Adolescent Substance Use and Misuse: Recognition and Management

Jessica A. Kulak; Kim S. Griswold

JESSICA A. KULAK, PhD, MPH, AND KIM S. GRISWOLD, MD, MPH

Am Fam Physician. 2019;99(11):689-696

Author disclosure: No relevant financial affiliations.

Adolescent use of illicit substances imposes an enormous burden on individuals, families, and communities. The types of illicit substances adolescents are using have changed drastically over the past decade with decreases in alcohol use (including binge alcohol use) offset by increases in electronic cigarette, marijuana, and opioid use. Primary care physicians have the opportunity to identify adolescents who use illicit substances. The U.S. Preventive Services Task Force and the American Academy of Family Physicians found insufficient evidence to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit substance use or nonmedical pharmaceutical use in children or adolescents. The American Academy of Pediatrics recommends that clinicians become familiar with Screening, Brief Intervention, and Referral to Treatment initiatives. Validated screening tools that may be used in primary care include the CRAFFT, POSIT, AUDIT, and NIAAA Screening Guide. During the clinical visit, a split-visit model encourages parents to participate in the visit for a limited time but also allows adolescents to have confidential conversations with physicians. Evidence-based treatment modalities range from school- and parent-based interventions to medication-assisted treatment. Brief interventions using components of motivational interviewing may be suitable for addressing substance use, even among adolescents not seeking treatment. Prevention efforts can supplement cessation programs to maximize program effectiveness.

Adolescent use of illicit substances imposes an enormous burden on individuals, families, and communities. Substance use has correlations with violence, including adolescent homicides¹ and relationship victimization.² Adolescence (typically encompassing youth 10 to 19 years of age)³ is a time of development, including ongoing maturing of the brain; therefore, it is essential to consider the pathophysiology of substance use.^4,5 Adolescent brains are more vulnerable to the temptation to use substances and to the effects of these substances because reward pathways develop before prefrontal cognition.⁵ Sustained substance use can affect neuropsychological functioning, resulting in attention deficits, memory problems, and decreased cognitive flexibility.⁵

WHAT IS NEW ON THIS TOPIC

Adolescent Substance Use and Misuse

In 2017, e-cigarettes were the most commonly used nicotine-delivery product among high school students.

Approximately 27% of adolescents 13 to 18 years of age who drink alcohol mix it with energy drinks. These adolescents are at increased risk for using tobacco and marijuana and for nonmedical use of prescription stimulants.

Seventeen percent of adolescents have taken prescription drugs without a doctor's prescription.

Clinical recommendation	Evidence rating	References
The American Academy of Pediatrics recommends that physicians become knowledgeable about the Screening, Brief Intervention, and Referral to Treatment (SBIRT) guidelines.	C	35
The U.S. Preventive Services Task Force and the American Academy of Family Physicians conclude that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit substance or nonmedical pharmaceutical use in children and adolescents.	C	48, 49
Primary care treatment for adolescent substance use should be coordinated with treatment from other mental health experts.	C	50
Brief interventions using components of motivational interviewing may reduce illicit substance use among adolescents.	C	41, 53

Scope and Prevalence

Adolescents who participated in the Youth Risk Behavior Survey (a survey of students in grades 9 to 12) in 2015 indicated that 32.8% of them have used alcohol and that 10.8% of them have smoked cigarettes in the past 30 days.⁶ Nearly 10% of high school students have used two or more tobacco products in the past 30 days,⁷ and dual users (i.e., users of two or more tobacco products) are at greater risk of engaging in other risky behaviors (e.g., other substance use) compared with nontobacco users and single-product users.⁸

One in five U.S. adolescents had used marijuana in 2015,⁶ and Monitoring the Future (a survey of 8th, 10th, and 12th graders) results indicated a significant increase in adolescent marijuana use in 2017 because of adolescents' lowered risk perceptions.⁹ Alcohol is the substance most consumed by adolescents; however, the Youth Risk Behavior and Monitoring the Future surveys show decreases in 30-day, annual, and lifetime use in 2015, including significant declines in current and binge drinking.¹⁰ Approximately 27% of alcohol-using adolescents 13 to 18 years of age mix alcohol with energy drinks, which is a risk factor for tobacco, marijuana, and nonmedical use of prescription stimulants.¹¹

In 2015, adolescent use of illicit substances was reported to be 2.1% for heroin, 5.2% for cocaine, 6.4% for hallucinogens, and 9.2% for synthetic marijuana.⁶ National estimates indicate that approximately 5% of adolescents had used ecstasy/methylenedioxymethamphetamine (MDMA).⁶ Other research, however, indicates that the estimate could be as high as 8% because many adolescents do not realize that the substance they know as Molly is a form of ecstasy.¹² Approximately 16.8% of adolescents have taken prescription drugs without a physician's prescription (nonmedical use of prescription drugs).⁶ In some high school seniors, the nonmedical use of prescription stimulants is associated with substance use disorders (SUDs) in adulthood,¹³ and lifetime nonmedical use of prescription opioids is a risk factor for lifetime heroin use among adolescents.¹⁴

The opioid epidemic does not spare the younger population. From 1997 to 2012, hospitalizations for prescription opioid poisoning in children and adolescents increased 165% (1.40 to 3.71 per 100,000); for adolescents older than 15 years, hospitalizations for heroin and methadone poisoning increased 161% (0.96 to 2.51 per 100,000) and 950% (0.10 to 1.05 per 100,000), respectively.¹⁵ Nonmedical consumption of codeine cough syrup is sometimes an introduction to opioid misuse among youth.¹⁶ The cough syrup is typically mixed with soda or occasionally alcohol and is colloquially known as lean, sizzurp, or purple drank.¹⁷ Previous research showed that misuse of codeine cough syrup was primarily by black youth. Other research, however, indicates that the use of lean is also high among Hispanic and Native American youth; males; homosexual, bisexual, and transgender individuals; and youth from urban areas.¹⁷

The types of products and the ways in which they are used have changed drastically over the past decade. Traditional cigarette use is low and declining, but high school students' use of any tobacco product within 30 days (19.6%) has not changed significantly from 2011 to 2017,¹⁸ primarily because of the increase in hookah and electronic cigarette (e-cigarette) use. The use of cigarillos (smaller, unfiltered cigars) is also prevalent. Cigarillo users often empty the tobacco and replace the contents with marijuana, creating a blunt.¹⁹

In 2017, e-cigarettes were the most commonly used nicotine-delivering product among high school students.¹⁸ E-cigarette usage, or vaping, has also become a method for administering marijuana; in national and community samples of high school students, rates of vaporizing marijuana by using e-cigarettes were high (10%⁹ to 29.2%²⁰). In 2018, 21% of U.S. 12th graders reported vaping nicotine in the past 30 days.²¹ A JUUL is a popular vaping tool that delivers high concentrations of nicotine and has a sleek appearance similar to a computer flash drive.²² JUUL products are promoted on social media platforms whose primary audiences are youth or young adults. JUUL Labs, Inc., and retailers selling the JUUL product have received warning letters from the U.S. Food and Drug Administration²² and have been subjected to fines for illegally selling these products to minors.²³

Physicians are valued as a trustworthy source of information, so they may be asked to provide information about vaping and e-cigarettes to patients and their families.²⁴ The role of e-cigarettes as a form of nicotine delivery continues to be debated, but physicians can provide accurate information on meaningful differences in product risks.²⁵

Sociodemographic Differences

Between 2002 and 2014, male and female adolescents 12 to 17 years of age had similar 12-month prevalence rates of SUDs and decreasing trends in use of illicit substances. Male adolescents are typically more likely to use most illicit substances; female adolescents are more likely to use nonmedical amphetamines and tranquilizers.¹⁰ Risk factors for illicit substance use include dropping out of high school and ease of access to substances.²⁶ Rural adolescents reported easier access to tobacco products and steroids; urban adolescents reported greater access to alcohol, marijuana, cocaine, methamphetamines, inhalants, ecstasy, hallucinogens, and prescription drugs.²⁷ Neighborhood economic disadvantage, social disorder, and high unemployment rates may play a larger role than individual-level factors in the variance of alcohol and illicit substance use among black adolescents compared with white adolescents.²⁸

Screening and Diagnosis

Mild, moderate, or severe SUD is identified in persons who meet criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., indicating significant clinical and/or functional impairment (Table 1).²⁹ Because 81% of patients seeking SUD treatment had been seen by a primary care physician during the previous year, primary care physicians have the opportunity to identify adolescents who use substances.³⁰ However, few primary care physicians screen adolescents according to guidelines,³⁰ likely because of low reported levels of preparedness,³¹ knowledge,³⁰ and low perceived confidence³² to identify and treat substance use.

A. A problematic pattern of use of an intoxicating substance not able to be classified within the alcohol; caffeine; cannabis; hallucinogen (phencyclidine and others); inhalant; opioid; sedative, hypnotic, or anxiolytic; stimulant; or tobacco categories and leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
Craving, or a strong desire or urge to use the substance.
Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
Recurrent use of the substance in situations in which it is physically hazardous.
Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following:
A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
A markedly diminished effect with continued use of same amount of the substance.
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for other (or unknown) substance (refer to Criteria A and B of the criteria sets for other [or unknown] substance withdrawal).
The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

Specify if:

In early remission: After full criteria for other (or unknown) substance use disorder were previously met, none of the criteria for other (or unknown) substance use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the substance,” may be met).

In sustained remission: After full criteria for other (or unknown) substance use disorder were previously met, none of the criteria for other (or unknown) substance use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the substance,” may be met).

Specify if:

In a controlled environment: This additional specifier is used if the individual is in an environment where access to the substance is restricted.

To assist physicians in managing substance use in adolescents, the Substance Abuse and Mental Health Services Administration (SAMHSA) launched the Screening, Brief Intervention, and Referral to Treatment (SBIRT) initiative.³³ Screening flowcharts based on the SBIRT model are available (http://pediatrics.aappublications.org/content/128/5/e1330 and http://pediatrics.aappublications.org/content/138/1/e20161211). The American Academy of Pediatrics (AAP) recommends that physicians become familiar with adolescent SBIRT practices.^34,35

SCREENING TOOLS

Several validated screening tools that may be used in primary care,^29,36 including the CRAFFT questionnaire, Problem Oriented Screening Instrument for Teenagers (POSIT), Alcohol Use Disorders Identification Test (AUDIT), and the National Institute on Alcohol Abuse and Alcoholism Screening Guide, are reviewed in Table 2^36–38; the CAGE questionnaire is not recommended for use with adolescents because of its low sensitivity. Self-administered computer screening may be a valid and time-efficient alternative to in-person screening.³⁹ Physicians who choose to screen adolescents for substance use may want to provide examples of specific drugs (e.g., if querying ecstasy use, indicate that the substance known as Molly is a form of ecstasy; if querying e-cigarette use, indicate this includes the use of vapes or JUULs).

Screening tool	Patients	Time to administer	Optimal cut-point associated with problem use	Sensitivity (95% CI)	Specificity (95% CI)
Alcohol Use Disorders Identification Test (AUDIT)³⁷	13 to 19 years of age; college students; emergency department patients	2 minutes	2	0.88 (0.83 to 0.93)	0.81 (0.77 to 0.85)
CAGE Questionnaire*³⁷	Adults (not recommended for use with adolescents)	Not applicable (not recommended for use with adolescents)	1	0.37 (0.29 to 0.44)	0.96 (0.94 to 0.98)
CRAFFT Questionnaire†³⁷	14 to 18 years of age	74 seconds via paper; 49 seconds via computer	1	0.92 (0.88 to 0.96)	0.64 (0.59 to 0.69)
National Institute on Alcohol Abuse and Alcoholism (NIAAA) Screening Guide³⁸	Offers age-specific screening questions (9 to 11, 11 to 14, and 14 to 18 years of age)	Not documented; only two questions in length	Varies by age	0.87 (0.76 to 0.94)	0.84 (0.82 to 0.86)
Problem Oriented Screening Instrument for Teenagers (POSIT)³⁷	12 to 19 years of age	20 to 30 minutes	1	0.84 (0.79 to 0.90)	0.89 (0.86 to 0.92)

CONFIDENTIALITY

Confidentiality in adolescent health care visits is a significant predictor of the number and subject matter of health topics discussed.⁴⁰ Adolescents particularly fear that alcohol, tobacco, or illicit substance use may be disclosed to their parents and/or legal authorities.⁴¹ Physicians should be aware of federal and state laws that apply to adolescent minor confidentiality because these may differ among states⁴² (https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law). Parental support for adolescent confidentiality can be mixed, so research suggests a split-visit model. This model encourages parents to participate in the clinical visit for a limited time but then requests that parents leave the examination room to allow for an adolescent-physician confidential conversation.⁴⁰ The American Academy of Family Physicians supports offering adolescents examinations and counseling separate from parents.⁴² It is essential for physicians and other health care professionals to explain the benefits of this model and to clarify adolescent and parent expectations and boundaries.^40,43,44

LABORATORY TESTING

Laboratory (urine or serum) testing has limited use for diagnostic purposes and documenting history of substance use.⁴⁵ Guidelines on the use of drug testing in children and adolescents are not clear, although the AAP supports further study of its safety and effectiveness.⁴⁶ The AAP further recommends against implementing school- and home-based testing and supports informing concerned parents about the limitations of such testing.⁴⁷

Prevention and Treatment

The U.S. Preventive Services Task Force and American Academy of Family Physicians have found insufficient evidence to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit substance use or nonmedical pharmaceutical use in children or adolescents.^48,49

Although early identification is ideal, screening and interventions can be useful at any stage of illicit substance use.⁵⁰ Prevention and treatment strategies often go together; prevention efforts can supplement cessation programs to maximize program effectiveness.⁵¹ Prevention programming aims to decrease risk and to promote protective factors while considering specific population characteristics, cultural influences, and determinants of health.²⁹ Among Monitoring the Future survey participants, 40% of past year users of narcotics stated that they were originally prescribed their narcotics.⁵² To deter nonmedical use of prescription drugs by adolescent patients, prescribing physicians should consider reducing the number of prescriptions or amount in the prescription. As in treatment planning and delivery, prevention strategies focus on families, schools, and communities (Table 3). Treatment should address the needs of the whole person.⁵⁰ Coexisting mental health problems should be identified and treated in conjunction with SUD,⁵⁰ and primary care physicians should refer, as appropriate, to child/adolescent psychiatrists. Evidence-based treatment modalities range from school- and parent-based interventions that seek to involve the family in treatment to medication-assisted treatment (such as buprenorphine and naltrexone [Revia] in the treatment of opioid use disorder; Table 4).⁵⁰

General information
The Community Guide: Adolescent Health
	https://www.thecommunityguide.org/topic/adolescent-health?field_recommendation_tid=All&items_per_page=5
National Institute on Drug Abuse: Children & Teens
	https://www.drugabuse.gov/children-and-teens
SAMHSA
	https://www.samhsa.gov/
Support and treatment
American Academy of Addiction Psychiatry: Find a Specialist
	http://www.aaap.org/?page_id=658?sid=658
American Academy of Child and Adolescent Psychiatry: Child and Adolescent Psychiatrist Finder
	http://www.aacap.org/AACAP/Families_and_Youth/Resources/CAP_Finder.aspx
American Society of Addiction Medicine: Search Membership Directory
	https://asam.ps.membersuite.com/directory/SearchDirectory_Criteria.aspx
National Institute on Alcohol Abuse and Alcoholism Screening Guide
	https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf
SAMHSA: Behavioral Health Treatment Services Locator
	800-662-4357 (800-662-HELP)
	https://www.findtreatment.samhsa.gov
SAMHSA – TIP 31: Screening and Assessing Adolescents for Substance Use Disorders
	https://store.samhsa.gov/product/TIP-31-Screening-and-Assessing-Adolescents-for-Substance-Use-Disorders/SMA12-4079
Cultural awareness
SAMHSA – TIP 59: Improving Cultural Competence
	https://store.samhsa.gov/system/files/sma14-4849.pdf

MOTIVATIONAL INTERVIEWING

Motivational interviewing is a way to develop conditions for positive behavior change⁵³ and is especially suitable for communication with adolescents.⁴¹ It has a patient-centered focus and is designed to help individuals explore and resolve ambivalence around behavior change, including illicit substance use.⁵³ Brief interventions using components of motivational interviewing may be suitable for addressing substance use, even among adolescents not seeking treatment for SUD.³³ A previous AFP article (https://www.aafp.org/afp/2018/1215/p719.html; Tables 5, 6, and 7) provides examples of motivational interviewing.

Current and future initiatives for further reduction of adolescent substance use include SBIRT programs, increased training of primary care physicians, and expansion of integrated primary care and behavioral health systems to overcome the fragmented nature of our current health care system and the way provision of and payment for treatment have been managed.⁵⁴ Public and private social welfare initiatives that work to safeguard vulnerable youth may help to mitigate or prevent health care disparities in child and adolescent populations.⁵⁵

This article updates a previous article by Griswold, et al.^⁴

Data Sources: We searched Medline using the key words adolescent, youth, substance use, substance abuse, alcohol, drug(s), tobacco, prevention, screening, treatment, primary care, physician. We repeated our search using Cochrane Database of Systematic Reviews and governmental websites, including SAMHSA, NIDA, and NIAAA. Search dates: October 2017 and December 2018.

Portions of this work were supported by the Health Resources Services Administration award number T32HP30035 (PI: L. Kahn) in support of Jessica A. Kulak.

The authors gratefully acknowledge the suggestions made by Dr. Gregory Homish, Dr. Linda Kahn, and Joan Kernan. We thank Angela Henke for her expert assistance on this manuscript.

Hohl BC, Wiley S, Wiebe DJ, Culyba AJ, Drake R, Branas CC. Association of drug and alcohol use with adolescent firearm homicide at individual, family, and neighborhood levels. JAMA Intern Med. 2017;177(3):317-324.

Walsh K, Moreland AM, Hanson RF, Resnick HS, Saunders BE, Kilpatrick DG. Relationship violence victimization and binge drinking trajectories among a nationally representative sample of adolescents. J Adolesc. 2017;58:49-55.

World Health Organization, 2014. Recognizing adolescence. http://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html. Accessed July 6, 2018.

Griswold KS, Aronoff H, Kernan JB, Kahn LS. Adolescent substance use and abuse: recognition and management. Am Fam Physician. 2008;77(3):331-336.

Squeglia LM, Gray KM. Alcohol and drug use and the developing brain. Curr Psychiatry Rep. 2016;18(5):46.

Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2015. MMWR Surveill Summ. 2016;65(6):1-174.

Jamal A, Gentzke A, Hu SS, et al. Tobacco use among middle and high school students—United States, 2011–2016. MMWR Morb Mortal Wkly Rep. 2017;66(23):597-603.

Creamer MR, Portillo GV, Clendennen SL, Perry CL. Is adolescent poly-tobacco use associated with alcohol and other drug use?. Am J Health Behav. 2016;40(1):117-122.

Johnston LD, Miech RA, O'Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the future: national survey results on drug use 1975–2017: 2017 overview. Key findings on adolescent drug use. http://monitoringthefuture.org/pubs/monographs/mtf-overview2017.pdf. Accessed October 16, 2018.

Peiper NC, Ridenour TA, Hochwalt B, Coyne-Beasley T. Overview on prevalence and recent trends in adolescent substance use and abuse. Child Adolesc Psychiatr Clin N Am. 2016;25(3):349-365.

Khan SR, Cottler LB, Striley CW. Correlates of use of alcohol mixed with energy drinks among youth across 10 US metropolitan areas. Drug Alcohol Depend. 2016;163:236-241.

Palamar JJ, Keyes K, Cleland CM. Underreporting of ecstasy use among high school seniors in the US. Drug Alcohol Depend. 2016;165:279-282.

McCabe SE, Veliz P, Wilens TE, Schulenberg JE. Adolescents' prescription stimulant use and adult functional outcomes: a national prospective study. J Am Acad Child Adolesc Psychiatry. 2017;56(3):226-233.e4.

Palamar JJ, Shearston JA, Dawson EW, Mateu-Gelabert P, Ompad DC. Nonmedical opioid use and heroin use in a nationally representative sample of US high school seniors. Drug Alcohol Depend. 2016;158:132-138.

Gaither JR, Leventhal JM, Ryan SA, Camenga DR. National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012. JAMA Pediatr. 2016;170(12):1195-1201.

Peters RJ, Kelder SH, Markham CM, Yacoubian GS, Peters LA, Ellis A. Beliefs and social norms about codeine and promethazine hydrochloride cough syrup (CPHCS) onset and perceived addiction among urban Houstonian adolescents: an addiction trend in the city of lean. J Drug Educ. 2003;33(4):415-425.

Agnich LE, Stogner JM, Miller BL, Marcum CD. Purple drank prevalence and characteristics of misusers of codeine cough syrup mixtures. Addict Behav. 2013;38(9):2445-2449.

Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A. Tobacco product use among middle and high school students—United States, 2011–2017. MMWR Morb Mortal Wkly Rep. 2018;67(22):629-633.

Giovenco DP, Miller Lo EJ, Lewis MJ, Delnevo CD. “They're pretty much made for blunts”: product features that facilitate marijuana use among young adult cigarillo users in the United States. Nicotine Tob Res. 2017;19(11):1359-1364.

Morean ME, Kong G, Camenga DR, Cavallo DA, Krishnan-Sarin S. High school students' use of electronic cigarettes to vaporize cannabis. Pediatrics. 2015;136(4):611-616.

Miech R, Johnston L, O'Malley PM, Bachman JG, Patrick ME. Adolescent vaping and nicotine use in 2017–2018—U.S. national estimates. N Engl J Med. 2019;380(2):192-193.

Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control. 2019;28:146-151.

U.S. Food and Drug Administration. Warning letters and civil money penalties issued to retailers for selling JUUL and other e-cigarettes to minors. Updated September 12, 2018. https://www.fda.gov/tobaccoproducts/newsevents/ucm605278.htm. Accessed January 2, 2019.

Singh B, Hrywna M, Wackowski OA, Delnevo CD, Jane Lewis M, Steinberg MB. Knowledge, recommendation, and beliefs of e-cigarettes among physicians involved in tobacco cessation: a qualitative study. Prev Med Rep. 2017;8:25-29.

Kozlowski LT, Sweanor DT. Young or adult users of multiple tobacco/nicotine products urgently need to be informed of meaningful differences in product risks. Addict Behav. 2018;76:376-381.

Tice P, Lipari RN, Van Horn SL. Substance use among 12th grade aged youths, by dropout status. The CBHSQ Report: August 15, 2017. Rockville, Md.: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2013:1–7.

Warren JC, Smalley KB, Barefoot KN. Perceived ease of access to alcohol, tobacco and other substances in rural and urban US students. Rural Remote Health. 2015;15(4):3397.

Cooper HL, West B, Linton S, et al. Contextual predictors of injection drug use among black adolescents and adults in US metropolitan areas, 1993–2007. Am J Public Health. 2016;106(3):517-526.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:577–578.

Sterling S, Kline-Simon AH, Wibbelsman C, Wong A, Weisner C. Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy. Addict Sci Clin Pract. 2012;7:13.

Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113-121.

Midboe AM, Cucciare MA, Trafton JA, Ketroser N, Chardos JF. Implementing motivational interviewing in primary care: the role of provider characteristics. Transl Behav Med. 2011;1(4):588-594.

Borus J, Parhami I, Levy S. Screening, brief intervention, and referral to treatment. Child Adolesc Psychiatr Clin N Am. 2016;25(4):579-601.

Levy SJ, Williams JF Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211.

Levy SJ, Kokotailo PK Committee on Substance Abuse. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128(5):e1330-e1340.

National Institute on Drug Abuse. Chart of evidence-based screening tools and assessments for adults and adolescents; June 2018. https://bit.ly/2t5N5Sk. Accessed October 16, 2018.

Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27(1):67-73.

D'Amico EJ, Parast L, Meredith LS, Ewing BA, Shadel WG, Stein BD. Screening in primary care: what is the best way to identify at-risk youth for substance use?. Pediatrics. 2016;138(6):e20161717.

Harris SK, Knight JR, Van Hook S, et al. Adolescent substance use screening in primary care: validity of computer self-administered versus clinician-administered screening. Subst Abus. 2016;37(1):197-203.

Gilbert AL, Rickert VI, Aalsma MC. Clinical conversations about health: the impact of confidentiality in preventive adolescent care. J Adolesc Health. 2014;55(5):672-677.

National Institute on Alcohol Abuse and Alcoholism. Alcohol screening and brief intervention for youth: a practitioner's guide; 2015. https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf. Accessed October 16, 2018.

American Academy of Family Physicians. Adolescent health care, confidentiality. July 2018. https://www.aafp.org/about/policies/all/adolescent-confidentiality.html. Accessed October 16, 2018.

Ham P, Allen C. Adolescent health screening and counseling. Am Fam Physician. 2012;86(12):1109-1116.

Klein DA, Hutchinson JW. Providing confidential care for adolescents. Am Fam Physician. 2012;85(6):556-560.

Winters KC, Kaminer Y. Screening and assessing adolescent substance use disorders in clinical populations. J Am Acad Child Adolesc Psychiatry. 2008;47(7):740-744.

Levy S, Siqueira LM, Ammerman SD, et al.; Committee on Substance Abuse. Testing for drugs of abuse in children and adolescents. Pediatrics. 2014;133(6):e1798-e1807.

American Society of Addiction Medicine. Appropriate use of drug testing in clinical addiction medicine; April 5, 2017. https://bit.ly/2DRS1Am. Accessed October 16, 2018.

Moyer VA. Primary care behavioral interventions to reduce illicit drug and nonmedical pharmaceutical use in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(9):634-639.

American Academy of Family Physicians. Clinical Preventive Service Recommendation: illicit drug use; 2018. https://www.aafp.org/patient-care/clinical-recommendations/all/illicit-drug-use.html. Accessed June 18, 2018.

National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: a research-based guide; January 2014. https://bit.ly/1VVAVW0. Accessed October 16, 2018.

Sussman S, Skara S, Ames SL. Substance abuse among adolescents. Subst Use Misuse. 2008;43(12–13):1802-1828.

Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the future: national survey results on drug use 1975–2017: 2017 volume 1. Secondary school students. http://www.monitoringthefuture.org//pubs/monographs/mtf-vol1_2017.pdf. Accessed January 2, 2019.

Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford; 2013.

Sterling S, Weisner C, Hinman A, Parthasarathy S. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. J Am Acad Child Adolesc Psychiatry. 2010;49(7):637-646.

Cluver LD, Orkin FM, Meinck F, Boyes ME, Yakubovich AR, Sherr L. Can social protection improve sustainable development goals for adolescent health?. PLoS One. 2016;11(10):e0164808.

Behavioral approach
Helps adolescents participate actively in recovery from illicit substance use; may include referral to community agencies that provide the following services:
	12-step facilitation
	Adolescent community reinforcement
	Cognitive behavior therapy
	Contingency management
	Group therapy
	Motivational enhancement therapy
Family-based approach
Highlights the need to engage the adolescent's family in treatment; may include assisting the family to access agencies that offer the following services:
	Brief strategic family therapy
	Family behavior therapy
	Functional family therapy
	Multidimensional family therapy
	Multisystemic therapy
Addiction medications
Can be effective, but none are approved by the U.S. Food and Drug Administration to specifically treat adolescents; some physicians use the following off-label for older adolescents:
	Alcohol use disorders
		Acamprosate (Campral)
		Disulfiram (Antabuse)
		Naltrexone
	Nicotine use disorders
		Bupropion (Zyban)
		Nicotine replacement therapies
		Varenicline (Chantix)
	Opioid use disorders
		Buprenorphine
		Methadone
		Naltrexone (Revia)
Recovery support services
Used to reinforce gains made in treatment and to improve quality of life; physicians can make referrals to these services, including the following:
		Assertive continuing care
		Mutual help groups
		Peer recovery support
		Recovery high schools