Substance Use Disorders

Description

Other Names

Addiction
Dependence on drugs
Substance abuse

Diagnosis Coding

ICD-10
Appropriate coding involves listing a specific substance, degree of dependence, and associated complications. Codes for specific substances are listed below, and the links lead to a comprehensive list of subcodes.

F10, alcohol related disorders
F11, opioid related disorders
F12, cannabis related disorders
F13, sedative, hypnotic, or anxiolytic related disorders
F14, cocaine related disorders
F15, other stimulant related disorders
F16, hallucinogen related disorders
F17, nicotine dependence
F18 inhalant related disorders
F19, other psychoactive substance related disorders.

DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) usually designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits including their codes or descriptions. [American: 2015]

Description

Substance use disorders (SUDs) are characterized by recurrent use of alcohol or drugs that causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Substance use occurs on a continuum from experimental or non-problematic through addiction.

Handing a Child Drugs-Children with Substance Use Disorders
Public Health England/Science Photo Library
Addiction typically starts during adolescence and occurs when the reward system is upregulated or hyper-stimulated. This results in enhanced dopamine function in the nucleus accumbens, which is often associated with forced release of other neurotransmitters. The massive dopamine shift results in euphoria; the release of neurotransmitters results in psycho-active and/or physical symptoms. The achieved euphoric state has then been “reset” as the reward center’s benchmark for attaining pleasure. There is also a significant behavioral component to the addictive process.

The medical provider maintains an important role in screening for drug use and providing anticipatory guidance, education about drugs of abuse, brief interventions, referrals to substance abuse treatment, ongoing monitoring, and follow-up. SUDs are frequently associated with other mental health issues that include mood disorders, anxiety disorders, ADHD, and impulse control disorders; therefore, identification of substance use warrants additional exploration and treatment of other mental health concerns.

Prevalence

The prevalence of SUDs among youth is difficult to estimate. Many national studies survey only students, but a number of at-risk youth do not regularly attend school. Clinicians may use procedure codes for treating symptoms of substance abuse, instead of codes for SUDS, and surveys tend to rely on only on self-reports, which are often under reported. According to the Monitoring the Future 2016 Survey (NIH), 14.3% of 8th, 10th, and 12th graders had used an illicit drug other than marijuana (including marijuana the number had increased to 32.6%) and 41.9% of students had tried alcohol in their lifetime (36.7% had used in the past year). In 2014, about 21.5 million Americans ages 12 and older (8.1%) were classified with a substance use disorder in the past year. [Han: 2015] See Trends in Drug Use, which tracks the annual prevalence of 31 substances.

Other health problems, such as having a chronic disease or intellectual disability, may increase an adolescent’s vulnerability to both substance use and its consequences. [Carroll: 2012]

Genetics

Family and twin studies suggest a genetic vulnerability to substance abuse initiation, continued use, and dependence. Studies of the genetics of addiction have identified several regions on chromosomes 4, 5, 9-11, and 17 that are likely to contain abuse susceptibility loci for multiple substances and involve vulnerabilities in the dopamine transporter system. Genes and Addiction (Genetic Science Learning Center) provides a sampling of the genes suspected to play a role in addiction.

Prognosis

While many young people experiment with substances without adverse effects, those who progress to substance abuse often develop social, mental, and physical problems. The long-term and sometimes short-term impact of substance abuse involves neurological, cardiovascular, renal, and hepatic changes. Other long-term impacts may involve the hematopoietic, immunologic, endocrine, dermatologic, dental, and gastrointestinal organ systems.

In addition, those with substance dependence or addiction have associated risks for poor peer relationships, depression, anxiety, and poor self-esteem. Teens engaging in high-risk behavior and substance use may experience unintended consequences, such as overdose, accidents involving injuries, physical altercations, school failure, legal difficulty, date rape, acquisition of sexually transmitted infection, and pregnancy. Adolescents who "experiment" by mixing drugs and pushing higher doses as addiction progresses are at a particularly high risk for medical sequelae and death.

Roles Of The Medical Home

Roles of the medical home provider include screening for drug use and providing anticipatory guidance, education about drugs of abuse, brief interventions, referrals to substance abuse treatment if necessary, and ongoing monitoring and follow-up.  [Levy: 2011]

The SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA) is a standardized approach used by primary care clinicians to target reduction of and abstinence from substance use. [Babor: 2017] [Levy: 2016] The tenets of the program are:
  • Screen with a short, well-tested questionnaire to identify risk. (The Screening section, below, provides links to validated screens.)
  • Brief Intervention is provided to reduce drug use and other risky behaviors. Intervention may involve education on how continued drug use may harm the brain, general health, relationships, and education. For a short table of intervention goals, please see Substance Use Spectrum and Goals for Office Intervention (AAP), which is Table 1 from [Levy: 2016].
  • Refer for in-depth assessment, diagnosis, and treatment as needed. (see all Substance Use Disorder Treatment services providers (8) in our database and Services, at the end of this module, for lists of providers.)
Motivational Interviewing (SAMHSA) is a technique used to explore and strengthen an individual's personal motivation for change. This technique relies on a partnership between the patient and clinician, rather than the clinician or external authorities imposing or mandating change. It involves using empathy, open-ended questioning, and reflective listening to help the patient weigh the pros and cons of different behaviors. By working at the patient's pace, planning for and achieving small realistic goals, and understanding that motivation to change fluctuates, the provider is able to help patients plan for success and help support during relapse. [Levensky: 2007]

In addition, the medical home clinician should screen for comorbid physical and mental illnesses, provide ongoing preventive care, and communicate with the substance abuse and/or mental health treatment team to ensure that all providers have current information regarding health and substance use status. For patients in treatment, clinicians can offer ongoing support of treatment participation and abstinence from drugs during follow-up visits. [National: 2014]

Practice Guidelines

Levy S, Williams J, Committee on Substance Use and Prevention.
Substance Use Screening, Brief Intervention, and Referral to Treatment.
Pediatrics. 2016;138(1). PubMed abstract

Bukstein OG, Bernet W, Arnold V, Beitchman J, Shaw J, Benson RS, Kinlan J, McClellan J, Stock S, Ptakowski KK.
Practice parameter for the assessment and treatment of children and adolescents with substance use disorders.
J Am Acad Child Adolesc Psychiatry. 2005;44(6):609-21. PubMed abstract / Full Text

Helpful Articles

PubMed search for adolescent substance use, last 1 year.

Seidel S, Böck A, Schlegel W, Kilic A, Wagner G, Gelbmann G, Hübenthal A, Kanbur I, Natriashvili S, Karwautz A, Wöber C, Wöber-Bingöl C.
Increased RLS prevalence in children and adolescents with migraine: A case-control study.
Cephalalgia. 2012. PubMed abstract

Riggs PD.
Treating adolescents for substance abuse and comorbid psychiatric disorders.
Sci Pract Perspect. 2003;2(1):18-29. PubMed abstract / Full Text

Brust JC.
Neurologic complications of illicit drug abuse.
Continuum (Minneap Minn). 2014;20(3):642-56. PubMed abstract

Winters KC, Kaminer Y.
Screening and assessing adolescent substance use disorders in clinical populations.
J Am Acad Child Adolesc Psychiatry. 2009;47(7):740-4. PubMed abstract / Full Text

Sanchez-Samper X, Knight JR.
Drug abuse by adolescents: general considerations.
Pediatr Rev. 2009;30(3):83-92; quiz 93. PubMed abstract

Clinical Assessment

Screening

For The Condition

The American Academy of Pediatrics recommends that clinicians screen adolescents 10 years and older for substance abuse during routine clinical care. [American: 2011] These short, well-tested screens and the scoring instructions can be downloaded or printed for free:
  • ASSIST (WHO): The Alcohol, Smoking, and Substance Involvement Screening Test contains 8 questions that relate to 10 substances; a clinician-administered version and a self-report version are provided.
  • S2BI (Boston Children's Hospital) (PDF Document 126 KB): The Screening to Brief Intervention tool has 7 questions about frequency of use. It is based on DSM-5 diagnoses for SUDs.
  • CRAFFT (CeASAR) (PDF Document 32 KB): The Car, Relax, Alone, Forget, Friends, Trouble screen has 6 questions developed to screen adolescents for high-risk alcohol and other drug use disorders. A clinician-administered version and a self-report version are provided. The American Academy of Pediatrics suggests that using this tool after a "yes" response from another screen may help reveal the extent of the patient's substance use problems. [Levy: 2016]
  • AUDIT (WHO) (PDF Document 13 KB): The Alcohol Use Disorders Identification Test is a 10-item screening tool that assesses alcohol consumption, drinking behaviors, and alcohol-related problems.
  • DAST-10 (PDF Document 161 KB) The Drug Abuse Screening Test is a 10-item screen that assesses drug use, not including alcohol or tobacco use, in the past 12 months. A clinician-administered version and a self-report version are provided.
Choice of screen will depend upon a practitioner's level of comfort with the tool. The Substance Abuse and Mental Health Services Administration recommends routine SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA). A 2013 report by SAMHSA found that only 10% of patients over age 12 with SUDs actually received specialty treatment. [Substance: 2014]

Of Family Members

A salient family history of addiction and mental health problems is often helpful, but no formal screening is currently recommended.

For Complications

SUDs are often comorbid and exacerbate underlying mental health issues, such as ADHD, antisocial personality disorder, major depression, eating disorders, posttraumatic stress disorder, and anxiety disorders. SUDs may also mimic symptoms of a mood or anxiety disorder. Screening for complications in a simplified and systematic manner can bring to light significant changes or ominous risk factors.
  • Screening for Complications of Drug Use (PDF Document 81 KB) provides screening ideas with sample questions.
  • H.E.A.D.S.S. (PDF Document 72 KB) is a psychosocial interview that contains questions about Home, Education, Activities, Drug and alcohol use, Sexuality, and Suicide.
  • SSHADESS (PDF Document 60 KB) is an interview framework that asks questions about Strengths, School, Home, Activities, Drug use, Emotions, Sexuality, and Safety. It underscores resiliency by identifying the patient's perceived and realized strengths before exploring environmental context and risks.
For more tools that may be useful if additional concern is raised based on in-office questioning, see: Adolescents who use substances are at increased risk of engaging in other high-risk behaviors, and screening for pregnancy, sexually transmitted infections, and other medical sequelae may also be warranted. Also, please see Oral Health (Dental) Screening & Prevention.

Presentations

Adolescents in the early stages of substance use typically have few adverse consequences, but are at risk for acute intoxication effects due to rapid consumption of toxic quantities.

Symptoms of intoxication, acute use, and withdrawal: Signs of early substance use or experimentation:
  • Increased or decreased need for sleep
  • Changes in appetite with sudden weight loss or gain
  • Slurring of speech or impaired coordination
  • Engaging in secretive behaviors
  • Changes in school or work performance
  • Glazed or bloodshot eyes; unusually large or small pupils
  • Characteristic odor of alcohol, marijuana, or inhalants
  • Changes in peer group, activities, and hobbies
Signs in the later stages of substance abuse:
  • School failure or truancy
  • Changes in dress, behavior, and peer groups
  • Relationship difficulties
  • Injuries/motor vehicle accidents
  • Sexual assault or sexual acting out
  • Legal difficulties
  • Personality and emotional changes
  • Cognitive changes

Diagnostic Criteria

A SUDs diagnosis is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. Each SUD is divided into mild, moderate, and severe subtypes. A person who meets at least 2 criteria is diagnosed with a SUD. The severity subtype of the disorder is determined by the specific number of the following criteria that is met:
  • Taking the substance in larger amounts or for a longer time than intended
  • Wanting to cut down or stop use, but not managing to
  • Spending a lot of time getting, using, or recovering from use of the substance
  • Experiencing cravings and urges to use the substance
  • Not managing responsibilities because of substance use
  • Continuing to use, even when it causes problems in relationships
  • Giving up important activities because of substance use
  • Using substances again and again even though it leads to being put in dangerous situations
  • Continuing to use while knowing a physical or psychological problem could have been caused or is made worse by the substance
  • Needing more of the substance to get the desired effect (tolerance)
  • Taking more of the substance to relieve withdrawal symptoms

Clinical Classification

Clinicians may encounter various levels of drug use or nonuse:
  • Abstinence: No use of any psychoactive substances
  • Experimental use: Occasional use of any psychoactive substance, used typically with peers
  • Non-problematic use: Intermittent, continuing use of alcohol or drugs without negative consequences
  • Problematic use: Adverse consequences occur as a result of substance use (school difficulties, relationship problems, injuries, legal difficulties); some can still reduce or stop their use with limited intervention.
  • Addiction: Encompasses not only physical dependence and cravings, but also the maladaptive psychosocial consequences resulting from use and behaviors that an individual engages in to obtain a substance
  • Physical dependence: Physiologic changes that occur from continued use of a substance and drive cravings and ongoing use
  • Withdrawal: Occurs from abruptly stopping heavy or prolonged use
  • Remission: Cessation of use after diagnosis of a SUD

Differential Diagnosis

Differential diagnoses vary according to the presenting symptom(s):
  • Inattentiveness and a decline in school performance may be due to ADHD, anxiety, lead poisoning, depression, sleep disorder, abuse/trauma, chronic illness, or hypothyroidism. Dissociation, or an appearance of inattentiveness with a subjective feeling of being detached from oneself, may be seen with severe anxiety or trauma.
  • Hyperactivity, agitation, and irritability may be related to depression, anxiety, bipolar disorder, hyperthyroidism, hyperparathyroidism, abuse/trauma, iatrogenic effect, or ADHD.
  • Hallucinations and disorganized behaviors may be seen in mood disorders (depression or bipolar) with psychotic features, psychotic disorders such as schizophrenia, metabolic disturbances, delirium, catatonia, or neurological conditions.
  • Weight loss or gain may be seen with depression, anxiety, eating disorders, metabolic disorders, or endocrine problems.
  • Sleep changes may be due to depression, bipolar, anxiety, psychotic disorders, primary sleep disorders, metabolic problems, endocrine problems, and many other medical issues.
  • Consider unintentional ingestion of illicit substances in young children or patients with developmental disabilities, particularly if others in the home or the peer group use drugs.

Comorbid Conditions

SUDs may cause or exacerbate underlying mental health conditions and vice versa. [Essau: 2011] Antisocial personality disorder is more common in men, while women have higher rates of major depression, posttraumatic stress disorder, and other anxiety disorders. The coexistence of a SUD and at least one other psychiatric disorder is known as dual diagnosis. Approximately 70-80% of adolescents with SUDs meet criteria for dual diagnosis. [Kaminer: 2007]

Additional mental health disorders that are associated with SUDs include:
  • Anxiety disorders
    • ~30-35% of patients with generalized anxiety disorder will have a comorbid SUD [Simon: 2009]
  • Trauma-related disorders, such as post-traumatic stress disorder
  • Attention deficit/hyperactivity disorder, if untreated (children with ADHD that is diagnosed and treated appropriately are less likely to develop SUD than those with untreated ADHD) [Wilens: 2008]
  • Conduct disorder
    • >50% of children and adolescents with conduct disorder also meet criteria for SUDs [Reebye: 1995]
  • Depression (suicidality)
  • Bipolar disorder
    • ~30-50% of children and adolescents with bipolar disorder will develop SUDs [Wilens: 2004]
  • Eating disorders
    • ~13% of patients with anorexia and 20% patients with bulimia and binge eating disorders have comorbid SUDs [Swanson: 2011]
  • Psychotic disorders
    • 3 to 5 times more likely than in the general population [Wu: 2011]
  • Autism spectrum disorder without ADHD or intellectual disability
    • 2 times the risk of substance use than the general population [Butwicka: 2017]
Comorbid medical conditions and high-risk behaviors related to SUDs include:
  • Pregnancy
  • Sexually transmitted infection (gonorrhea, chlamydia, herpes, syphilis, HIV, hepatitis B)
  • Hepatitis C and HIV transmission (with intravenous drug use)
  • Dermatologic abscesses
  • Thrombophlebitis and bacterial endocarditis
  • Organ impairment and damage (skin, heart, kidneys, liver, dental, nutritional stores)

Pearls & Alerts

Poor validity of CAGE assessment in adolescents

The CAGE questions include 4 parameters: feeling the need to Cut down on use, feeling Annoyed when others comment on use, feeling Guilty about use, and needing an Eye opener (a drink first thing in the morning). Although commonly used in adult populations for assessing alcohol use disorders, the CAGE screen has poor validity in children and adolescents. [Knight: 2003]

Disclosure laws: Strict adherence is mandated and serious financial penalties applied

Federal law (42 CFR 2.14 - Minor Patients (LII) (PDF Document 22 KB)) prohibits the oral or written disclosure of any information that could identify a patient, adult or minor, as a drug or alcohol abuser. Thus, it protects diagnostic information, such as urinalysis results, verbal communications, printed medical records, and any type of confirmation that a patient is receiving treatment. Providers only may disclose drug or alcohol treatment records to parents if the following 3 conditions are met:

  1. The minor’s situation poses a substantial threat to the life or physical well-being of the minor or another person.
  2. This threat may be reduced by communicating relevant facts to the minor’s parents.
  3. The minor lacks the capacity, because of extreme youth or a mental or physical condition, to make a rational decision on whether to disclose to the parents.
A minor must sign consent prior to release of information that indicates substance abuse, even to his or her parent or guardian.

Suicide risk

SUDs are an independent risk factor for increased suicidality and suicide completion. Suicide and Suicide Attempts in Adolescents (AAP) [Shain: 2016] has information about how clinicians can approach and evaluate youth who may be at risk for suicide. Also, please see the Portal's page about Suicidality.

History & Examination

Family History

Focus questions on substance abuse and mental health disorders in other family members. Parental alcohol or drug use is a strong predictor of substance abuse in offspring. Additionally, parental substance use may result in prenatal substance exposure, receiving inadequate medical care, and significant psychosocial stressors related to substance use. [Smith: 2016] The presence of mental health disorders in family members (e.g., conduct disorder, bipolar disorder) may suggest comorbid psychopathology.

Pregnancy Or Perinatal History

Ask about a history of pregnancy.

Current & Past Medical History

When taking an interim medical history from the adolescent with a known SUD, consider asking about:
  • Access to substances, intercurrent use patterns, types of substances used, amount, and frequency
  • A detailed history of substance use patterns, such as age at first use, substances tried, current substances used along with quantity and frequency
  • Accidents (individuals who abuse substances are more likely to ride in an automobile with a driver who had been abusing alcohol or drugs), injuries, or pregnancies
  • Symptoms or signs of mental health disorders such as depression, anxiety, ADHD, conduct disorder, bipolar disorder, and eating disorders
  • Sexually transmitted infection, infection with blood-borne pathogens (through needle sharing), thrombophlebitis, and endocarditis (in cases of intravenous drug use)
Risk factors associated with development or progression of SUDs should be explored. [Newcomb: 1995] Consider asking about:
  • Chronic, domestic violence and physical and emotional abuse
  • Sexual abuse
  • Early-onset mental health/behavioral disorders, such as ADHD, conduct disorder, mood disorders, anxiety disorders, and learning disorders
  • Association with drug-using peers and gang affiliation
  • Initiation of substance use at a young age
  • Academic truancy, drop-out, underachievement or failure
  • In utero exposure to substances

Developmental & Educational Progress

Inquire about general development as well as recent changes in school performance. Children with learning disabilities are at risk for substance abuse. Recent academic changes may signify progression to problematic use or may raise concern for an associated mental health disorder.

Maturational Progress

Evidence suggests that early pubertal development is associated with higher rates of substance abuse independent of age and school grade. [Patton: 2004] Identification of "early bloomers" with other risk factors for substance abuse may allow timely initiation of preventive counseling measures. In girls who use substances, menstrual cycles may become more erratic than expected for adolescence. Ask about amenorrhea, which may be due to alterations in hormonal cascades caused by heavy substance use.

Social & Family Functioning

Consider asking about the following factors as they pertain to substance use:
  • Impacts on physical and emotional heath
  • Effects on school, family, and friends
  • Negative consequences of use (e.g., accidents, legal difficulties, injuries, altercations, school failure)
  • Use in risky situations, including driving while intoxicated
  • Risky sexual activity
  • Gang affiliation
  • Parental modeling of substance use, negative communication patterns, and lack of anger control in families
  • Relationships with peers and substance use in peer group - associating with friends who use drugs is a strong predictor of personal drug use.
  • Family relationships
  • Victimization by bullying
Parents may be interviewed as part of the substance abuse assessment, although parents generally underestimate the severity of substance abuse in their teenage children.

Physical Exam

"Designer drugs” (synthetic cannabinoids and bath salts, heroin, inhalants, MDMA, PCP, and androgenic-anabolic steroids) and other substances are associated with renal damage and failure, either directly or indirectly from dangerous increases in body temperature. [National: 2017]

Vital Signs

Abnormalities in heart rate, blood pressure, and respiratory rate may represent complications of acute or chronic substance abuse.

Growth Parameters

Check growth - steroid use during childhood or adolescence, resulting in artificially high sex hormone levels, can signal the bones to stop growing earlier than they normally would have, leading to short stature, gynecomastia and decrease sperm counts in males, and masculinization in females. Some of these changes may be irreversible.

Skin

Examine for needle marks suggestive of intravenous drug use. Methamphetamine use may cause compulsive skin picking leading to scattered excoriations and ulcerations. Intravenous drug use may produce micro-emboli in nail beds.

HEENT

Pupillary constriction may be seen with intoxication from opioids or other depressants. Pupillary enlargement could indicate use of stimulants or hallucinogens. Cannabis can cause conjunctival injection. Examine nasal mucosa for inflammation or erosion associated with nasal insufflation (snorting). Redness around the nares may be a sign of inhalant use (huffing).

Mouth/Teeth

Poor dentition due to lack of dental hygiene is often associated with substance use. Methamphetamine use may lead to rapidly progressive dental decay due to alteration of salivary acid balance. Poor dental hygiene is common with SUDs and may lead to gingivitis, caries, and abscesses.

Chest

Smoking tobacco, marijuana, cocaine, or heroin may result in abnormal breathing sounds, such as wheezing, and lead to bronchitis.

Heart

A new murmur may suggest endocarditis due to venipuncture-associated bacteremia. Arrhythmia may suggest acute stimulant intoxication or effect from stimulant/cocaine-induced infarction. Several substances of abuse, particularly psychostimulants, may contribute to arrhythmias. Injection drug use can also lead to collapsed veins and bacterial infections of the blood vessels and heart valves. [National: 2017]

Abdomen

Palpate the liver for tenderness or enlargement suggestive of hepatitis. Constipation is associated with chronic opioid use.

Neurologic Exam

Altered mental status suggests acute intoxication or withdrawal symptoms. Cognitive problems may be noted with multiple substances of abuse. Persistent leukoencephalopathy and sensory neuropathy may be noted with prolonged inhalant use. [Brust: 2014]

Testing

Laboratory Testing

Random urine testing for substances of abuse may be an important component of a substance abuse treatment program. Urine specimens must be collected according to the Mandatory Guidelines for Federal Workplace Drug Testing Programs.

Initial testing is performed with immunoassay. Positive results must be confirmed with gas chromatography (GC) or mass spectroscopy (MS). Quantitative results may be helpful for some significant false-positives (THC, alcohol, cocaine). Synthetically crafted opioids (i.e. opiates) will not be detectable on an opioid screen, but will be identified with GC or MS.

If a clinician suspects abuse of a non-detectable substance, then order a toxicology screen with the specific agent identified. No screen or labs are available to identify inhalants, except for hair analysis, which is rarely used. A thorough, confidential history is the most effective way to screen and diagnose SUDs. 

Obtaining laboratory studies without the consent of the competent adolescent is damaging to the doctor-patient relationship and should only be done in emergent situations. [American: 1996] [Knight: 2007] In general, drug screens should not be performed at the request of parents because the clinical information yielded from such testing is limited. False-positive results are common and can have significant medical and social consequences. [Moeller: 2008] The following link provides a summary of agents that contribute to false-positive screens for drugs of abuse by immunoassay: Drugs of Abuse, Cross Reactivity .

Other laboratory studies should be considered based on clinical findings or concerns (e.g., thyroid stimulating hormone (TSH) and thyroxine if thyroid dysfunction is suspected as a cause for behavioral changes). Other studies may be helpful in identifying complications of substance abuse:
  • Labs for substance abuse include: a comprehensive metabolic panel, complete blood count, TSH, free thyroxine (fT4), urinary analysis, gamma-glutamyl transpeptidase (GGT) for suspected alcohol abuse, and human chorionic gonadotropin (HCG) for women
  • If engaging in unprotected sex is suspected, test for gonorrhea, chlamydia, HIV, syphilis, and hepatitis B (if not vaccinated)
  • If intravenous drug use is suspected, test for hepatitis C and HIV
  • Risk factors for tuberculosis should be considered and tuberculin purified protein derivative (PPD) placed if concerned

Imaging

A 12-lead EKG should be obtained in those with chest pain associated with known or suspected stimulant use (e.g., cocaine, methamphetamine, ecstasy) due to the risk of myocardial infarction. Extensive inhalant abuse is associated with cardiomyopathies. Echocardiography is indicated to identify intracardiac vegetations in known or suspected intravenous drug users who present with a new heart murmur.

Genetic Testing

Genetic testing for individuals with SUDs currently has little clinical value and is not recommended. [Mathews: 2012]

Other Testing

Perform a detailed psychosocial history if a patient receives a score of ≥ 2 on the CRAFFT (CeASAR) (PDF Document 32 KB) screen.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Consult if a comorbid mental health disorder is suspected or if pharmacotherapies for a SUD are needed.

Psychologist, Child-18 (see Services below for relevant providers)

Refer for testing if a learning or intellectual disability is suspected. Testing may include the Millon Adolescent Clinical Inventory (MACI) for an indication of defensive responding, clients’ level of insight and awareness of the effects of their substance misuse, evidence of emotional pain, and relative risk of involvement with the legal/judicial system. Other tests that may include the Minnesota Multiphasic Personality Inventory®-Adolescent (MMPI®-A).

Treatment & Management

How should common problems be managed differently in children with Substance Use Disorders?

Growth Or Weight Gain

Although weight changes can be a direct effect of substance use, screening for a contributing eating disorders and other psychiatric disorders is important. Individuals with fear of weight gain may abuse stimulant medications to lose weight. Individuals with SUDs may be more prone to nutritional deficiencies, such as thiamine (more commonly associated with chronic alcohol use, but also can be seen with cocaine abuse), due to decreased intake of nutritive substances. [Sukop: 2016]

Development (cognitive, motor, language, social-emotional)

SUDs should be considered in the differential diagnosis of any child or adolescent who experiences a change in academic performance, peer groups, or interpersonal functioning. Academic and cognitive testing may need to be delayed until a period of prolonged abstinence is achieved to provide more accurate results. Prenatal exposure to drugs of abuse may also affect cognitive development.

Viral Infections

Adolescents with SUDs may engage in high-risk behaviors, such as unprotected sexual intercourse and needle sharing, which increases risk for viral infections including HIV and hepatitis; therefor, more intensive counseling and testing may be warranted.

Over The Counter Medications

Abuse of over the counter medications, such as cough syrup, is common. Families should be counselled to lock up all medications in the home in order to prevent unintentional overdose.

Common Complaints

Drugs use (inhalants, MDMA, PCP, and steroids) may be the cause of muscle cramping and overall muscle weakness.

Pearls & Alerts

Comorbidities are the rule, rather than the exception

SUDs are frequently associated with other mental health issues, including mood disorders, anxiety disorders, ADHD, and impulse control disorders. Therefore, identification of substance use warrants additional exploration and treatment of other mental health concerns.

Treat comorbid psychiatric disorders, but be aware of medication abuse potential

Pharmacotherapy for primary mental health disorders may be safely and effectively be used for patients with substance abuse problems but the clinician should recognize the potential for abuse when with any schedule II medication(s). Alternative agents for ADHD treatment with low-abuse potential include atomoxetine and bupropion. Selective serotonin reuptake inhibitors and buspirone offer less potential for abuse than benzodiazepines in the treatment of comorbid depression and anxiety. Trazodone and melatonin may be helpful sleep aids with low abuse potential compared to hypnotics. Behavioral interventions should be considered as well.

Substance abuse and ADHD

Untreated ADHD is associated with high incidence of SUDs, and adequately treating ADHD may decrease that risk. [Wilens: 2008] [Wilens: 2003]

Prescription Drug Monitoring Program Database

Most states have websites that allow authorized users to monitor dispensing of controlled substances. This helps track possible diversion and misuse of controlled substances. States vary in their laws regarding access to this information. Individual state contacts can be found at the Prescription Drug Monitoring Programs (NASCSA).

SUDs and Asthma

Some drugs of abuse cause breathing to slow and block air from entering the lungs, which exacerbates asthma symptoms.

Systems

Other

Determining Level of Care
SUDs are a chronic condition with potential for relapse. Complications related to co-morbid mental health disorders, medical issues, and social complications are common. Because of the complexity and potential for progression of these disorders, most adolescents will require referral to substance abuse services. 

The American Society of Addiction Medicine (ASAM) has a placement guidelines for 4 levels of care (with sub-set levels):
  • Outpatient Treatment: No risk of withdrawal, no biomedical or emotional concerns, accepting of and cooperative with treatment, good coping skills and internal resources, and a supportive environment
  • Intensive Outpatient or Partial Hospitalization (Day Treatment): No risk of withdrawal, mild biomedical or emotional concerns, some resistance to change, high risk of relapse, and an unsupportive environment
  • Residential Facility (clinically managed, low-intensity; medium/high intensity; 24/7 medically monitored and high intensity): Minimal to moderate risk of withdrawal, mild to moderate biomedical or emotional concerns requiring monitoring and behavioral and/or medical intervention, high risk for continued use, and an obstructive environment for recovery
  • Medically Managed Inpatient Services: Severe risk of withdrawal or moderate to severe biomedical and/or emotional concerns (dimensions 4-6, listed below, are obsolete for this level of care)
The recommended level of care is based on scores attained from 6 dimensions of assessment. The 6 dimensions are (1) potential for medical withdrawal; (2) bio-medical conditions; (3) emotional/behavioral disturbances; (4) acceptance or resistance to treatment; (5) potential for relapse; and (6) social/recovery environment.
More information about application of the ASAM guidelines can be found at ASAM Criteria (American Society of Addiction Medicine). A more detailed description of addiction services can be found in Outpatient and Inpatient Treatment for Substance Use Disorders.

Care may also involve referral to:

Mental Health/Behavior

The Adverse Childhood Experiences Study (CDC) is the largest investigation ever conducted to assess associations among childhood maltreatment and later-life health and well-being. The ACE studies have documented robust associations among untreated childhood trauma and addiction, as well as chronic psychiatric and medical illnesses. Typically in these cases, there is early onset and rapid progression of substance abuse with multiple types of substances, including opiate and/or stimulant-like substance (methamphetamine, cocaine, etc.), being used. Individuals with a SUD in the course of mental illness may require higher levels of care.

In addition, SUDs can exacerbate and mimic psychiatric disorders, such as depression, anxiety, and psychosis. A detailed history of psychiatric symptoms during periods free from, or prior to, alcohol or drug use can help distinguish between a primary SUD and a primary mental health disorder. Patients with a primary mental health disorder often seek relief from symptoms by self-medicating with substances. Intoxication with multiple substances can result in mental status changes ranging from euphoria, excitation, and agitation to sedation and coma, either from direct effects or as consequences such as traumatic injuries from disinhibited behaviors.

Conduct disorder is the most common psychiatric disorder in adolescents who use alcohol and is a strong predictor of subsequent development of alcohol use or dependence. Conduct disorder is characterized by maladaptive behaviors, including disrespect toward authority figures, engagement in illegal activities, threats of violence or aggressive/assaultive behaviors, and a general disregard for the safety of others. However, features of conduct disorder may be present and secondary to a significant, untreated mental health disorder, including substance abuse. Therefore, conduct disorder should be diagnosed based on history and after resolution of the primary disorder. Chronic use of some drugs of abuse can cause long-lasting changes in the brain, which may lead to paranoia, depression, aggression, and hallucinations. 

Substance use is also a risk factor for suicide attempts and completions. For additional information, please refer to Suicidality.

In addition to the services listed below, care may involve referral to:

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Refer for diagnosis and treatment of comorbid psychiatric conditions and treatment if indicated.

Mental Health Counselor (LPC, CMHC) (see Services below for relevant providers)

Refer for implementation of behavioral strategies applied in substance abuse treatment programs and engage the client and/or family in the therapeutic process.

Pharmacy & Medications

Detoxification occurs when the body fully eliminates substances. It is often accompanied by unpleasant and potentially harmful side effects; acute withdrawal from alcohol and/or benzodiazepine and/or barbiturate dependence can potentially be lethal and detoxification under medical supervision is typically recommended. Any adolescent who meets criteria for alcohol, opioid, or sedative-hypnotic dependence and who displays symptoms of physical dependence should be admitted to a hospital for medically supervised withdrawal (detoxification).

Medically supervised withdrawal treatment protocols vary according to substance(s) used and symptoms present. Medications are available to assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives and should be administered by a physician experienced in addiction treatment. No medications have been FDA-approved for the treatment of substance abuse in adolescents. Medications for substance abuse are best prescribed in collaboration with referral to a behavioral program.

Opioids
: Methadone (full mu agonist) and buprenorphine (partial mu agonist) are long-acting opioid receptor agonists that reduce opioid withdrawal symptoms and cravings. Buprenorphine/naloxone (Suboxone) also contains naloxone, which blocks other opiates, resulting in less potential for overdose and may therefore be preferred over methadone; preliminary studies of its safety and efficacy in adolescents are encouraging. Naltrexone is a competitive antagonist at the mu and kappa opioid receptors. In patients with a chronic history of opioid use, acute reversal of opioid effects with naloxone, a related medication, may precipitate withdrawal symptoms, limiting its use to patients who have opiate overdose. Naltrexone should not be used in patients with questionable compliance concerns.

Tobacco: Nicotine replacement systems are available as over-the-counter sprays, patches, gum, and lozenges. Bupropion and varenicline have received FDA approval for the treatment of nicotine addiction in adults. Bupropion inhibits the reuptake of norepinephrine and dopamine, resulting in a mild stimulant effect that reduces craving for nicotine. Varenicline has mixed agonist and antagonist effects at nicotine receptor subsets resulting in less nicotine craving.

Alcohol
: Naltrexone, acamprosate, and disulfiram have received FDA approval for treating alcohol dependence in adults. Naltrexone is a competitive opiate receptor antagonist that blocks opioid receptors involved in the rewarding effects of drinking and thus lessens the craving for alcohol. It reduces relapse to heavy drinking during the first 3 months of treatment, but is less effective for treatment maintenance. The exact mechanism of acamprosate is unknown. Acutely, it acts predominantly by regulating glutamate surges and may reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria, through upregulation of gamma-aminobutyric acid (GABA) (to which it is structurally similar). Disulfiram inhibits the enzyme (acetaldehyde dehydrogenase) that is responsible for degradation of acetaldehyde (a byproduct of alcohol metabolism) to acetic acid, resulting in the accumulation of acetaldehyde, which leads to an unpleasant reaction, that includes flushing, nausea, and palpitations, if the patient drinks alcohol. Disulfiram is rarely used in adolescents for alcohol dependence. Intermediate to long acting benzodiazepines are used in medically supervised withdrawal from alcohol and sedative-hypnotic agents, as this withdrawal syndrome can be life-threatening.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Refer for diagnosis and treatment of comorbid psychiatric conditions and pharmacotherapeutic treatment if indicated.

Substance Abuse - Inpatient Facilities (see Services below for relevant providers)

A substance abuse treatment center may offer residential or outpatient treatment including individual, group, and/or family counseling. Pharmacotherapeutic management may be offered in centers staffed with a physician with experience and expertise in substance abuse management.

Gastro-Intestinal & Bowel Function

Among other adverse effects, many drugs of abuse have been known to cause nausea and vomiting soon after use. Cocaine and other psychostimulant use can also cause abdominal pain. [National: 2017] Constipation is a common side effect to prolonged opioid use and management information can be found at Constipation. Several drugs of abuse including alcohol, heroin, inhalants, and anabolic-androgenic steroids cause hepatotoxicity and/or transaminitis.

Nutrition/Growth/Bone

Stimulant medications may decrease appetite and growth. Chronic alcohol use and use of cocaine may contribute to vitamin deficiencies, particularly thiamine. A referral to see all Nutrition/Dietary services providers (3) in our database may be warranted.

Funding & Access to Care

Inpatient hospitalization, prolonged residential treatment, and outpatient treatment programs can be very costly, particularly for the un- and underinsured. Most substance abuse treatment programs will have a social worker or case manager who can assist in exploring payment options for patients and their families. Insurance coverage for substance abuse treatment varies according to treatment center. The Substance Abuse Treatment Facility Locator (SAMHSA) has a detailed search feature that identifies facilities that accept Medicaid programs, major insurance plans, and have sliding fee scales and payment assistance programs.

Frequently Asked Questions

I have just identified a teen in my practice with a substance use disorder. What treatment facility can I refer her to?

The Substance Abuse Treatment Facility Locator (SAMHSA) lists facilities by zip code. Guardians may also request a list of authorized providers and/or facilities from their insurance provider. Services can also be found at:

What is my obligation in notifying parents of a patient with substance use?

Laws related to confidentiality and results of screening for substance use and toxicology reports are mandated by individual states. In general, experimental use or nonproblematic use is not disclosed with a family without the child’s permission. If behavior associated with substance use is compromising a child’s safety, consider breaking confidentiality and discussing this possibility with the patient. Regardless, the patient should always be encouraged to use the supports of parents or other healthy adult caregivers.

My patient has ADHD, but has also had problems with marijuana and alcohol use. I am worried that he may start abusing his ADHD medications. Would it be in his best interest to stop using the ADHD medications to remove the temptation for abuse?

Although stimulant medications used to treat ADHD have the potential for abuse, studies have shown that the risk of substance abuse in those with ADHD is reduced if the ADHD is appropriately treated. The most common substance of abuse associated with untreated ADHD is marijuana and not stimulants.

Still, a small number of youth prescribed stimulants may abuse these medicines themselves or sell them to others. Clinicians are advised to monitor the use of these medications and the frequency at which refills are required. The formulation of some of the long-acting stimulant preparations, (lisdexamfetamine or Vyvanse), limits the potential for misuse. Alternative ADHD medications that are not in the stimulant class include atomoxetine, clonidine, and guanfacine. The Medical Home Portal's Attention Deficit Hyperactivity Disorder (ADHD), Treatment & Management contains more information about management with prescribed medications.

How do I counsel parents who are interested in home screening their child for substance use?

Home drug screening kits are available, but they have limitations:

  • Not all substances are detected - a particular issue with newer synthetic agents.
  • Whether use is acute or chronic affects how long after last use that a screen can detect a substance.
  • False-positive results can occur.
The results of a drug screen must be considered in the context of an individual’s functioning, clinical presentations, and other factors.

Issues Related to Substance Use Disorders

Resources

Information for Clinicians

Intoxication, Chronic, and Withdrawal Effects of Commonly Abused Drugs (PDF Document 633 KB)
A clinically useful chart organized by drug classification that lists the main effects of various drugs; Medical Home Portal.

Resources for Primary Care (AACAP)
A resource center for clinicians treating substance use disorders and mental health issues. Includes practice parameters, a guide for integrating mental health care into the medical home, and information about policy and advocacy; American Academy of Child & Adolescent Psychiatry.

American Academy of Addiction Psychiatry (AAAP)
A professional membership organization for clinicians interested in learning and sharing information about the art and science of addiction psychiatry treatment.

American Society of Addiction Medicine (ASAM)
A resource for clinicians and families that includes an ASAM addiction specialist locator, links to family support groups, patient guides, and practice guidelines.

Substance Abuse Treatment Facility Locator (SAMHSA)
A tool for people seeking (by ZIP Code) treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems; Substance Abuse and Mental Health Service Administration.

Motivational Interviewing (SAMHSA)
A list of online resources, webinars, and courses for clinicians interested in Motivational Interviewing; Substance Abuse and Mental Health Services Administration.

A Tour of Motivational Interviewing - Free Online Course (Addiction Technology Transfer Centre Network)
By completing this course, the learner can make an informed decision about whether to pursue more advanced training; prepared by the University of Missouri Kansas City School of Nursing and Health Studies’ Mid-America Addiction Technology Transfer Center.

Implementing Mental Health Priorities in Practice: Disruptive Behavior and Aggression (AAP)
Video tool to help with motivational interviewing techniques to elicit concerns and address behaviors in the primary care setting; American Academy of Pediatrics Mental Health Initiatives.

Helping Patients Who Drink Too Much: A Clinician's Guide (NIAA) (PDF Document 1.6 MB)
A 40-page booklet that presents a 4-step clinical approach to helping patients who drink too much; National Institute on Alcohol Abuse and Alcoholism.

Suicide and Suicide Attempts in Adolescents (AAP)
Information about how clinicians can approach and evaluate youth who may be at-risk for suicide; American Academy of Pediatrics.

Resources for Medical and Mental Health Professionals (NIDA)
Contains tools and resources for the medical practice, continuing education and training, clinical trials information, and other educational materials that may be downloaded or ordered; National Institute on Drug Abuse.

Helpful Articles

PubMed search for adolescent substance use, last 1 year.

Brust JC.
Neurologic complications of illicit drug abuse.
Continuum (Minneap Minn). 2014;20(3):642-56. PubMed abstract

Riggs PD.
Treating adolescents for substance abuse and comorbid psychiatric disorders.
Sci Pract Perspect. 2003;2(1):18-29. PubMed abstract / Full Text

Sanchez-Samper X, Knight JR.
Drug abuse by adolescents: general considerations.
Pediatr Rev. 2009;30(3):83-92; quiz 93. PubMed abstract

Seidel S, Böck A, Schlegel W, Kilic A, Wagner G, Gelbmann G, Hübenthal A, Kanbur I, Natriashvili S, Karwautz A, Wöber C, Wöber-Bingöl C.
Increased RLS prevalence in children and adolescents with migraine: A case-control study.
Cephalalgia. 2012. PubMed abstract

Winters KC, Kaminer Y.
Screening and assessing adolescent substance use disorders in clinical populations.
J Am Acad Child Adolesc Psychiatry. 2009;47(7):740-4. PubMed abstract / Full Text

Clinical Tools

Assessment Tools/Scales

ASSIST (WHO)
The Alcohol, Smoking, and Substance Involvement Screening Test detects and manages substance use and related problems in primary care settings. It contains 8 main questions that relate to 10 substances; a clinician-administered version and a self-report version are provided. The screen and scoring instructions are available in 11 languages and can be downloaded or printed for free; developed for the World Health Organization.

AUDIT (WHO) (PDF Document 13 KB)
The Alcohol Use Disorders Identification Test is a 10-item screening tool that assesses alcohol consumption, drinking behaviors, and alcohol-related problems. The AUDIT Questionnaire and scoring instructions can be downloaded or printed for free; developed by the World Health Organization.

CRAFFT (CeASAR) (PDF Document 32 KB)
The Car, Relax, Alone, Forget, Friends, Trouble screening tool consists of a series of 6 questions developed to screen adolescents for high-risk alcohol and other drug use disorders. A clinician-administered version and a self-report version are provided. The screen and scoring instructions are available in 13 languages and can be downloaded or printed for free; developed by the Center for Adolescent Substance Abuse Research at Children's Hospital Boston.

H.E.A.D.S.S. (PDF Document 72 KB)
A psychosocial interview for adolescents with questions related to Home; Environment, education, and employment; Activities; Drugs; Sexuality; and Suicide; adapted from Contemporary Pediatrics, Getting into Adolescent Heads (July 1988), by John M. Goldenring, MD, MPH, & Eric Cohen, MD.

POSIT (NIH)
The Problem Oriented Screening Instrument for teenagers identifies problems and potential treatment or services needed in 10 areas, including substance abuse, mental and physical health, and social relations. It is self-administered and has 139 "yes/no" screening questions. Downloadable version for PC available; developed by Elizabeth Rahdert, Ph.D., Division of Clinical and Services Research, National Institute on Drug Abuse, National Institutes of Health.

S2BI (Boston Children's Hospital) (PDF Document 126 KB)
The Screening to Brief Intervention tool has up to 7 questions about frequency of use and is based on DSM-5 diagnoses for substance use disorders.

Medication Guides

Addiction Medications for Adolescents (NIDA)
A research-based guide with information about various medication treatments for substance use disorders; National Institute on Drug Abuse.

Medication for the Treatment of Alcohol Use Disorder (SAMHSA) (PDF Document 507 KB)
A 30-page reference about pharmacological treatments for alcohol use disorder; Substance Abuse and Mental Health Services Administration.

Patient Education & Instructions

Patient Guide: Get Help for Addiction (CASA)
A guide that can be downloaded and printed for help finding quality addiction treatment; National Center on Addiction and Substance Abuse.

Warning Signs for Suicide (American Foundation for Suicide Prevention)
Information about suicide signs related to speech, behavior and mood.

Helping Your Teen Cope with Traumatic Stress and Substance Abuse (NCTSN) (PDF Document 377 KB)
A 15-page guide for parents and caregivers who believe their teenagers might be experiencing problems as a result of traumatic stress and substance abuse; National Child Traumatic Stress Network.

Recognizing Drug Use in Adolescents (NCTSN) (PDF Document 1.0 MB)
Summarizes the signs of intoxication, use, and abuse commonly reported by substance users; National Child Traumatic Stress Network.

Using Drugs to Deal with Stress and Trauma (NCTSN) (PDF Document 215 KB)
An 11-page booklet for teens about the connections and risks of using drugs to deal with stress and trauma; National Child Traumatic Stress Network.

Patient Materials (NIDA)
Booklets, fact sheets, and posters for patient education; National Institute on Drug Abuse.

Toolkits

Tobacco and Nicotine Cessation Toolkit (AAFP)
Includes office-based tools and information about coding, payment, and working with community partners; American Academy of Family Physicians.

SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA)
Describes this evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs; Substance Abuse and Mental Health Services Administration.

Other

Prescription Drug Monitoring Programs (NASCSA)
Electronic databases which collect, maintain and disseminate controlled substance prescription information specific to each jurisdiction's laws and regulations; National Association of State Controlled Substances Authorities.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Family Resources (AACAP)
Provides facts for families, videos, and a psychiatrist finder tool; American Academy of Child and Adolescent Psychiatry.

Drug Guide for Parents (Partnership for Drug-Free Kids)
A comprehensive, up-to-date source of drug information for parents that include warning signs of adolescent drug use.

NIDA for Teens (NIDA)
Videos, games, blogs, and facts developed specifically for students and young adults; National Institute on Drug Abuse.

Understanding Drug Abuse and Addiction (NIDA)
A simple explanation of addiction and its effect on the brain; National Institute on Drug Abuse.

Substance Abuse Treatment Facility Locator (SAMHSA)
A tool for people seeking (by ZIP Code) treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems; Substance Abuse and Mental Health Service Administration.

Drug Abuse and Addiction: Tools for Parents and Educators (NIDA)
Science-based information about the health effects and consequences of drug abuse. Lesson plans and school resources for teachers. Videos for parents about talking with kids about the impact of drug use; National Institute on Drug Abuse.

National Center on Addiction and Substance Abuse (CASA)
Useful information about addiction, statistics, treatment plans, and how to find treatment.

Prescription Drug Abuse (MedlinePlus)
Many links to charts, videos, and educational materials about commonly abused, over-the-counter and prescription drugs; sponsored by National Institute on Drug Abuse.

National Alliance of Mental Illness (NAMI)
A national organization that provides information and resources for families and professionals, including helpline, local chapter resources, and advocacy.

Above the Influence
A nationwide substance use prevention campaign.

Support National & Local

Narcotics Anonymous
Literature, news, and meeting locator services from an organization that supports freedom from active addiction.

Alcoholics Anonymous (A.A.)
This is the national website for Alcoholics Anonymous. A meeting locator tool can help find local support groups.

Al-Anon/Alateen
Support for teens, parents, and caregivers to help cut back or stop drinking.

National Alliance of Mental Illness (NAMI)
A national organization that provides information and resources for families and professionals, including helpline, local chapter resources, and advocacy.

Students Against Destructive Decisions
A student advocacy group promoting awareness of the dangers of underage drinking and driving; formerly Students Against Drunk Driving.

Partnership for a Drug-Free America
Prevention campaigns, information, and support to reduce teen substance abuse and to support families impacted by addiction.

Allies with Families
Provides emotional support, training, and resource information for families of children with emotional, behavioral, and mental health disabilities; also includes workshops for siblings.

Services for Patients & Families

Clinical Social Worker (LCSW, MSW)

See all Clinical Social Worker (LCSW, MSW) services providers (1) in our database.

Family Counseling

See all Family Counseling services providers (6) in our database.

Juvenile Justice Services

We currently have no Juvenile Justice Services service providers listed; search our Services database for related services.

Local Support Groups, Addiction

See all Local Support Groups, Addiction services providers (1) in our database.

Mental Health Counselor (LPC, CMHC)

See all Mental Health Counselor (LPC, CMHC) services providers (4) in our database.

Mentoring

See all Mentoring services providers (2) in our database.

Nutrition/Dietary

See all Nutrition/Dietary services providers (3) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (126) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (7) in our database.

Substance Abuse - Inpatient Facilities

See all Substance Abuse - Inpatient Facilities services providers (3) in our database.

Substance Use Disorder Treatment

See all Substance Use Disorder Treatment services providers (8) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Authors: Catherine Jolma, MD - 12/2011
Susan Wiet, MD - 8/2014
Mark Pepper, MS, CPCI - 6/2010
Reviewing Author: Mary Steinmann, MD - 5/2017
Content Last Updated: 5/2017

Bibliography

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AAP Recommends Substance Abuse Screening as Part of Routine Adolescent Care.
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Neurologic complications of illicit drug abuse.
Continuum (Minneap Minn). 2014;20(3):642-56. PubMed abstract

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Substance use screening, brief intervention, and referral to treatment for pediatricians.
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Treating adolescents for substance abuse and comorbid psychiatric disorders.
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Drug abuse by adolescents: general considerations.
Pediatr Rev. 2009;30(3):83-92; quiz 93. PubMed abstract

Seidel S, Böck A, Schlegel W, Kilic A, Wagner G, Gelbmann G, Hübenthal A, Kanbur I, Natriashvili S, Karwautz A, Wöber C, Wöber-Bingöl C.
Increased RLS prevalence in children and adolescents with migraine: A case-control study.
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Screening and assessing adolescent substance use disorders in clinical populations.
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