CURRENT Diagnosis and Treatment Pediatrics, (Current Pediatric Diagnosis & Treatment) 22nd Edition

5. Adolescent Substance Abuse

Paritosh Kaul, MD

Substance abuse tends to be a chronic, progressive disease. The first or initiation stage—from nonuser to user—is such a common feature of becoming an American adult that many authorities call it normative behavior. At this stage, substance use is typically limited to experimentation with tobacco or alcohol (so-called gateway substances). During adolescence, young people are expected to establish an independent, autonomous identity. They try out a variety of behaviors within the safety of families and peer groups. This process often involves experimentation with psychoactive substances, usually in culturally acceptable settings. Progression to the second or continuation stage of substance abuse is a nonnormative risk behavior with the potential to compromise adolescent development. The American Psychiatric Association has outlined criteria to judge the severity of substance use that progresses beyond the experimentation stage to substance abuse or dependency. Progression within a class of substances (eg, from beer to liquor) and progression across classes of substances (eg, from alcohol to heroin) are the third and fourth stages of substance abuse. Individuals at these stages are polysubstance abusers, and most manifest one or more symptoms of dependency, such as tolerance or withdrawal. The transition from one stage to the next is often a cyclic process of regression, cessation, and relapse. Common physiologic effects and symptoms of intoxication (which can occur at any stage) and withdrawal (a symptom of dependency) for the major classes of substances are shown in Tables 5–1and 5–2.

Table 5–1. Physiologic effects of commonly abused mood-altering substances by organ/system.

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Table 5–2. Effects of commonly abused mood-altering substances by agent.

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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. American Psychiatric Association; 2000.

Meyers JL, Dick DM: Genetic and environmental risk factors for adolescent-onset substance use disorders. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):465–477 [PMID: 20682215].

Salomonsen-Sautel S et al: Medical marijuana use among adolescents in substance abuse treatment. J Am Acad Child Adolesc Psychiatry 2012 Jul;51(7):694–702 [PMID: 22721592].

SCOPE OF THE PROBLEM

The best current source of information on the prevalence of substance abuse among American adolescents is the Monitoring the Future study (2013), which tracks health-related behaviors in a sample of over 45,000 8th, 10th, and 12th graders in the United States. This study probably understates the magnitude of the problem of substance abuse because it excludes high-risk adolescent groups—school dropouts, runaways, and those in the juvenile justice system. Substance abuse among American youth rose in the 1960s and 1970s, declined in the 1980s, peaked in the 1990s, and declined in the early 2000s. There was a decrease in substance use initiation between 1999 and 2008, but this trend reversed between 2008 and 2010 and substance use in adolescents continues to be a significant problem. The lifetime use of any illicit drug was 49% in 2012. The use of alcohol, tobacco, and illicit drugs doubled from 8th to 12th grade. The use of alcohol and cigarettes more than tripled from adolescence (12–17 years) to young adulthood (18–25 years). Initiation of substance abuse is rare after age 20 years.

The Monitoring the Future survey and others show that alcohol is the most frequently abused substance in the United States. Experimentation with alcohol typically begins in or before middle school. It is more common among boys than girls. It is most common among whites, less common among Hispanics and Native Americans, and least common among blacks and Asians. Almost three-fourths (69%) of adolescents consume alcohol before graduating from high school. Approximately one-sixth (16%) of eighth graders and 54% of high school students report being drunk at least once in their life. Marijuana is the most commonly used illicit drug in the United States. First experiences with marijuana and the substances listed in Table 5–2 typically occur during middle or early high school. Marijuana use continued to rise in 2011 and leveled off in 2012 among all students. The lifetime prevalence of marijuana use among 12th graders in 2012 was 45.2% and daily use of marijuana continued to increase, with 1 in 16 (6.5%) high school seniors a daily or near daily user. Synthetic marijuana, often called spice and K-2, was scheduled by the Drug Enforcement Agency in 2011. Over 1 in 10 (11.4%) of 12 graders had used it in the past year. In the past decade, LSD, and methamphetamine use has decreased, while cocaine use has increased. Recently, ecstasy use has increased after a steady decline of several years. In the past 10 years, there has also been an increase in the recreational use of prescription medications and over-the-counter (OTC) cough and cold medications among adolescents. In one study, 1 in 10 high school seniors reported nonmedical use of prescription opioids, and almost half (45%) used opioids to “relieve physical symptoms” in the past year. Vicodin use decreased among 12th graders to 8% in 2010, but it remains one of the most widely used illicit drugs. Overall, the psychotherapeutic drugs (amphetamines, sedatives, tranquilizers, and narcotics other than heroin) make up a large part of the overall US drug problem. Medication used in the management of chronic pain, depression, anxiety, and attention-deficit/hyperactivity disorder can all be drugs of abuse.

Studies indicate that variations in the popularity of a substance of abuse are influenced by changes in the perceived risks and benefits of the substance among adolescent users. For example, the use of inhalants was rising until 2006, when both experience and educational efforts resulted in a perception of these substances as being “dangerous.” As the perception of danger decreases, old drugs may reappear in common use. This process is called “generational forgetting.” Currently, use of LSD, inhalants, and ecstasy all reflect the effects of generational forgetting. Legalization of marijuana in certain states in the United States may increase the scope and breath of the substance abuse problem. A recent study has shown an increase of medical marijuana use among adolescents in substance abuse programs.

Johnston LD et al: Monitoring the Future national results on drug use: 2012 overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan; 2013.

Kuehn BM: Teen perceptions of marijuana risks shift: use of alcohol, illicit drugs, and tobacco declines. JAMA 2013 Feb 6; 309(5):429–430 [PMID: 23385247].

Salomonsen-Sautel S et al: Medical marijuana use among adolescents in substance abuse treatment. J Am Acad Child Adolesc Psychiatry 2012 Jul;51(7):694–702 [PMID: 22721592].

Substance Abuse and Mental Health Services Administration: Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.

Young AM et al: Nonmedical use of prescription medications among adolescents in the United States: a systematic review. J Adolesc Health 2012 Jul;51(1):6–17 [PMID: 22727071].

Supplement Use & Abuse

Use of supplements or special diets to enhance athletic performance dates to antiquity. Today, many elite and casual athletes use ergogenic (performance-enhancing) supplements in an attempt to improve performance. The most popular products used by adolescents are anabolic-androgenic steroids, steroid hormone precursors, creatine, human growth hormone, diuretics, and protein supplements. Anabolic-androgenic steroids increase strength and lean body mass and lessen muscle breakdown. However, they are associated with side effects including acne, liver tumors, hypertension, premature closure of the epiphysis, ligamentous injury, and precocious puberty. In females, they can cause hirsutism, male pattern baldness, and virilization; in boys, they can cause gynecomastia and testicular atrophy. Creatine increases strength and improves performance but can cause dehydration, muscle cramps, and has potential for renal toxicity. Human growth hormone has no proven effects on performance although it decreases subcutaneous fat. Potential risks include coarsening of facial features and cardiovascular disease. Strength athletes (ie, weight lifters) use protein powders and shakes to enhance muscle repair and mass. The amount of protein consumed often greatly exceeds the recommended daily allowance for weight lifters and other resistance-training athletes (1.6–1.7 g/kg/d). Excess consumption of protein provides no added strength or muscle mass and can provoke renal failure in the presence of underlying renal dysfunction. The American Academy of Pediatrics (AAP) cautions against the use of performance-enhancing substances.

As the use of supplements and herbs increases, it is increasingly important for pediatric care providers to be familiar with their common side effects. The Internet has become a source for information about and distribution of these products. The easy accessibility, perceived low risk, and low cost of these products significantly increase the likelihood that they will become substances of abuse by adolescents.

Castellanos D et al: Synthetic cannabinoid use: a case series of adolescents. J Adolesc Health 2011 Oct;49(4):347–349 [PMID: 21939863].

Harmer PA: Anabolic-androgenic steroid use among young male and female athletes: is the game to blame? Br J Sports Med 2010 Jan;44(1):26–31 [PMID: 19919946].

Howland J et al: Risks of energy drinks mixed with alcohol. JAMA 2013 Jan 16;309(3):245–246 [PMID: 23330172].

Marsolek MR et al: Inhalant abuse: monitoring trends by using poison control data, 1993–2008. Pediatrics 2010 May;125(5): 906–913 [PMID: 20403928].

McCool J et al: Do parents have any influence over how young people appraise tobacco images in the media? J Adolesc Health 2011 Feb;48(2):170 [PMID: 21257116].

Sepkowitz KA: Energy drinks and caffeine-related adverse effects. JAMA 2013 Jan 16;309(3):243–244 [PMID: 23330171].

Bath Salts

Since 2010, there has been an increase in the use of a newer drug of abuse called “bath salts.” These products, which are not related to hygienic products, are also known as Vanilla Sky or Ivory Wave. The main ingredient is 4-methylene-dioxypyrovalerone, a central nervous stimulant that acts by inhibiting norepinephrine-dopaminergic reuptake. The effects of these substances are similar to those of stimulants like PCP, ecstasy, and LSD (see Tables 5–1and 5–2). Overdoses can potentially be severe and lethal. Their use increased rapidly in 2010, peaked in the first half of 2011, and declined by half in 2012. The recent decrease in use occurred due to efforts of drug enforcement agencies and media dissemination of messages about the dangers of bath salts, resulting in increased perception of risk. Additionally, they are now less easily available via the Internet. These substances cannot be detected by routine drug screen, which may complicate management in the emergency department. The 2012 Monitoring the Future survey found annual prevalence rate of use to be 1.3% among grade 12 adolescents.

Centers for Disease Control and Prevention (CDC): Emergency department visits after use of a drug sold as “bath salts”—Michigan, November 13, 2010–March 31, 2011. MMWR Morb Mortal Wkly Rep. 2011 May 20;60(19):624–627 [PMID: 21597456].

http://www.aapcc.org/alerts/bath-salts/ accessed from American Association of Poison Control Centers.

Ross EA et al: “Bath salts” intoxication. N Engl J Med 2011 Sep 8; 365(10):967–968 [PMID: 21899474].

Spiller HA et al: Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States. Clin Toxicol (Phila) 2011 Jul;49(6):499–505 [PMID: 21824061].

MORBIDITY DATA

Use and abuse of alcohol or other mood-altering substances in adolescents in the United States are tightly linked to adolescents’ leading causes of death, i.e., motor vehicle accidents, unintentional injury, homicide, and suicide. Substance abuse is also associated with physical and sexual abuse. Drug use and abuse contribute to other high-risk behaviors, such as unsafe sexual activity, unintended pregnancy, and sexually transmitted disease. Adolescents may also be involved with selling of drugs.

Risks associated with tobacco, alcohol, and cocaine are listed in Table 5–2. Less well known are the long- and short-term adolescent morbidities connected with the currently most popular illicit drugs, marijuana, and ecstasy. The active ingredient in marijuana, δ-9-tetrahydrocannabinol (THC), transiently causes tachycardia, mild hypertension, and bronchodilation. Regular use can cause lung changes similar to those seen in tobacco smokers. Heavy use decreases fertility in both sexes and impairs immunocompetence. It is also associated with abnormalities of cognition, learning, coordination, and memory. It is possible that heavy marijuana use is the cause of the so-called amotivational syndrome, characterized by inattention to environmental stimuli and impaired goal-directed thinking and behavior. Analysis of confiscated marijuana recently has shown increasing THC concentration and adulteration with other substances.

The popularity and accessibility of ecstasy is again increasing among adolescents. Chronic use is associated with progressive decline of immediate and delayed memory, and with alterations in mood, sleep, and appetite that may be permanent. Even first-time users may develop frank psychosis indistinguishable from schizophrenia. Irreversible cardiomyopathy, noncardiogenic pulmonary edema, and pulmonary hypertension may occur with long-term use. Acute overdose can cause hyperthermia and multiorgan system failure.

Prenatal and environmental exposure to abused substances also carries health risks. Parental tobacco smoking is associated with low birth weight in newborns, sudden infant death syndrome, bronchiolitis, asthma, otitis media, and fire-related injuries. Maternal use of marijuana during pregnancy is associated with an increased risk of sudden infant death syndrome. In-utero exposure to alcohol may produce fetal malformations, intrauterine growth restriction, and brain injury.

Bada HS et al: Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures. Pediatrics 2012 Dec;130(6):e1479-e1288 [PMID: 23184114].

Bailey JA: Addressing common risk and protective factors can prevent a wide range of adolescent risk behaviors. J Adolesc Health 2009 Aug;45(2):107–108 [PMID: 19628134].

Delcher C et al: Driving after drinking among young adults of different race/ethnicities in the United States: unique risk factors in early adolescence? J Adolesc Health 2013 May;52(5):584–591 [PMID: 23608720].

Frese W et al. Opioids: Nonmedical use and abuse in older children. Pediatr Rev 2011 Apr;32(4):e44-e52 [PMID: 21460089].

Grenard JL et al: Exposure to alcohol advertisements and teenage alcohol-related problems. Pediatrics 2013 Feb;131(2): e369–e379 [PMID: 23359585].

Herrick AL et al: Sex while intoxicated: a meta-analysis comparing heterosexual and sexual minority youth. J Adolesc Health 2011 Mar;48(3):306–309 [PMID: 21338904].

Hingson RW et al: Age of drinking onset, alcohol use disorders, frequent heavy drinking, and unintentionally injuring oneself and others after drinking. Pediatrics 2009;123:1477–1484 [PMID: 19482757].

McCabe SE et al: Medical misuse of controlled medications among adolescents. Arch Pediatr Adolesc Med. 2011 Aug;165(8): 729–735 [PMID: 21810634].

Walton MA et al: Sexual risk behaviors among teens at an urban emergency department: relationship with violent behaviors and substance use. J Adolesc Health 2011 Mar;48(3):303–305 [PMID: 21338903].

PREDICTING THE PROGRESSION FROM USE TO ABUSE

Initially, most adolescents use mood-altering substances intermittently or experimentally. The challenge to pediatric healthcare providers is to recognize warning signs, identify potential abusers early, and intervene in an effective fashion before acute or chronic use produces morbidity. The prediction of progression from use to abuse is best viewed within the biopsychosocial model. Substance abuse is a symptom of personal and social maladjustment as often as it is a cause. Because there is a direct relationship between the number of risk factors listed in Table 5–3 and the frequency of substance abuse, a combination of risk factors is the best indicator of risk. Even so, most teenagers with multiple risk characteristics never progress to substance abuse. It is unclear why only a minority of young people exhibiting the high-risk characteristics listed in Table 5–3 go on to abuse substances, but presumably the protective factors listed in Table 5–3 give most adolescents the resilience to cope with stress in more socially adaptive ways. Being aware of the risk domains in Table 5–3 will help physicians identify youngsters most apt to need counseling about substance abuse.

Table 5–3. Factors that influence the progression from substance use to substance abuse.

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Chartier KG et al: Development and vulnerability factors in adolescent alcohol use. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):493–504 [PMID: 20682217].

McCoy SI et al: A trajectory analysis of alcohol and marijuana use among Latino adolescents in San Francisco, California. J Adolesc Health 2010 Dec;47(6):564–574 [PMID: 21094433].

Meyers JL et al: Genetic and environmental risk factors for adolescent-onset substance use disorders. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):465–477 [PMID: 20682215].

Prado G et al: What accounts for differences in substance use among U.S.-born and immigrant Hispanic adolescents? Results from a longitudinal prospective cohort study. J Adolesc Health 2009 Aug;45(2):118–125 [PMID: 19628137].

Strachman A et al: Early adolescent alcohol use and sexual experience by emerging adulthood: a 10-year longitudinal investigation. J Adolesc Health 2009 Nov;45(5):478–482 [PMID: 19837354].

Sutfin EL et al: Protective behaviors and high-risk drinking among entering college freshmen. Am J Health Behav 2009;33:610–619 [PMID: 19296751].

Tobler AL et al: Trajectories or parental monitoring and communication and effects on drug use among urban young adolescents. J Adolesc Health 2010 Jun;46(6):560–568 [PMID: 20472213].

EVALUATION OF SUBSTANCE ABUSE

Office Screening

The AAP Committee on Substance Abuse recommends that pediatricians include discussions of substance abuse as part of their anticipatory care. This should include screening for substance abuse with parents at the first prenatal visit. Given the high incidence of substance abuse and the subtlety of its early signs and symptoms, a general psychosocial assessment is the best way to screen for substance abuse among adolescents. The universal screening approach outlined in the American Medical Association (AMA) Guidelines for Adolescent Preventive Services (GAPS) is a good guide for routine screening and diagnosis. Interviewing and counseling techniques and methods for taking a psychosocial history are discussed in Chapter 4. In an atmosphere of trust and confidentiality, physicians should ask routine screening questions of all patients and be alert for addictive diseases, recognizing the high level of denial often present in addicted patients. Clues to possible substance abuse include truancy, failing grades, problems with interpersonal relationships, delinquency, depressive affect, chronic fatigue, recurrent abdominal pain, chest pains or palpitations, headache, chronic cough, persistent nasal discharge, and recurrent complaints of sore throat. Substance abuse should be included in the differential diagnosis of all behavioral, family, psychosocial, and medical problems. A family history of drug addiction or abuse should raise the level of concern about drug abuse in the pediatric patient. Possession of promotional products such as T-shirts and caps with cigarette or alcohol logos should also be a red flag because teenagers who own these items are more likely to use the products they advertise. Pediatricians seeing patients in emergency departments, trauma units, or prison should have an especially high index of suspicion.

In the primary care setting, insufficient time and lack of training are the greatest barriers to screening adolescents for substance abuse. Brief questionnaires can be used if time does not allow for more detailed investigation. A screening instrument that has been rigorously studied in primary care settings is the CAGE questionnaire. CAGE is a mnemonic derived from the first four questions that asks the patient questions regarding their substance use. These are their need to reduce it, annoyance if asked about it, feeling guilty about the use, and the need of the drug/alcohol as an eye opener. A score of 2 or more is highly suggestive of substance abuse. Although constructed as a screening tool for alcohol abuse in adults, the CAGE questionnaire can be adapted to elicit information about use of other mood-altering substances by pediatric patients and their close contacts (eg, parents and older siblings). Clinicians may find it helpful to use such questionnaires to stimulate discussion of the patient’s self-perception of his or her substance use. For example, if an adolescent admits to a previous attempt to cut down on drinking, this provides an opportunity to inquire about events that may have led to the attempt. Unfortunately, despite guidance to screen adolescents for substance abuse, recent studies demonstrate that clinicians do not regularly ask/advise adolescents about substance use.

Chung T et al: Drinking frequency as a brief screen for adolescent alcohol problems. Pediatrics 2012 Feb;129(2):205–212 [PMID: 22218839].

Ewing JA: Detecting alcoholism. The CAGE questionnaire. JAMA 1984 Oct;252(14):1905–1907 [PMID: 6471323].

Hassan A et al: Primary care follow-up plans for adolescents with substance use problems. Pediatrics 2009;124:144–150 [PMID: 19564294].

Hingson RW et al: Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol. J Gen Intern Med 2012 Feb;27(2):179–184 [PMID: 21935753].

Hingson RW et al: Physician advice to adolescents about drinking and other health behaviors. Pediatrics 2013 Feb;131(2):249–257 [PMID: 23359580].

Kokotailo B: Alcohol use by youth and adolescents: a pediatric concern. Pediatrics 2010 May;125(5):1078–1087 [PMID: 20385640].

Sims TH: Committee on Substance Abuse. From the American Academy of Pediatrics: technical report—tobacco as a substance of abuse. Pediatrics 2009 Nov;124(5):e1045–e1053 [PMID: 19841120].

Strasburger VC: Policy statement—children, adolescents, substance abuse, and the media. Pediatrics 2010 Oct;126(4): 791–799 [PMID: 20876181].

Diagnosis

When the psychosocial history suggests the possibility of substance use, the primary tasks of the diagnostic interview are the same as for the evaluation of other medical problems (Table 5–4).

Table 5–4. Evaluation of positive psychosocial screens for substance abuse.

I. Define the extent of the problem by determining:

Age at onset of substance use

Which substances are being used

Circumstances of use

Where?

When?

With whom?

To what extent substances are being used

How frequently?

How much (quantity)?

With what associated symptoms (eg, tolerance, withdrawal)?

With what result?

What does the patient gain from becoming high?

Does the patient get into risky situations while high?

Does the patient engage in behaviors while high that are later regretted?

II. Define the cause of the problem

First, specific information about the extent and circumstances of the problem is gathered. Eliciting information through multiple-choice questions is a useful technique. For example, “Has anything really good ever happened to you when you are high? Some of my patients like to get high because they feel good; others find it helps them relax and be sociable with friends; and some find it helps them forget their problems. Are any of these things true for you?”

Second, the provider should determine why the patient has progressed from initiation to the continuation or maintenance phase of substance abuse. The cause may be different at different periods of development. Although peer group characteristics are one of the best predictors of substance use among early and middle adolescents, this is not so among older adolescents and young adults.

Although few children and adolescents will have been abusing substances long enough to have developed overt signs and symptoms, it is important to look for them on physical examination. Positive physical findings can be a tool to penetrate a patient’s denial and convince him or her of the significance of alcohol or drug use.

Griffin KW et al: Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):505–526 [PMID: 20682218].

Van Hook S et al: The “Six T’s”: barriers to screening teens for substance abuse in primary care. J Adolesc Health 2007;40:456 [PMID: 17448404].

Comorbidity

Comorbidities, especially other psychiatric disorders, are common among substance-abusing patients (Table 5–5). Affective disorder, anxiety disorder, and mania are most strongly associated with alcohol and drug dependence. Attention-deficit/hyperactivity has also been closely linked with adolescent substance abuse. Adolescents with depression are likely to use drugs in an attempt to feel pleasure, but this type of self-medication may exacerbate their underlying condition. Although it is often difficult to determine which diagnosis is primary, it is important for pediatric healthcare providers to recognize the possibility of a comorbid condition and provide appropriate treatment. Finally, in addition to identifying psychiatric comorbidities, it is imperative that providers look for medical conditions that mimic symptoms of drug withdrawal or intoxication.

Table 5–5. Common comorbid conditions associated with adolescent substance abuse.

1. Attention-deficit/hyperactivity disorder

2. Bipolar disorder

3. Depression disorder

4. Anxiety disorders (often with depressive disorders)

Bukstein OG et al: Management of the adolescent with substance use disorders and comorbid psychopathology. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):609–623 [PMID: 20682224].

Burnett-Zeigler I et al: Prevalence and correlates of mental health problems and treatment among adolescents seen in primary care. J Adolesc Health 2012 Jun;50(6):559–564 [PMID: 22626481].

Tamm L et al: Predictors of treatment response in adolescents with comorbid substance use disorder and attention-deficit/hyperactivity disorder. J Subst Abuse Treat 2013 Feb;44(2):224–230 [PMID: 22889694].

Warden D et al: Major depression and treatment response in adolescents with ADHD and substance use disorder. Drug Alcohol Depend 2012 Jan 1;120(1–3):214–219 [PMID: 21885210].

Pharmacologic Screening

The use of urine and blood testing for detecting substance abuse is controversial. The consensus is that pharmacologic screening should be reserved for situations in which behavioral dysfunction is of sufficient concern to outweigh the practical and ethical drawbacks of testing. The AAP recommends testing under certain circumstances (eg, an inexplicably obtunded patient in the emergency department), but discourages routine screening for the following reasons: (1) voluntary screening is rarely truly voluntary owing to the negative consequences for those who decline to participate; (2) infrequent users or individuals who have not used substances recently may be missed; (3) confronting substance-abusing individuals with objective evidence of their use has little or no effect on behavior; and (4) the role of healthcare providers is to provide counseling and treatment, not law enforcement, so drug testing should not be done for the purpose of detecting illegal use. If testing is to be performed, the provider should discuss the plan for screening with the patient, explain the reasons for it, and obtain informed consent. The AAP does not consider parental request and permission sufficient justification for involuntary screening of mentally competent minors.

If testing is to be performed, it is imperative that it be done accurately and that the limitations of testing be understood. Tests range from inexpensive chromatographic spot tests, which can be performed in the office, to gas chromatography and mass spectrometry, which require specialized laboratory equipment and are usually reserved for forensic investigations. Most commercial medical laboratories use the enzyme multiplication immunoassay technique, in which a sample of the fluid to be tested is added to a test reagent containing a known quantity of radiolabeled index drug. If the index drug is present in the patient’s urine or serum, it competes with the radiolabeled drug for binding sites on the test kit antibody. The unbound or excess drug can then be quantified with a spectrophotometer. Most of the commonly abused mood-altering substances, with the exception of solvents and inhalants, can be detected by this method.

Interpretation of results is complicated by false-positives resulting from antibody cross-reactions with some medications and substances (Table 5–6) or from a patient’s passive exposure to illicit substances. The most common cause of false-negative tests is infrequent use. Table 5–7 shows the duration of detectability in the urine after last use by class of substance and duration of use. Detectability ranges from a few hours for alcohol to several weeks for regular marijuana use. False-negative results can also occur if the patient alters or adulterates the test specimen. Some of the commercial products used to adulterate samples include glutaraldehyde, nitrite, pyridinium chlorochromate, peroxidase, and peroxide (stealth). Household products such as bleach, vinegar, Visine® eye drops (for marijuana), strong alkali drain cleaners, and detergents are also used. Teenagers should be advised that, despite street lore, ingesting these compounds is an ineffective and potentially dangerous way to prevent drug detection in the urine. Close observation during collection and testing the temperature, specific gravity, and pH of urine samples may detect attempts at deception.

Table 5–6. Causes of false-positive drug screens.

Opioids

Poppy seeds

Dextromethorphan

Chlorpromazine

Diphenoxylate

Amphetamines

Ephedrine

Phenylephrine

Pseudoephedrine

N-acetylprocainamide

Chloroquine

Procainamide

Phencyclidines

Dextromethorphan

Diphenhydramine

Chlorpromazine

Doxylamine

Thioridazine

Table 5–7. Duration of urine positivity for selected drugs.

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Home drug-testing products are available for parents and can be procured via the Internet; however, these products have limitations and potential risks. The AAP recommends that home and school-based drug testing not be implemented until the safety and efficacy of these procedures can be established. It further recommends that parents be encouraged to consult the adolescent’s primary care provider rather than relying on home drug-testing products.

Committee on Substance Abuse, American Academy of Pediatrics; Council on School Health, American Academy of Pediatrics, Knight JR, Mears CJ: Testing for drugs of abuse in children and adolescents: addendum—testing in schools and at home. Pediatrics 2007;119:627 [PMID: 17332219].

Goldberg L et al: Outcomes of a prospective trial of student-athlete drug testing: The Student Athlete Testing Using Random Notification (SATURN) study. J Adolesc Health 2007;41: 421–429 [PMID: 17950161].

Jaffee WB et al: Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing. J Subst Abuse Treat 2007;33:33 [PMID: 17588487].

James-Burdumy S et al: The effectiveness of mandatory-random student drug testing: a cluster randomized trial. J Adolesc Health 2012 Feb;50(2):172–178 [PMID: 22265113].

Levy S et al: Acceptability of drug testing in an outpatient substance abuse program for adolescents. J Adolesc Health 2011 Mar;48(3):229–233 [PMID: 21338892].

TREATMENT & REFERRAL

Office-Based Treatment

The AMA and the AAP recommend that all children and adolescents receive counseling about the dangers of substance use and abuse from their primary care providers. By offering confidential healthcare services and routinely counseling about the risks associated with drug abuse, primary care providers can help most patients avoid the adverse consequences of experimentation with mood-altering substances. However, more intervention is required for youngsters in environments where substance abuse is regarded as acceptable recreational behavior. Counseling strategies appropriate for patients who wish to change their behavior may be ineffective for patients who do not consider use of mood-altering substances to be a problem. It may therefore be preferable to begin discussions about treatment by helping youngsters consider alternative ways of meeting the needs that substance use is currently addressing. The clinician in this way may help the patient devise alternatives that are more attractive than substance use. Brief interventions for adolescents have yielded some improvement among high-risk youth. However, few substance-abusing teenagers will choose to quit because of a single conversation, even with a highly respected healthcare provider. The message is most effective when offered repeatedly from many sources—family, peers, guidance counselors, and teachers. Motivational interviewing and computer-facilitated screening and brief advice for substance-abusing teens have shown promise.

Assessment of the patient’s readiness to change is a critical first step in office-based intervention. Clinicians should consider the construct presented in Table 5–8. In theory, individuals pass through this series of stages in the course of changing problem behaviors. To be maximally effective, providers should tailor their counseling messages to the patient’s stage of readiness to change.

Table 5–8. Stages of change and intervention tasks.

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Once it has been established that a patient is prepared to act on information about treatment, the next step is to select the program that best fits his or her individual needs. Most drug treatment programs are not designed to recognize and act on the individual vulnerabilities that have predisposed the patient to substance abuse. When programs are individualized, even brief (5- to 10-minute) counseling sessions may promote reductions in cigarette smoking and drinking. This strategy appears to be most effective when the healthcare provider’s message is part of an office-wide program so that the entire staff reinforces the cessation message with every patient.

Garner BR et al: Using pay for performance to improve treatment implementation for adolescent substance use disorders: results from a cluster randomized trial. Arch Pediatr Adolesc Med 2012 Oct;166(10):938–944 [PMID: 22893231].

Harris SK et al: Computer-facilitated substance use screening and brief advice for teens in primary care: an international trial. Pediatrics 2012 Jun;129(6):1072–1082 [PMID: 22566420].

Heinzerling KG et al: Pilot randomized trial of bupropion for adolescent methamphetamine abuse/dependence. J Adolesc Health 2013 Apr;52(4):502–505 [PMID: 23333007].

Kaplan G et al: Pharmacotherapy for substance abuse disorders in adolescence. Pediatr Clin North Am 2011 Feb;58(1):243–258 [PMID: 21281859].

Molina BS et al: Adolescent substance use in the multimodal treatment study of Attention-Deficit/Hyperactivity Disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry 2013 Mar;52(3): 250–263 [PMID: 23452682].

Smoking Cessation in Pediatrics

Although more than half of adolescents who smoke regularly say they want to quit and have tried to quit, only a minority report that they have been advised or helped to do so by a healthcare provider. Practitioners unfamiliar with approaches to smoking cessation may feel that smoking cessation interventions are time consuming, not reimbursable, and impractical in a busy office. An easy guideline for healthcare providers is the “five A’s” for tobacco cessation (Table 5–9), published by the Public Health Service and endorsed by the AAP.

Table 5–9. “Five A’s” for tobacco cessation.

Ask about tobacco use from all patients

Advise all tobacco users to quit

Assess willingness and motivation for tobacco user to make a quit attempt

Assist in the quit attempt

Arrange for follow-up

Adapted from Fiore MC et al: Treating Tobacco Use and Dependence. Clinical Practice Guidelines. U.S. Department of Health and Human Services, Public Health Service; 2000.

Smoking cessation is a process that takes time. Relapse must be regarded as a normal part of quitting rather than evidence of personal failure or a reason to forgo further attempts. Patients can actually benefit from relapses if they are helped to identify the circumstances that led to the relapse and to devise strategies to prevent subsequent relapses or respond to predisposing circumstances in a different manner.

Nicotine is a physically and psychologically addictive substance. Providers should be aware that adolescents may not exhibit the same symptoms of nicotine dependence as adults and that dependence may be established within as little as 4 weeks. Replacement therapy improves smoking cessation rates and may relieve withdrawal symptoms. Both nicotine gum and transdermal nicotine patch replacement therapies are recommended for teens. Those who are not comfortable prescribing and monitoring nicotine-replacement therapies should limit their involvement with patients who smoke to those who do not exhibit signs of nicotine dependency (eg, patients who smoke less than a pack of cigarettes a day or do not feel a craving to smoke their first cigarette within 30 minutes after waking). Patients who exhibit nicotine dependency can be referred to community smoking cessation programs, including “smoking quit lines.” In addition to nicotine-replacement therapies, sustained-release forms of the antidepressants bupropion, clonidine, and nortriptyline have been shown in randomized trials to help smokers quit and to decrease relapse rates fivefold.

DiFranza JR: Who are you going to believe? Adolescents and nicotine addiction. J Adolesc Health 2011 Jan;48(1):1–2 [PMID: 21185515].

Doubeni CA et al: Early course of nicotine dependence in adolescent smokers. Pediatrics 2010 Jun;125(6):1127–1133 [PMID: 20439592].

Hanewinkel R et al: Cigarette advertising and teen smoking initiation. Pediatrics 2011 Feb;127(2):e271–e278 [PMID: 21242217].

Lessov-Schlaggar CN et al: Sensitivity to secondhand smoke exposure predicts future smoking susceptibility. Pediatrics 2011 Aug;128(2):254–262 [PMID: 21746728].

Rubinstein ML et al: Smoking-related cue-induced brain activation in adolescent light smokers. J Adolesc Health 2011 Jan;48(1):7–12 [PMID: 21185518].

Referral

There is no consensus about which substance-abusing patients can be adequately treated in the office, which require referral, and which require hospitalization. Factors to be considered prior to referral are summarized in Table 5–10. When doubt exists about the seriousness of the problem or the advisability of office management, consultation with a specialist should be sought.

Table 5–10. Factors to consider prior to referral for substance abuse.

Duration and frequency of substance use

The type of substances being used

Presence of other psychological disorders

Attention-deficit/hyperactivity disorder

Depression

Antisocial personality disorder

Presence of other social morbidities

School failure

Delinquency

Homelessness

Ongoing or past physical or sexual abuse

Program evaluation

View on substance abuse as primary disorder vs symptom

Offers comprehensive evaluation of patient and can manage associated problems identified in initial assessment (eg, comorbid conditions)

Adherence to abstinence philosophy

Patient-staff ratios

Separate adolescent and adult treatment programs

Follow-up and continuing care

Although most primary pediatric providers will not assume responsibility for the treatment of substance-abusing youngsters, clinicians can be instrumental in motivating patients to seek treatment and in guiding them to appropriate treatment resources. Substance-abusing teenagers are best treated in teen-oriented treatment facilities. Despite the similarities between adult and adolescent substance abuse, adult programs are usually developmentally inappropriate and ineffective for adolescents. Many adolescents are concrete thinkers and their inability to reason deductively, especially about emotionally charged issues, makes it difficult for them to understand the abstract concepts (such as denial) that are an integral component of most adult-oriented programs. This invariably frustrates counselors who misinterpret lack of comprehension as resistance to therapy and concrete responses as evidence of deceit.

Treatment programs range from low-intensity, outpatient, school-based student-assistance programs, which rely heavily on peers and nonprofessionals, to residential, hospital-based programs staffed by psychiatrists and other professionals. Outpatient counseling programs are most appropriate for motivated patients who do not have significant mental health or behavioral problems and are not at risk for withdrawal. Some investigators have raised the concern that in pediatric settings, users who lack significant mental health or behavioral comorbidities may actually experience a strengthening of the drug subculture by associating in group therapy with users who have a greater burden of comorbidities. More intensive day treatment programs are available for those who require a structured environment. Inpatient treatment should be considered for patients who need medical care and detoxification in addition to counseling, education, and family therapy.

Finally, special dual-diagnosis facilities are available for substance-abusing patients who also have other psychological conditions. These patients are difficult to diagnose and treat because it is often unclear whether their symptoms are a consequence of substance use or a symptom of a comorbid psychological disorder. Recognition of such disorders is critical because they must be treated in programs that include psychiatric expertise.

Approaches to the treatment of substance abuse in children and adolescents are typically modeled after adult treatment programs. Key elements of an effective adolescent drug treatment program include: assessment and treatment matching, a comprehensive and integrated treatment approach, family involvement, a developmentally appropriate program, engagement and retention of teens, qualified staff, gender and cultural competence, continuing care, and satisfactory treatment outcomes. Several studies of adolescent substance abuse treatment programs have shown that many do not adequately address all of the important components of therapy.

Fang L et al: Preventing substance use among early Asian-American adolescent girls: initial evaluation of a web-based, mother-daughter program. J Adolesc Health 2010 Nov;47(5):529–532 [PMID: 20970090].

Kaminer Y et al: From assessment reactivity to aftercare for adolescent substance abuse: are we there yet? Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):577–590 [PMID: 20682222].

Macgowan MJ et al: Evidence for optimism: behavior therapies and motivational interviewing in adolescent substance abuse treatment. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):527–545 [PMID: 20682219].

Rowe CL: Multidimensional family therapy: addressing co-occurring substance abuse and other problems among adolescents with comprehensive family-based treatment. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):563–576 [PMID: 20682221].

Stanger C et al: Contingency management approaches for adolescent substance use disorders. Child Adolesc Psychiatr Clin N Am 2010 Jul;19(3):547–562 [PMID: 20682220].

Tripodi SJ et al: Interventions for reducing adolescent alcohol abuse: a meta-analytic review. Arch Pediatr Adolesc Med 2010 Jan;164(1):85–91 [PMID: 20048247].

Williams JF: Adolescent substance abuse and treatment acceptability. J Adolesc Health 2011 Mar;48(3):217–219 [PMID: 21338890].

PREVENTION

Prevention of substance abuse has been a public health priority since the 1980s. Pediatric healthcare providers are important advocates and educators of the community and government on developmentally appropriate programs. Primary level programs focus on preventing the initiation of substance use. The Drug Awareness and Resistance Education (DARE) program is a familiar example of a primary prevention program that attempts to educate elementary and middle school students about the adverse consequences of substance abuse and enable them to resist peer pressures.

Secondary level programs target populations at increased risk for substance use. Their aim is to prevent progression from initiation to continuance and maintenance, relying on individualized intervention to reduce the risk and enhance protective factors listed in Table 5–3. This approach enables the provider to focus scarce resources on those who are most likely to benefit from them. Alateen, which supports the children of alcoholic parents, typifies secondary level prevention.

Tertiary level prevention programs target young people who have been identified as substance abusers. Their aim is to prevent the morbid consequences of substance use. One example is the identification of adolescents who misuse alcohol and drugs at parties and providing them with a safe ride home. Because prevention is more effective when targeted at reducing the initiation of substance use than at decreasing use or associated morbidity, tertiary prevention is the least effective approach.

Very few population-based programs undergo rigorous scientific evaluation, and few programs have been shown to be effective. Although tertiary prevention programs are the least effective approach, it is the consensus among drug educators that primary prevention programs, such as D.A.R.E., also have limited effect. Parents and others should understand that most adolescents who abuse alcohol and drugs do not do so just for the high. Rather, these behaviors are often purposeful, developmentally appropriate coping strategies. To the extent that these behaviors meet young peoples’ developmental needs, they are not apt to be abandoned unless equally attractive alternatives are available. For example, even though many teenagers cite stress and anxiety as reasons for smoking, teen-oriented smoking cessation programs rarely address the young smoker’s need for alternative coping strategies by offering stress management training. Similarly, for the youngster growing up in an impoverished urban environment, the real costs of substance abuse may be too low and the rewards too high to be influenced by talk and knowledge alone. It is unreasonable to expect a talk-based intervention to change attitudes and behaviors in a direction that is opposite to that of the child’s own social milieu. The efficacy of the most promising prevention models and interventions is apt to decay over time unless changes in the social environment provide substance-abusing children and adolescents with realistic alternative ways to meet their developmental needs.

Ellickson PL et al: Long-term effects of drug prevention on risky sexual behavior among young adults. J Adolesc Health 2009;45:111–117 [PMID: 19628136].

Feinstein EC et al: Addressing the critical health problem of adolescent substance use through health care, research, and public policy. J Adolesc Health 2012 May;50(5):431–436 [PMID: 22525104].

Schinke SP et al: Longitudinal outcomes of an alcohol abuse prevention program for urban adolescents. J Adolesc Health 2010 May;46(5):451–457 [PMID: 20413081].