In this lecture, we will review the basics of substance abuse in adolescents. This is a huge topic
and we could never do it justice but we’ll cover the important areas. So, substance abuse
is a very prevalent problem in the United States. In substance abuse, we would define it as
the use of a drug which results in physical, psychological, financial, legal, or social distress.
In other words, it’s not substance use. It’s substance abuse. Substance dependence is when there is
substance abuse accompanied by tolerance withdrawal, unsuccessful efforts to stop, or continued abuse
despite awareness of having persistent problems related to that use. So, this is how we can distinguish
a child who’s for example abusing or dependent on a drug versus one who is experimenting.
Alcohol, tobacco, and marijuana are the most commonly used substances by adolescents in the US.
Roughly 1/3 of all 10th graders report the use of illicit drugs in the last year. Comorbid mental health
conditions are common among those who use substances. Adolescent development and drug use
is intertwined in many ways. Sometimes adolescents are more likely to use drugs because they in particular
can fail to recognize long term consequences of drug use. There is a lot of primary peer influence
and need for acceptance among adolescents which may drive increased likelihood of use.
Adolescents may struggle with autonomy or challenge of parental authority. They’re dealing with
becoming themselves and becoming their own person and relieving themselves of parental authority
and they’re making that transition. The drugs may make things feel transiently better, although in the end,
there may be long term consequences. In adolescents, sometimes we under recognize the role of
depression and mental health problems. Those can feel better transiently with drug use which drives up
use and abuse of these drugs. Also, adolescents naturally are in a stage in their lives
when they’re interested in experimenting, when they’re interested in taking risks.
So, when there is a feeling like taking a drug may be a risky thing to try but intriguing, they’re more likely
to do it than an adult in a similar circumstance. Causes of drug use and drug abuse are complex.
They involve genetic, neurobiologic, and social factors. Certainly, you may have a predisposition
to drug abuse if it runs in your family. But that may be both genetic and environmental.
There is increased concordance of drug abuse in monozygotic twins. So, there are some risk factors
environmentally though that can tip you off that a child may be at increased risk for drug abuse.
Examples would be parents or peers who use drugs, poor parental supervision, decreased impulse
control in that patient. An early age of first exposure or intoxication is likely to herald
a drug abuse problem. Mood or anxiety disorders commonly are associated with drug abuse.
Patients with conduct disorders or antisocial behaviors are more likely to use drugs.
When you have a patient where you want to intervene or want to find out if they’re using drugs,
it’s critically important to interview the adolescent alone. The presence of a parent is really
not even a screen for drug abuse. Before talking about drugs, it’s important to establish a trusting
and therapeutic relationship. So, you have to set the stage for sitting down and talking to an adolescent
and have them understand that you are a person who they can trust, who they can interact with
and for whom information is confidential. You also should establish upfront what information
will not be confidential such as if they disclose that they’re being abused or want to commit suicide.
Establish these rules upfront and therefore, you’ll engage in a trusting relationship
and then you can engage and discuss about drug abuse and other more personal questions.
When you get past that setting the stage moment, it’s important to ask other questions as well.
Ask about weight loss or mood swings. Are they having problems with sleep? Do they have a decline
in academic performance, school truancy, suspensions? These are all signs of drug abuse.
You can also use the CRAFT screening tool. The CRAFT screening tool is a mnemonic for things
that are putting children at risk for becoming drug abusers as opposed to experimenters.
So, C stands for car. Have you ever ridden in a car driven by someone including yourself who is high
or had been using alcohol or drugs? R stands for relax. Do you ever use alcohol or drugs to relax,
to feel better about yourself or fit in? A is alone. Do you ever use alcohol or drugs
while you are by yourself alone? F is friends. Do your family or friends ever tell you that you should
cut down on your drinking or drug use? And T is trouble. Have you ever gotten in trouble
while you were using drugs or alcohol? If a patient is responding yes to these questions,
they're at increased risk for having a problem with the drugs as opposed to just using them experimentally.
There are also some physical exam findings that you can see as a result of drug use.
For alcohol, patients are often disinhibited, will have slurred speech, ataxia, emotional ability,
and will report having blackouts where they have interacted in ways with people and have no memory
of that experience. For marijuana, patients generally develop euphoria. They may have red conjunctivae,
a dry mouth and throat, increased appetite, or impaired reaction time and with very frequent chronic use
may develop gynecomastia. For stimulants, patients are often hyperalert, restless, agitation.
Aggression is possible. They may have paranoia. Frequently while high, they have tachycardia
and hypertension. They may suffer arrhythmias. You will note dilated pupils. In severe cases,
they may have seizures. Patients on opioids tend to be drowsy or euphoric. They may have flushing
or a floating feeling. They may have constipation as a side effect of the medication.
They may have miosis or very small pupils. They can suffer respiratory depression and in severe cases,
hypotension or overdose may result in death. For hallucinogens, patients may develop dizziness,
a heightened sensual awareness, nausea, or hallucinations, or flushing, an elevated temperature,
tachycardia, and mydriasis. In inhalant use, you may notice dizziness, headaches, slurred speech,
sleepiness, lacrimation, rhinorrhea, mucous membrane irritation from the inhalants getting in their mouth,
ataxia, or impaired memory. So, let’s review the pupillary response because I think it’s important
to remember and it can be confusing. Miosis is pinpoint pupils. This is what you see in opiates.
Mydriasis in enlarged pupils. You see this typically in stimulants. The sluggish pupillary response
is present in barbiturates. A rotary nystagmus which is fairly unusual is something we see
specifically with PCP. You may see skin identifications which can tip you off that a patient is a drug user.
Certainly, track marks, a cellulitis, abscesses, or phlebitis are all signs of a patient who likes to inject drugs.
Patients with rhinitis, nasal septum damage, or a nasal septal perforation may be snorting drugs
such as especially cocaine. Mental status changes can be seen in patients with chronic cognitive changes
or acute distortions in reality. These are signs of chronic mental altering drugs. So, how do we diagnose
a patient with a substance abuse problem? Certainly, screening for other mental health problems
is important. We can do urine or blood drug testing. But it’s important not only just to test for drugs
but for test for problems that can come along with drugs. So, HIV testing is key both in patients
who are having unprotected sex because of poor decisions while high or in patients who may be sharing
needles in IV drug abuse. STD testing is often indicated in patients who use drugs as under the influence
of drugs were less likely to think about things like remembering to use a condom.
Testing should target a problem. We don’t necessarily just universally drug test.
Drug testing may be necessary if a patient is hospitalized or if there are legal considerations at foot.
But generally speaking, we don’t need to just do drug testing on adolescents as it may interfere
with our therapeutic relationship.