Drug and Substance Use in Adolescents

By
Sharon Levy
, MD, MPH, Harvard Medical School
Substance use among adolescents ranges from sporadic use to severe substance use disorders.
The acute and long-term consequences range from minimal to minor to life threatening,
depending on the substance, the circumstances, and the frequency of use. However, even
occasional use can put adolescents at increased risk of significant harm, including overdose,
motor vehicle crashes, violent behaviors, and consequences of sexual contact (eg, pregnancy,
sexually transmitted infection). Substance use also interferes with adolescent brain
development in a dose-dependent fashion. Regular use of alcohol, cannabis (marijuana),
nicotine, or other drugs during adolescence is associated with higher rates of mental health
disorders, poorer functioning in adulthood, and higher rates of addiction.
(See also Overview of Substance-Related Disorders.)
Adolescents use substances for a variety of reasons:
 To share a social experience or feel part of a social group
 To relieve stress
 To seek new experiences and take risks
 To relieve symptoms of mental health disorders (eg, depression, anxiety)
Additional risk factors include poor self-control, lack of parental monitoring, and various
mental disorders (eg, attention-deficit/hyperactivity disorder, depression). Parental attitudes
and the examples that parents set regarding their own use of alcohol, tobacco, prescription
drugs, and other substances are a powerful influence.
According to US national surveys, the proportion of high school seniors who report lifetime
abstinence from all substances has been steadily increasing over the past 40 years. However,
at the same time, a broad range of more potent, addictive, and dangerous products (eg,
prescription opioids, high-potency cannabis products, fentanyl, e-cigarettes) has become
available. These products put adolescents who do initiate substance use at higher risk of
developing both acute and long-term consequences.
The COVID-19 pandemic had a mixed impact on adolescent substance use. During stay-at-
home periods, rates of initiation decreased, but rates of heavy use increased because some
adolescents increased their substance use as a mechanism for coping with stress. All
substance use, inhalational substance use in particular, increases the risk of infection and also
the risk of severe disease. Thus, interventions that reduce substance use are an important part
of a COVID-19 mitigation strategy.
Specific Substances
The substances that are used most by adolescents are alcohol, nicotine (in tobacco or vaping
products), and cannabis.
Alcohol
Alcohol use is common and is the substance most often used by adolescents. The Monitoring
the Future Survey on Drug Use reported that in 2021 by 12th grade, 54% of adolescents have
tried alcohol, and nearly 26% are considered current drinkers (having consumed alcohol
within the past month) (1). Heavy alcohol use is also common, and adolescent drinkers may
have significant alcohol toxicity. Nearly 90% of all alcohol consumed by adolescents occurs
during a binge, putting them at risk of accidents, injuries, unwanted sexual activity, and other
bad outcomes. A binge is defined as a pattern of alcohol consumption that raises the blood
alcohol level to 80 mg/dL (17.37 mmol/L). The number of drinks that constitute a binge
depends on age and sex and can be as few as 3 drinks within 2 hours for younger adolescent
girls.
Society and the media portray drinking as acceptable, fashionable, or even as a healthful
mechanism for managing stress, sadness, or mental health problems. Despite these
influences, parents can make a difference by conveying clear expectations to their adolescent
regarding drinking, setting limits consistently, and monitoring. On the other hand,
adolescents whose family members drink excessively may think this behavior is acceptable.
Some adolescents who try alcohol go on to develop an alcohol use disorder. Known risk
factors for developing a disorder include starting drinking at a young age and genetics.
Adolescents who have a family member with an alcohol use disorder should be made aware
of their increased risk.
Tobacco
The majority of adults who smoke cigarettes began smoking during adolescence. If
adolescents do not try cigarettes before age 19, they are very unlikely to become smokers as
adults. Children as young as age 10 may experiment with cigarettes (1).
Rates of combustible tobacco use among adolescents fell dramatically in the 1990s and 2000s
and continue to decline. The Monitoring the Future Survey reported that in 2021, about 4.1%
of 12th graders reported current cigarette use (smoked in the previous 30 days), down from
28.3% in 1991 and from 5.7% in 2019; only about 2% report smoking every day.
The strongest risk factors for adolescent smoking are having parents who smoke (the single
most predictive factor) or having peers and role models (eg, celebrities) who smoke. Other
risk factors include
 Poor school performance
 High-risk behavior (eg, excessive dieting, particularly among girls; physical fighting
and drunk driving, particularly among boys; use of alcohol or other substances)
 Poor problem-solving abilities
 Availability of cigarettes
 Poor self-esteem
Adolescents may also use tobacco products in other forms. About 2% of high school students
are current users of smokeless tobacco (1); this rate has declined over the past 10 years.
Smokeless tobacco can be chewed (chewing tobacco), placed between the lower lip and gum
(dipping tobacco), or inhaled into the nose (snuff). Pipe smoking is relatively rare in the US.
The percentage of people > age 12 who smoke cigars has declined.
Parents can help prevent their adolescent from smoking and using smokeless tobacco
products by being positive role models (that is, by not smoking or chewing), openly
discussing the hazards of tobacco, and encouraging adolescents who already smoke or chew
to quit, including supporting them in seeking medical assistance if necessary ( see Smoking
Cessation).
Electronic cigarette products (vaping products)
Electronic cigarettes (e-cigarettes, e-cigs, vapes) use heat to volatilize a liquid containing the
active ingredient, typically nicotine or tetrahydrocannabinol (THC). Electronic cigarettes
initially entered the market as alternatives to smoking for adult smokers, and initial models
were not used much by adolescents. They have since morphed into "vapes," which are highly
attractive to and have become increasingly popular among adolescents over the past several
years, especially among adolescents of middle and upper socioeconomic status. Current e-
cigarette use (nicotine vaping, not counting other substances) among 12th graders increased
markedly from 11% in 2017 to 25.5% in 2019. According to the Monitoring the Future
Survey, in 2021 e-cigarette use decreased to 19.6%, and about 40.5% of 12th graders tried e-
cigarettes (nicotine and other substances), which is a decrease from 45.6% in 2019 (1).
Electronic cigarettes cause different adverse effects compared to smoking. Other chemicals
contained in vaping products can cause lung injury, which can be acute, fulminant, or chronic
and, in its most severe form, lethal. In addition, these products can deliver very high
concentrations of nicotine and THC. THC and nicotine are highly addictive, and toxicity is
possible. E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine,
but their effect on the rate of adult smoking is unclear. Other potential long-term risks of e-
cigarettes are also unknown (2).
Cannabis (marijuana)
The Monitoring the Future Survey reported that in 2021 the prevalence of current cannabis
use among high school seniors was 19.5%, which is a decrease from 22.3% in 2019. About
38.6% of high school seniors reported having used cannabis one or more times in their life
(1). In 2010, the rate of current cannabis use surpassed the rate of current tobacco use for the
first time.
The most significant increase in cannabis use is in THC vaping. The number of 12th graders
who reported current THC vaping increased from 4.9% in 2017 to 14% in 2019 (see also
vaping products). This percentage decreased to 12.4% in 2021 (1).
Other substances
Use of substances other than alcohol, nicotine, and cannabis during adolescence is relatively
rare.
In the 2021 Monitoring the Future Survey, the following percentages of 12th grade students
reported using illicit substances one or more times in their life (1):
 Prescription drugs (without a prescription): 8.8%
  Inhalants (eg, glue, aerosols): 5.0%
 Hallucinogens (eg, LSD, PCP, mescaline, mushrooms): 7.1%
 Cocaine: 2.5%
 Anabolic steroids (oral or injectable): 0.8%
 Methamphetamines (nonprescription): 0.6%
 Heroin: 0.4%
Prescription drugs most frequently misused include opioid analgesics (eg, oxycodone),
stimulants (eg, ADHD drugs such as methylphenidate or dextroamphetamine), and sedatives
(eg, benzodiazepines).
Nationwide, 1.6% of high school students had used a needle to inject any illegal drug (2).
Specific substances references
 1. Johnston LD, Miech RA, O’Malley PM, et al: Monitoring the Future National
Survey Results on Drug Use 1975-2021: 2021 Overview, Key Findings on Adolescent
Drug Use. Ann Arbor, Institute for Social Research, University of Michigan, 2022.
 2. Underwood JM, Brener N, Thornton J, et al: Youth Risk Behavior Surveillance—
United States, 2019. MMWR Suppl 69(1):1–83, 2020. doi: 10.15585/mmwr.su6901a1
Screening for Substance Use Disorders in Adolescents
 Clinical evaluation, including routine screening
 Screening questions and drug testing
Some behaviors should prompt parents, teachers, or others involved with an adolescent to be
concerned about a possible substance use disorder. Other behaviors are nonspecific, for
example
 Erratic behavior
 Depression or mood swings
 A change in friends
 Declining school performance
 Loss of interest in hobbies
Adolescents who exhibit any of these behaviors should have a full medical evaluation for
mental health and substance use. Substance use disorders should be considered as possible
causes of these behaviors even if screening is negative. Substance use disorders are diagnosed
based on clinical criteria.
Screening adolescents for substance use
Screening for use of tobacco, alcohol, and other drugs is a standard part of health
maintenance. Adolescents and their parents can benefit from advice about safely using and
monitoring over-the-counter and prescription drugs. Universal substance use screening can
normalize discussions about substance use, reinforce healthy behaviors and choices, identify
adolescents at risk of problematic substance use or of a substance use disorder, guide
interventions, and identify adolescents in need of referral for treatment.
There are a number of different validated screening tools. The National Institute on Drug
Abuse (NIDA) has two such electronic screening tools available for use with patients ages 12
to 17, the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) tool and the
Screening to Brief Intervention (S2BI) tool. Each screening tool may be either self-
administered by the patient or administered by a health care professional. Self-administration
is recommended because it is preferred by adolescents. The tools begin with questions about
frequency of use of tobacco, alcohol, and cannabis in the past year. A positive answer
prompts questions about additional types of substance use. The tools triage adolescents into
one of three risk categories for a substance use disorder: no reported use, lower risk, and
higher risk. Based on the results, the tools offer an action plan based on guidance derived
from expert consensus. Although times may vary based on method of administration and
number of follow-up questions, these tools can typically be completed in under 2 minutes.
The CRAFFT questionnaire is an older, validated screening tool for alcohol and drug use.
Because the original CRAFFT questionnaire does not screen for tobacco use, provide
information on frequency of use, or discriminate between drug and alcohol use, it is no longer
widely used and other screening tools have been developed, including the updated CRAFFT
2.1+N questionnaire, which does have a question about use of tobacco and nicotine.
Alcohol screening
For more specific and comprehensive alcohol screening, the National Institute on Alcohol
Abuse and Alcoholism (NIAAA) has developed a guide that suggests beginning with two
screening questions. The questions and interpretation of answers vary by age (see table
NIAAA Alcohol Screening Questions for Children and Adolescents).
Table
NIAAA Alcohol Screening Questions for Children and Adolescents

For moderate- and highest-risk patients, ask about

 Drinking patterns: Usual and maximal consumption
 Problems caused by or risks taken due to drinking: Missing school, fights, injuries, car
crashes
 Use of other substances: Any other things taken to get high
The NIAAA guide also provides useful strategies to address problems that are discovered.
Drug testing
Drug testing may be useful to identify substance use but has significant limitations. When
parents demand a drug test, they may create an atmosphere of confrontation that makes it
difficult to obtain an accurate substance use history and form a therapeutic alliance with the
adolescent. Screening tests (including at-home tests) are typically rapid qualitative urine
immunoassays that are associated with a number of false-positive and false-negative results.
Furthermore, testing cannot determine frequency and intensity of substance use and thus
cannot distinguish casual users from those with more serious problems. Clinicians must use
other measures (eg, thorough history, questionnaires) to identify the degree to which
substance use has affected each adolescent's life.
Given these concerns and limitations, it is often useful to consult with an expert in substance
use disorders to help determine whether drug testing is warranted in a given situation.
However, the decision not to drug test should not prematurely terminate assessment for a
possible substance use disorder or a mental health disorder. Adolescents with nonspecific
signs of a substance use disorder or a mental health disorder should be referred to a specialist
for a complete evaluation.
Treatment of Drug and Substance Use in Adolescents
 Behavioral therapy tailored for adolescents
Typically, adolescents with a moderate or severe substance use disorder are referred for
further assessment and treatment, often by a behavioral health specialist, or, in some cases, to
a specialty substance use disorder treatment program. In general, the same behavioral
therapies used for adults with substance use disorders can also be used for adolescents.
However, these therapies should be adapted. Adolescents should not be treated in the same
programs as adults; they should receive services from adolescent programs and therapists
with expertise in treating adolescents with substance use disorders.
Drugs that are used to treat withdrawal symptoms resulting from stopping the use of nicotine,
THC, and other substances are available for adolescents and can be prescribed by a primary
care provider.