Several evidence-based communication strategies can foster a supportive environment when addressing substance use in adolescent patients.

“Prioritizing confidentiality, harm reduction and mental health fosters a patient-centered approach that can empower patients to make healthier choices,” said Brittany K. Badal, M.D., adolescent medicine physician with Norton Children’s Medical Group.

Establish trust and confidentiality

Building trust is key to open and productive discussions about substance use. Adolescents are more likely to disclose their behaviors when they know their health care provider respects confidentiality.

“Be upfront and honest with them by saying, ‘Whatever you share today will stay between us, unless I’m worried about your safety,’” Dr. Badal said.

Use motivational interviewing techniques

Motivational interviewing is an effective method for discussing substance use in a way that promotes autonomy and positive change. This approach helps adolescents recognize risks and consider change without feeling pressured.

Ask open-ended questions to explore experiences and attitudes. Sometimes, asking questions about others can make it less intimidating to open up about their own behaviors.

• “Can you tell me about your experiences with substances?”
• “Have you seen your peers at school vaping?” or “What do your friends at school use?”

Use reflective listening to validate concerns and encourage deeper reflection.

• “It sounds like you use substances to manage stress; let’s talk more about that.”

Incorporate nonconfrontational language to encourage engagement.

• “What do you think would happen if you cut back or stopped?”

Explore pros and cons to help adolescents assess their substance use.

• “What do you like about using? What challenges has it created for you?”

“A patient will often tell me they’re using because it helps them calm down, deal with their anxiety or sleep at night,” Dr. Badal said. “That always gives me an in to say, ‘Hey, you’re really struggling with XYZ. Can we use something evidence-based to help with that?’”

Harm-reduction strategies

For adolescents who are not ready to stop using substances, harm-reduction strategies can help minimize risks:

• Educate on safer use practices, such as avoiding polysubstance use and ensuring safe transportation.
• Encourage “tolerance breaks” to assess dependence and cravings.
• Provide cessation resources, including nicotine replacement therapy (when appropriate) and behavioral interventions for tobacco and cannabis use.

Address comorbid mental health conditions

Substance use often coexists with mental health conditions, such as anxiety, depression and trauma-related disorders.

“Adolescents may not know how to get those difficult emotions off their chest. They are just trying to cope, so they use other strategies to try to cope, including substances,” Dr. Badal said.

Substance use should be addressed as a symptom of broader concerns rather than a behavioral issue. Pediatricians should take an integrated approach:

• Incorporate routine mental health screenings alongside substance use assessments.
• Refer to evidence-based therapies, such as cognitive behavioral therapy (CBT), for co-occurring conditions
• Consider pharmacologic treatment when appropriate for underlying mental health issues and consider if a consultation with psychiatry may be helpful

Ongoing support and follow-up

Setting structured, measurable goals for reducing or stopping substance use improves treatment success. Setting SMART (specific, measurable, achievable, relevant, time-bound) goals can be useful for follow-up appointments.

An example script may include: “We know substance use is not helpful for our health, and my ultimate goal is for you not to use. But if you’re not ready for that, how can we set a goal to cut back?”

Pediatricians should:

• Work with adolescents to set realistic goals, like reducing use frequency, identifying triggers or developing healthier coping strategies.
• Document progress and reassess at follow-up visits to maintain engagement and adjust strategies as needed.
• Emphasize a strengths-based approach, reinforcing resilience and positive change.

Confidentiality and disclosure

Substance use screening tools should be incorporated into well-child visits for early detection and intervention.

According to a confidentiality report by the American Academy of Pediatrics: “Although reports of substance use are often maintained in confidence between adolescents and their health care professionals, escalating patterns of use (i.e., amount, frequency, types of substances used), use associated with severe impairment and life disruption, or use linked with potentially dangerous behaviors such as driving, may warrant disclosure to parents or others to ensure the safety of the adolescent.”

When disclosure is necessary, caregivers play a critical role in prevention and recovery. Pediatricians should encourage open, nonjudgmental communication between caregivers and adolescents, provide education on harm-reduction and treatment strategies, and provide referrals to family therapy and caregiver supports as needed.