Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. Some of the most effective and cost-effective interventions for substance abuse disorders are preventive ones, such as parent education and early recognition in pediatric practice.
Substance abuse risk
While the prevalence of substance use disorders has dropped in youth since the 1980s, an estimated 5% of youth aged 12-17 years suffered from a substance use disorder in 2014, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Epidemiologic studies have repeatedly demonstrated that earlier first use of alcohol (under 14 years old) or tobacco predicts use of illicit drugs and is associated with higher lifetime rates of alcohol and drug dependence. There is emerging evidence that early use of addictive substances such as tobacco and alcohol has distinct neurobiologic effects that increase the propensity toward dependence, rather than being simply a function of an underlying vulnerability to dependence.1 While tobacco and alcohol use among youth have been trending down since the 1980s, rates are still high. The 2016 Monitoring the Future Survey found that 7% of 8th graders, 20% of 10th graders, and 33% of 12th graders reported having used alcohol in the 30 days prior to the study. Of particular concern is the recent upward trend in rates of binge drinking (five or more drinks in 2 hours), particularly among those enrolled in college, with rates as high as 43% in 2014, according to SAMHSA. Also notable is the strong shift in attitudes of youth toward marijuana, with fewer believing that “regular use” poses risks. Finally, rates of prescription opioid abuse among youth have started to decline, from more than 11% of 12th graders in 2013 to less than 8% in 2016. But there is evidence that those who regularly use marijuana in adolescence are more likely to abuse prescription opioids in their 20s. So interventions that can delay the first use of any substance, and discourage use of particularly addictive substances, can be a very effective way of preventing later substance use disorders.
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens ( teens.drugabuse.gov ).
Be pragmatic. After learning about what is being used by their peers, think with them about how they could say no to trying a drink, a smoke, or something more without creating drama or drawing attention to themselves. Are they seeing worrisome problems at parties, or are their friends using substances? What should they do if they see a friend falling unconscious? Have they seen anyone in a dangerous situation? How do they handle driving? If an anxious or impulsive adolescent has a plan to respond in these situations, they are much more likely to follow their plan to delay or decline.
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Parents also benefit from practical strategies on how to talk about drugs and alcohol with their children. Letting parents know that 5th or 6th grade is not too early to have a conversation in which they introduce their rules around drugs and alcohol. Parents should look for opportunities to talk often with their kids in less proscriptive ways about drugs and alcohol. Such opportunities can arise around stories in the news about sports stars, musicians, or television stars and drug or alcohol use. Or they may occur when watching a favorite television show or movie together. Talking about these issues in a less confrontational way, when the subject is a celebrity or character rather than your child, can make the conversation more open, comfortable, and useful for everyone.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org , have detailed resources for parents in particular.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.