Adolescents and Substance Use

Experimentation with a variety of substances, especially alcohol, tobacco, and marijuana, is common among adolescents. Many adolescents use substances frequently, even daily, including legally available substances (alcohol, tobacco, inhalants, prescription drugs, wild plants) as well as illicit drugs (marijuana, cocaine, narcotics, numerous hallucinogens.) According to the 2009 Youth Risk Behavior Surveillance (Centers for Disease Control and Prevention), among U.S. high school students, 34% of females and 39% of males have used marijuana at least once, 18% of females and 23% of males have used it in the past month. Five percent of females and 10% of males report using marijuana for the first time before age 13 years.  Inhalant use is reported by 13% of females and 10% of males, Ecstasy by 5% of females and 7% of males.

The most serious short-term risk of substance abuse is unintended overdose and even sudden death due to ignorance of the harmful effects of a specific amount of any substance, unawareness of unidentified additives, or misperceptions of safety in its use. Intoxication with any substance can produce drowsiness, inattention, or loss of coordination leading to risk of injury while driving or participating in any physical activity. Intoxication can affect judgment in sexual relationships, increasing the risk of unintended, often unprotected sexual intercourse and even acquaintance rape. Some substances increase aggressive behavior leading to interpersonal violence. Substance use can complicate underlying chronic illnesses such as hypertension or diabetes. Many substances pose risk to the fetus, especially in the pregnant adolescent who is not yet diagnosed or is in denial. Intravenous use, uncommon in adolescents, carries risk of  infections (skin bacteria, hepatitis B or C, HIV). Buying, selling, or even using any illegal substance can lead to arrest and detention.

Adolescents may try one or more substances (experimentation), especially when coaxed or pressured by friends, but many do not continue use or use very infrequently. Adolescents may use substances to satisfy curiosity, to experience pleasurable feelings (“get high”), to be socially accepted, or to deal with boredom or stress. Risk factors for substance abuse (problem drug use) include substance abuse by parents, siblings, or peers, family problems, poor school performance, mood or anxiety disorders, use of tobacco and/or alcohol, history of physical or sexual abuse, and other behavioral problems.

ACOG recommends that Obstetricians/Gynecologists and other providers of health care to adolescents should ask about use of substances, as well as alcohol and tobacco, as part of the routine health history during any preventive health visit. If the adolescent admits use, the extent and potential risks of use of each substance should be addressed. The CRAFFT questionnaire has been validated for assessing alcohol and substance use in adolescents (Knight, 2002).  A positive response of 2 or more items indicates that substance use is problematic due to frequency, extent, and/or health risks.  The adolescent should be assisted in further evaluation and treatment and referred directly to a substance abuse treatment provider or to his or her primary care provider. In addition, female adolescents who are abusing substances should be counseled and assisted in using effective contraception. Parents who are concerned about possible substance use/abuse in their daughter or son should be directed to their child’s primary care provider or the state’s public health substance abuse agency for further discussion and appropriate evaluation and referral.  To find an appropriate substance abuse provider within a geographic area, go to the SAMHSA substance abuse treatment finder: www.findtreatment.samhsa.gov.

The following resources are listed to assist health professionals in educating patients and their parents about the health risks of substance use, approaches to diagnosis and treatment,  and strategies for reducing or preventing substance use. Resources also will inform health professionals about the extent of adolescent substance use, contributing factors, and strategies for clinical assessment, intervention and prevention. Additional related resources can be found in the ACOG Resource Guides: Adolescents and Alcohol and Adolescents and Tobacco.

The following resources are available from ACOG:

American College of Obstetricians and Gynecologists. Alcohol, tobacco, and other substance use and abuse. In: Guidelines for adolescent health care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2011. p. 97-110.

American College of Obstetricians and Gynecologists. Fact sheet: substance abuse. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.

American College of Obstetricians and Gynecologists. Substance abuse: a fact sheet for parents. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.

American College of Obstetricians and Gynecologists. Substance use: obstetric and gynecologic implications. In: Special issues in women's health. Washington, DC: ACOG; 2005. p. 105-50.

American College of Obstetricians and Gynecologists. Tobacco, alcohol, drugs, and pregnancy. ACOG Patient Education Pamphlet AP170. Washington, DC: ACOG; 2008.

At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. ACOG Committee Opinion No. 422. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:1449-60.

Methamphetamine abuse in women of reproductive age. Committee Opinion No. 479. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:751-5.

Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist. Committee Opinion No. 473. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:200-1.

The resources listed below are for information purposes only. Referral to these sources and sites does not imply the endorsement of ACOG. Further, ACOG does not endorse any commercial products that may be advertised or available from these organizations or on these web sites. The lists are not meant to be comprehensive. The exclusion of a source or site does not reflect the quality of that source or site. Please note that sites and URLs are subject to change without notice.

References for Professionals

General

Bukstein O. Substance use disorders in adolescents with attention-deficit/hyperactivity disorder. Adolesc Med State Art Rev 2008;19:242-53, viii.

Comerci GD, Schwebel R. Substance abuse: an overview. Adolesc Med 2000;11:79-101.

Gee RL, Espiritu RC, Huang LN. Adolescents with co-occurring mental health and substance use disorders in primary care. Adolesc Med Clin 2006;17:427-52.

Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med Clin 2006;17:283-318.

Greydanus DE, Patel DR. The adolescent and substance abuse: current concepts. Curr Probl Pediatr Adolesc Health Care 2005;35:78-98.

Hassan A, Csemy L, Rappo MA, Knight JR. Adolescent substance abuse around the world: an international perspective. Adolesc Med State Art Rev 2009;20:915-29, ix.

Hogan MJ. Diagnosis and treatment of teen drug use. Med Clin North Am 2000;84:927-66, vii.

Kaminer Y, editor. Adolescent substance use disorders [special issue]. Child Adolesc Psychiatr Clin N Am 2010;19(3).

Kaul P, Coupey SM. Clinical evaluation of substance abuse. Pediatr Rev 2002;23:85-94.

Liepman MR, Keller DM, Botelho RJ, Monroe AD, Sloane MA. Understanding and preventing substance abuse by adolescents: a guide for primary care clinicians. Prim Care 1998;25:137-62.

Sanchez-Samper X, Knight JR. Drug abuse by adolescents: general considerations [published erratum appears in Pediatr Rev 2009;30:369]. Pediatr Rev 2009;30:83-92; quiz 93.

Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev 1997;18:204-15.

Weinberg NZ, Rahdert E, Colliver JD, Glantz MD. Adolescent substance abuse: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1998;37:252-61.

Windle M, Windle RC. Adolescent tobacco, alcohol, and drug use: current findings. Adolesc Med 1999;10:153-63, vii.

 Epidemiology

Casey BJ, Jones RM. Neurobiology of the adolescent brain and behavior: implications for substance use disorders. J Am Acad Child Adolesc Psychiatry 2010;49:1189-201; quiz 1285.

Charach A, Yeung E, Climans T, Lillie E. Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. J Am Acad Child Adolesc Psychiatry 2011;50:9-21.

Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth risk behavior surveillance - United States, 2009. Centers for Disease Control and Prevention (CDC). MMWR Surveill Summ 2010;59(SS-5):1-142. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Retrieved December 6, 2011.

Horigian VE, Lage OG, Szapocznik J. Cultural differences in adolescent drug abuse. Adolesc Med Clin 2006;17:469-98.

Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national results on adolescent drug use: overview of key findings, 2010. Ann Arbor (MI): Institute for Social Research, University of Michigan; 2010. Available at: http://monitoringthefuture.org/pubs/monographs/mtf-overview2010.pdf. Retrieved December 6, 2011.

Latimer W, Zur J. Epidemiologic trends of adolescent use of alcohol, tobacco, and other drugs. Child Adolesc Psychiatr Clin N Am 2010;19:451-64.

Lynskey MT, Agrawal A, Heath AC. Genetically informative research on adolescent substance use: methods, findings, and challenges. J Am Acad Child Adolesc Psychiatry 2010;49:1202-14.

Meyers JL, Dick DM. Genetic and environmental risk factors for adolescent-onset substance use disorders. Child Adolesc Psychiatr Clin N Am 2010;19:465-77.

Rutherford HJ, Mayes LC, Potenza MN. Neurobiology of adolescent substance use disorders: implications for prevention and treatment. Child Adolesc Psychiatr Clin N Am 2010;19:479-92.

Thompson KM. Addicted media: substances on screen. Child Adolesc Psychiatr Clin N Am 2005;14:473-89, ix.

Diagnosis

Testing for drugs of abuse in children and adolescents: addendum--testing in schools and at home. Policy Statement. American Academy of Pediatrics. Pediatrics 2007;119:627-30.

Delaney-Black V, Chiodo LM, Hannigan JH, Greenwald MK, Janisse J, Patterson G, et al. Just say "I don't": lack of concordance between teen report and biological measures of drug use. Pediatrics 2010;126:887-93.

Gray KM, Upadhyaya HP, Deas D, Brady KT. Advances in diagnosis of adolescent substance abuse. Adolesc Med Clin 2006;17:411-25.

Heyman RB. Screening for substance abuse in the office setting: a developmental approach. Adolesc Med State Art Rev 2009;20:9-21, vii.

Knight JR, Goodman E, Pulerwitz T, DuRant RH. Reliabilities of short substance abuse screening tests among adolescent medical patients. Pediatrics 2000;105:948-53.

Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156:607-14.

Levy S, Sherritt L, Gabrielli J, Shrier LA, Knight JR. Screening adolescents for substance use-related high-risk sexual behaviors. J Adolesc Health 2009;45:473-7.

Levy S, Van Hook S, Knight J. A review of Internet-based home drug-testing products for parents. Pediatrics 2004;113:720-6.

Winters KC, Kaminer Y. Screening and assessing adolescent substance use disorders in clinical populations. J Am Acad Child Adolesc Psychiatry 2008;47:740-4.

 Intervention

Alegria M, Carson NJ, Goncalves M, Keefe K. Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth. J Am Acad Child Adolesc Psychiatry 2011;50:22-31.

Bukstein OG, Bernet W, Arnold V, Beitchman J, Shaw J, Benson RS, et al. Practice parameter for the assessment and treatment of children and adolescents with substance use disorders. Work Group on Quality Issues. J Am Acad Child Adolesc Psychiatry 2005;44:609-21.

Improving substance abuse prevention, assessment, and treatment financing for children and adolescents. American Academy of Pediatrics. Pediatrics 2001;108:1025-9.

Indications for management and referral of patients involved in substance abuse. American Academy of Pediatrics. Pediatrics 2000;106:143-8.

Barangan CJ, Alderman EM. Management of substance abuse. Pediatr Rev 2002;23:123-31.

Brannigan R, Schackman BR, Falco M, Millman RB. The quality of highly regarded adolescent substance abuse treatment programs: results of an in-depth national survey. Arch Pediatr Adolesc Med 2004;158:904-9.

Griswold KS, Aronoff H, Kernan JB, Kahn LS. Adolescent substance use and abuse: recognition and management. Am Fam Physician 2008;77:331-6.

Hassan A, Harris SK, Sherritt L, Van Hook S, Brooks T, Carey P, et al. Primary care follow-up plans for adolescents with substance use problems. Pediatrics 2009;124:144-50.

Kaplan G, Ivanov I. Pharmacotherapy for substance abuse disorders in adolescence. Pediatr Clin North Am 2011;58:243-58, xiii

Knopf A. How do you code for substance abuse prevention and intervention. Contemp Pediatr 2006;23(suppl):12-6.

Kulig JW, American Academy of Pediatrics Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention, identification, and management of substance abuse. Clinical Report. American Academy of Pediatrics. Pediatrics 2005;115:816-21

Levy S, Knight JR. Helping adolescents to stop using drugs: role of the primary care clinician. Adolesc Med 2008;19:83-98.

Lord S, Marsch L. Emerging trends and innovations in the identification and management of drug use among adolescents and young adults. Adolesc Med State Art Rev2011;22:649-69, xiv.

Macgowan MJ, Engle B. Evidence for optimism: behavior therapies and motivational interviewing in adolescent substance abuse treatment. Child Adolesc Psychiatr Clin N Am 2010;19:527-45.

Sterling S, Weisner C, Hinman A, Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. J Am Acad Child Adolesc Psychiatry 2010;49:637-46; quiz 725-6.

Tellier PP. The adolescent and substance use, an approach to office management. Prim Care 2006;33:517-30.

Toumbourou JW, Stockwell T, Neighbors C, Marlatt GA, Sturge J, Rehm J. Interventions to reduce harm associated with adolescent substance use. Lancet 2007;369:1391-401.

Winters KC, Leitten W, Wagner E, O'Leary Tevyaw T. Use of brief interventions for drug abusing teenagers within a middle and high school setting. J Sch Health 2007;77:196-206.

Prevention

Children, adolescents, substance abuse, and the media. Policy Statement. American Academy of Pediatrics. Pediatrics 2010;126:791-9.

The role of schools in combating illicit substance abuse. Policy Statement. American Academy of Pediatrics. Pediatrics 2007;120:1379-84.

Briones DF, Wilcox JA, Mateus B, Boudjenah D. Risk factors and prevention in adolescent substance abuse: a biopsychosocial approach. Adolesc Med Clin 2006;17:335-52.

Griffin KW, Botvin GJ. Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am 2010;19:505-26.

Hallfors D, Van Dorn RA. Strengthening the role of two key institutions in the prevention of adolescent substance abuse. J Adolesc Health 2002;30:17-28.

West SL, O'Neal KK. Project D.A.R.E. outcome effectiveness revisited. Am J Public Health 2004;94:1027-9.

Marijuana/Hallucinogens

Legalization of marijuana: potential impact on youth. Policy Statement. American Academy of Pediatrics. Pediatrics 2004;113:1825-6.

Foley JD. Adolescent use and misuse of marijuana. Adolesc Med Clin 2006;17:319-34.

Macleod J, Oakes R, Copello A, Crome I, Egger M, Hickman M, et al. Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studies. Lancet 2004;363:1579-88.

Schwartz RH. Marijuana: a decade and a half later, still a crude drug with underappreciated toxicity. Pediatrics 2002;109:284-9.

Rickert VI, Siqueira LM, Dale T, Wiemann CM. Prevalence and risk factors for LSD use among young women. J Pediatr Adolesc Gynecol 2003;16:67-75.

Rickert VI, Wiemann CM, Berenson AB. Flunitrazepam: more than a date rape drug. J Pediatr Adolesc Gynecol 2000;13:37-42.

Sigel E. Club drugs: nothing to rave about. Contemp Pediatr 2002;19(10):47,48, 53, passim.

Tellier PP. Club drugs: is it all ecstasy? Pediatr Ann 2002;31:550-6.

Inhalants

Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse by adolescents. J Adolesc Health 2001;28:170-80

Marsolek MR, White NC, Litovitz TL. Inhalant abuse: monitoring trends by using poison control data, 1993-2008. Pediatrics 2010;125:906-13.

Williams JF, Storck M, American Academy of Pediatrics Committee on Substance Abuse. Inhalant
abuse. Pediatrics 2007; 119:1009-17.

Wu LT, Pilowsky DJ, Schlenger WE. Inhalant abuse and dependence among adolescents in the United States. J Am Acad Child Adolesc Psychiatry 2004;43:1206-14.

Prescription and OTC Drugs

Boyd CJ, McCabe SE, Cranford JA, Young A. Adolescents' motivations to abuse prescription medications. Pediatrics 2006;118:2472-80.

Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan abuse in adolescence: an increasing trend: 1999-2004. Arch Pediatr Adolesc Med 2006;160:1217-22.

Hertz JA, Knight JR. Prescription drug misuse: a growing national problem. Adolesc Med Clin 2006;17:751-69; abstract xiii.

Joffe A. Your role in curbing prescription and OTC drug abuse by adolescents. Contemp Pediatr 2006;23(10):97-8, 100-1.

Kaminer Y. Problematic use of energy drinks by adolescents. Child Adolesc Psychiatr Clin N Am 2010;19:643-50.

McCabe SE, Boyd CJ, Cranford JA, Teter CJ. Motives for nonmedical use of prescription opioids among high school seniors in the United States: self-treatment and beyond. Arch Pediatr Adolesc Med 2009;163:739-44.

McCabe SE, West BT, Cranford JA, Ross-Durow P, Young A, Teter CJ, et al. Medical misuse of controlled medications among adolescents. Arch Pediatr Adolesc Med 2011;165:729-35.

Rogers PD, Copley L. The nonmedical use of prescription drugs by adolescents. Adolesc Med State Art Rev 2009;20:1-8, vii.

Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011;127:511-28.

Williams JF, Kokotailo PK. Abuse of proprietary (over-the-counter) drugs. Adolesc Med Clin 2006;17:733-50; abstract xiii.

Wu LT, Ringwalt CL, Mannelli P, Patkar AA. Prescription pain reliever abuse and dependence among adolescents: a nationally representative study. J Am Acad Child Adolesc Psychiatry 2008;47:1020-9.

Books for Professionals

Essau C, editor. Adolescent addiction: epidemiology, assessment, and treatment. Boston (MA): Academic Press; 2008.

Gilvarry E, McArdle P, editors. Alcohol, drugs and young people: clinical approaches. London (UK): Mac Keith Press; 2007.

Kaminer Y, Bukstein OG, editors. Adolescent substance abuse: psychiatric comorbidity and high-risk behaviors. New York (NY): Routledge; 2008.

Keegan K, Moss HB. Chasing the high: a firsthand account of one young person's experience with substance abuse. New York (NY): Oxford University Press; 2008.

Winters KC, editor. Adolescent substance abuse: new frontiers in assessment [special issue]. J Child Adolesc Subst Abuse 2006;16(1).

Books for Parents/Older Adolescents

Babbit N. Adolescent drug and alcohol abuse: how to spot it, stop it, and get help for your family. Sebastopol (CA): O’Reilly & Associates; 2000.

Califano JA Jr. How to raise a drug-free kid: the straight dope for parents. New York (NY): Simon & Schuster; 2009.

Cermak TL. Marijuana: what’s a parent to believe? Center City (MN): Hazelden; 2003.

Karson J. Teen addiction. Detroit (MI): Greenhaven Press; 2006.

Ketcham K, Pace NA. Teens under the influence: the truth about kids, alcohol, and other drugs: how to recognize the problem, and what to do about it. New York (NY): Ballantine Books; 2003.

Merino N. Introducing issues with opposing viewpoints: marijuana. Detroit (MI): Greenhaven Press; 2011.

Nelson DE. Teen drug abuse. Detroit (MI): Greenhaven Press; 2010.

Sheff N. Tweak: growing up on methamphetamines. New York (NY): Atheneum Books for Young Readers; 2008.

Sheff N. We all fall down: living with addiction. New York (NY): Little, Brown; 2011.

Tardiff J, editor. Marijuana. Detroit (MI): Greenhaven Press; 2008.

Books for Adolescents

Clayton L. Working together against drug addiction. New York (NY): Rosen; 1996.

Croft J. Drugs and the legalization debate. Rev. ed. New York (NY): Rosen; 2000.

Lobo IA. Inhalants. Philadelphia (PA): Chelsea House Publishers; 2004.

Loonin M. Legalizing drugs. Detroit (MI): Lucent Books; 2006.

Magill E, editor. Drug information for teens: health tips about the physical and mental effects of substance abuse. 3rd ed. Detroit (MI): Omnigraphics; 2011.

Mass W. Teen drug abuse. San Diego (CA): Lucent Books; 1998.

Menhard FR. The facts about inhalants. New York (NY): Benchmark Books; 2005.

Packer AJ. Wise highs: how to thrill, chill and get away from it all without alcohol or other drugs. Minneapolis (MN): Free Spirit; 2006.

Organization/Websites

American Academy of Family Physicians
www.aafp.org/online/en/home.html

Information on Substance Abuse
http://familydoctor.org/familydoctor/en/diseases-conditions/substance-abuse.html

American Academy of Pediatrics
www.aap.org

Levy S, Knight JR. Office management of substance abuse. Adolesc Health Update 2003;15(3):1-8.
Pamphlets: Inhalant abuse: your child and drugs
      Substance abuse prevention: what every parent needs to know
      Testing your teen for illicit drugs: information for parents

Channing-Bete Company
www.channing-bete.com

Booklet: Prescription drug abuse: get the facts

Drug Strategies
www.drugstrategies.org

ETR Associates
www.etr.org

Pamphlets: Drugs: talking with your teen
      Marijuana
      Prescription drug abuse

Krames
www.krames.com

Pamphlet: Alcohol and drug use

National Center on Addiction and Substance Abuse at Columbia University
www.casacolumbia.org

National Center on Addiction and Substance Abuse at Columbia University. Adolescent substance use: America’s #1 public health problem. New York (NY): CASA; 2011. Available at: http://www.casacolumbia.org/download.aspx?path=/UploadedFiles/enfchozt.pdf. Retrieved December 1, 2011.

National Institute on Drug Abuse
www.nida.nih.gov/nidahome.html
NIDA for Teens
www.teens.drugabuse.gov

National Institute on Drug Abuse. Preventing drug use among children and adolescents: a research-based guide for parents, educators, and community leaders. 2nd ed. NIH Publication No. 04-4212(A). Bethesda (MD): NIDA; 2003. Available at: http://drugabuse.gov/pdf/prevention/RedBook.pdf. Retrieved December 6, 2011.

Booklet: Drug facts: shatter the myths

The Prevention Researcher
www.tpronline.org/index.cfm

Adolescent substance abuse: prevention, intervention, and recovery. Prev Res 2011;18(2).
Fullwood H, Ginther DW. Inhalant abuse: the silent epidemic. Prev Res 2000;7(3):1-3.
Adolescent Prescription Drug Abuse. Prev Res 2012;19(1).

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

Booklet:What is substance abuse treatment: a booklet for families

Contact:

Caitlin Phelps, MA
Director of Gynecology
clinical@acog.org

Lyndona Charles
Special Assistant, Gynecology and Ethics
lcharles@acog.org