Substance Use Disorders

Basics

Description

In adolescence, substance use tends to occur along a continuum from abstinence to experimentation to nonproblematic use to problematic use to substance use disorder.
DSM-5 defines substance use disorder as a maladaptive pattern of use leading to clinical impairment or distress, which is based on presence of specific criterion including the following:
- Substance use resulting in failure to fulfill obligations (such as school or work)
- Substance use in situations that are hazardous (such as driving)
- Continued use despite interpersonal problems exacerbated by use
- Development of tolerance
- Development of withdrawal
- Craving for the substance
- Persistent desire or unsuccessful efforts to curb/cut down usage
- Significant time and energy spent obtaining substances
- Continued use despite recognition of associated psychological or physical consequences of continued use (with or without physiologic dependence)
Substance use disorder combines the previous diagnoses of substance abuse and substance dependence from the DSM-IV.
Substance use disorder exists along a continuum from mild to severe depending on the number of criterion met.

Epidemiology

Substance use estimates vary by substance, age of youth, and geographical location. Up to date, epidemiologic data can be found online at www.monitoringthefuture.org which includes data for cigarette, alcohol, and other illicit drug use among 8th,10th, and 12th graders. Another source of substance abuse data includes the Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention.
Tobacco, alcohol, and marijuana are the most commonly used; however, prescription medication misuse is a significant challenge.
Adolescent substance use has been associated with increased morbidity and mortality including depression, suicide, motor vehicle accidents, unintentional injuries, teenage pregnancy, high-risk sexual activity, and sexually transmitted infections (STIs).

Risk Factors

Early initiation: Adolescents who begin using alcohol or drugs at an early age have an increased risk of developing an addictive disorder later in life. Later initiation of use may be a protective factor.
Individual factors such as low self-esteem and impulsivity
Social factors such as peer use
Family factors such as a parental tolerance of use, negative parent–child/adolescent relationship, permissive or authoritarian parenting style, parental divorce during adolescence
Other environmental factors such as school failure and availability of substances within the community
Individual and family factors may be protective as well such as positive self-esteem and positive, open, and supportive relationships with family.

Genetics

Research demonstrates a genetic predisposition to alcohol dependence. Children of alcoholic parents are 4 to 6 times more prone to developing alcohol dependence.

Commonly Associated Conditions

Mood disorders
Anxiety disorders, including posttraumatic stress disorder
Eating disorders (specifically bulimia nervosa)
Attention deficit disorder
Learning disorders
Conduct disorders
Psychotic disorders

Diagnosis

History

Adolescent-appropriate screening using a validated measure should be administered at least annually at every adolescent preventive care visit and appropriate urgent/acute care visits.
Screening should be performed confidentially and with the adolescent alone (without parents/guardians).
SBIRT model recommended for adolescents. Includes the following steps: Screening, Brief Intervention, and Referral to Treatment. The Brief Intervention is based in principles of motivational interviewing in addressing behavior change.
The CRAFFT (an acronym for key components in the questions: Car, Relax, Alone, Forget, Family/Friends, Trouble) screen is one of several tools validated for adolescents.
All patients who screen positive warrant a more complete assessment including more in-depth substance use history. Questions should include what substances are used, frequency of use, mode of use (nasal, ingestions, smoking, IV), how they are obtaining the substances, and peer group usage.
The 5 A’s was developed to address smoking cessation and includes Asking about use; Advising all smokers to quit; Assessing a patients willingness to quit; Assisting the patient with smoking cessation; and Arranging follow-up.

Physical Exam

Vital signs: increased blood pressure and increased pulse seen in stimulants (such as cocaine, amphetamines), cannabis, phencyclidine (PCP)
General: odor of alcohol, marijuana, or tobacco; poor personal hygiene; slurred speech; intoxicated appearance
HEENT: rhinitis and/or nasal mucosa irritation if snorting substances
Eyes: injected conjunctiva with cannabis; nystagmus with PCP; pupillary constriction with opiates; pupillary dilatation with cocaine, PCP, and opiate withdrawal
Respiratory depression with opiates, overdose on depressants (such as alcohol and benzodiazepines)
Respiratory: wheezing/abnormal breath sounds due to smoking substances (tobacco, cannabis, other substances)
Skin: needle marks in injection users

Differential Diagnosis

Mood disorders
Attention deficit disorder
Psychotic disorders

Diagnostic Tests and Interpretation

Initial Tests

Urine drug screens are most commonly used. Their use in the emergency situation is critical when overdose or acute intoxication is suspected. They can be used effectively as part of a drug treatment program. With limited exceptions, random and routine drug screening is not recommended by the American Academy of Pediatrics and is of limited value.
Urine drug screens typically include
- Cannabinoids
- Cocaine
- Amphetamines
- Opiates
- PCP

Diagnostic Procedures/Other

Screening for STIs including HIV (particularly in IV drug users) and hepatitis B and C is recommended as part of a risk reduction program.

Treatment

General Measures

School-based prevention programs have demonstrated efficacy.
Treatment can be provided in a number of different settings both outpatient and inpatient with varying intensity, including the following:
- Outpatient treatment: typically 1 hour weekly, may be individual therapy or family therapy
- Intensive outpatient program or partial hospitalization program: more intensive outpatient program where teen lives at home but may be participating in individual and group therapy multiple hours per day and multiple days per week
- Residential treatment/therapeutic boarding school: where teen is no longer living at home and receiving more intensive services

Medication (Drugs)

Cigarette/nicotine dependence
- Nicotine replacement available in number of different forms including nicotine replacement patch, lozenge, inhaler, and gum
- Bupropion may be recommended in those who have failed with nicotine replacement alone.
- Varenicline is not approved in those <18 years of age.
Alcohol dependence
- Medications available for adults such as naltrexone, disulfiram, and acamprosate are not approved for adolescents.
Buprenorphine (partial agonist of the mu opioid receptor) for treatment of opioid dependence. Approved in those aged 16 years and older and may be used for maintenance. Methadone has been used for short-term detoxification but not typically used for maintenance due to poor adherence.
Comorbid and associated psychiatric illnesses such as mood disorders, anxiety disorders, and attention deficit hyperactivity disorder (ADHD) should be medicated appropriately.

Issue for Referral

Rates of treatment are low, with only 6–10% of those adolescents with substance use disorders receiving treatment.
All youth with a concern for substance abuse or comorbid disease should be referred to an experienced mental health professional or addiction specialist.

Additional Therapies

Strongest body of evidence in the treatment of adolescent substance use disorders is therapy.

Cognitive behavioral therapy: structured and goal-oriented therapy designed to assist teen in identifying behavioral strategies to address distorted thoughts and subsequent emotions
Family therapy: Some research demonstrates that family treatments are superior to individual therapy.
12-step programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA): typically small group format where participants may provide support for each other
Brief intervention/brief advice/motivational interviewing: a counseling style that is patient-focused, aimed at exploring benefits and cons of usage in order to direct the patient toward behavior change

Inpatient Consideratons

Detoxification should be considered for youth when there is concern for withdrawal; includes medical management of withdrawal symptoms
Residential treatment is an intensive, structured program for adolescents who may require this particularly acutely; for those who require 24-hour care and support

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Patients should be screened annually at all preventive visits.
When an action plan is created or in those receiving brief advice or brief interventions, patients should be followed closely.
The pediatrician may play an important role in monitoring for relapse in those who have undergone treatment.

Patient Teaching

All youth who have not initiated substance use should be given positive reinforcement about their behaviors and encouraged to discuss the topic in the future.

Prognosis

Youth who receive treatment do better than those who do not.
Approximately 1/3 to 1/2 of youth who receive treatment will relapse within 12 months following treatment completion.
Factors associated with relapse include psychiatric comorbidity, poor coping skills, poor familial relationships, and return to prior peer groups.
Continued involvement in therapy and ongoing support helps to protect against relapse.

Complications

Acute intoxication/overdose can have significant associated morbidity and mortality.

Additional Reading

Adger H Jr, Saha S. Alcohol use disorders in adolescents. Pediatr Rev. 2013;34(3):103–114. [PMID:23457197]
Das JK, Salam RA, Arshad A, et al. Interventions for adolescent substance abuse: an overview of systematic reviews. J Adolesc Health. 2016;59(Suppl 4):S61–S75. [PMID:27664597]
Kaplan G, Ivanov I. Pharmacotherapy for substance abuse disorders in adolescence. Pediatr Clin North Am. 2011;58(1):243–258. [PMID:21281859]
Levy SJ, Williams JF; for Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211. [PMID:27325638]
Ryan SA, Ammerman SD; for Committee on Substance Use and Prevention. Counseling parents and teens about marijuana use in the era of legalization of marijuana. Pediatrics. 2017;139(3):e20164069. [PMID:28242859]
Sanchez-Samper X, Knight J. Drug abuse by adolescents: general considerations. Pediatr Rev. 2009;30(3):83–93. [PMID:19255122]

Codes

ICD-9

305.90 Other, mixed, or unspecified drug abuse, unspecified use
305.00 Alcohol abuse, unspecified
305.20 Cannabis abuse, unspecified
305.1 Tobacco use disorder
305.60 Cocaine abuse, unspecified
305.30 Hallucinogen abuse, unspecified
304.90 Unspecified drug dependence, unspecified use
305.40 Sedative, hypnotic or anxiolytic abuse, unspecified
305.70 Amphetamine or related acting sympathomimetic abuse, unspecified
303.0 Acute alcoholic intoxication
305.50 Opioid abuse, unspecified
305.80 Antidepressant type abuse, unspecified

ICD-10

F19.10 Other psychoactive substance abuse, uncomplicated
F10.10 Alcohol abuse, uncomplicated
F12.10 Cannabis abuse, uncomplicated
Z72.0 Tobacco use
F16.10 Hallucinogen abuse, uncomplicated
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F11.10 Opioid abuse, uncomplicated
F15.10 Other stimulant abuse, uncomplicated
F14.10 Cocaine abuse, uncomplicated
F18.10 Inhalant abuse, uncomplicated

SNOMED

66214007 Substance abuse (disorder)
15167005 Alcohol abuse (disorder)
37344009 Cannabis abuse
89765005 Tobacco dependence syndrome (disorder)
84758004 amphetamine abuse (disorder)
5602001 Opioid abuse (disorder)
191928000 Abuse of antidepressant drug
231462006 Barbiturate abuse
74851005 Hallucinogen abuse
78267003 cocaine abuse (disorder)

FAQ

Q: Should I screen adolescents who use substances for suicide risk?
A: Yes. All adolescents with a history of substance misuse should be screened for suicide risk and suicidal ideations. Adolescents who use substances have a higher percentage of psychiatric comorbidity and a higher risk of suicide.
Q: What do I tell parents about their teen’s substance use?
A: The laws about confidentiality pertaining to adolescent substance use and disclosure to parents depend on the state. It is important to know the laws in your state.
Q: What symptoms would you expect to see based on a patient’s blood alcohol level (BAL)?
A: BAL can be indicative of the severity and may vary due to metabolism and body weight. A BAL of 0.05% is associated with slowing reaction time and altered cognition; 0.1–0.2%: intoxication, drowsiness, and loss of balance; 0.2–0.3% may lead to vomiting and stupor; 0.3–0.4% may lead to hypothermia and coma; and >0.4% may lead to death.

Authors

Sara M. Buckelew, MD, MPH