Brief Intervention, and Referral to Treatment for Alcohol and Other Drug Use Using the CRAFFT Screening Tool. Massachusetts Department of Public Health Bureau of Substance Abuse Services 2009.)

Once information about substance use and patterns has been obtained, it is important to evaluate the youth’s readiness for treatment or motivation for change to help determine initial goals and level of care. Motivational interviewing techniques or frameworks such as the “5 A’s” Model for Managing Tobacco Use and Dependence can help identify motivations the patient may have for change.

Toxicology screen: Urine is usually used for a toxicology screen, but tests can also be done on blood or hair. Toxicology screens are often used in the course of substance use disorder treatment as part of the initial evaluation and in follow-up, with assent from the youth involved.

(Source: Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders. J Am Acad Child Adolesc Psychiatry 2005.)

Management

Treatment for substance use disorders is generally systemic, comprehensive, and designed to address issues the youth may be facing in multiple domains of life. The strongest evidence supports the efficacy of family therapy approaches. In youth, the ultimate treatment goal is abstinence, with harm reduction as an interim goal. The goal of harm reduction is to reduce consumption or negative outcomes without emphasis on total avoidance. Even when adolescents are not motivated for abstinence, interventions and treatments can lead to improved outcomes.

Confidentiality: At the beginning of treatment, a discussion about confidentiality is important, including a review of the limits of confidentiality. Laws may be state dependent, but in general, adolescents have a right to privacy when seeking substance abuse treatment, with limits. If there is concern for acute danger to self or others, such as substance use or withdrawal requiring acute medical hospitalization, the clinician will need to inform a responsible adult (usually parents or guardians).

Nonpharmacologic Management

Family interventions are critical in the treatment of adolescent substance use disorders, and multiple modalities of family therapy may be utilized successfully. Goals of treatment include:

• family education regarding the disorder

• assisting parents to initiate and maintain efforts to get the adolescent into treatment and achieve abstinence

• establishing structure and setting limits consistently

• improving communication

Even if the adolescent is not participating in treatment, parents or guardians can learn skills to improve the chances that the adolescent will ultimately enter care. Parent education and involvement is often central to safety planning (e.g., ensuring an adolescent has zero access to a car if they may be impaired or ensuring that a family is trained in the use of nasal naloxone in the setting of opioid abuse).

Individual interventions, including motivational interviewing and cognitive behavioral therapy, in addition to the crucial work of family interventions, have been shown to be effective in adolescents with substance use disorders. Motivational interviewing is a nonjudgmental, nondirective strategy that can heighten motivation for change and increase self-efficacy. Although data are limited on the utility of 12-step recovery programs, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), clinically such groups appear useful to some adolescents. It is important for youth to develop peer groups who do not utilize substances, and AA or NA can be useful in this regard.

Pharmacologic Management

The pharmacologic management of substance use disorders in youths is generally extrapolated from use in adult populations due to limited data in children and adolescents.

• Treatment of alcohol, benzodiazepine, and opioid withdrawal in youth is comparable to management in adults.

• Medications used to target alcohol-related cravings (e.g., acamprosate or naltrexone) and agonist treatment for opioid use disorders (e.g., Suboxone or methadone) have been used in the management of pediatric substance use disorders.

• Naloxone (Narcan) is a lifesaving intervention that is increasingly administered by laypeople, including parents. Family members of youth with opioid use disorders are strongly advised to consider receiving training and having access to naloxone.

• The efficacy of N-acetylcysteine in reducing cannabis cravings and days of use in adolescents was reported in one randomized, controlled study, although efficacy in adults has been equivocal.

Comorbidity

Comorbidity is significant between substance use disorder and other psychiatric disorders. Disruptive behavior disorders, such as conduct disorder and attention deficit-hyperactivity disorder (ADHD), are the most common psychiatric disorders diagnosed in children and adolescents with substance use disorders. Of note, early and assertive treatment for ADHD decreases the incidence of later substance use disorders. Mood and anxiety disorders are also prevalent. Treatment for comorbid disorders should occur in conjunction with treatment for the substance use disorder (e.g., treat both the depression and alcohol use simultaneously). When prescribing pharmacotherapy, avoid prescribing abusable medications (e.g., benzodiazepines or stimulants) to youth with established substance use disorders, and in such cases use alternative agents (e.g., selective serotonin-reuptake inhibitors [SSRIs] or atomoxetine).

Prognosis

Substance use disorders are often chronic and require ongoing intervention. Completion of treatment programs, longer treatment duration, and family involvement in treatment are associated with better outcomes. Additionally, youth with a non-substance-using peer group have better outcomes. Referral to specialist treatment is recommended when diagnosis is uncertain, a patient has poor or limited response to treatment, and in patients with comorbid serious mental illness.