Adolescent Drug Abuse

Aka: Adolescent Drug Abuse, Adolescent Chemical Dependency, Drug Abuse in Adolescents, Adolescent Substance Misuse, Teen Substance Abuse

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II. Epidemiology

  1. Opioid Overdose child and teen hospital admissions have increased more than 1.5 fold over the last 20 years
  2. Gender
    1. Male teens tend to abuse illicit substances
    2. Female teens tend to abuse nonmedical Amphetamines and Sedatives
  3. Locale (related to access to substance)
    1. Rural teens tend to abuse Tobacco and Anabolic Steroids
    2. Urban teens abuse a broader range of polysubstances
  4. High school student substance use in last 30 days (2015)
    1. Alcohol: 32.8%
      1. One quarter combine Alcohol with energy drink (risk for other substance use)
    2. Tobacco or Nicotine products: 19.6% (10% use more than one type)
      1. Smoked Cigarettes: 10.8% (replaced by other forms below)
      2. Hookah
      3. Electronic Cigarette (e-cig, Vaping, JUUL): 21% (high school seniors in 2018)
      4. E-Cig Vaporization of Marijuana: 29%
      5. Cigarillos (unfiltered cigars, often emptied and filled with Marijuana)
    3. Marijuana: 20% (increasing use, lower risk Perception)
    4. Prescription drugs taken without a prescription: 16.8%
      1. ADHD Stimulants
      2. CodeineCough Syrup (with soda or Alcohol, known as Lean, Sizzurp, Purple Drink)
        1. More common use among Black, Hispanic and Native American teens
    5. Synthetic Marijuana: 9.2%
    6. Hallucinogens: 6.4%
    7. Methylenedioxymethamphetamine (MDMA, Ecstasy, Molly): 5-8%
    8. Cocaine: 5.2%
    9. Heroin: 2.1%
  5. References
    1. Kann (2016) MMWR Surveill Summ 65(6): 1-174 [PubMed]
    2. Jamal (2017) MMWR Morb Mortal Wkly Rep 66(23): 597-603 [PubMed]

III. Pathophysiology

  1. Chemical Dependency is a Developmental Disorder that starts in childhood
  2. Teens are more susceptible to substance use temptations
    1. Reward pathways develop before prefrontal cognition (emotional control, problem solving) in teen brains
    2. Teen substance use has long lasting effects on the developing brain, impacting attention, memory and cognition
  3. Drug progression among teen users (NY study n=7611, oudated example)
    1. Level 1: Alcohol and Tobacco use
    2. Level 2: Marijuana
      1. Originally thought of as "Gateway Drug"
      2. In 2019, with broad access to polysubstances, difficult to determine what are the "gateways"
    3. Level 3: Stimulants, Inhalants or Hallucinogen use
    4. Level 4: Cocaine Abuse
    5. Level 5: Crack use

IV. Risk Factors: Social corollaries to escalating use

  1. Declining:
    1. Decreasing Grades and Homework time
    2. Decreasing Family and Religious involvement
    3. Decreased parental rule following
    4. Decreasing health status
  2. Rising
    1. Increased absenteeism
    2. Increased doctor visit frequency

V. Causes: Common Illicit Drugs in Adolescents

  1. Cannabinoids (Marijuana, K2, Spice)
    1. Most common drug of abuse in U.S. and progressively increasing annually among grades 8-12
  2. Opioids (e.g. Oxycodone, Morphine, Heroin)
    1. Non-medical use of prescription Analgesics (10% Incidence ages 12-18 years old)
      1. Oxycodone (e.g. Percocet)
    2. Over-the-counter pharmaceuticals
      1. Dextromethorphan Abuse (Hallucinogenic effects)
    3. Unintentional associated agent toxicity
      1. High risk of Acetaminophen Overdose (due to combination agent abuse, e.g. Percocet)
      2. Risk of Anticholinergic Toxicity in OTC compounds containing Diphenhydramine (e.g. Coricidin)
  3. Stimulants (e.g. MDMA, Psychoactive Bath Salts, Cocaine)
    1. Amphetamines (e.g. MDMA or Ecstasy, Methamphetamine)
    2. Synthetic Cathinones (Psychoactive Bath Salts)
  4. Volatile Inhalants (Sniffing, Huffing, Bagging)
    1. More common drug of abuse in ages 10-14 years old
    2. Risk of Sudden Sniffing Death Syndrome
  5. Hallucinogens (LSD, PCP, Ketamine, Dextromethorphan)
    1. See Ketamine Abuse (includes Methoxetamine)
    2. See Dextromethorphan Abuse
  6. Alcohol
    1. Ethanol-based hand sanitizer (especially in health care centers)
      1. Small ingestions of hand sanitizer can cause significant Alcohol Intoxication (60% Alcohol)
      2. Some abusers of hand sanitizer extract the Alcohol with salt
  7. Methylenedioxymethamphetamine (MDMA, Ecstasy)
  8. Gamma Hydroxybutyrate (GHB)

VI. Causes: Other Substance Misuse

  1. Nitrous Oxide Abuse (Laughing Gas, Whippets)
  2. Dextromethorphan (used at high doses as an Opioid)
    1. See Dextromethorphan Abuse
  3. Diphenhydramine
    1. Used at high doses as a Hallucinogenic
    2. Other Anticholinergic Medications have been similarly abused (e.g. Dicyclomine, Oxybutynin)
    3. Diphenhydramine Overdose also risks Seizures, coma and death
  4. Bupropion (Wellbutrin)
    1. Crushed and snorted to induce a high ("poor man's Cocaine")
  5. Loperamide (Imodium)
    1. Used in doses as high as 60 mg/day for Opioid effects or for Opioid Withdrawal symptoms

VII. Exam

  1. See Dermatologic findings in chemical dependency
  2. See Eye Examination Signs of Chemical Dependency
  3. See Toxin Induced Vital Sign Changes
  4. See Toxin Induced Neurologic Changes

VIII. Labs

  1. Lab testing (including urine drug testing) is of variable efficacy and often misses abused substances
  2. Perform as indicated for medical indications (e.g. Unknown Ingestion)

IX. Evaluation: Emergency Department Ingestion Evaluation

  1. See Emergency Psychiatric Evaluation
  2. See Chemical Dependency Evaluation
  3. See Unknown Ingestion
  4. See Altered Level of Consciousness
  5. See Toxin Induced Altered Level of Consciousness Causes
  6. See Toxin-Induced Seizure Causes
  7. See Date Rape Drug

X. Evaluation: Screening

  1. See Substance Abuse Evaluation
  2. See HEADSS Screening (Adolescent History)
  3. Brief questions (2 minutes)
    1. Alcohol Use Disorders Identification Test - Consumption (AUDIT-C)
    2. CRAFFT Questionanaire
    3. Avoid CAGE Questions in teens (low efficacy)
  4. Extensive questions (20-30 min)
    1. Problem Oriented Screening Instrument for Teenagers (POSIT)
      1. http://www.emcdda.europa.eu/html.cfm/index4439EN.html

XI. Precautions

  1. Consider toxicity from co-ingestions
    1. Acetaminophen Overdose in combination Opioid Abuse
      1. Most common emergency presentation following prescription Opioid Abuse in ages 15-17 years
    2. Niacin Overdose to mask Urine Drug Screen
  2. Confidentiality and consent for services for teen falls under varying U.S. state regulations
    1. https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law

XII. Management: Initial Identification and Intervention

  1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiative
    1. https://www.integration.samhsa.gov/clinical-practice/sbirt
  2. Motivational Interviewing (e.g. Five Rs Technique) is an effective tool in teens
    1. Bridge while awaiting formal treatment

XIII. Management: Treatment Programs

  1. Adolescent Community Reinforcement Approach (A-CRA)
    1. Replaces susbtance use with healthier alternatives (family, social, work, school)
    2. Based on assessment of needs and functioning level
    3. Applies specific strategies to address problem-solving, coping and communication
  2. Cognitive Behavioral Therapy (CBT)
    1. Prepare for future problems and effective coping responses
    2. Explore consequences of substance use (positive and negative)
    3. Identify distorted thinking patterns and cues triggering chemical use
    4. Practice self control skills (e.g. emotion and anger control, substance refusal, practical problem solving)
  3. Contingency Management (CM)
    1. Problem behavior is modified via immediate reinforcement of positive behaviors
    2. Low cost incentives (e.g. prizes, money) are earned in exchange for treatment goals, participation, abstinence
    3. Weakens drug use reinforcers while strengthening healthier alternative reinforcers
  4. Motivational Enhancement Therapy (MET)
    1. Motivational Interviewing (e.g. Five Rs Technique) to engage patient in substance abstinence
    2. Transitions patient from ambivalence about their substance use to interest in Substance Abuse treatment
    3. Non-confrontational, empathic approach to stimulating a patient's self-motivation
  5. Twelve Step Programs (e.g. AA, NA)
    1. Patient accepts that their life is not manageable, drug abstinence is needed and they cannot do this alone
    2. Less utilized in adolescents than adults (but can be effective in a subset of teens)

XIV. Management: Medications

  1. See specific Substance Abuse disorders
  2. Most medications are not FDA approved for Substance Abuse treatment in teens
    1. Buprenorphine is FDA approved for age >16 years

XV. Prevention

  1. Reconsider every controlled substance prescription
    1. Opioid Abusers report initial exposure via prescribed Opioid in 40% of cases
    2. Diversion and misuse of ADHD Stimulants is common
      1. However, child and adolescent ADHD Management is effective and important
  2. D.A.R.E school based program is ineffective
    1. West (2004) Am J Public Health 94:1027-9 [PubMed]

XVI. Resources

  1. Campaign for Tobacco-Free Kids
    1. http://www.tobaccofreekids.org
  2. Adolescent and School Health
    1. http://www.cdc.gov/healthyyouth/

XVII. References

  1. Fontes (2014) Crit Dec Emerg Med 28(1): 14-24
  2. Oesterle (2024) Mayo Clinic Pediatric Days, lecture attended 1/18/2024
  3. (1994) Am Fam Physician 50(8):1737-40 [PubMed]
  4. Kulak (2019) Am Fam Physician 99(11): 689-96 [PubMed]

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