Key points

Introduction

Knowing how to manage substance abuse in all youth is an important aspect of pediatric care, including providing clinically appropriate anticipatory guidance, monitoring, assessment, and treatment. Although most lesbian, gay, bisexual, and transgender (LGBT) youth do not abuse substances, as a group they experience unique challenges in self-identity development that put them at somewhat of an increased risk for substance abuse. This article addresses the prevention and management of substance use in LGBT youth relevant to clinical practice in pediatrics and allied professions as an aspect of their overall health care. It reviews basic information about substance abuse in youth and discusses special considerations relevant to LGBT youth.

Introduction

Knowing how to manage substance abuse in all youth is an important aspect of pediatric care, including providing clinically appropriate anticipatory guidance, monitoring, assessment, and treatment. Although most lesbian, gay, bisexual, and transgender (LGBT) youth do not abuse substances, as a group they experience unique challenges in self-identity development that put them at somewhat of an increased risk for substance abuse. This article addresses the prevention and management of substance use in LGBT youth relevant to clinical practice in pediatrics and allied professions as an aspect of their overall health care. It reviews basic information about substance abuse in youth and discusses special considerations relevant to LGBT youth.

Epidemiology

A number of national epidemiologic surveys monitor substance use among youth in the United States (available: www.monitoringthefuture.org ); the National Survey on Drug Use and Health (available: https://nsduhweb.rti.org/ ); the Youth Risk Behavior Surveillance System: biennial Centers for Disease Control Survey (available: www.cdc.gov/healthyyouth/yrbs/index.htm ), although these have not monitored routinely in LGBT youth specifically. The epidemiology of drug use among LGBT youth needs to be studied further. Dimensions on sexual orientation (sexual identity, sexual attraction, and sexual behavior) should be incorporated as each confers differential drug use profile. Subsequent trends can then be followed meaningfully and contrasted with heterosexual youth.

However, some data do exist on the epidemiology of substance use among this group. A community-based cohort of US adolescents were surveyed from 1999 to 2005 looking at whether minority sexual orientation is a risk for drug use. Respondents whose sexual orientation was mostly heterosexual, bisexual, or lesbian/gay were more likely than completely heterosexual youth to report past-year illicit drug use and misuse of prescription drugs. Further, bisexual females were most likely to report use. Age was also considered significant with larger use during adolescence compared with early adulthood. In this study, the prevalence of drug use was much higher when compared with respondents in the 2002 National Survey of Drug Use and Health. Marijuana is the most prevalent drug of abuse. Other studies replicated these results. Drug use has been found to accelerate more quickly over time among LGBT youth compared with heterosexual youth. There is also increased prevalence of methamphetamine and alcohol use and binge drinking among young men who have sex with men.

Neurobiology of drug abuse

Substance abuse is related to activity in specific brain regions. This includes a “reward circuit” of dopaminergic neurons in the ventral tegmental area that communicate to the nucleus accumbens, which then communicates to the cortex. Drugs of abuse are active in these brain regions, either mimicking the effects neurotransmitters (eg, heroin and lysergic acid diethylamide), blocking transmission (eg, phencyclidine), blocking synaptic reuptake (eg, cocaine) with net increase in presynaptic cells, or increasing release of neurotransmitters (methamphetamine).

Although biologically mediated, drug-seeking behavior is best understood in the context of its environment. Understanding that drug use or relapse can be triggered by environmental cues that precede use is key in identifying high-risk situations and learning new coping skills through alternative, non–drug-seeking behaviors.

Gateway drugs

The gateway hypothesis posits that tobacco or alcohol use sets the stage for subsequent marijuana and other illicit drug use. Consistent with this hypothesis, younger onset and increased frequency of use predict progression. In an animal model, nicotine potentiates subsequent cocaine exposure involving the amygdala, one of the structures implicated in drug use. Below is information on substances that are more likely to be used by LGBT youth and hypothesized to act as gateway drugs.

Psychiatric comorbidity

Many youth with substance abuse problems also have other, cooccurring psychiatric diagnoses (“comorbidity”). For example, the National Comorbidity Survey used a structured diagnostic interview in a representative sample to assess the prevalence and correlates of psychiatric disorders. A subgroup of adolescents, the National Comorbidity Survey—Adolescents (n = 10,000) had a median age of onset of 15 years for substance use. Having a substance use disorder was associated with an increased likelihood of developing a subsequent mood disorder such as major depressive disorder. This underscores the importance of simultaneously addressing all mental health needs in youth with or at risk for substance abuse (see Stewart Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue).

Substance use is also related to other high-risk behaviors that may increase morbidity and mortality, and place youth’s physical health at risk. For example, one study found that LGBT youth reported higher drug use, increased high-risk sexual behaviors, and increased suicidal thoughts or attempts compared with heterosexual youth. Among youth ages 13 to 24 years, young gay and bisexual men accounted for an estimated 19% (8800) of all new HIV infections in the United States, and 72% of new HIV infections among youth in 2010, underscoring the importance of HIV prevention among this group, including addressing any substance abuse.

Substance abuse prevention

Preventive strategies are already incorporated into general pediatric care settings as part of overall health promotion: health maintenance, nutrition, and sober lifestyle with engagement of the youth and the family in the dialogue during each visit. These can serve to reinforce what may already been offered at school. More focused are training in social skills, communication and assertiveness, anger management, problem-solving skills to more specific areas that are substance focused, and needing referrals (psychoeducation on drug use, its consequences to individual and to the families, refusal skills and like) when abuse is already considered. In some programs, elements are implemented over several years. Programs are needed for LGBT youth that address specific risk factors and issues that affect them, and are conducted in a safe and supportive way. However, even in programs not specifically designed for LGBT youth, facilitators can and should be nonjudgmental, caring, empathic and inclusive, consistent with standard mental health practice principles (see Stewart Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue). Additionally, programs like straight and gay alliances may enhance the inclusion of LGBT youth in general community programs. Structured substance abuse prevention programs are often deployed in schools and other community organizations and agencies. Clinicians should be familiar with programs and resources in their communities and be ready to refer youth at risk or otherwise in need of these.

Screening for substance abuse

As with all health and mental health issues, medical professionals should provide a welcoming and nonjudgmental environment (see Scott E. Hadland and colleagues’ article, “ Caring for LGBTQ Youth in Inclusive and Affirmative Environments ”; and Stewart Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue) in assessing substance use in LGBT youth. In addition to resources referenced throughout this volume, standard professional education curricula for medical, nursing and paramedical staff include training to help them achieve clinical and cultural competence. Parents of sexual minority youth increasingly look for such providers to meet their child’s needs. This approach should be used in eliciting information about drug use as part of routine history taking, in support of a drug-free lifestyle as a part of overall wellness. Few clinic settings provide a full continuum of substance abuse services from screening to active substance abuse treatment. However, screening should be done routinely, and serves to identify those who are abusing substances and in need of treatment, as well as those at risk and possibly benefiting from preventive services.

Along with screening, triaging is necessary to identify any acute safety issues that warrant immediate attention. Examples include intoxications states with changes in mentation or disorientation (cannabis, hallucinogens/psychedelic drugs, inhalants); with prominent agitation/aggression with or without changes in mentation or disorientation (phencyclidine, K2, bath salts); with prominent psychiatric symptoms of hallucinations (cannabis, hallucinogens/psychedelic drugs, phencyclidine); and withdrawal states complicated by suicidal depression (cocaine withdrawal, dextromethorphan).

History from both patients and collateral informants can help the clinician assess the need for further medical intervention, including emergency room evaluation.

As a useful screening tool in some settings, clinicians can consider using an evidenced based screening tool for adolescents known as the “CRAFFT” questionnaire), an acronym for the following 6 questions :

• 
  

  C —Have you ever ridden in a car driven by someone (including yourself) who was “high” or has been using alcohol or drugs?

  
  
• 
  

  R —Do you use alcohol or drugs to feel relax , feel better about yourself, or fit in?

  
  
• 
  

  A —Do you ever use alcohol or drugs while alone [modified for LGBT youth to: when you feel different or alone]?

  
  
• 
  

  F —Do you forget things you did while using alcohol or drugs?

  
  
• 
  

  F —Do your family members and friends ever tell you that you should cut down on your drinking or drug use?

  
  
• 
  

  T —Have you gotten into trouble while you were using drugs or alcohol?

Although this tool has not been studied in or specifically modified for LGBT youth, it has been reliably used among inpatients and level 1 pediatric trauma settings. A computer version has been found to gather information reliably, and may be a tool to improve office practice efficiency in appropriate settings. Any 2 or more positive response to these questions is indicative of a likely substance use problem in keeping with current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 classification.

Another screening instrument, the Alcohol Use Disorders Identification Test (AUDIT), has been used in randomized controlled trials of adolescent screening, referral and treatment. The domains include alcohol use (frequency and amount), dependence symptoms (loss of control and withdrawal), and harmful consequences. CRAFFT and AUDIT (with a threshold of 8 for responders over the age of 18 and 3 for those younger than 18) have good psychometric predictive values, and are therefore preferable as structured screening instruments with youth, compared with “CAGE” ( Cut down —Have you ever felt you needed to cut down on your drinking? Annoyed —Have people annoyed you by criticizing your drinking? Guilty —Have you ever felt guilty about drinking? Eye-opener —Have you ever felt you needed a drink first thing in the morning [ eye opener ] to steady your nerves or get rid of a hangover?) with poor specificity and sensitivity in underage drinkers.

These self-report tools have been found to be reliable and valid in majority of adolescents. Nevertheless, a subset of adolescents in drug clinics and school settings will deny or minimize their use and collaborative information and objective drug screens can be helpful to support diagnosis and document sobriety.

Diagnosis of substance abuse

In some primary care settings, substance abuse screening will be followed by referral to a mental health or substance use specialist for a full diagnostic evaluation and targeted substance use treatment. In other cases, substance abuse treatment will be integrated with other aspects of pediatric care. Because treatment settings and community resources vary widely, clinicians should plan for the particular needs of LGBT youth, keeping in mind the welcoming health care and mental health principles (see Scott E. Hadland and colleagues’ article, “ Caring for LGBTQ Youth in Inclusive and Affirmative Environments ”; and Stewart Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue), in familiarizing themselves with available resources and appropriate referral through the continuum of care. The following is an overview of substance abuse evaluation.

The DSM-5 Criteria for Substance use Disorder are given below.

• A.
  

  Problematic pattern of use leading to clinically significant impairment or distress, manifested by at least 2 of the following:

  
  
  
  
  • 1.
    

    Often taken in larger amounts or over a longer period than was intended.

    
    
  • 2.
    

    Persistent desire or unsuccessful efforts to cut down or control use.

    
    
  • 3.
    

    A great deal of time is spent in activities necessary to obtain (drug), use (drug), or recover from its effects.

    
    
  • 4.
    

    Craving, or strong desire to use (drug).

    
    
  • 5.
    

    Recurrent (drug) use resulting in failure to fulfill major role obligations at work, school, or home.

    
    
  • 6.
    

    Continued (drug use) despite having persistent or recurrent social or interpersonal problems caused by the effects of (drug).

    
    
  • 7.
    

    Important social, occupational, or recreational activities are given up or reduced because of (drug) use.

    
    
  • 8.
    

    Recurrent (drug) use in situations in which it is physically hazardous.

    
    
  • 9.
    

    (Drug) use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by (drug).

    
    
  • 10.
    

    Tolerance to either of the following:

    
    
    
    
    • •
      

      A need for markedly increased amounts of alcohol to achieve intoxication or desired effects.

      
      
    • •
      

      Markedly diminished effect with continued use of the same amount of alcohol.

    
    
    
    
  • 11.
    

    Withdrawal, as manifested by either of the following:

    
    
    
    
    • •
      

      The characteristic withdrawal syndrome for (drug).

      
      
    • •
      

      (Drug, or a closely related substance), is taken to relieve or avoid withdrawal symptoms.

    
    

  
  

In addition to the DSM-5 criteria, important aspects of diagnosing substance use involves being mindful of special principles relevant to youth in general and LGBT youth in particular. To assess the problem clearly, it is useful to do a functional assessment of drug use, eliciting a thorough inventory for each drug of abuse on the following:

• •
  

  Last use, amount, route: to address at the outset the potential for life-threatening withdrawal symptoms (particularly for alcohol, benzodiazepines, and cocaine).

  
  
• •
  

  Onset.

  
  
• •
  

  Context and progression of use; triggers.

  
  
• •
  

  Current amount, frequency (contrasting with past use).

  
  
• •
  

  Positive and negative consequences of drug use.

  
  
• •
  

  Polydrug use (as drugs as commonly used in combination, such as marijuana and nicotine [to boost the high], cocaine and benzodiazepines (drugs that complement each effects to achieve an even high), cocaine and alcohol.

  
  
• •
  

  Periods of sobriety and what supports it.

  
  
• •
  

  Treatment history: of different levels of care (outpatient, intensive outpatient, day program, inpatient detox, rehab, long-term residential halfway houses, etc.); use of medications specific for substance of abuse (to include methadone, buprenorphine, naltrexone, acamprosate, disulfiram); 12 steps, rational recovery, Relapse Prevention; dual diagnosis (substance abuse and psychiatric disorders)

This functional assessment is to establish the presence of substance use disorder using the DSM-5.

Confidentiality

Confidentiality is an important clinical consideration with adolescents, and is particularly so with sexual and gender minority youth (see Scott E. Hadland and colleagues’ article, “ Caring for LGBTQ Youth in Inclusive and Affirmative Environments ”; and Stewart Adelson and colleagues’ article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue). Owing to the special issues faced by them in establishing trust in the clinical alliance, issues related to identity disclosure, and possible alienation from peers, family, or other supports, it is important to consider these matters tactfully and to weigh carefully the overall benefits and risks of disclosure in supporting sobriety, safety issues (including adverse physical and medical consequences), and methods of monitoring and involving family, who are often important treatment allies. In many cases, adolescents will agree to share clinical information and treatment with significant others, and family therapy can be an integral part treatment in addition to individual therapy. However, for LGBT youth who are nondisclosed, who are unsure of their identity, or have concerns about adverse family or peer reactions to issues of sexual orientation or gender that cannot be disentangled from substance use issues, the clinician must weigh these factors carefully in the treatment plan, bearing in mind the ethical and legal guidelines regarding privileges of confidentiality. In some cases, it may be useful to obtain expert consultation on these. For patients who have entrenched drug use problems and poor insight or motivation for seeking care, leverage for treatment from external sources, such as protective agencies, Youth Service Bureaus, case managers, or probation may be necessary.

Dr M asked GP, a 15-year-old male, how he identifies his sexual preference, during a routine well-child visit. GP disclosed being homosexual. Although he is comfortable about his orientation, he has only “came out” to his close friends and not to his family. GP was assured that this would be kept confidential. He was likewise offered a referral for counseling should he desire to learn how to deal with coming out to his parents. Referral to a substance abuse prevention program was given after GP was found to be at risk for alcohol abuse. This was also made confidentially with clear parameters of defining acute safety issues that would require the pediatrician to disclose alcohol abuse (although not sexual orientation) information to his parents.

Only gold members can continue reading. Log In or Register to continue

Share this:

• X
• Facebook

Related

Related posts:

1. Lesbian, Gay, Bisexual, and Transgender Youth
2. Lesbian, Gay, Bisexual, and Transgender Youth
3. Bullying Among Lesbian, Gay, Bisexual, and Transgender Youth
4. What the Primary Care Pediatrician Needs to Know About Gender Incongruence and Gender Dysphoria in Children and Adolescents

Stay updated, free articles. Join our Telegram channel

Join