CHAPTER 63

Substance Use/Abuse

Monica Sifuentes, MD

Primary care physicians are in a unique position to educate their patients, particularly young teenagers, about alcohol and substance use/abuse through primary prevention and anticipatory guidance. Ideally, this should begin before the teenager has first tried a cigarette or alcoholic drink, with the physician gradually introducing each topic as the preteen enters middle school and becomes accus-tomed to speaking to his, her, or their physician alone. Opportunities for education include health maintenance visits, the preparticipation sports physical evaluation as the teenager enters high school, and medical encounters for an acute injury or illness. More importantly, if a primary care physician is fortunate enough to have a long-standing relationship with the teenager, the physician can identify, evaluate, and manage a substance use disorder as soon as it develops and assist the patient and family proactively with appropriate referrals and local resources, thereby improving the adolescent’s overall outcome.

Ideally, all preteen and adolescent patients would be questioned and counseled about the use of illicit substances, alcohol, and tobacco at each health maintenance visit (see Chapters 4 and 38). Unfortunately, this does not occur consistently because some health professionals do not feel comfortable opening that avenue of conversation or simply do not have the time and resources to inquire and intervene. Time constraints, unfamiliar billing codes, and difficulty maintaining confidentiality for sensitive services in a busy office or clinic make screening for substance use challenging. As a result, primary care physicians miss valuable opportunities to adequately assess adolescents for alcohol and substance use disorders and provide them with the necessary guidance to ensure their future health, safety, and well-being.

Substance use is use of or experimentation with illicit drugs, prescription medications, alcohol, or tobacco. Illicit drugs include marijuana; cocaine; amphetamines; hallucinogens, such as lysergic acid diethylamide (LSD), mescaline, and psilocybin, which is found in Psilocybe mexicana mushrooms; opiates; and phencyclidine hydrochloride (PCP). Substance abuse refers to the chronic use of mind-altering drugs despite adverse effects. Addiction, a chronic relapsing disorder, is the term applied to compulsive and continued use of a substance despite adverse consequences. Because addiction is neurologically based, the substance may produce physical dependence or symptoms of withdrawal when it is discontinued.

Epidemiology

Current Trends and Prevalence Rates

Adolescents in the United States currently use a wide range of substances. Alcohol, tobacco, and marijuana are by far the more common and most popular substances and can serve as gateway drugs to more serious illicit drug use. Several surveys tracking substance use/abuse among adolescents are conducted annually in the United States to identify the magnitude of high-risk behavior among those in 8th through 12th grade. The most well-known of these surveys are Monitoring the Future, which is administered annually to students in 8th, 10th, and 12th grade by the University of Michigan for the National Institute on Drug Abuse; the Youth Risk Behavior Surveillance System (YRBSS) survey, conducted biannually by the Centers for Disease Control and Prevention (CDC) of students in grades 9 through 12; and the National Survey on Drug Use and Health, a computer-assisted interview of residents 12 years and older conducted in the home. It is important to remember that most statistics do not include the estimated 15% to 20% of students who drop out of high school before their senior year.

In a 2017 survey of graduating high school seniors, approximately 60% admitted to alcohol use at some time during their life. Almost 30% of students reported drinking alcohol during the month preceding the survey. Binge drinking likely has contributed most to the overall morbidity and mortality associated with alcohol use in adolescents and young adults. Among high school seniors in the class of 2017, approximately 20% reported having 5 or more drinks in a row within a couple hours on at least 1 day during the 30 days before the YRBSS was administered. Although tobacco use among adolescents decreased from 1999 to 2017, data from the CDC indicate that in 2017 approximately 10% of teenagers nationwide reported current cigarette use and another 10% percent smoked at least one-half pack of cigarettes per day. Nationwide, the current rates of smokeless tobacco use (eg, chewing tobacco, snuff, dip) and cigar or cigarillo use are 6% and 8%, respectively. As expected, use of smokeless tobacco is much higher among males than females. Electronic vapor products (ie, electronic [e-] cigarettes, e-cigars, and e-pipes; vape pipes, vaping pens, hookahs), which were introduced in the US market in the middle of the first decade of the 21st century, have become the most commonly used tobacco product among youth in the United States, with many adolescents and young adults later transitioning to traditional cigarettes. In 2017 alone, greater than 40% of high school students reported ever having used an electronic vapor product. E-cigarette advertising aimed at teenagers and marketing strategies promoting flavored solutions have contributed greatly to the popularity of e-cigarettes among this age group. By 2019, there were an increasing number of reports of deaths related to vaping, and a number of states issued a ban on vaping product marketing, issued a ban on flavored vaping solutions, or withdrew vaping products from the market.

Marijuana is the most commonly used illicit psychoactive substance. In 1993, 35% of high school seniors reported ever having used marijuana; in 1997, this figure increased to greater than 50%. Per current estimates from the 2017 YRBSS, this figure is approximately 36%, with nearly 20% of high school seniors reporting marijuana use 1 or more times during the month preceding the survey. Daily use of marijuana has been reported in 6% of high school seniors.

The use of other substances among adolescents was generally on a downward trend in the late 1980s and early 1990s; however, use is once again on the rise. This phenomenon is known in the substance use/abuse literature as “generational forgetting,” which occurs as acknowledgment of adverse effects of specific drugs fade over the years. Reportedly, approximately 9% of high school graduates in 1997 tried cocaine, with approximately 4% having used it in the previous month. These figures remained essentially unchanged until 2007, when cocaine use declined; currently, use of this substance is at an historical low of 1% among 12th-graders. The 1991 prevalence rate for LSD usage was 5%, and its use also remained stable over in the next 10 years until 2001, when the rate increased to 8% and became more widespread than cocaine use among high school students. According to the 2017 YRBSS survey, 9% of 12th-graders nationwide tried LSD or another hallucinogenic drug. Lifetime amphetamine use among 12th-graders was 3% in 2017, with a range of 2.3% to almost 8% across state surveys. Additionally, nationwide ecstasy use was reportedly approximately 4%.

Concurrently, the reported use of over-the-counter (OTC) nonprescription stimulants that contain caffeine has increased, with popular energy drinks now sold in many convenience stores and supermarkets. Other substances used to “get high,” such as inhalants (eg, aerosol spray paints, hair sprays, paint thinners, whipped cream containers), are often used by younger students (ie, preteens) and unfortunately can be found in many garages, workrooms, and basements. Although the rate has decreased from 1997, in 2017 7% of early adolescents (ie, ninth graders) reported sniffing or inhaling substances to become intoxicated. Dextromethorphan also has become popular as an OTC product used/abused by adolescents secondary to its hallucinogenic effects and easy accessibility in cough syrups. Studies confirm an increasing trend in its use/abuse, particularly in teenagers younger than 18 years.

The nonmedical use/abuse of prescription drugs, such as Oxycontin, Percocet, Vicodin, Adderall, Ritalin, and Xanax, has increased more than that of most illicit drugs in the past 2 decades. Many teenagers report the ease by which prescription drugs can be obtained, resulting in continued use/abuse and future dependence as an adult. In 2017, nonmedical prescription drug use was reported by up to 17% of teenagers 1 or more times during their life. Certain prescription drugs, namely opioids, stimulants, sleeping pills, and anxiolytics, now represent the third most widely used/abused substance in adolescents after alcohol and marijuana.

Although not everyone considers them an illicit substance, anabolic steroids are used/abused by some adolescents, mostly males, to increase muscle size and strength. In 1997, approximately 3% of adolescent males admitted to using them at some time in their life. More recently, studies indicate as many as 5.5% of high school students participating in sports use anabolic steroids (6.6% males, 3.9% females). The 2017 nationwide figure per the CDC is almost 3%; however, state and local surveys indicate a range of 2% to 7% for use of anabolic steroids.

Demographics

Generally, adolescent males use illicit drugs more than females do, with a few exceptions. Males are more likely to use anabolic steroids, but females reportedly use amphetamines, barbiturates, tranquilizers, and OTC diet pills more than their male counterparts. Additionally, although annual prevalence rates for overall alcohol use show little difference by sex, adolescent males have a higher rate of heavy or binge drinking compared with adolescent females. Tobacco usage is essentially the same for both sexes, except for smokeless tobacco and cigars, with more boys using these products.

Adolescents who do not plan to attend college are more likely to use illicit substances than their college-bound counterparts, and these adolescents and young adults also are more likely to use illicit drugs more frequently. No difference between the 2 groups exists, however, in the rates of ever having tried illicit substances. Binge drinking also continues to escalate among older adolescents and young adults attending college. The specific influence of parental education, socioeconomic status, and race or ethnicity on the use/ abuse of illicit substances is difficult to determine because many other factors, such as genetics and the environment, contribute to heavy drug use and addiction.

Risk Factors and Behaviors

Although alcohol and tobacco are considered licit or lawful drugs, it is illegal for minors to purchase and use alcohol and tobacco in the United States. Use of these substances often begins during adolescence, however, including during the preteen years. The strongest predictor of drug use by youth is having friends who regularly use drugs, that is, alcohol, tobacco, or other substances (eg, marijuana). Additionally, it has been shown that the more risk factors identified, the greater the risk of substance use/abuse in the teenager.

Several factors are important precursors to (ie, risk factors for) drug use during adolescence. These risk factors include association with drug-using peers; attitudinal factors, such as favorable attitudes toward drug use in the family; low religiosity; poor school performance or academic failure, often beginning in the late elementary years; young age of initiation of alcohol or drug use; presence of a conduct disorder; environmental factors, such as the prevalence of drug use in a given community; history of child abuse; family history of alcoholism or drug use; poor parenting practices; high levels of conflict within the family; minimal bonding between parents and children; family disruption; and early and persistent problem behaviors during childhood, such as untreated attention-deficit/ hyperactivity disorder (ADHD).

It is well documented in the literature that early age of onset of alcohol and tobacco use is predictive for the use of other drugs, a greater variety of drugs, and more potent agents. Additionally, the use of alcohol at an early age is associated with future alcohol-related problems, such as lifetime alcohol dependence and use/abuse. The early initiation of alcohol also results in increased sexual risk- taking behavior during adolescence (ie, unprotected sexual intercourse, exposure to multiple sexual partners, being drunk or high during sexual intercourse, increased risk of pregnancy) as well as academic problems and delinquent behavior later in adolescence. Long-term effects during young adulthood include difficulties with employment, criminal and aggressive behavior, and continued substance use/abuse. Potential long-term health risks associated with the early initiation of alcohol, tobacco, and substance use/abuse depend on the specific exposure but include conditions such as pulmonary disease, chronic liver disease, cardiovascular complications, and cancer.

The role of the media and technology in adolescent alcohol and tobacco use has been the subject of much discussion in the past 20 years. Previous studies confirmed that exposure to smoking on television and in movies was 1 of the key factors that prompted teenagers to smoke and that preteens whose parents forbad them from viewing R-rated movies were less likely to begin smoking or drinking. One prospective study reported that exposure to R-rated movies or having a television in the bedroom significantly increased the risk of initiating smoking for white teenagers. Additionally, watching more movie depictions of alcohol use is strongly predictive of drinking onset and binge drinking in adolescents in the United States. Advertising also contributes to the depiction of alcohol and tobacco use as normative activities. In fact, it has been reported that advertising may be responsible for up to 30% of alcohol and tobacco use among adolescents. The influence of advertising on adolescents is now even more apparent with the current marketing of electronic vapor products to attract teenage consumption.

Clinical Presentation

Adolescents who are consuming alcohol or are involved in drug use may present to the health professional in several different ways. Illicit substance use might be uncovered during a routine confidential interview at an annual health maintenance visit, preparticipation sports physical evaluation, or urgent care appointment. Alternatively, the adolescent might have physical symptoms including chronic cough, persistent allergies, chest pain, and fatigue. Chronic conditions, such as asthma, may continue to worsen despite appropriate therapy in the adolescent smoking tobacco or marijuana or using e-cigarettes.

Abdominal tenderness may be noted on physical examination and found to be associated with gastritis, hepatitis, or pancreatitis. The adolescent also may have been in a recent motor vehicle crash or involved in other trauma, or their parent or parents may report that their teenager exhibits frequent mood swings, irritability, or erratic sleep patterns.

Pathophysiology

Although several theories have been proposed to explain why casual substance use develops into use/abuse and addiction in some adolescents and young adults and not others, the most critical factor seems to be the presence of underlying psychopathology. Adolescents who have untreated major depressive disorders, ADHD, or schizophrenia, for example, may use mood-altering substances to manage unpleasant feelings of dysphoria and low self-esteem. Initially used as a temporary measure, this method of self-medication increases the likelihood of chronic substance use/abuse.

It is well known that genetic influences also play a major role in adult use/abuse of alcohol; however, less evidence exists for adolescent drug use. What is known is that families and parental attitudes play a significant role in the development of alcohol and other drug use in teenagers. Permissive attitudes toward alcohol and drug use by parents or guardians and parental or older sibling drug use in the setting of other environmental risk factors are predictive of increased drug and alcohol use in the adolescent.

Differential Diagnosis

The differential diagnosis for symptoms and behaviors associated with substance use/abuse includes underlying psychiatric disorders. Affective, antisocial, and conduct disorders as well as ADHD can be the primary or secondary condition in adolescents who are abusing drugs. Like adults, adolescents may use illicit drugs to self-medicate associated depression, anxiety, or auditory hallucinations. The pharmacology and toxicity of the illicit substances most commonly used by adolescents are summarized in Table 63.1.

Evaluation

History

The interview should be conducted in a private, quiet area to minimize interruptions. If parents or guardians have accompanied the adolescent, they should be politely asked to leave the room after they have had an opportunity to express their concerns and after issues of confidentiality are addressed in the presence of both parties. Doing so helps avoid future uncomfortable moments when a parent or guardian returns and asks what was disclosed in their absence. After parents or guardians have left the room, issues addressing confidentiality and privacy should be reviewed once again with the patient. Special circumstances, such as a disclosure of sexual or physical abuse or possible suicidal ideation or homicidal intent, that dictate that confidentiality be broken also should be discussed with the teenager before proceeding with the interview (see Chapter 4).

The interview should proceed in a casual, non-pressured, nonjudgmental fashion. Initial inquiries should address less threatening general topics, such as school, home life, and outside activities, including activities with friends. Use of the HEADSS (home, employment and education, activities, drugs, sexuality [including a history of sexual abuse or assault], suicide and/or depression) assessment allows for a thorough review of the essential components of the psychosocial history (see Chapter 4). Another interview tool, the SSHADESS (strengths, school, home, activities, drugs and alcohol, substance use, emotions and depression, sexuality, safety) assessment, has been developed to emphasize and review positive components in an adolescent’s life in addition to any high-risk behavior.

Some practitioners prefer to use questionnaires or other formal validated screening tools to initially obtain this background information. A questionnaire is given to patients to fill out while they are waiting to be seen, and responses are reviewed privately with the health professional during the actual visit. Some questionnaires address only issues concerning substance use/abuse, whereas others are more general but also include questions about alcohol, tobacco, and drugs (Figure 63.1 and Box 63.1). Controversy exists about the role of such questionnaires, primarily concerning the truthfulness of answers, because parents or guardians may be with teenagers as they are attempting to complete the form. Administering questionnaires via technology and in a designated, private space can help improve honesty.

More specific questions about the use of alcohol and tobacco as well as illicit substances should be asked after general subjects have been discussed (Box 63.2). If adolescents seem wary of answering these questions, it may be helpful to initially inquire about their friends. Questions should be phrased with the assumption that the responses will be affirmative (eg, “How many beers do your friends drink in a week? And do you drink the same amount?”). It is hoped that this less-threatening approach invites more honest answers. An assessment of the risk of suicidal behavior is also indicated.

Because many physicians lack unlimited time to interview adolescents and obtain all the details in a single visit, various standardized methods have been developed to efficiently screen teenagers for substance use in the context of health supervision visits. Brief screening tools that are both self- and interviewer-administered can be used to glean important information even in a busy practice. For example, 1 screening tool uses the following 3 questions: During the past 12 months, have you smoked marijuana? Have you drunk any alcohol? Have you used anything else to get high? If an adolescent answers “no” to all 3 questions, the patient should still be asked if he or she have ridden in a car with a driver who was high or had been using alcohol or drugs. Additional screening is recommended for any teenager who answers “yes” to any of the 3 initial screening questions. Six questions, known as the CRAFFT screening tool, are then reviewed with the adolescent to further identify drug and alcohol risk or problems associated with their use. The teenager receives 1 point for each “yes” answer; a total score of 2 or more indicates a positive result and high risk for a substance use disorder. It also indicates the need for additional follow-up as well as referral to a mental health professional or therapeutic treatment program. The validity of this brief, developmentally appropriate tool for screening adolescents has been reported in the literature and is well supported by experts in the field of adolescent and addiction medicine for use by primary care physicians. Another screening tool, funded by the National Institute on Drug Abuse, is the Screening to Brief Intervention tool (S2BI). It is used to assess the frequency of past-year substance use for tobacco, alcohol, marijuana, and 5 other classes of substances (Figure 63.1). Depending on the results of the S2BI tool, motivational intervention is recommended as the next step.

Physical Examination

Positive findings on physical examination are rare, especially in adolescents who consume alcohol or other substances only occasionally. In adolescents with a history of chronic substance use/abuse, however, certain physical findings may be present.

Abbreviations: CNS, central nervous system; GABA, γ-aminobutyric acid; LSD, lysergic acid diethylamide; PCP, phencyclidine hydrochloride.

Derived from Schwartz B, Alderman EM. Substances of abuse. Pediatrics in Review. 1997;18(6):204–215, and Joffe A, Blythe MJ, eds. Mental health, psychotropic medications, and substance abuse. Adolesc Med. 2003;14:455–466.

Figure 63.1. The Screening to Brief Intervention tool approach to clinical screening, brief intervention, and referral to treatment.

Abbreviation: SUD, substance use disorder.

Reprinted from S Levy, L Shrier. 2014. Boston, MA: Boston Children’s Hospital. Copyright 2014, Boston Children’s Hospital. Reprinted under Creative Commons Attribution-Noncommercial 4.0 International License.

All vital signs should be reviewed. Tachycardia and hypertension occur primarily with acute intoxication with cocaine or stimulants (eg, amphetamines). The current weight also should be recorded and compared with previous values, and any significant weight loss should be noted. The skin should be examined closely for track marks, skin abscesses, or cellulitis, especially if the patient admits to using drugs intravenously. The skin should also be examined for evidence of self-injurious behaviors, such as cutting. Findings consistent with hepatitis (ie, hepatomegaly, jaundice) may be present in these individuals. The presence of diffuse adenopathy, thrush, leukoplakia, seborrheic dermatitis, or parotitis should raise the suspicion of HIV infection. A nonspecific maculopapular rash also may be seen during the acute viremic phase of an HIV infection. Upper respiratory symptoms, such as chronic nasal congestion, long-lasting “colds” and “allergies,” and epistaxis can occur with chronic inhalation of cocaine or another illicit substance. Signs of nasal congestion, septal perforation, and wheezing also may be noted on examination. Additionally, smoking crack cocaine can cause chronic cough, hemoptysis, and chest pain. Smoking marijuana over long periods can result in similar findings. Gynecomastia can occur with use of anabolic steroids, marijuana, amphetamines, and heroin. The adolescent female using anabolic steroids may exhibit signs of virilization, such as a deep voice, hirsutism, and male pattern baldness. The detailed neurologic evaluation is arguably the most important aspect of the examination. Any abnormalities in memory, cognitive functioning, or affect should be noted. Chronic marijuana use is sometimes accompanied by amotivational syndrome.

Acute intoxication with some drugs (eg, cocaine) may result in delirium, confusion, paranoia, seizures, hypertension, tachycardia, arrhythmias, mydriasis, and hyperpyrexia. Acute PCP intoxication produces abnormal neurologic signs, tachycardia, and hypertension. Findings such as central nervous system and respiratory depression, miosis, and cardiovascular effects (eg, pulmonary edema, orthostatic hypotension) are consistent with opiate overdose. Signs and symptoms of acute intoxication generally are seen in the emergency department setting rather than in the primary care physician’s office or clinic.

Laboratory Tests

In the clinic setting, routine drug screening as part of the initial evaluation of substance use is not recommended and generally not indicated to initiate treatment. Specific laboratory studies should be performed, however, in those patients with a history of known substance use/abuse and who are enrolled in a drug treatment program to monitor for abstinence; in patients who are required by court order; and in patients who exhibit acute altered mental status, intoxication, or abnormal neurologic findings, such as may be seen in an emergency department setting. In the office setting, these symptoms are frequently absent, and urine or serum studies to “check” for drug use are not particularly useful.

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