Mental Health Book


Adolescent Drug Abuse

Aka: Adolescent Drug Abuse, Adolescent Chemical Dependency, Drug Abuse in Adolescents, Adolescent Substance Misuse
  1. See Also
    1. Chemical Dependency
    2. Substance Abuse Evaluation
  2. 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]
  3. Pathophysiology
    1. 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
    2. 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
  4. 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
  5. 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)
  6. 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. DiphenhydramineOverdose 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
  7. 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
  8. 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)
  9. 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
  10. 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)
  11. 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
  12. Management
    1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiative
    2. Motivational Interviewing (e.g. Five Rs Technique) is an effective tool in teens
      1. Bridge while awaiting formal treatment
  13. 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]
  14. Resources
    1. Campaign for Tobacco-Free Kids
    2. Adolescent and School Health
  15. References
    1. Fontes (2014) Crit Dec Emerg Med 28(1): 14-24
    2. (1994) Am Fam Physician 50(8):1737-40 [PubMed]
    3. Kulak (2019) Am Fam Physician 99(11): 689-96 [PubMed]

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