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., such as parent education and early recognition in pediatric practice.
Substance abuse risk
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 ().
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.