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Substance Use in Adolescents


Sharon Levy

, MD, MPH, Harvard Medical School

Reviewed/Revised Jul 2022 | Modified Oct 2022

Substance use among adolescents ranges from experimentation to severe substance use disorders Overview of Substance-Related Disorders Medications and other substances, whether used for legitimate medical purposes, as a habit (for example, caffeine), or recreationally, are an integral part of everyday life for many people ... read more . All substance use, even experimental use, puts adolescents at risk of short-term problems, such as accidents, fights, unwanted sexual activity, and overdose Overdose Toxicity Overdose toxicity refers to serious, often harmful, and sometimes fatal toxic reactions to an accidental overdose of a medication (because of an error on the part of the doctor, pharmacist,... read more . Substance use also interferes with adolescent brain development. Adolescents are vulnerable to the effects of substance use and are at increased risk of developing long-term consequences, such as mental health disorders Overview of Mental Health Disorders Children and Adolescents Several important mental health disorders, such as depression, anxiety disorders, and eating disorders, often start during childhood and adolescence. Some disorders, such as autism, start only... read more , underachievement in school, a substance use disorder, and higher rates of addiction, if they regularly use alcohol, cannabis (marijuana), nicotine, or other drugs during adolescence.

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 many adolescents will try alcohol before high school graduation. Recurring or ongoing substance use is much less common, but 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.

According to national surveys in the United States, the proportion of 12th graders who report they have not used any substances in their lifetime has been steadily increasing over the past 40 years. However, at the same time, a broad range of more potent, addictive, and dangerous products, such as prescription opioids, high-potency cannabis products, fentanyl, and e-cigarettes, has become available. These products put adolescents who do start using substances at higher risk of developing both short- and long-term consequences.

The COVID-19 COVID-19 COVID-19 is an acute respiratory illness that can be severe and is caused by the coronavirus named SARS-CoV-2. Symptoms of COVID-19 vary significantly. Two types of tests can be used to diagnose... read more pandemic had a mixed impact on adolescent substance use. During stay-at-home periods, the rate of adolescents who started to use substances decreased, but, at the same time, the rate of heavy use increased because some adolescents who were already using substances increased their use as a mechanism for coping with stress.

The substances that are used most by adolescents are alcohol, nicotine (in tobacco or vaping products), and cannabis.

Alcohol Use in Adolescents

Alcohol use is common and is the substance most often used by adolescents. The Monitoring the Future Survey on Drug Use is a long-term study of substance use conducted by the U.S. National Institute on Drug Abuse. This survey reported that in 2021 in the United States, 54% of 12th graders had tried alcohol, and 26% had consumed alcohol in the past month and were considered current drinkers. About 39% of 12th graders said they had ever been drunk. Heavy alcohol use is also common, and nearly 90% of all alcohol consumed by adolescents occurs during a binge. A binge is defined as a pattern of alcohol consumption that raises the blood alcohol level to 80 milligrams per deciliter (17.37 millimoles per liter). 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. However, because adolescents often drink alcohol directly from the bottle or pour their own drinks, a drink for them may be larger than a "standard" drink for adults. Binges put adolescents at risk of accidents, injuries, unprotected or unwanted sexual activity, and other unfortunate situations. For these reasons, adolescents should be discouraged from drinking.

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 Alcohol Use Alcohol (ethanol) is a depressant (it slows down brain and nervous system functioning). Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma,... read more . 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 began smoking Smoking and Other Tobacco Use Tobacco use is a major individual and public health problem. Using tobacco is harmful to almost every organ in the body. Tobacco is used because of the effects of nicotine. Nicotine is highly... read more during adolescence. If adolescents do not try cigarettes before age 19, they are very unlikely to become smokers as adults.

Combustible tobacco products are products that need to be burned so they can be consumed, for example, cigarettes, cigars, and hookahs. 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), which was down from 28.3% in 1991 and from 5.7% in 2019. Only about 2% of 12th graders reported smoking every day.

The strongest risk factors for adolescent smoking are

  • Having parents who smoke

  • Having peers and role models (such as celebrities) who smoke

Other risk factors often associated with starting smoking during childhood include

  • 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 substances)

  • Poor problem-solving abilities

  • Availability of cigarettes

  • Poor self-esteem

Pipe smoking is relatively rare in the United States. The percentage of people over age 12 who smoke cigars has declined.

Adolescents may also use tobacco products in other forms. About 2% of high school students are current users of smokeless tobacco, and this rate has declined over the past 10 years. Smokeless tobacco Smoking and Other Tobacco Use can be chewed (chewing tobacco), placed between the lower lip and gum (dipping tobacco, or dip), or inhaled into the nose (snuff).

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 Changing behavior Most people who smoke want to quit and have tried doing so with limited success. Effective tools to help quit smoking include counseling, nicotine replacement products, and medications. While... read more .

Electronic Cigarettes (Vaping Products)

Electronic cigarettes (e-cigarettes, e-cigs, vapes) are battery-operated devices that use heat to turn a liquid into a vapor that can be inhaled. These liquids typically contain nicotine, which is the active ingredient in tobacco, or tetrahydrocannabinol (THC), which is the active ingredient in cannabis. Both nicotine and THC are addictive. (See also Vaping Vaping Vaping refers to inhaling vapor (volatilized liquid) produced by battery-powered devices. The vapor can contain nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances... read more .)

E-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 social and economic 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.

E-cigarettes cause different negative health effects than smoking tobacco Long-term effects Tobacco use is a major individual and public health problem. Using tobacco is harmful to almost every organ in the body. Tobacco is used because of the effects of nicotine. Nicotine is highly... read more . However, like regular cigarettes, chemicals contained in e-cigarettes can cause lung injuries. Lung injuries can be sudden, severe, or long-lasting and, when most severe, lethal. In addition, these products can deliver very high concentrations of nicotine and THC. THC and nicotine are highly addictive, and toxicity is possible. Secondhand vapor from e-cigarettes exposes people to nicotine and other chemicals.

E-cigarettes are increasingly the initial form of exposure for adolescents to nicotine, but their effect on the rate of adult smoking is unclear. The long-term risks of e-cigarettes are not currently known.

Cannabis (Marijuana)

The Monitoring the Future Survey reported that in 2021 19.5% of 12th graders were current cannabis Marijuana Marijuana (cannabis) is a drug made from the plants Cannabis sativa and Cannabis indica that contain a psychoactive chemical called delta-9-tetrahydrocannabinol (THC). Marijuana... read more users, which is a decrease from 22.3% in 2019. About 38.6% of 12th graders reported having used cannabis one or more times in their life. 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 Electronic Cigarettes (Vaping Products) Substance use among adolescents ranges from experimentation to severe substance use disorders. All substance use, even experimental use, puts adolescents at risk of short-term problems, such... read more ). This percentage decreased slightly to 12.4% in 2021.

Other Substances

Use of substances other than alcohol, nicotine, and cannabis during adolescence is less common.

In the 2021 Monitoring the Future Survey, the following percentages of 12th graders reported using illicit substances one or more times in their life:

Although anabolic steroid Anabolic Steroids Anabolic steroids are synthetic (man-made) versions of testosterone that are used to increase muscle size. Anabolic steroids are hormones that promote muscle growth and increase strength and... read more use is more common among athletes, non-athletes use them too. Use of anabolic steroids is associated with a number of side effects. A problem specific to adolescents includes 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.

Nonprescription, over-the-counter (OTC) drugs that are commonly misused include cough and cold drugs that contain dextromethorphan. OTC cough and cold drugs are widely available and are considered safe by many adolescents and now serve as gateway drugs. Gateway drugs are introductory substances that can increase the likelihood of other drug use and the risk of substance use disorders later on. Other gateway drugs include cigarettes, alcohol, and cannabis.

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 Overview of Substance-Related Disorders Medications and other substances, whether used for legitimate medical purposes, as a habit (for example, caffeine), or recreationally, are an integral part of everyday life for many people ... read more .

Diagnosis of Substance Use in Adolescents

  • A doctor's evaluation, including routine screening and use of screening tools

  • Sometimes a drug test

There are behavioral and physical signs that a child may be using drugs, other substances, or both. Knowing the signs can help parents and caregivers determine whether their child should be seen by a health care professional.

Some behavioral signs of possible drug or substance use:

  • Erratic behavior

  • Depression or mood swings, change in attitude

  • Acting paranoid, irritable, or anxious

  • Having difficulty staying on task or staying focused

  • Stealing, lying

  • Becoming secretive, locking bedroom door

  • A change in friends

  • Declining school performance

  • Loss of interest in hobbies

  • Acting aggressive or angry or irresponsibly

  • Sleeping more or less than usual

  • Missing school, sports, or work

Some physical signs of possible drug or substance use:

  • Poor hygiene/change in appearance

  • Glazed, watery, or bloodshot eyes

  • Pupils larger (dilated) or smaller (constricted) than usual

  • Frequent nosebleeds or runny nose

  • Sores in the mouth, on the lips, or both

  • Puffy face

  • Small (due to needle use) on arms or legs, wearing long sleeves (even in warm weather)

  • Shaking hands or cold, sweaty palms

  • Headaches

  • Fidgeting

  • Shakes or tremors

  • Sudden weight loss

Parents also should be concerned about possible drug or substance use if they find drugs or drug paraphernalia (such as vapes, pipes, syringes, and scales) among their child's possessions.

During routine health care visits Preventive Health Care Visits in Adolescents Annual health care visits (also called well-child visits) allow doctors and other health care professionals to monitor physical growth and sexual maturation (puberty) and provide advice and... read more , parents should expect their child’s doctor to screen their child for substance use by asking confidential questions about tobacco/nicotine, alcohol, and other drug use. Screening tools are used for adolescents age 12 to 17. These brief tools may be self-administered by an adolescent or may be administered by a doctor or other health care practitioner. The tools begin with questions about frequency of use of tobacco, alcohol, and cannabis in the past year. Additional related questions are generated based on the adolescent's responses. Screening tools can help doctors and other practitioners assess whether an adolescent has a substance use disorder or is at risk of developing a substance use disorder and implement an appropriate intervention or make a referral for treatment.

Drug tests (including at-home tests) may be a useful part of an assessment but have 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 (false-positive). Even a true-positive test does not indicate how often and how heavily a drug is used and thus cannot distinguish casual use from more serious problems.

Given these limitations, a doctor with expertise in this area should determine whether a drug test is needed in a given situation. When parents maintain their child’s confidentiality, they make it easier for a doctor to obtain an accurate substance use history and form a trusting relationship with their child.

Treatment of Substance Use in Adolescents

  • Therapy tailored for adolescents

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 Treatment Substance use disorders generally involve behavior patterns in which people continue to use a substance (for example, a recreational drug) despite having problems caused by its use. The substances... read more , including therapeutic drugs and counseling, 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 and should not be treated in the same programs as adults.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

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