For pediatricians, staying informed about current trends in adolescent substance use is necessary to provide comprehensive care and effective guidance to young patients and their families. According to a presentation by Brittany K. Badal, M.D., adolescent medicine physician with Norton Children’s Medical Group, the landscape of substance use among teens is dynamic, influenced by societal changes, emerging products and evolving legislation. Here’s an overview of recent patterns and concerns in adolescent substance use.

Common substances: Alcohol, nicotine, and cannabis

The most frequently used substances among adolescents remain alcohol, nicotine and cannabis, which includes marijuana. Staying informed and proactive can support young patients in navigating the challenges of teen substance use and other types of substance use during adolescence.

Nicotine use and vaping

Vaping continues to be a prevalent trend among teens, though the types of devices have diversified. JUUL was once dominant, but now the market is saturated with various prefilled pods, vape pens and refillable devices. A Monitoring the Future survey revealed that approximately one-third of 12th graders had vaped nicotine in the past year. While overall use appears to be declining, the prevalence of daily or habitual use remains a concern.

Alcohol use

Alcohol consumption among high school seniors has been declining steadily. Despite this, nearly half of 12th graders reported using alcohol within the last year. This statistic underscores the need for continued vigilance and education about the risks of underage drinking.

Cannabis use

Cannabis remains a significant substance of use, with about one-third of seniors reporting usage in the past year. The conversation around cannabis is particularly pertinent given the changing legal landscape and increased societal acceptance. However, pediatricians must emphasize the potential risks and long-term impacts of adolescent cannabis use.

Cannabis and marijuana are often used interchangeably, but there is a subtle difference between the two terms. Cannabis refers to all products derived from the cannabis sativa plant. Essentially, marijuana is part of the cannabis plant that has higher levels of the psychoactive component tetrahydrocannabinol (THC).

Opioid crisis

Kentucky, like many states, continues to grapple with the opioid crisis. A staggering 81% of overdose deaths in Kentucky in 2020 involved opioids, with fentanyl playing a predominant role. Adolescents are not immune to these dangers, especially given the increasing presence of fentanyl in various street drugs. This trend highlights the critical need for pediatricians to educate teens and their families about the severe risks of experimenting with any illicit drug.

Xylazine: A newer concern

Xylazine, often called “tranq” or “tranq dope,” has emerged as a new challenge. This nonopioid sedative is increasingly found mixed with fentanyl in street drugs, significantly raising the risk of fatal overdoses. Importantly, naloxone (Narcan), which reverses opioid overdoses, is ineffective against xylazine. While use primarily is seen in adult patients, pediatricians should be aware of its potential impact on adolescents.

Substance use screening tools for pediatricians

Screening for substance use in adolescents is essential for early intervention and prevention of substance use disorders.

“When screening for substance use disorder, keep it conversational and aligned with the message, ‘I am here to help.’ Recommend abstaining, and if the patient is not ready, try to set a goal with them to cut back,” Dr. Badal said. “I’m all about using smart goals, where I try to have the teen set a really specific goal with me, like, ‘When are we going to check in about it?’ And we just keep reassessing and taking small, baby steps forward.”

Here are summaries of three key screening tools:

1. Screening to Brief Intervention (S2BI)

Purpose: The S2BI tool aims to identify the frequency of substance use and guide subsequent intervention based on the level of use.

Screening questions:

• “In the past year, how many times have you used any of these substances?”
• Follow-up questions about the use of any prescription drug, illegal drug (e.g., cocaine, ecstasy), inhalants, herbs or synthetic drugs (like K2).

Workflow:

• No use: Reinforce positive choices and encourage continued abstinence.
• Occasional use: Provide brief advice on the health risks and suggest strategies for avoiding use in social settings.
• Frequent use (monthly or more): Assess the impact on the patient’s life, recommend quitting, develop a plan to reduce use and consider referring to treatment.

2. Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)

Purpose: BSTAD focuses on initial screening, especially effective for younger adolescents, by starting with questions about friends’ use before addressing personal use.

Screening process:

• Begin with questions about the use of substances by friends or peers.
• Progress to questions about the patient’s personal use.

Key questions:

• Do your friends smoke tobacco products?
• Do your friends drink alcohol?
• Do your friends use any substances?

Follow-up:

• If any answers are positive, inquire about more illicit substances and recent use (last month, 90 days, or longer).

Application:

• Integrate into well-adolescent visits.
• Use responses as a basis for further discussion and reinforcement of positive behavior.

3. Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT)

Purpose: The CRAFFT tool is widely validated and effective for assessing substance use-related risks and the probability of a substance use disorder.

Screening Questions:

• C: Have you ever driven a car or ridden with someone under the influence?
• R: Do you use substances to relax, feel better about yourself or fit in?
• A: Do you use substances when alone?
• F: Do you ever forget things while using substances?
• F: Do family or friends ever tell you to cut down on your use?
• T: Have you ever gotten into trouble because of substance use?

Usage:

• Start with an estimation of how many days substances are used.
• Use initial responses for a deeper assessment.
• Address any signs of life impact or concern from family and friends.

Assessment and referral:

• The more positive answers a patient has on the CRAFFT, the higher the likelihood of a Diagnostic and Statistical Manual of Mental Disorders – 5 substance use disorder.
• Scores of 5 or 6 indicate a need for considering a referral to specialized treatment.

Implementation tips

• Integrate these tools into routine visits, ensuring the screening is nonjudgmental and supportive.
• Use the screening results to initiate conversations about substance use, focusing on education and prevention.
• Reinforce positive behaviors and provide resources or referrals when necessary.

By using these screening tools effectively, pediatricians can play an important role in early identification and intervention for adolescent substance use, ultimately reducing the risk of long-term substance use disorders.

Summary of treatment options for substance use in adolescents

Treatment strategies

1. Harm reduction:

• Approach: Focus on reducing the risks associated with substance use, even if the adolescent is not ready to quit.
• Counseling: Engage in nonjudgmental conversations, providing strategies to reduce harm and reinforcing safe behaviors.

2. Nicotine replacement therapy (NRT):

• Usage: Consider off-label use for adolescents under 18 who are moderately or severely addicted to nicotine and motivated to quit.
• Forms: Use a combination of long-acting (e.g., nicotine patches) and short-acting (e.g., gum, lozenges) NRT.
• Guidance: Educate on proper use, potential side effects (e.g., vivid dreams with patches), and monitor adherence and relapse.

3. Behavioral support:

• Intervention: Emphasize behavioral strategies alongside NRT, including counseling and support for cessation.
• Resources: Use tools like texting quit lines, online resources (e.g., TeenSmokefree.gov), and the American Academy of Pediatrics’ Behavioral Cessation Supports for Youth and Young Adults.

4. Cannabis use:

• Withdrawal management: Educate the patient on symptoms of cannabis withdrawal (e.g., sleeplessness, irritability, appetite changes), typically resolving in one to two weeks.
• Tolerance breaks: Encourage tolerance breaks to help patients recognize withdrawal symptoms and build motivation to reduce use.

5. High-risk substance use (e.g., prescription drug misuse, illicit drugs, injectable drugs):

• Assessment: Conduct detailed history and social assessments such as HEADSS (home, education, activities, substance use and abuse, sexual behavior, suicidality and depression); evaluate the need for inpatient detoxification.
• Comprehensive exam: Include physical exams, lab screenings (e.g., urine drug screen, complete metabolic panel, liver function tests), and consider screenings for pregnancy, HIV, sexually transmitted infections and hepatitis C.

6. Naloxone (Narcan):

• Importance: Educate on the critical role of Narcan in preventing overdose death from opioid use.
• Access: Promote over-the-counter availability; prescribe Narcan to improve affordability and access.
• Community education: Normalize having Narcan at home, especially if there’s any history of opioid use, even if use is infrequent.

7. Referral to treatment:

• When to refer: Consider referring adolescents to a specialized treatment program if they show high levels of use or score high on screening tools (e.g., CRAFFT).
• Local resources: Stay informed about local treatment resources and changes in services available for adolescents.

Implementation tips

• Use a strengths-based approach, emphasizing the patient’s positive actions and motivations.
• Regularly follow up with adolescents undergoing treatment or using NRT to monitor progress and address any challenges.
• Integrate screening tools (S2BI, BSTAD, CRAFFT) into routine visits to identify substance use early and initiate appropriate interventions.

Importance of early intervention 

Early substance use is a significant predictor of developing a substance use disorder (SUD) as a young adult or later in life. According to the National Institute on Drug Abuse (NIDA), individuals who begin using addictive substances before age 15 are four times more likely to develop a substance use disorder compared with those who delay use until age 21 or older.

Early use can disrupt brain development, increases the risk of engaging in risky behaviors, and can lead to future addiction issues. Pediatricians can help identify early signs of substance use, provide timely counseling and refer patients to appropriate addiction treatment resources.

It is also critical to recognize how teen mental health is related to substance use disorder.

Research indicates that there is a strong connection between mental health issues such as depression and anxiety and young patients turning to substance use. Addressing mental health treatment options during regular visits also can help serve as a preventive measure against substance misuse.

Minimize the stigma

When discussing or treating teen substance use, it is important to remember to meet a young person where they are in their journey.

When addressing teen substance use, providers should avoid stigmatizing language to ensure patients feel respected and understood. The term “substance abuse” carries negative connotations and can contribute to stigma surrounding addiction. Instead, using terms like “substance use” or “misuse” is more neutral and focuses on behavior rather than moral judgment.

Similarly, labeling individuals as “addicts” can be stigmatizing as it may reduce their identity to their condition. Instead, referring to them as “patients” emphasizes the importance of providing compassionate and supportive care.

For health care providers seeking guidance on using nonstigmatizing language, NIDA offers a valuable resource outlining appropriate terms to use when discussing addiction.