Epidemiology and Pathogenesis

Patterns of drug initiation and drug use vary by age, gender, race, ethnicity, and substance availability in an adolescent’s community. Monitoring the Future Study (MTFS) is a nationally representative study that follows trends in adolescent drug use and attitudes. As adolescents mature, they report higher rates of substance use (Figure 82-1). Notably, alcohol is the most commonly reported substance used by adolescents followed by cigarette use and marijuana use. Use of other illicit drugs substances, although less common, poses risks resulting from acute impairments in judgment or long-term addiction. More recent surveys have highlighted the increased availability and recreational use of prescription drugs such as hydrocodone bitartrate (Vicodin), oxycodone (Percocet), and methylphenidate hydrochloride (Ritalin). Although illicit substances can signify an increased risk for an individual adolescent, pediatricians need to routinely discuss alcohol-related issues given that 43% of 12th graders; 29% of 10th graders; and 16% percent of 8th graders reported using alcohol based on 2008 MTFS data. Although adolescents drink less frequently than adults, when consuming alcohol, teens tend to drink more at one time compared with adults. Remarkably, from the same survey, 25% of 12th graders, 16% of 10th graders, and 8% of 8th graders report having consuming five or more drinks on at least one occasion.

Figure 82-1 Thirty-day reported substance use by grade.

Pediatricians will find that a substantial proportion of their adolescent patients will report trying substances, yet of these teens, only a minority will abuse a substance or become physiologically dependent (Figure 82-2). Progression from experimentation to abuse or physiologic dependence results from the complex interplay of numerous biopsychosocial risks and protective factors, including adolescent physical, emotional, and cognitive development, and environmental factors, including peers’ and family’s attitudes and behaviors, genetic predisposition, and mental health stressors.

Figure 82-2 Substance dependence (addiction).

Recent research elucidates how maturation of the prefrontal cortex impacts risks associated with substance use. Initially, the adolescent brain learns to feel intense emotions with limited self-control followed later by the maturation of regulatory systems, which temper these emotions and allow the adolescent to assess immediate and long-term risks. This developmental sequence helps to explain why younger adolescents may experience excessively positive emotions associated with a substance and less moderation of behavior, resulting in risk of immediate harm and long-term dependence. Adolescents who physically mature earlier are at increased risk because they may have the opportunity to socialize with older adolescents and be exposed to a wider variety of substances. Learning what substances are commonly available and used by adolescents in a particular school or community can be extremely helpful in screening for particular substance use. Although availability and social cues from peers are strongly correlated with continued substance use, the highest predictor of long-term substance use or abuse is the adolescent’s family’s substance use patterns. This may be due to ongoing behavioral stimuli or a genetic predisposition; both mechanisms have been implicated in alcohol dependency and nicotine addiction.

Mental health issues and past traumas can increase the risk that an adolescent will begin using substances on a regular basis to elevate mood, dull anxiety, or avoid feelings altogether. Adolescents with depression, anxiety, attention-deficit/hyperactivity disorder, and conduct disorders are at significantly increased risk for using substances to manage symptoms related to these disorders (Figure 82-3). A history of having experienced childhood physical or emotional abuse, past or ongoing family conflict, inadequate parental supervision, isolation from school, poor academic achievement, and sexual or gender identity concerns can increase the risk that an adolescent may begin to use and experience harm from substances.

Figure 82-3 Mood disorders.

Evaluation and Clinical Presentation

Management

After an adolescent has been identified as using a substance, the pediatrician should assess the need for an emergency evaluation, referral for specialized substance abuse treatment, referral for outpatient psychiatric consultation and counseling, or an office-based intervention.

Adolescents with acute intoxication or a significant change in mental status, including somnolence, confusion, agitation, aggression, paranoia, or hallucination, and those who appear to pose a safety risk to themselves or others will need immediate medical and psychiatric evaluation in an emergency department, including laboratory testing for substance use. Laboratory assessment of substance abuse consists primarily of urine and serum toxicology, which is often reserved for the emergency setting. Adolescents should be informed of the limits of laboratory testing, including the possibility of false-positive test results, when pediatricians are asking their consent for this testing. A pediatrician may forego an adolescent’s consent for laboratory screening when the patient does not have decision-making capacity (e.g., significantly altered mental status). Positive test results should be confirmed by secondary analysis, usually mass spectrometry or gas chromatography. The clinical scenario will guide additional testing, including blood alcohol concentration, rapid glucose, electrolytes, creatinine, hepatic function panel, pancreatic enzymes, pregnancy and STI testing.

Indications for inpatient management of patients with substance abuse or dependence include severe, acute, or life-threatening presentations; drug dependence that requires specialized care to prevent withdrawal; psychiatric comorbidities that prohibit safe, reliable treatment as an outpatient; or the failure of outpatient management. Inpatient options include hospitalization on medical or psychiatric wards as well as residential treatment facilities for longer term care.

For patients not requiring immediate referrals, the pediatrician should assess by discussing the degree to which the substance use is the main concern or exploring if there are symptoms of other mental health issues that require referral for specialized mental health care. Adolescents who are using substances to manage severe depression will benefit from an evaluation and therapy with a child psychiatrist. While supporting adolescents and respecting their confidentiality, pediatricians can help adolescents to share their concerns with caring adults who can facilitate referral to this mental health professional. Referral for outpatient family-based therapy programs can be effective in treating adolescents with substance use disorders, particularly when familial stress and substance use contribute to the adolescent’s substance use.

For adolescents who have experimented with substances or are thinking about trying a new substance, pediatricians can provide important and accurate information regarding the immediate and long-term risks. Pediatricians who are aware of the commonly used substances in an adolescent community can begin an ongoing dialogue before an adolescent is likely to be exposed to the substance so that risks associated with initial experimentation and later use are easily discussed.

Different intervention models have been proposed to manage different types of substance use. One model for talking to an adolescent regarding smoking use is based on the U.S. Department of Health and Human Services Clinical Practice Guideline; Treating Tobacco Use and Dependence. These intervention models have proven to be effective in decreasing tobacco use among adults and may be of promise among youth, although adequate studies are not conclusive. These guidelines recommend that primary care providers follow the “five As.” First, the provider should (1) ask every patient at every visit about their tobacco use, (2) the provider should advise patients that the best thing they could do for their health would be to quit smoking, (3) the provider then can assess patients’ interest and willingness to quit smoking at this time, (4) if the patient is interested in quitting, the provider can assist the patient in quitting, and (5) the provider should always arrange for a follow-up to further discuss substance use and cessation.

Pediatricians caring for adolescents report that they often find themselves at a loss about what to do if an adolescent reports that he or she does not wish to stop smoking or using other substances. In this case, the U.S. Department of Health and Human Services Clinical Practice Guidelines recommend that the provider follows the “five Rs”—(1) the provider can ask if cessation would even be relevant or meaningful for the patient, (2) the provider may ask the patient if he or she associates any risks related to smoking and any potential rewards associated with quitting, (3) for example, an adolescent may believe that by buying cigarettes, he or she risks not being able to save to go to the prom, and a reward of quitting would be increased savings, (4) by helping the patient identify roadblocks to quitting, such as how to deal with being around friends and family who smoke, the pediatrician can start a dialogue about ways to overcome some of these challenges, and (5) repetition and follow-up are key for increasing motivation to decrease or stop substance use. A more specialized technique, motivational interviewing, may also have promise with adolescents who smoke and are not yet ready to commit to quitting. This technique focuses on expressing empathy, enhancing awareness of discrepancies between desires and behavior, accepting resistance, and supporting self-efficacy. Studies focusing on adolescent alcohol use have not yet definitely described effective office-based interventions, although pediatricians working in coordination with family and schools may promote a comprehensive community-wide intervention that decreases alcohol use among adolescents.

Future Directions

Future research will continue to help pediatricians become more effective in screening for and managing substance use by adolescent patients. Interventions using in-office motivational counselors, online programs, and brief, repetitive counseling sessions may help to increase the effectiveness of pediatricians in reducing substance use and improving the immediate and long-term health of adolescents.