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.
• The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (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 previous edition of the DSM-4.
• Substance use disorder exists along a continuum from mild to severe depending on the number of criterion met.

EPIDEMIOLOGY

• Prevalence estimates vary by substance, age of youth, and geographical location.
• Types of substance use
  • Tobacco, alcohol, and marijuana are the most commonly used.
  • Prescription medication misuse is a significant challenge. The Youth Risk Behavior Survey (YRBS) notably documents the cooccurrence of prescription opioid misuses by adolescents with recent marijuana and alcohol use.
  • There has been a steady increase of vaping (mostly tobacco but also marijuana) by adolescents since 2016 among 8th, 10th, and 12th graders.

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.
• 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/hyperactivity disorder (ADHD)
• Learning disorders
• Conduct disorders
• Psychotic disorders

HISTORY

• Screening approach
  • 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). Studies confirm the importance of clinicians who are verbally reassuring adolescents about confidentiality.
• Screening tools
  • Screening, brief intervention, referral, and treatment (SBIRT) is an approach recommended for adolescents. 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 patient’s willingness to quit; Assisting the patient with smoking cessation; and Arranging follow-up.
• Because the physical exam is often within normal limits, the history remains essential for identifying substance use disorder in adolescents.

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
• Head, ears, eyes, nose, throat (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)
• Chest: Gynecomastia may reflect marijuana use; galactorrhea may be caused by prescription opiate use.
• Skin: needle marks in injection users

DIFFERENTIAL DIAGNOSIS

• Mood disorders
• ADHD
• Psychotic disorders

DIAGNOSTIC TESTS & INTERPRETATION

GENERAL MEASURES

• School-based prevention programs have demonstrated efficacy.
• Treatment can be provided in many 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 adolescent 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 adolescent is no longer living at home and receiving more intensive services

MEDICATION

• 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 for those who are <18 years of age.
• Alcohol dependence
  • 1st-line treatments include medications such as naltrexone, μ-opioid receptor antagonists, and acamprosate, a γ-aminobutyric acid (GABA) agonist/glutamate antagonist, are not approved for adolescents.
  • 2nd-line agents, for patients who do not respond, include disulfiram, an aversive agent causing accumulation of alcohol’s primary metabolite, acetaldehyde, and topiramate, which primary use is an anticonvulsant treatment.
• Opioid dependence
  • Naltrexone has robust data in adults, with early evidence for effectiveness for adolescents, with no overdose or abuse potential. Available in oral and injectable formulations; it is used for maintenance but not for withdrawal.
  • Buprenorphine (partial agonist of the mu opioid receptor), in combination with naloxone (formulated as Suboxone^®) for treatment of opioid dependence, is available in transmucosal and injectable formulations and is approved for patients ages ≥16 years. This medication suppresses craving and withdrawal symptoms and blocks the effects of other opioids, thereby reducing illicit opioid use.
  • Methadone has been used for short-term detoxification but not typically used for maintenance due to poor adherence.
  • Clonidine
• Comorbid and associated psychiatric illnesses such as mood disorders, anxiety disorders, and ADHD should be medicated appropriately.

ISSUES FOR REFERRAL

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

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 adolescent 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—all essential components of SBIRT: a counseling style that is patient-focused, aimed at exploring benefits and cons of usage to direct the patient toward behavior change

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

• Detoxification should be considered for youth when there is a 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

FOLLOW-UP RECOMMENDATIONS

PATIENT EDUCATION

• 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.
• Ongoing education about confidentiality and about the continuum of treatment, including counseling, medications, and intensification of treatment, remains paramount.
• Ongoing education about effective pregnancy and STI prevention including preexposure prophylaxis (PrEP) are also important parts of our toolkit to decrease morbidities related to substance use.

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

• Adolescent substance use has been associated with increased morbidity and mortality including depression, anxiety, suicide, motor vehicle accidents, unintentional injuries, unintended pregnancy due to unprotected sexual intercourse, and STIs including HIV and hepatitis C infection due to unprotected sexual intercourse and/or shared-needle use.
• E-cigarette/vaping product use–associated lung Injury (EVALI)
  • Can result in airway reactivity and even pneumothorax
  • THC has been detected in most EVALI case samples.
• Cannabinoid hyperemesis syndrome (CHS) due to chronic marijuana use is considered a subset of cyclic vomiting disorder and can lead to electrolytes derangement and dehydration, requiring hospitalization.
• Acute intoxication/overdose can have significant associated morbidity and mortality.
  • Fatal overdose remains a risk for opiate and benzodiazepine users, especially when used in combination with alcohol or marijuana.
  • The increased presence of fentanyl in street heroin has increased the risk of fatal overdose.

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