Substance Use Disorders in Children and Adolescents

Educational Objectives

The goal of this program is to improve the detection of substance use trends. After hearing and assimilating this program, the clinician will be better able to:

1. Identify risk factors for and effects of substance use among adolescents in the United States.
2. Recognize longstanding and emerging challenges in adolescent substance use, including those attributable to alcohol, cannabis, e-cigarettes, and opioids.
3. Utilize evidence-based screening practices for substance use disorders in adolescent primary care.

Summary

Teen substance use: the top 3 leading causes of death among adolescents in the United States (US) are motor vehicle accidents (MVAs), suicide, and homicide; alcohol and other substances are involved in a sizable proportion of these events

Alcohol: there has been an overall steady decline in binge drinking among teens, with less decline in female and Black adolescents, and adolescents from low socioeconomic backgrounds; fatal alcohol-related MVAs — have decreased overall but remain steady in those aged 16 to 17 yr; rates increase dramatically in age groups 18 to 20 yr and 21 to 30 yr; the majority of alcohol-related MVAs occur during late hours on weekends; risk — introduction to recreational alcohol use at younger ages is associated with a higher risk of developing an alcohol use disorder; family history of substance use disorder (SUD) also increases risk for substance abuse; delaying alcohol use until age 18 to 21 yr lowers the risk for substance use

Cannabis

Overview: has been legalized for recreational and medical use in many states and only for medical use in others; in some states, specific forms of cannabis have been legalized, including cannabis products that are higher in cannabidiol (a nonpsychoactive component that has pain- and anxiety-reducing properties) and lower in tetrahydrocannabinol (THC; a principal psychoactive component that produces a feeling of euphoria); some states have no policies surrounding cannabis, ie, it is not legalized for any use; in some states, cannabis is decriminalized; there seems to be a decline in the perceived risk of regular use of marijuana; the amount of students who report daily intake of cannabis has increased; 6.5% of high school seniors report using cannabis daily in the previous month

Health risks of cannabis use: must be communicated to students through counseling; driving under the influence of cannabis is not as risky as alcohol but still doubles the odds of an MVA; there are no cardiovascular or lung effects from cannabis use among youths; effects on male sexual function include potentially decreased levels of testosterone and sperm counts; there is a clear link with gastrointestinal function, eg, hyperemesis and changes in appetite as a result of heavy cannabis use or withdrawal; numerous studies show a possible association with alterations in brain structure and function; some studies demonstrate poorer intelligence quotient attainment among individuals who used cannabis heavily as adolescents; many emerging studies show links with depression, anxiety, and acute and chronic psychosis and schizophrenia following heavy use during adolescence; these do not occur in most adolescents who use cannabis, but there is some link

Effect of changing policies on cannabis use: Kann et al — surveyed ninth to twelfth graders in all 50 states of the US between 1993 and 2017 (Youth Risk Behavior Surveillance); showed that medical cannabis use laws are not associated with changes in past-30-day use or frequent use; recreational use laws are associated with a decrease in odds of cannabis, contrary to expectations; study by Plunk et al — involved 38 states; showed decline in mean arrest rates for cannabis possession over 3 yr in states with recreational use or decriminalization laws; states without policy changes had slight increases in adult arrests and slight decreases in youth arrests

Methods of cannabis consumption: the means by which cannabis products are consumed has changed; more young people are using vaporizable cannabis concentrates, eg, “shatter,” oil, wash, and butane hash; dabbing — involves heating a small amount of concentrated cannabis product to a high temperature and vaporizing it; the vaporized product is inhaled and delivers an enormously high amount of THC; associated with adverse health outcomes, particularly risk for psychosis; these new delivery methods are exposing young people to cannabis levels much higher than was achieved in the past

Electronic Cigarettes (ECs) and Vaping

Overview: data from the National Youth Tobacco Survey (NYTS) demonstrate that use of traditional tobacco products has declined in recent years, especially in 2011 to 2019; however, rates of EC (eg, JUUL) use have increased in recent years; JUUL devices became popular among young individuals in 2017; >25% of young persons report using an EC in the past 30 day; easy concealability of JUUL and other smaller devices contributes to popularity among youths

Central worry for teens: opposite to concerns of adult public health and harm reduction advocates; adults can use ECs to wean off cigarettes by decreasing nicotine levels and eventually reaching a state of abstinence, whereas EC use among teens may serve as a gateway toward traditional combustible cigarettes in the future; observational data validate this concern; recent meta-analytic data suggest that young people who use ECs are more likely to progress to traditional cigarette use; 2017 meta-analysis (Soneiji et al) — odds ratio was >3.5 with significant confidence intervals for transitioning to traditional cigarette use among young people who use ECs; 2018 NYTS — included >38,000 young persons; reported that history of vaping THC was 3% in children aged 9 to 12 yr, 11% in ages 13 to 15 yr, 24% in ages 16 to 17 yr, and 28% in ages ≥18 yr; the percentage of youth who had ever vaped THC was 6% among middle school students, 22% among high school students, 43% among youth who had ever tried any kind of vaping, 30% among youth with family members who vape, and 18% among youth with family members who had used any kind of tobacco product; risk is higher in families with history of nicotine use disorder

E-cigarette or vaping use-associated lung injury (EVALI): as of February 2020, there have been ≈2800 lung injury cases across 50 states and 68 confirmed deaths in 29 states; most individuals reported a history of vaping THC; vitamin E is frequently used to cut THC products, particularly those sold illicitly, and seems to be the cause in many cases; among patients who develop severe EVALI, 80% are aged <35 yr and >33% are aged <21 yr

Opioids

Trends in opioid overdose deaths: between 1999 and 2016, overdose deaths among youths aged 15 to 19 yr increased by 95% for prescription opioids, 405% for heroin, and 2925% for synthetic opioids (eg, fentanyl); fentanyl — contamination is now implicated in the majority of opioid-involved deaths; highly potent (50-100 times more potent than heroin); typically not prescribed but illicitly manufactured overseas and smuggled into the US; youth overdose on opioids combined with other substances (eg, cocaine, methamphetamines, benzodiazepines) became more common in 2017, indicating a polysubstance overdose crisis; ≈67% of individuals on opioid addiction treatment report first use at age <25 yr, and ≈33% report first use at age <18 yr; past-year use of nonheroin narcotics show a decline in recent years, but ≈3.5% of students report recreational use or misuse of prescription opioids for nonmedical purposes in the past year

Treatment: medications approved by the US Food and Drug Administration include buprenorphine, naltrexone, and methadone; randomized clinical trials show fewer relapses and cravings for opioids, and longer retention in addiction treatment; medications should be combined with behavioral therapy; national data show that only 11% of youth who need treatment receive evidence-based treatment and only 3% of these individuals receive evidence-based medication

Screening to Brief Intervention (S2BI): includes questions about alcohol, cannabis, and tobacco use in the past year; if all answers are negative, questionnaire can be stopped; if positive, ask about other substances, including prescription and illegal drugs, inhalants, herbs, and synthetic drugs; proceed to CRAFFT questionnaire; frequency of use in the past year strongly correlates with risk for SUD; CRAFFT questions identify the types of problems one has; having more affirmative answers increases the likelihood of having SUD; one affirmative answer indicates a 33% chance of having SUD; 2 affirmative answers indicates a 67% chance of having SUD; brief intervention — brief recommendation to not use; finding an appropriate hook for that person is helpful; illustrate how reduction of use can help the patient attain personal goals; some youth need more extensive treatment and require referral; the clinician should become familiar with local treatment programs for substance use; the Substance Abuse and Mental Health Services Administration website can be useful for finding local treatment options; telemedicine is a viable option

Readings

Anderson DM, Hansen B, Rees DI, et al. Association of marijuana laws with teen marijuana use: New estimates from the youth risk behavior surveys. JAMA Pediatr. 2019;173(9):879-881. doi:10.1001/jamapediatrics.2019.1720; Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. 2020; 382(8):697-705; Dai H. Self-reported marijuana use in electronic cigarettes among US youth, 2017 to 2018. JAMA. 2020; 323(5):473-474; Gaither JR, Shabanova V, Leventhal JM. US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558. Published 2018 Dec 7. doi:10.1001/jamanetworkopen.2018.6558; Hadland SE, Xuan Z, Sarda V, et al. Alcohol policies and alcohol-related motor vehicle crash fatalities among young people in the US. Pediatrics. 2017; 139(3):e20163037; Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698):1383-1391. doi:10.1016/S0140-6736(09)61037-0; Jiloha RC. Prevention, early intervention, and harm reduction of substance use in adolescents. Indian J Psychiatry. 2017;59(1):111-118. doi:10.4103/0019-5545.204444; Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveill Summ. 2018;67(No. SS-8):1–114. DOI: http://dx.doi.org/10.15585/mmwr.ss6708a1external icon; Karila L, Roux P, Rolland B, et al. Acute and long-term effects of cannabis use: a review. Curr Pharm Des. 2014;20(25):4112-4118. doi:10.2174/13816128113199990620; King BA, Jones CM, Baldwin GT, et al. The EVALI and youth vaping epidemics — implications for public health. N Engl J Med. 2020; 382:689-691; Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr. 2014; 168(9):822-8; Lim JK, Earlywine JJ, Bagley SM, et al. Polysubstance involvement in opioid overdose deaths in adolescents and young adults, 1999-2018. JAMA Pediatr. 2021; 175(2):194-196; Mitchell SG, Kelly SM, Gryczynski J, et al. The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs: A re-evaluation and re-examination. Subst Abus. 2014; 35(4), 376–80; Plunk AD, Peglow SL, Harrell PT, et al. Youth and adult arrests for cannabis possession after decriminalization and legalization of cannabis. JAMA Pediatr. 2019;173(8):763-769. doi:10.1001/jamapediatrics.2019.1539; Soneiji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr. 2017; 171(8):788-97.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Hadland was recorded at the 36th Annual Pediatrics for the Practitioner: Update 2021, held virtually October 28-29, 2021, and presented by The Johns Hopkins University School of Medicine, Division of General Pediatrics, and Division of Adolescent and Young Adult Medicine; Johns Hopkins Children's Center; and the American Academy of Pediatrics, Maryland Chapter. For information about upcoming CME activities from this presenter, please visit https://hopkinscme.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD681501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.