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Approach to Adolescent Substance Use

Introduction

Substance use in adolescence can have widespread negative effects on adolescent health, including school failure, respiratory disease, high-risk sexual behaviours, injury and even death. Although some view the occasional use of substances such as alcohol or marijuana as part of normal adolescent development, there exists significant potential for injury even with occasional use. In North America, over 30% of deaths from all injuries are directly related to alcohol.

Substance use often begins in early adolescence, with 14-15 years being the average age of first substance use in Canada. Given that many youth in Canada struggle with substance abuse and addiction, pediatricians must commit themselves to the early identification of youth at risk of substance abuse and provide early interventions to prevent negative health outcomes.

This article outlines the presentation and management of adolescent substance use and presents an overview of the intoxication effects of the most commonly used substances (note: Nicotine not included in this article).

Local Statistics

A recent survey of over 29,000 British Columbian youth enrolled in Grades 7-12 provides recent estimates of substance use for school-enrolled youth in B.C., Canada. The following table outlines the percentage of youth surveyed who had ‘ever tried’ each substance.

Substance Percentage that had “ever tried”
Alcohol 54% (44% of these reported binge drinking in past month)
Marijuana 30% (58% of these had used in the past month)
Cigarettes 26%
Ecstacy 7%
Mushrooms 4%
Inhalants 4%
Amphetamines 2%
Steroids 2%
Heroin 1%

In this survey, 41% of students who had used any substance reported getting so intoxicated that they didn’t remember what they had done while intoxicated.

General presentation

Adolescents with substance use problems present in a variety of ways:

  • Intoxicated in the emergency department
  • In your clinic with physical complaints: e.g. persistent abdominal pain, palpitations, chest pain, recurrent sore throat, persistent nasal discharge
  • Brought in by parents for behavioural concerns: changes in school performance, sudden mood swings, stealing or lying
  • No presenting signs or symptoms; disclosed only on direct questioning by health care professionals

Thus, it is imperative that you consider substance use in the differential diagnosis for all psychosocial, behavioural and medical problems. It is also important to screen for co-morbid conditions such as ADHD or psychiatric illness, since their identification is imperative to successful treatment.

Defining Substance Abuse & Dependence

Currently accepted definitions for substance abuse and dependence were developed for use in adults and can be found in the DSM-IV. These have limitations in adolescents due to different use patterns and developmental considerations, but are nevertheless a useful guide for characterizing adolescent substance use.

Substance abuse is generally defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one of the following criteria: Failure to fulfill obligations, recurrent use in physically hazardous situations, substance-related legal problems, substance-related interpersonal problems.

In contrast, substance dependence (a.k.a. addiction) is defined by three of the following criteria over a 12-month period: Drug tolerance, withdrawal symptoms, inability to cut down on substance use despite motivation, continued use despite awareness of consequences, reduction of activities (social, occupational, recreational) due to substance use. For full definitions please consult the DSM-IV.

History Taking: Questions to Ask

All adolescents should be screened for substance use as part of a comprehensive HEADSS interview (home, employment, activities, drugs, sex, suicide).  Standardized screening tools such as the CRAFFT test (see table below) have high sensitivity and specificity for diagnosing substance abuse or dependence.

C Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself, Alone?
F Do you ever Forget things that you did while using alcohol or drugs?
F Do your Friends or Family ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten into Trouble while you were using alcohol or drugs?

Score 1 point for every “yes” answer. Score of 2 or higher has 80% sensitivity and 86% specificity for a diagnosis of substance abuse or dependence.

If the CRAFFT screening tool is positive or substance use is disclosed, you should take a more detailed history that includes the following:

  • Age of first use & types of drugs used
  • Current pattern of use: Circumstances/frequency/timing of use
  • Impact on health/school/family; other negative consequences
  • Family history of substance use/abuse
  • Screening for co-morbid psychiatric conditions

Physical Examination

Signs to look for on physical examination will depend on the type of substances used, the chronicity of use and the presence of acute intoxication. To help guide the physical examination, intoxication effects and long-term health consequences of the most commonly used substances are presented below.

**NOTE: insert link to “Commonly Abused Drugs” here

Investigations

  • Acute intoxication: basic bloodwork including CBC, electrolytes, BUN, creatinine
  • If decreased level of consciousness, other tests may be indicated (e.g. blood glucose, calcium, toxicology screening)
  • Drug screening not recommended without informed patient consent, unless the adolescent has altered mental status.
  • When ordering drug screening tests, keep in mind that the window of detection for most substances is brief and that false-positive results can occur from other substances.

The following table outlines the screening tests available for drugs of abuse:

Drug Test Window of Detection
Alcohol Urine, Blood Blood: 7-10 hrsUrine: 10-13 hrs
Cannabinoids Urine Occasional use: 3-10 daysChronic use: 1-2 months
Cocaine Urine, Blood Acute use: 2-4 daysChronic use: 2 weeks
Opioids Urine Urine: 2-4 days
Amphetamines Urine < 48 hours
Phencyclidine (PCP) Urine 8 -14 days
Anabolic steroids Urine Days to weeks
Inhalants, Ecstasy, No sensitive, widely available screening tests

Management

The following is a basic approach to managing adolescent substance use based on the stages of change model. Any adolescent with substance abuse or dependence should be referred for appropriate inpatient or outpatient treatment services.

Patient Stage Motivation Tasks
Pre-contemplation Create doubt, help patient connect substance use with problems & risks identified during history taking, express your concern.
Contemplation Help the patient weigh the pro’s & con’s of substance use (favour change). Strengthen the patients’ self-efficacy for changing current use.
Preparation Help the patient determine the best course of action to change substance use.
Action Positive reinforcement.
Maintenance Help the patient identify and use strategies to prevent relapse. Positive reinforcement.
Relapse Help the patient renew the process of change starting at contemplation

References

  • Adolescent Substance Abuse. In: Kliegman et al., eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007.
  • Adolescent Substance Abuse. In: Hay et al., eds. CURRENT Diagnosis & Treatment: Pediatrics. 19th ed. U.S.A; McGraw-Hill Companies Inc; 2009.
  • Baydala, L. Inhalant Abuse. Pediatric Child Health 2010;15(7): 443-448.
  • Substance Use in Adolescence. In: Parker et al., eds. Developmental and Behavioural Pediatrics: A Handbook for Primary Care. Philadelphia, PA: Lippincott Williams and Wilkins; 2005; 329-332.
  • U.S. Department of Health and Human Services. Chart of Commonly Abused Drugs. National Institute on Drug Abuse website. Available at: http://www.drugabuse.gov/DrugPages/DrugsofAbuse.html. Accessed Sept 20, 2010.
  • Smith, A., Stewart D., Peled, M., Poon, C., Saewyc, E. and the McCreary Centre Society. A Picture of Health: Highlights from the 2008 BC Adolescent Health Survey. Vancouver, BC: McCreary Centre Society: 2009.

Acknowledgments

Written by: Katrina Stockley

Edited by: Elmine Statham

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