Substance Use

​Most teens are making healthy decisions not to use substances. The most commonly abused substances among children and adolescents are nicotine, alcohol, and marijuana.  According the National Center for Drug Abuse Statistics 2020 data:

  • 9.2% of 12- to 17-uear-olds used alcohol in the past month.
  • 0.4% of 8th graders drink daily, as do 1.0% of 10th graders and 2.7% of 12th graders, and 16.8% of 12-graders have 5+ drinks in a row when consuming alcohol.
  • 6.9% of 12- to 17-year-olds have used marijuana in the past month and 12.8% have used marijuana in the past year.
  • 2.52% report misusing pain relievers.
  • High school students who legitimately use prescription opioids are 33% more likely to misuse opioids after high school.
  • 5.0% of 12- to 17-year-olds report using cocaine in the last year.

According to the Center for Disease Control, 4.5% of middle school students and 16.5% of high school students reported current use of a tobacco product in 2022.  Among high school students currently using tobacco products, 85% were using e-cigarettes.

Substance use among adolescents ranges from experimental or occasional use to daily use and dependence. All substance use, however, conveys risk. Children and adolescents who use alcohol or drugs are at risk for injury, victimization, and dangerous behaviors. The age at first substance use is inversely correlated with the incidence of developing a substance use disorder.

Screening, Brief Intervention & Referral to Treatment (SBIRT)

Pediatricians are in an ideal position to provide anticipatory guidance around substance use. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends the SBIRT (universal screening, brief intervention and/or referral to treatment) model as a part of routine care.

The US Preventive Services Task Force reviewed the efficacy of substance use prevention programs in 2020 and concluded the evidence was “inconsistent and imprecise, with some interventions associated with reduction in use and others associated with no benefit or increased use” (O’Connor et al., 2020). The AAP acknowledges this deficit in the substance use prevention literature but endorses the incorporation of SBIRT practices into medical care for adolescents based on the low cost, minimal potential for harm, and benefit for any reduction in substance use at the population level (COMMITTEE ON SUBSTANCE USE AND PREVENTION et al., 2016).

Harm Reduction

SBIRT aims to prevent substance use in young people who have never started and to move those who have started using substances to cessation or to engaging in treatment.  As in other areas of risk-associated behaviors in adolescence, abstinence may not be attainable. Some teenagers will endorse enjoying substance use, not seeing it as a problem, and having no interest in abstaining.  In these cases, motivational interviewing strategies can provide an opportunity to engage youth and work to reduce harms.

Strategies involving harm reduction are appropriate to mitigate risk associated with substance use.  These strategies do not endorse or support substance use, but take the form of: "Given that you plan to continue to use substances, I would like to help you stay as safe and healthy as possible.  We can keep talking about stopping substance use in the future, but I need to meet you where you with your substance use now."

Key components of harm reduction are understanding motivation for substance use and acknowledging perceived benefits, decreasing risk of intoxication, decreasing risk of driving-related injury, reducing risk of fatal overdose, and reducing risk of infectious disease transmission through needle sharing or through risky sexual behaviors that can be associated with substance use.

Harm reduction may include helping teens understand the effects of substances on their level of functioning, avoid dangerous situations while using, and moderate level of use. Harm reduction strategies may involve families.  Teens who acknowledge they may drink at a party may have an arrangement with their parent that they can call for a ride home if they are unsafe to drive, and the parent will pick them up with no scolding.  

Screening

Substance use screening should be universal. The SSHADESS mnemonic provides a framework for the psychosocial assessment of adolescent strengths and risk factors and cues screening for substance in the teen as well as in their friends or family members (Coble et al., 2022). Using one of the freely available screening tools can further help identify youth at risk for substance use disorders and provide guidance on next steps. 

Substance Use Disorder DSM-5 Criteria

A problematic pattern of use of an intoxicating substance lead­ing to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. The substance is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.
  3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  4. Craving, or a strong desire or urge to use the substance.
  5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued use of the substance despite having persistent or recurrent social or in­terpersonal problems caused or exacerbated by the effects of its use.
  7. Important social, occupational, or recreational activities are given up or reduced be­cause of use of the substance.
  8. Recurrent use of the substance in situations in which it is physically hazardous.
  9. Use of the substance is continued despite knowledge of having a persistent or re­current physical or psychological problem that is likely to have been caused or ex­acerbated by the substance. 
  10. Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
    • A markedly diminished effect with continued use of the same amount of the sub­stance.
  11. Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for the substance
    • The substance (or a closely related substance) is taken to relieve or avoid with­drawal symptoms.

Specify if:

Mild: Presence of 2–3 symptoms.

Moderate: Presence of 4–5 symptoms.

Severe: Presence of 6 or more symptoms

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

The Continuum of Use & Intervention

The SBIRT model outlines a continuum of substance use ranging from abstinence to addiction and recommends interventions appropriate to each step in the continuum (Levy et al., 2016). We have added harm reduction strategies that may be appropriate at each step involving substance use.

Abstinence

Characterized by: no drug use; no alcohol more than a few sips.
Brief intervention: provide positive reinforcement for the decision to be/remain abstinent. Give the adolescent credit for making a healthful decision. Normalize abstinence.
Language you can use: “I am glad to hear that you are not using drugs or alcohol. Most people your age are not using alcohol or drugs, and it is always the right decision.”

Substance use without a disorder

Characterized by: occasional use without related problems. Generally occurs in social situations.
Brief intervention: Clear advice to stop substance use. Provide concise information about the adverse negative health effects of substance use. Leverage your patient’s personal strengths in support of refraining from use.
Language you can use: For the sake of your health, I encourage you to stop using alcohol. Alcohol impairs your judgement and decreases your awareness of what's going on around you.  This can put you in dangerous situations, like riding in a car with a driver who is drinking, or being vulnerable to someone who might want to harm you.
Harm reduction strategies: Consider setting a drink limit for a party.  Alternate water or soda with alcoholic drinks.  Have a clear plan to ask for ride home, or plan to not drive if planning to drink.  

Mild to moderate substance use disorder

Characterized by: Problems such as change in school performance, fights, school suspension, or arrest, high-risk situations such as driving or use with strangers, or attempts at emotional regulation, such as relief from stress, anxiety, or depression.
Defined as meeting 2 to 5 of the 11 DSM-5 criteria for a substance use disorder.
Brief intervention: Use motivational interviewing strategies to help your patient compare the benefits of continued substance use with the potential benefits of decreasing or stopping use. Motivational interviewing respects the patient’s autonomy while fostering self-efficacy.
Language you can use: It sounds like you have been vaping marijuana to deal with stress, but that your marijuana use is also causing stress in your life. Your parents have been upset with you and you got suspended from school. I am glad that you have told me about this, and I am concerned about the effect your marijuana use is having on your health, and your schoolwork and your relationships. How is this lining up with what you want from your life right now? I strongly encourage you to quit using marijuana. Can you see value in quitting marijuana use?
Harm reduction strategies: Explore the possibility of rising cost of vaping due to development of tolerance.  Consider a tolerance break to reduce rising use.  Educate about possible withdrawal effects.  Consider lower potency products.  

Severe substance use disorder

Characterized by: Compulsive drug use associated with neurologic changes in the reward system of the brain.
Brief intervention: Use motivational interviewing strategies to help your patient and your patient’s parents or guardians to pursue substance use treatment. Provide resource and referral information. Be prepared for denial and resistance. Maintain engagement.
Language you can use: You have told me that you have been getting Xanax from friends and using it several times a week to help you relax. I am glad you told me about this, and I am very concerned about your health and safety. Medications like Xanax are addictive, and they can also be dangerous to stop abruptly if you have been using them daily. I think you are going to need some help stopping and staying off Xanax. I would like to refer you to a colleague who specializes in helping people make decisions about substance use. Would you be willing to meet with her and learn more about options?
Harm reduction strategies: Educate patient and family about risks and signs of overdose.  For youth who use opioids or other drugs that could mixed/laced with opioids (like pills pressed with fentanyl), consider prescribing naloxone (Narcan) to be available to the family in the event of overdose.  Explore how the patient is obtaining and using the substances.  Identify and mitigate risk in that process.  

Treatment

Substance use treatment options range from individual and family counseling to residential treatment programs. Medications for substance use treatment can be helpful for nicotine, opioid, and alcohol use disorders. Treatment options may be limited by insurance coverage, geography, wait lists and patient/family preference.

You may use the comprehensive Substance Abuse Treatment Facility Locator on the SAMHSA Web site to find resources for your patients.  The site also lists  a Buprenorphine Physician & Treatment Program Locator and an Opioid Treatment Program Directory.

Recovery from substance use disorders is a process that often requires ongoing support. The pediatric medical home can provide continuity, ongoing coordination and referrals, and help monitor for relapse.

Substance Use & Mental Health

Substance use and substance use disorders may arise from, precipitate, or worsen mental health disorders. Teens with social anxiety may consume alcohol to prepare for social interactions. Teens with depression may drink to relieve depression symptoms. Cannabis and hallucinogens increase the risk for psychotic symptoms and schizophrenia. Synthetic cannabinoids may cause toxicity that includes high blood pressure, vertigo, chest pain, and panic symptoms that may persist long after single use. Assessment of substance use should occur together with mental health assessment.

References

Apantaku-Olajide, T., & Smyth, B. P. (2013). Non-medical use of psychotropic prescription drugs among adolescents in substance use treatment. In J Psychoactive Drugs (Vol. 45, Issue 4, pp. 340–346). https://doi.org/10.1080/02791072.2013.825029

Coble, C., Srivastav, S., Glick, A., Bradshaw, C., & Osman, C. (2022). Teaching SSHADESS v HEADSS to Medical Students:Association with Improved Communication and Increased Psychosocial Assessments. Academic Pediatrics. https://doi.org/10.1016/j.acap.2022.09.012

COMMITTEE ON SUBSTANCE USE AND PREVENTION, Levy, S. J. L., Williams, J. F., Ryan, S. A., Gonzalez, P. K., Patrick, S. W., Quigley, J., Siqueira, L., Smith, V. C., & Walker, L. R. (2016). Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics, 138(1), e20161210. https://doi.org/10.1542/peds.2016-1210

Hadland, S. E., Copelas, S. H., & Harris, S. K. (2017). TRAJECTORIES OF SUBSTANCE USE FREQUENCY AMONG ADOLESCENTS SEEN IN PRIMARY CARE: IMPLICATIONS FOR SCREENING. The Journal of Pediatrics, 184, 178–185. https://doi.org/10.1016/j.jpeds.2017.01.033

Levy, S. J. L., Williams, J. F., COMMITTEE ON SUBSTANCE USE AND PREVENTION, Ryan, S. A., Gonzalez, P. K., Patrick, S. W., Quigley, J., Siqueira, L., Smith, V. C., & Walker, L. R. (2016). Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics, 138(1), e20161211. https://doi.org/10.1542/peds.2016-1211

O’Connor, E., Thomas, R., Senger, C. A., Perdue, L., Robalino, S., & Patnode, C. (2020). Interventions to Prevent Illicit and Nonmedical Drug Use in Children, Adolescents, and Young Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 323(20), 2067–2079. https://doi.org/10.1001/jama.2020.1432

Teenage Drug Use Statistics [2022]: Data & Trends on Abuse. (n.d.). NCDAS. Retrieved September 29, 2022, from https://drugabusestatistics.org/teen-drug-use/

Winer, J. M., Yule, A. M., Hadland, S. E., & Bagley, S. M. (2022). Addressing adolescent substance use with a public health prevention framework: The case for harm reduction. Annals of Medicine, 54(1), 2123–2136. https://doi.org/10.1080/07853890.2022.2104922