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Identifying Substance Abuse in Adolescents

The use of illicit substances in adolescents is a significant and often unrecognized problem that can be a great burden on not only the individual, but also their loved ones and the greater community. According to the 2020 National Survey of Drug Use and Health (NSDUH), 20.9% of teenagers aged 12 to 17 admitted to using illicit drugs (marijuana, cocaine, heroin, PCP, LSD, ecstasy, inhalants, methamphetamines, and/or prescription pain relievers) in their lifetime, with more than 17% reporting use in the past year. Nearly 23% of adolescents reported alcohol use at some point in their life, with 18.5% having used within the past year.

Although the types of illicit substances that adolescents use have shifted over the past several years, the consumption of alcohol has decreased and the use of electronic cigarettes, marijuana, ecstasy and opioids (e.g, fentanyl, heroin) has increased. Regardless of these changes, the result is still the same: substance use remains a significant issue.

How do I approach my patients about substance abuse?

As pediatric healthcare providers, the most important thing you can do is start by having open and honest conversations. It is crucial to start these conversations early, in grade school (as early as 11 years old), because most children that age have not begun to use any illicit substances. Begin by asking open-ended questions, such as asking about what they heard or what they know about drugs. Remember to ask in a non-judgmental way. This way, you are likely to get an honest response. Talk about healthy choices, risky behaviors and the negative effects of drug and alcohol use.

Most parents know if their child is using drugs or alcohol, right?

According to the Mott Poll Report, parents are often unaware of their child’s drug or alcohol use. According to the poll, only 10% of parents of teens 13 to 17 years old believed their child had consumed alcohol in the past year, while 5% believed their teens had used marijuana in the last year. The same teenagers self-reported that 52% of them drank alcohol and 28% had used marijuana. Given this information, it is crucial for us as their pediatricians to advocate for our patients by being proactive and asking them about substance use early, because early intervention likely leads to better outcomes.  

What are some signs that your patient might be using drugs or alcohol? 

  • Withdrawing from friends/family members
  • Decreased interest in personal hygiene and overall appearance
  • Physical changes such as sunken eyes, bloodshot eyes, weight loss
  • Poor memory, difficulty finding words when speaking
  • Sudden behavioral problems, poor or falling grades in school
  • Getting in trouble with the law

Drug use in teenagers is usually precipitated by significant events, which can include: 

  • Peer pressure, especially if the child is spending time with peers who use drugs
  • Trauma including sexual, emotional, physical abuse 
  • Family conflict (e.g., parental divorce, worry about family finances)
  • Recent death in the family
  • Pre-existing depression or anxiety

While some teens may use drugs and alcohol to get high, others may be using drugs and alcohol to manage or cope with academic, social, emotional, or physical stress. According to the most recent AAP guidelines, it is recommended that all adolescents starting ages 12-21 are screened with a HEEADSSS exam (Home environment, Education/Employment, Eating, peer-related activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence and includes media use).

Because drug use can be associated with increased risk of poor grades, violence, homicides, suicides and habitual drug use in adulthood, it is important to recognize the signs and intervene early. 

Giving advice to parents and patients on how to say “No”:

Have a discussion with the patient and parents about how to say no to drugs. Inform them that one of the best ways to say no to drugs is to make up excuses or be honest and confident. These are only some of the examples you can provide to the patient.  

  • “My parents are picking me up in a few minutes, and they would kill me if they ever found out.”
  • “I’ve smelled that before, and I bet it tastes nasty!” (e.g. when referring to alcohol or marijuana)
  • “I’m actually not into that kind of stuff.”
  • “Thanks, but I don’t drink/use drugs. I’ve got an important test/competition/meet/performance coming up and I need to do my best/be at the top of my game.”

It may be helpful for parents to role play with their child to help them become more comfortable saying no.

Resources you can give to your teenage patients who are using:  

Finding out their teenage child may be using drugs or alcohol can be very scary for any parent. If the patient feels comfortable sharing this information with them, we encourage you as the child’s provider to have an open and honest discussion. Any conversation the parent has with their child about substance use is likely to be uncomfortable, and could end in frustration or anger; therefore, warn parents that before they have any conversation, they need to prepare themselves. The more informed they are, the better the outcome will likely be. There are many resources available for teenagers and parents to help guide the patient. These include: 

  • Online resources:
  • School support: Encourage the patient to talk to their school counselors. Many schools have counselors trained to guide teenagers struggling with drug or alcohol use. They can help by discussing the availability of therapy and educational intervention. 
  • Individual therapy: Encourage patients to attend individual therapy, particularly cognitive behavioral therapy (CBT). It is useful to have a list of trustworthy therapists that work in your community that you can refer to at any time.
  • Family-based therapy: It may also be helpful for families to undergo family behavior therapy (FBT) together. This allows families to address behaviors and co-existing conditions, learn new coping skills, and apply those strategies
  • Recommend parents safeguard their prescription medications by counting pills and keeping them locked up. 

Remember that as their pediatrician, you are one of the patient’s greatest allies. You may be the first person they share any of this information with, so it is extremely important to create an environment that is non-judgmental, encouraging, and open-minded.