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Substance Use and Abuse in Adolescents

By Sharon Levy, MD, MPH, Harvard Medical School;Children's Hospital, Boston

Substance use among adolescents ranges from experimentation to severe substance use disorders (see Overview of Substance-Related Disorders). All substance use, even experimental use, puts adolescents at risk of short-term problems, such as accidents, fights, unwanted sexual activity, and overdose. Adolescents are vulnerable to the effects of substance use and are at increased risk of developing long-term consequences, such as mental health disorders, underachievement in school, and a substance use disorder.

In modern Western society, substance use is an easy way for adolescents to satisfy the normal developmental need to take risks and seek thrills. Not surprisingly, substance use is common as adolescents get older, and about 70% of adolescents will try alcohol before high school graduation. However, recurring or ongoing substance use is much less common. Even occasional substance use is risky and should not be trivialized, ignored, or allowed by adults. Parental attitudes and the examples that parents set regarding their own use of alcohol, tobacco, prescription drugs, and other substances are a powerful influence.

Alcohol Use in Adolescents

Alcohol is the substance most often used by adolescents. About 70% of 12th graders report having tried alcohol, although only 55% say they have ever been drunk. About 50% of 12th graders have consumed alcohol in the past month and are considered current drinkers. Heavy alcohol use is also common, and nearly 90% of all alcohol consumed by adolescents occurs during a binge. A binge is generally considered to be consuming more than 4 drinks within 2 hours or less. However, for small people, such as younger girls, as few as 2 drinks may cause enough intoxication to be considered a binge. Binges put adolescents at risk of accidents, injuries, unwanted sexual activity, and other unfortunate situations. For these reasons, adolescents should be discouraged from drinking.

Society and the media portray drinking as acceptable or even fashionable. 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. 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 Use in Adolescents

The majority of adults who smoke cigarettes begin smoking during adolescence. Even young children may experiment with cigarettes. Nearly one fifth of 9th graders report smoking regularly. In the United States, more than 2,000 people begin smoking every day. Of these new smokers, 31% are under age 16 and more than 50% are under age 18. If adolescents do not try cigarettes before age 19, they are very unlikely to become smokers as adults.

The single strongest risk factor for adolescent smoking is

  • Having parents who smoke

Other risk factors often associated with starting smoking during childhood include

  • Peers and role models (such as celebrities) who smoke

  • Poor school performance

  • Other high-risk behavior (such as excessive dieting, particularly among girls; physical fighting and drunk driving, particularly among boys; or use of alcohol or other drugs)

  • Poor problem-solving abilities

  • Availability of cigarettes

  • Poor self-esteem

Adolescents may also use tobacco in other forms. About 3.3% of people 18 and older and about 7.9% of high school students use smokeless tobacco. 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 United States, but use has increased among middle and high school students since 1999. The percentage of people over 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 Cessation in children and adolescents).

Electronic cigarettes

Electronic cigarettes (e-cigarettes, vapes) have also been increasing in popularity and may be mislabeled as safe alternatives to cigarettes. E-cigarettes contain liquid nicotine, which is the highly addictive part of tobacco. The liquid may contain small amounts of toxins, the effects of which are not currently known. Second-hand vapor from e-cigarettes contains both nicotine and other toxins. The majority of adolescents who use e-cigarettes also use traditional tobacco products. Thus e-cigarettes have become a new gateway to smoking.

Other Substances

Marijuana use is on the rise and recently surpassed tobacco use. Inhalant use (huffing—see Solvent Inhalants) is also a problem, particularly among young adolescents.

Prescription drugs, particularly opioid (narcotic) pain relievers, antianxiety drugs, and stimulants (such as methylphenidate and similar drugs used for attention-deficit disorder—see also Attention-Deficit/Hyperactivity Disorder (ADHD)), and nonprescription, over-the-counter (OTC) drugs (such as cough and cold drugs) are now misused by adolescents more than any other substance other than alcohol and marijuana. In 2013, about 18% of students had taken a prescription drug without a doctor's prescription at some time in their life. OTC cough and cold drugs that contain dextromethorphan are used by adolescents to get high. These drugs are widely available and are considered safe by many adolescents and now serve as gateway drugs. Even young adolescents may try drugs, with some reporting drug use as early as age 12. Many adolescents who experiment with OTC, prescription, and other substances go on to develop substance use disorders.

Other substances of abuse include

  • Amphetamines and methamphetamines

  • Inhalants

  • Cocaine

  • Anabolic steroids

  • Opioids

  • Hallucinogens (PCP [phencyclidine], LSD [lysergic acid diethylamide], and some kinds of mushrooms)

  • So-called club drugs (MDMA [methylenedioxymethamphetamine], Ecstasy, or Molly) and GHB (gamma hydroxybutyrate)

In 2007, about 47% of 12th graders had used an illicit substance at some time in their life, and 25% had used a drug other than marijuana.

About 3% of 12th graders have used anabolic steroids (see Anabolic Steroids) in their lifetime. Although steroid use is more common among athletes, non-athletes are not immune. Use of anabolic steroids is associated with a number of side effects, including premature closure of the growth plates at the ends of bones, resulting in permanent short stature. Other side effects are common to both adolescents and adults.

Behaviors that should prompt parents to discuss their concerns with their child and doctor include

  • Erratic behavior

  • Depression or mood swings

  • A change in friends

  • Declining school performance

  • Loss of interest in hobbies

Parents who find drugs or drug paraphernalia (such as pipes, syringes, and scales) should discuss their concerns with their child.

During routine health care visits, parents should expect their child’s doctor to ask their child confidential questions about substance use. Doctors can help assess whether an adolescent has a substance use disorder and implement an appropriate intervention or make a referral. A drug test may be a useful part of an assessment but has significant limitations. Results of a urine test may be negative in adolescents who use drugs if the drug has been cleared from the body before the test is done, if a drug not included on a standard testing panel has been used, or if the urine specimen has been contaminated. Sometimes, drug test results are positive in adolescents who have not used drugs. Given these limitations, a doctor with expertise in this area should determine whether a drug test is needed in a given situation, and parents should respect their doctor’s advice. When parents demand a drug test or demand information that would break their child’s confidentiality, they may create an atmosphere of confrontation and accidentally make it difficult for a doctor to obtain an accurate substance use history and form a trusting relationship with their child.

If the doctor thinks the adolescent has a substance use disorder, a referral for further assessment and treatment may be needed. In general, the same treatment used for adults with substance use disorders (see Overview of Drug Abuse : Treatment) can also be used with adolescents. However, the treatment should be tailored to the adolescent's needs. Adolescents should receive services from adolescent programs and therapists with expertise in treating adolescents with substance use disorders. In general, adolescents should not be treated in the same programs as adults.

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