
- Vol 40, Issue 5
Substance Use Among Adolescents and Young Adults
In this CME, check out best practices for screening and treating adolescents and young adults with substance use issues.
CATEGORY 1 CME
Premiere Date: May 20, 2023
Expiration Date: November 20, 2024
This activity offers CE credits for:
1. Physicians (CME)
2. Other
All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
ACTIVITY GOAL
The goal of this activity is to recognize substance use disorders among adolescents and young adults, as well as learn strategies for treatment.
LEARNING OBJECTIVES
1. Understand the general epidemiology of substance use and substance use disorders among adolescents and young adults.
2. Understand best practices for screening and treating adolescents and young adults with substance use issues.
TARGET AUDIENCE
This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals seeking to improve the care of patients with mental health disorders.
ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource®, LLC, and Psychiatric Times®. Physicians’ Education Resource®, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
Physicians’ Education Resource, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.
OFF-LABEL DISCLOSURE/DISCLAIMER
This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource, LLC.
FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION
None of the staff of Physicians’ Education Resource, LLC, or Psychiatric Times or the planners of this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. Dr Quiggle reports nothing to disclose regarding this article. Dr Burke reports he receives the following grant: NIDA/AACAP K12, Grant # 3K12DA000357-22S1. Dr Wilens reports he is a coeditor for Elsevier Psychiatric Clinics of North America (ADHD). Additionally, he receives grant/research support from the NIH (NIDA). He receives royalties for intellectual property from Cambridge University Press, Guilford Press, and Ironshore. Dr Wilens also works as a clinical consultant for Bay Cove Human Services, the Gavin Foundation, US Minor/Major League Baseball, the US National Football League, and White Rhino/3D.
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HOW TO CLAIM CREDIT
Once you have read the article, please use the following URL to evaluate and request credit:
Adolescence is a developmental stage characterized by rapid physical and psychosocial growth and maturation.1 With such dynamic neurobiological and social changes come a unique set of vulnerabilities to risk taking and
As compared to other age demographics, adolescents have the greatest access to substances coupled with the lowest perception of substance-associated risks.3 This is a critical point, as perception of the harm a substance may pose is generally inversely related to its use in adolescents and young individuals. By the senior year of high school, more than 61% of students report having tried alcohol, 41% have experimented with illicit drugs, and nearly 10% have used a prescription medication nonmedically.4 In a recent study evaluating the history of cannabis use, adolescents were twice as likely to develop a
According to the 2021 National Survey on Drug Use and Heath, nearly 10% of youth aged 12 to 17 met criteria for a
Impacts of Substance Use
Substance use is a major cause of disability among adolescents and young adults globally.9 Substance use has been shown to have a multitude of developmental impacts across the psychosocial, neuropsychological, and physical domains. Impaired familial relationships, lower educational attainment, higher rates of unemployment, and lower reports of overall life satisfaction have been found among adolescents and young adults who use substances, even after correcting for multiple potential confounders.10
Although some neuropsychological features may increase the underlying risk of substance use in adolescents (eg, deficits in inhibitory executive function control), longitudinal studies suggest that cannabis use is associated with worse performance on tests of attention and memory, lower processing speeds,11 as well as potential long-term deficits in executive functioning and verbal IQ even after cessation of use.12 Short-term cognitive effects of cannabis can last up to 8 hours and highlight concerns about driving under the influence. The risk of involvement in a motor vehicle accident increases 2-fold after recent cannabis use.13 Structural and functional neuroimaging studies have likewise found an association between heavy
Adolescent-onset SUDs have also been shown to predict all-cause mortality in young adulthood and are associated with infectious diseases such as HIV and hepatitis C, risky sexual behaviors, motor vehicle accidents, drug trafficking, and
Screening and Evaluation
Given the high rates of substance use and associated morbidity among adolescents and young adults, adequate screening and referral is of paramount importance. The American Academy of Pediatrics (AAP) recommends universal screening, brief intervention, and referral to treatment (SBIRT) in the primary care setting.15 Several validated screening instruments (free and available online) can be used across a range of clinical settings and are outlined in the
Because more than 75% of adolescents with an SUD have a comorbid mental health diagnosis, any comprehensive evaluation should include careful attention to the assessment of common psychiatric comorbidities, including disorders of conduct, mood, anxiety, and
The DSM-5 can aide in the diagnosis of an SUD.17 In order to make a diagnosis, one must establish a history of problematic use leading to clinically significant impairment or distress over a 12-month period. At least 2 of 11 criteria, generally involving impaired control, social impairment, risky use, and physiologic dependence, must be met. SUDs can be conceptualized on a spectrum of severity: mild (2-3 criteria), moderate (4-5 criteria), and severe (6 or more criteria). While the diagnostic criteria to establish an SUD are the same for adolescents and adults, diagnostic challenges can arise from the discordance between patient and parent report. Special attention to functional impairment as evidenced by declining grades, changes in friend groups, social problems, and risky behaviors can be helpful in making a diagnosis.
Treatment
An integrated, multipronged approach that pays particular attention to the developmental stage of the patient is recommended for the treatment of adolescents and young adults with SUDs. Motivational interviewing, a communicative strategy that attempts to elicit a patient’s intrinsic motivation for change by resolving ambivalence, can be a useful framework for engaging and working with this patient population.18 In addition, motivational enhancement therapy, Adolescent Community Reinforcement Approach (A-CRA), cognitive behavioral therapy (CBT), contingency management, and a variety of family-based therapies are all considered effective behavioral interventions for youth.19 The Community Reinforcement and Family Training (CRAFT) model can provide family members with helpful evidence-based tools that teach strategies targeting motivation and behavior change, positive communication, and self-care.20 Given both the vulnerabilities to substance use and lack of treatment engagement in the adolescent population, low-threshold treatment models that are flexible to the developmental needs of this population have emerged.21
Evidence-based psychopharmacologic treatments for core symptoms of SUD in adolescents and young adults are limited. For OUD, only
Data are mixed on how the treatment of co-occurring psychiatric disorders impact substance use. For example, in mood disorders, in a small RCT looking at adolescents with underlying bipolar disorder, the use of
Concluding Thoughts
Overall, substance use in adolescents and young adults remains a serious public health concern and poses a unique set of risks to the developing brain. Further efforts are needed to screen for SUDs and engage this vulnerable population in treatment.
Dr Quiggle is an addiction psychiatry fellow at Mass General Brigham. Dr Burke is a psychiatrist in Boston, Massachusetts and is affiliated with multiple hospitals in the area, including Massachusetts General Hospital and McLean Hospital. Dr Wilens is chief of the Division of Child and Adolescent Psychiatry and is codirector of the Center for Addiction Medicine at Massachusetts General Hospital.
References
1. Chulani VL, Gordon LP.
2. Casey BJ, Jones RM.
3. Key substance use and mental health indicators in the United States: results from the 2021 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. December 2022. Accessed April 3, 2023.
4. Johnston LD, Miech RA, Patrick ME, et al. Monitoring the future: national survey results on drug use, 1975–2022. Institute for Social Research, The University of Michigan. 2023. Accessed April 3, 2023.
5. Volkow ND, Han B, Einstein EB, Compton WM.
6. Compton WM, Thomas YF, Stinson FS, Grant BF.
7. Hadland SE, Wharam JF, Schuster MA, et al.
8. Terranella A, Guy GP, Mikosz C.
9. Erskine HE, Moffitt TE, Copeland WE, et al.
10. Stormshak EA, DeGarmo DS, Chronister KM, et al.
11. Squeglia LM, Gray KM.
12. Castellanos-Ryan N, Pingault JB, Parent S, et al.
13. Hartman RL, Huestis MA.
14. Clark DB, Martin CS, Cornelius JR.
15. Levy SJL, Kokotailo PK; Committee on Substance Abuse.
16. Garofoli M.
17. Diagnostic and statistical manual of mental disorders, Fifth Edition. American Psychiatric Association Publishing; 2013.
18. Jensen CD, Cushing CC, Aylward BS, et al.
19. Adams ZW, Marriott BR, Hulvershorn LA, Hinckley J.
20. Kirby KC, Versek B, Kerwin ME, et al.
21. Wilens TE, McKowen J, Kane M. Transitional-aged youth and substance use: teenaged addicts come of age. Contemp Pediatr. November 1, 2013. Accessed April 3, 2023.
22. Miranda R, Ray L, Blanchard A, et al.
23. Gray KM, Carpenter MJ, Baker NL, et al.
24. Gray KM, Sonne SC, McClure EA, et al.
25. Geller B, Cooper TB, Sun K, et al.
26. Yule AM, DiSalvo M, Kramer J, et al.
27. Riggs PD, Mikulich-Gilbertson SK, Davies RD, et al.
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