Download Preview the material

Adolescents And Addiction
Introduction
Substance abuse and addiction, whether to alcohol, illicit drugs, or other
substances, is harmful to those of any age, but is particularly damaging to
adolescents. Teens across various socioeconomic and cultural backgrounds
abuse drugs and alcohol. This leads to physical or psychological problems
and can also affect a teen’s learning abilities, capacity to retain and
remember information, and activities and relationships with family and
peers. Also, teens who start to use alcohol or tobacco or to experiment with
certain types of drugs are at higher risk of moving on to other drugs and
further increasing their risks of addiction.
Unfortunately, adolescents often engage in potentially harmful behavior
before considering the consequences. The growth and maturity that
develops during adolescence does not necessarily stay in sync with the
physical progress that occurs during this time. In other words, adolescents
often experience increased physical growth, the effects of increased
hormone secretion and puberty; and, teens are subject to social pressures
that result in them potentially making choices that are not always the best
for their health and well-being. Adolescents and young adults tend to more
actively experiment with drugs and alcohol, but these groups are also more
likely to develop substance use disorders.7
Poor habits or even addictions that develop during adolescence can continue
to plague a person as an adult, long after the teen years have ended. That is
to say, choices that a person makes during adolescence, such as whether to
use drugs or alcohol or whether to start smoking, can lead to habits that are
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
1
not only difficult to break later, but that can cause dangerous complications
if they continue into adulthood.
Types Of Substance Use Disorders
The reasons adolescents develop substance use disorders and addiction on
drugs and alcohol are varied and complex, but unfortunately, substance use
addiction is more common among teens than many would like to admit.
According to the Substance Abuse and Mental Health Services Administration
(SAHMSA), over 23 million people over the age of 12 years needed
treatment for substance use in 2012.1 Adolescents are often under
significant pressure and are influenced by their peers, family members, and
others in the community, all of whom have an effect on whether many teens
start to experiment with harmful substances. Whether a substance use
disorder takes the form of alcohol, illegal drugs, tobacco, or prescription
drugs, teens that use these substances are at risk of the damaging and longterm effects that can last into adulthood.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) was developed to assist trained mental health clinicians to diagnose
mental and substance use disorders. The DSM-5 chapter, Substance-Related
and Addictive Disorders, includes diagnostic criteria and symptoms of a
substance use disorder and summarize characteristic signs and symptoms
suggestive of an underlying disorder. In the sections below, the DSM-5
changes to the substance use disorders groups and the criteria defining
substance use conditions or addictions are discussed.
Alcohol
Alcohol is one of the most commonly used substances across all age groups.
It is legally available for purchase by people over a certain age, which is 21
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
2
years old in the United States, and adolescents are not legally eligible to
purchase or drink alcohol, regardless of its prominence among this age
group. According to the Monitoring the Future study, approximately 80
percent of adolescents have consumed some amount of alcohol by the time
they reach their senior year of high school, and half of these teens have
taken their first drink by the time they have reached the eighth grade.2
An adolescent may develop an alcohol use disorder after repeated use. An
alcohol use disorder and addiction develops when a person is unable to stop
using alcohol despite making attempts to quit; when a person suffers
negative symptoms and effects of withdrawal when stopping intake; or when
a person is unable to stop drinking alcohol routinely, even though its use is
negatively impacting work, school, and relationships. An alcohol use disorder
develops when a person uses alcohol and drinks too much or too often; the
person may engage in dangerous activities as a result of alcohol intoxication,
such as driving while drunk or engaging in unsafe sexual practices. Alcohol
addiction involves a craving for alcohol, an inability to stop drinking once
starting, increased tolerance to alcohol, requiring more and more of it to
achieve the same effects of intoxication, and withdrawal symptoms when not
drinking alcohol.40
Alcohol is a central nervous system depressant, and the adolescent who
consumes it may initially feel tired and sluggish, but may also experience
euphoria and pleasant or happy feelings. The short-term use of alcohol
increases the work of inhibitory neurotransmitters such as GABA and
serotonin, which produces these initial effects. Over time, though, alcohol
use then increases the work of excitatory transmitters, such as epinephrine
and norepinephrine and decreases the effects of inhibitory
neurotransmitters. The person then experiences tolerance and requires more
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
3
drinks to achieve the same effects as was initially felt early on.40 Increased
consumption because of tolerance can eventually lead to a substance use
disorder and addiction when the person craves the effects of alcohol and has
a desire to drink and continues to consume alcohol despite negative
consequences.
The DSM-5 section on Alcohol-Related Disorders defines alcohol use disorder
as “a problematic pattern of alcohol use leading to clinical significant
impairment or distress, as manifested by at least two of the following
occurring within a twelve month period”, and the criteria are listed as:77

Alcohol 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 alcohol use.

A great deal of time is spent in activities necessary to obtain alcohol,
use alcohol, or recover from its effects.

Craving, or a strong desire or urge to use alcohol.

Recurrent alcohol use resulting in a failure to fulfill major role
obligations at work, school, or home.

Continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of
alcohol.

Important social, occupational, or recreational activities are given up
or reduced because of alcohol use.

Recurrent alcohol use in situations in which it is physically hazardous.

Alcohol use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbate by alcohol.

Tolerance, as defined by either of the following:
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
4
o A need for markedly increased amounts of alcohol to achieve
intoxication or desired effect.
o A markedly diminished effect with continued use of the same
amount of alcohol.

Withdrawal as manifested by either of the following:
o The characteristic withdrawal syndrome for alcohol (refer to
Criteria A and B of the criteria set for alcohol withdrawal)
o Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid withdrawal
symptoms.
An alcohol use disorder causes many significant effects to various body
systems. Alcohol has been shown to contribute to liver disease, including
cirrhosis and hepatitis; gastrointestinal dysfunction, such as esophageal
varices and portal hypertension; heart disease, obesity, poor sleep habits,
osteoporosis, pneumonia, and certain types of cancer.40 Both short- and
long-term use of alcohol can cause cognitive changes, which can be
especially damaging to the adolescent who is continuing to undergo
neurological development. Cognitive changes may include memory
problems, difficulties with concentration, and problems with learning. These
effects may be permanent in some people, even after they quit drinking.
Alcohol is also dangerous for teens because it is commonly associated with
other forms of drug use and with smoking. People who use alcohol and drink
to the point of intoxication can become aggressive and violent, which places
them at risk of accidents, injuries, and suicide. Drinking alcohol in college is
an extremely widespread phenomenon, with approximately 4 out of 5
college students drinking alcohol and half of these participating in binge
drinking, which is the consumption of more than 4 drinks for women or 5
drinks for men in a span of less than 2 hours.43
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
5
Many teens enter college and start drinking alcohol during their experience
there, even if they were not prior alcohol users. Unfortunately, drinking
alcohol is often seen as part of the college experience, with alcohol being
available to students at parties, social groups, and within college dorm
rooms. The negative consequences of such rampant alcohol consumption
affect thousands of students and their families each year, with college
students experiencing injuries, academic problems, destruction of property,
sexual assaults, and suicide attempts, as well as some deaths related to
alcohol consumption, at college campuses throughout the United States.
The younger a person is when he or she starts drinking, the higher the risk
is that he or she will develop an alcohol use disorder. Teens who are not yet
college age and who drink alcohol are more likely to develop an alcohol use
disorder, even into adulthood. By comparison, those who wait until they are
21 years old, or who wait until they are in college to participate in binge
drinking or routinely consume alcohol may not necessarily develop an
alcohol use disorder as they grow into adulthood.
Alcohol use among underage youth is widespread, and according to the
National Institute on Alcohol Abuse and Alcoholism, over half of adolescents
have tried alcohol by the time they turned 15, with over 70 percent having
tried alcohol by the time they have reached age 18.44 Random use of alcohol
or experimentation is not the same as an alcohol use disorder and addiction
but the negative results associated with chronic alcohol use can be
staggering and affect thousands of people every year, many of whom
started drinking during adolescence. While many healthcare providers may
assume that an occasional drink or attempt at trying alcohol for teens is
harmless, they must remember that every person who has become an
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
6
alcoholic, whether during adolescence or in adulthood, started with that first
drink.
Illegal Drugs
Drugs used by adolescents that are commonly abused are often classified as
illegal or “street” drugs. These drugs are considered those that are not
classified as prescription drugs or household substances. The most
commonly abused illegal drug is marijuana, although there are many
different types of illegal drugs that lead to a substance use disorder and
addiction.
Marijuana
Marijuana is one of the most commonly used illegal drugs by adolescents in
the United States. According to the Monitoring the Future Study, a research
study conducted by the National Institute on Drug Abuse, over 44 percent of
12th graders have tried marijuana, and 21 percent have used it within the
last month.46 Because of the uses of medical marijuana, the legalization of
some types of marijuana use within some states, and the fact that
marijuana comes from a plant leads many teens to believe that it is a
harmless drug or that it does not result in addiction. Marijuana can be
harmful, however, when its use impacts a teen’s daily activities and when it
leads to other forms of substance use.
Marijuana comes from the hemp plant; it consists of dried and cut pieces of
the plant, including its stems, flowers, and leaves. It is most often used
when its pieces are rolled in paper or are put into a pipe and it is smoked.
Marijuana may also be added to certain foods and eaten, brewed as tea,
used as lollipops, or inhaled as vapor. The person who uses marijuana
experiences psychotropic effects of pleasurable feelings, as well as a lack of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
7
coordination, increased appetite, and dizziness.47 The effects are caused by
a component of the drug called delta-9-tetrahydrocannabinol, also referred
to as THC.
While there are some states that have changed their laws and allowed the
use of marijuana for medical purposes, or in some states, even for
recreational purposes, it is still illegal for a teen to buy, possess, and use
marijuana. The THC in marijuana affects several specific areas of the brain
that can lead to cognitive changes that could potentially be permanent, even
if the teen stops using marijuana later. THC affects coordination and
memory, which may make it difficult for a person to make good decisions
after using marijuana; additionally, THC impacts the area of the brain
responsible for learning and memory, which can impair a teen’s abilities to
perform in school and to remember information. Studies have also shown
that people who consistently smoke marijuana starting in their teens have a
drop in IQ points that is not regained, even if they quit using it later.47
Cannabis-related disorders is defined in the DSM-5 as “a problematic pattern
of cannabis use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12-month
period”, and the criteria are listed as:77

Cannabis 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 cannabis use.

A great deal of time is spent in activities necessary to obtain cannabis,
use cannabis or recover from its effects.

Craving, or strong desire or urge to use cannabis.

Recurrent cannabis use resulting in a failure to fulfill major role
obligations at work, school, or home.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
8

Continued cannabis use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of
cannabis.

Important social, occupational, or recreational activates are given up
or reduced because of cannabis use.

Recurrent cannabis use in situations in which it is physically
hazardous.

Cannabis use is continued despite knowledge or having a persistent
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by cannabis.

Tolerance, as defined by either of the following:
o A need for markedly increased amounts of cannabis to achieve
intoxication or desired effect.
o Markedly diminished effect with continued use of the same
amount of cannabis.

Withdrawal, as manifested by either of the following:
o The characteristic withdrawal syndrome for cannabis (refer to
Criteria A and B of the criteria set for cannabis withdrawal)
o Cannabis (or a closely related substance) is taken to relieve or
avoid withdrawal symptoms.
Adolescents can become addicted to marijuana; over time, the person may
start to crave the high that comes from using this drug. People have also
experienced symptoms of withdrawal when stopping use of marijuana,
including symptoms of dizziness, irritability, and sleep problems. Most teens
that try marijuana do not go on to use other drugs or to become addicted.
However, teens who use marijuana, alcohol, and tobacco are at higher risk
of developing a substance use disorder later.47 Marijuana use can lead to
multiple physical and social problems, including changes in heart rate,
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
9
breathing problems, mental health issues, and increased risk of injuries from
accidents or use while driving. Although many people consider marijuana to
be relatively safe when compared to other drugs that teens could get
involved with, there are too many dangers associated with this drug to have
it be considered safe.
Opioids
Opioids are drugs that are often considered to be prescription drugs, and
they are typically administered as prescription drugs for pain control.
However, opioids may also be classified as illegal drugs that have the
potential for abuse when they are not used for medical purposes. Heroin is
the most common form of opioid drug that is not prescribed for medical use
but is abused as an illegal drug. Because of its high potential for causing a
substance use disorder and addiction, heroin is classified as a Schedule I
controlled substance.
Opioid-related disorders is defined in the DSM-5 as “a problematic pattern of
opioid use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12-month
period”, and the criteria are listed as:77

Opioids are 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 opioid use.

A great deal of tie is spent in activities necessary to obtain the opioid,
use the opioid, or recover from its effects.

Craving, or a strong desire or urge to use opioids.

Recurrent opioid use resulting in a failure to fulfill major role
obligations at work, school, or home.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
10

Continued opioid use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of
opioids.

Important social, occupational, or recreational activities are given up
or reduce because of opioid use.

Recurrent opioid use in situations in which it is physically hazardous.

Continued opioid use despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
used or exacerbated by the substance.

Tolerance, as defined by either of the following.
o A need for markedly increased amounts of opioids to achieve
intoxication or desired effect.
o A markedly diminished effect with continued use of the same
amount of an opioid.

Withdrawal as manifested by either of the following:
o The characteristic opioid withdrawal syndrome (refer to Criteria
A and B of the criteria set for opioid withdrawal)
o Opioids (or a closely related substance) are taken to relieve or
avoid withdrawal symptoms.
A person can use heroin in a number of ways to derive its effects. One of the
most common methods is through injection, but it can also be smoked or
sniffed. Because it is an opioid, heroin binds to opiate receptors in the brain
when it enters the body, which gives the sensation of intense euphoria,
leading to a very pleasant and relaxed state. When the drug binds to opioid
receptors, they block the sensation of pain by blocking receptors in the
central nervous system. Heroin also puts a person into a state of stupor,
which causes a slowed response, drowsiness, and mood changes. Lilley,
Collins, and Snyder, authors of the book Pharmacology and the Nursing
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
11
Process, defines this state of stupor as narcosis, which is why a drug such as
heroin is referred to as a narcotic.3
Stimulants
Stimulants are drugs that are stimulating to the central nervous system.
There are different classes of stimulants, some of which are classified as
illegal drugs, while others are given as prescription medications. A teen may
use prescription stimulants inappropriately in order to get the feelings of
pleasure and euphoria that these drugs can cause. Many prescription
stimulants, such as those administered for the treatment of ADHD, are
meant as timed-release medications, in which they slowly release the
medication into the body after the person takes them. However, these drugs
could instead be crushed and then mixed with another solution of water to
be injected, which causes a person to get high when the effects of the drug
are released all at once.
Amphetamines are stimulants that may be abused among adolescents and
young adults; amphetamines, depending on their form, may be available as
illegal drugs or as prescription drugs. Methamphetamine produces much
more significant effects on the body when compared to some other types of
stimulants. Crystallized methamphetamine, also referred to as crystal meth,
is a smokeable form of the drug that is highly powerful. It is a man-made
substance that is created from common products, including
pseudoephedrine, which is found in some over-the-counter cold and sinus
preparations. When a person smokes crystal meth, he or she experiences a
rapid and very intense high from the release of excess dopamine. However,
the feeling is short lived and when the intense feelings diminish, the person
is left with lower levels of dopamine than before, which causes feelings of
depression.5 The person using the drug then often feels compelled to repeat
the cycle of use to ward off the effects of depression and to experience the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
12
high feelings again. Meth addiction is very dangerous because it can cause
permanent damage to the brain by affecting how the body adjusts
neurotransmitter levels.
Because crystal meth is created in homemade laboratories using some overthe-counter medications, the sale and distribution of products that contain
pseudoephedrine has changed since 2005.3 Pseudoephedrine is normally
used in cold and sinus medications to shrink the size of the blood vessels in
the nose, which decreases nasal congestion. Because people who reate
methamphetamine may use larger amounts of pseudoephedrine for the drug
preparation, the sale of cold medications that contain pseudoephedrine has
been regulated so that purchasers must buy these drugs directly from the
pharmacy counter, rather than buying it off the shelf.
Cocaine is an illegal drug that is a type of stimulant that impacts the central
nervous system by causing an elevated state of being alert. Rather than
producing a state of stupor, as with some opioid drugs, cocaine tends to
have an opposite effect of euphoria, mental alertness, and increased energy.
Among teens, cocaine use has actually been shown to be declining in the
past decade, however, its availability, relatively inexpensive price, and
multiple methods of use have made cocaine a dangerous drug that can lead
to addiction among adolescents.
Similar to other types of stimulants, cocaine produces its effects by
increasing levels of dopamine, which leads to feelings of pleasure and
satisfaction. Unfortunately, the effects of cocaine on the brain enable people
to quickly become addicted, and teens may have a more difficult time
overcoming cocaine addiction or may be predisposed to abusing cocaine or
other stimulant drugs later in life. The changes that occur in the brain as a
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
13
result of cocaine use, coupled with the neurodevelopmental changes
occurring during adolescence, place a teen addicted to cocaine at high risk of
permanent changes in neurotransmitter levels in the brain and ultimately
greater risk of future drug abuse.6
Stimulant-related disorders is defined in the DSM-5 as “a pattern of
amphetamine-type substance, cocaine, or other stimulant use leading to
clinically significant impairment or distress, as manifested by at least two of
the following, occurring within a 12-month period”, and the criteria are listed
as:77

The stimulant is often taken in larger amounts or over a loner period
than was intended.

There is a persistent desire or unsuccessful efforts to cut down or
control stimulant use.

A great deal of time is spent in activities necessary to obtain the
stimulant, use the stimulant or recover from its effects.

Craving, or a strong desire or urge to use the stimulant.

Recurrent stimulant use resulting in a failure to fulfill major role
obligations at work, school, or home.

Continued stimulant use despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of the
stimulant.

Important social, occupational, or recreational activities are given up
or reduced because of stimulant use.

Recurrent stimulant use in situations in which it is physically
hazardous.

Stimulant use is continued despite knowledge of have a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the stimulant.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
14

Tolerance, as defined by either of the following:
o A need for markedly increased amounts of the stimulant to
achieve intoxication or desired effect.
o A markedly diminished effect with continued use of the same
amount of the stimulant.

Withdrawal as manifested by either of the following:
o The characteristic withdrawal syndrome for the stimulant (refer
to Criteria A and B of the criteria set for stimulant withdrawal)
o The stimulant (or a closely related substance) is taken to relieve
or avoid withdrawal symptoms.
Stimulants can be dangerous because their changes in dopamine levels
cause an elevation in heart rate and blood pressure. The person who abuses
stimulants is at higher risk of eventual heart failure when the heart must
work harder as a result of beating faster when using the drugs. The blood
vessels are constricted with stimulant use and the person who regularly uses
these drugs may suffer the effects of repeated blood vessel constriction
followed by relaxation. Further negative effects can occur based on the
method of using these drugs; for instance, a teen who regularly snorts
cocaine can develop skin breakdown in the nose; those who inject stimulants
are at higher risk of contracting infectious diseases spread by shared
needles.
Another illegal drug that is part stimulant and part hallucinogen is
methylenedioxymethamphetamine (MDMA), which is also called Ecstasy and
is on the rise in use among adolescents. Ecstasy, also called Molly, produces
the effects of stimulants in that the person taking it feels more energy and
experiences a sense of euphoria, acceptance of others, and feelings of
pleasure. Additionally, Ecstasy also causes psychedelic effects, which makes
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
15
it very attractive for users. It is typically taken as an oral tablet, but it may
also be injected or snorted.
Ecstasy produces a high because it affects the neurotransmitters dopamine,
serotonin, and norepinephrine in the brain. People who use it may feel
sexually aroused and emotionally close to those around them, which can be
dangerous for teens who may find themselves in situations where there is
considerable peer pressure to use the drug and then engage in unsafe
sexual practices. People who use Ecstasy can develop drug tolerance in
which they require more of the drug to experience the same effects. Some
teens have died from abusing Ecstasy because the drug causes an increase
in body temperature that can result in dangerous hyperthermia.8
Because adolescence is such an important time of building skills, learning,
and growing developmentally, illegal drug use can significantly inhibit teens’
abilities to grow and mature into healthy and responsible adults. The
accessibility of illegal drugs may vary for some teens, with some kids having
greater access to illegal drugs and others not having the connections needed
to buy or use street drugs. Still, many adolescents can find and use illegal
drugs when they want to, which can potentially lead to greater problems and
can prevent the healthy normal teen development.
Prescription Drugs
Although most people use prescription drugs appropriately and take them as
they are ordered, prescription drugs can cause health issues and can lead to
addiction for anyone who uses them inappropriately, including adolescents.
Teens are at high risk of the negative effects of drug use when they take
prescription drugs inappropriately, whether the drugs are prescribed for
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
16
them by a healthcare provider or whether they are accessing someone else’s
prescription to use.
The National Institute on Drug Abuse (NIDA), when performing the
Monitoring the Future Survey in 2014 found that 1 in 12 high school seniors
reported inappropriate use of prescription Vicodin within the last year.
Misuse of prescription drugs is the fourth most common type of drug abuse
among teens after alcohol, tobacco, and marijuana.9 The availability of
certain drugs makes inappropriate use of prescription drugs more common,
particularly among teens; however, the effects of a prescription drug use
disorder are just as damaging to adolescents and can include severe health
problems, overdose, and death.
Opioids
The most commonly abused prescription drugs among adolescents include
opioids, stimulants, and depressants. Opioids are administered to relieve and
control pain. Because they cause pleasant effects, they are also more
commonly misused and abused. Opioids interrupt the pain signal between
the nervous system and the brain so that the person experiencing pain does
not feel the effects of it as much while taking these types of drugs. Opioids
can also cause negative side effects of drowsiness, constipation, and
confusion; further negative effects can also develop when a person takes the
drugs in a method in which it was not originally intended. For example, some
opioid preparations are designed to be extended-release tablets, but some
people instead take them by crushing the pills and snorting or injecting
them, which provides a rapid response. Unfortunately, taking the drug in
this manner can also significantly increase the risk of overdose and
respiratory depression.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
17
Examples of opioids are codeine, oxycodone (OxyContin®), morphine,
meperidine (Demerol®), and hydrocodone (Vicodin®). Depending on the
patient’s condition, these drugs may be prescribed for various reasons.
Some opioids are administered for mild pain or to control coughs associated
with illness; an example of this type of drug is codeine. Alternatively, some
drugs are prescribed after medical procedures that can cause significant
pain, such as with morphine or hydrocodone. Misuse of these medications
cannot only lead to addiction but can also cause significant side effects.
Opioid medications cause a histamine release in the body, which results in
vasodilation, low blood pressure, and flushed skin. The person may also
experience intense itching, hives, sweating, urinary retention, and
constipation.3 More significantly, respiratory depression can occur with
overuse of opioids, leading to apnea and death if the situation is not
corrected.
Opioids, when taken appropriately according to a prescription, can be used
safely for long-term use, even among adolescents. An opioid use disorder
can lead to serious consequences when the patient seeks to get more of the
drug than is allowed by prescription. Because opioids can cause respiratory
depression, overdose of these types of drugs can be fatal even the first time
that they are misused.
Stimulants
Prescription stimulants may be misused and abused among adolescent
patients even if they are given to the adolescent under a prescription.
Prescription stimulants may be ordered for some adolescent patients who
need medications for treatment of conditions that require management of
fatigue or mood. Methylphenidate (Ritalin®) is a common medication
prescribed for the treatment of ADHD and has the potential to be abused. If
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
18
a teen patient with ADHD has been given a prescription for a stimulant such
as methylphenidate, there is potential for abuse of the drug and resulting
addiction when it is used inappropriately for a long enough period of time.
Methylphenidate stimulates the central nervous system and helps a person
to focus and concentrate on activities around him; it can help the person
taking it to feel more awake and alert.4 Teens who abuse this drug may be
more likely to do so because of the results it provides; for instance, an
adolescent patient may use methylphenidate inappropriately because it
helps him or her to stay awake longer to study and get better grades.
Stimulants have also been prescribed for other reasons as well, such as
weight loss, to stimulate the respiratory center of the brain and prevent
central apnea, and for treatment of sleep disorders such as narcolepsy.
Some teens have found the effects of stimulants to be beneficial to
appearance because they help with weight loss and promote activity and
wakefulness. Unfortunately, adolescents are often plagued by messages of
the importance of appearance and being thin. Some teens are able to secure
prescription stimulants that cause weight loss and they take them
inappropriately to attempt to lose weight and try to keep up with images
seen on television and online. Whether or not they are prescribed for this
purpose, prescription stimulants tend to suppress appetite, so they can be
useful for weight loss among some people because taking stimulants will
most likely cause them to eat less. Stimulants have also been shown to
enhance performance, so some teens may be more likely to take them in
order to keep up with the demands of schoolwork and extracurricular
activities.
Unfortunately, prescription stimulants also increase dopamine levels, which
normally lead to feelings of pleasure and an increased ability to concentrate,
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
19
but these drugs can also cause high blood pressure and an increase in heart
rate and body temperature.4 They also disrupt sleep and lead to insomnia,
which can negatively impact an adolescent’s performance at school or
abilities to maintain friendships and relationships.
Central Nervous System Depressants
Central nervous system (CNS) depressants are another form of drug that
may be prescribed and abused by some teens. Depressant medications
include such drugs as benzodiazepines and barbiturates and are used as
sedatives to control anxiety or to induce sleep. Benzodiazepines are typically
prescribed for management of anxiety or for sleep disturbances; because
they can cause dependence and are at increased risk of being abused,
benzodiazepines are often only prescribed for short-term use.9 Examples of
benzodiazepine medications include alprazolam (Xanax®) and diazepam
(Valium®).
Non-benzodiazepines are medications that have depressant effects and act
in a manner similar to benzodiazepines, but they are chemically different.
They are considered to be less risky when it comes to dependence and they
typically produce fewer side effects. Examples of these types of drugs
include zolpidem (Ambien®) and zalepon (Sonata®). Barbiturates are
depressants that are also prescribed for anxiety; because of their risk of
abuse and overdose, they are not as commonly prescribed. Examples of
barbiturates include mephobarbital (Mebaral®) and pentobarbital
(Nembutal®). Barbiturate use was more prominent in the 1960s and 1970s
in U. S. history, resulting in a number of prominent deaths from overdose.
Many of today’s adolescents are unaware or do not remember some of the
celebrity deaths associated with barbiturate use and they may not be aware
of how dangerous these drugs can be.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
20
Central nervous system depressants work by affecting gamma-aminobutyric
acid (GABA) to produce a sense of drowsiness and a feeling of calm or
relaxation. Depressant medications more commonly cause tolerance, in
which a person who uses them requires more of the drug; among many
benzodiazepines and barbiturates, tolerance can develop within a few days’
use.9 If an adolescent becomes addicted to benzodiazepines, he or she may
suffer withdrawal symptoms that can lead to seizures, increased anxiety or
panic attacks, insomnia, and psychosis. Alternatively, barbiturate addiction
can cause life-threatening effects during withdrawal, such as seizures and
hyperthermia, and the person undergoing detoxification from these drugs
must be monitored closely.
Prescription drug abuse among adolescents is a serious problem; teens that
abuse these types of drugs have been shown to start even before reaching
the 8th grade. Adolescents who admit to misusing prescription drugs have
stated that they most often use drugs that they take or buy from someone
else who has the prescription, making these drugs relatively easy to access
for many teens. Further, teens who abuse prescription drugs are more likely
to misuse other types of drugs as well, including alcohol, tobacco, or
marijuana.
When combining prescription drugs with other types of drugs, the effects of
more than one substance together can result in effects that are multiplied,
which is often dangerous. For example, a teen who misuses prescription
benzodiazepines and who drinks alcohol can suffer the consequences of both
types of CNS depressants used together, which can lead to significant
drowsiness, changes in mental status, and respiratory depression.
Healthcare providers play important roles in recognizing the signs of a
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
21
prescription drug use problem among adolescent patients and assisting them
to obtain the help they need to overcome an issue of addiction.
Household Items
Drugs can be found within the home, which makes abusing household items
very dangerous for teens. Adolescents have easy access to these items.
When an adolescent can find these items at home he or she often does not
need to buy anything or find someone to sell the drugs or alcohol. These
items are also dangerous because they are completely unregulated; and, it
is just as easy to overdose on inhalants and toxic substances used as drugs
from household items as it is for a person to overdose on prescription or
illegal drugs.
Inhalants
Inhalants are common, everyday products found in the environment that
people inhale to get high. A teen may use inhalants by sniffing the fumes
from a container or spraying items directly into the mouth or nose. Huffing is
the process of soaking a rag or cloth with an inhalant, putting it in the
mouth, and then breathing in the fumes. Inhalants can be found in all sorts
of substances, chemicals, and products found in the home, in the yard, or in
the garage. Examples of inhalants may include:

Aerosols: spray bottles of hairspray, deodorant, compressed air for
cleaning keyboards, whipped cream dispensers, and spray paint.

Solvents: paint thinner, gasoline, glue, correction fluid, nail polish
remover, and cleaning solutions.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
22

Nitrates: amyl nitrate, butyl nitrate; found in products labeled as
leather cleaner, or room odorizer10

Gases: Propane tanks, butane lighters, refrigerant solutions,
chloroform, nitrous oxide.
After inhaling the gas or spray, the person feels a rush or high right away
that is short lived. Inhalants often produce feelings of euphoria, dizziness,
lightheadedness, and the person using them may experience hallucinations.
He or she must continue to use the inhalants in order to get the same
feeling because it is often so short. In larger amounts, inhalants can produce
anesthesia, but too much can cause the person to lose consciousness.
Because the inhalant is breathed in, the gas or fumes take the place of
oxygen in the lungs. This puts the user at risk for respiratory problems and
decreased oxygen levels in the bloodstream, which then leads to decreased
oxygen reaching the brain. The heart also beats faster and must work much
harder, which can lead to heart failure.
Inhalant-related disorders is defined in the DSM-5 as “a problematic pattern
of use of a hydrocarbon-based inhalant substance leading to clinically
significant impairment or distress, as manifested by at least two of the
following, occurring within a 12-month period”, and the criteria are listed
as:77

The inhalant 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 inhalant substance.

A great deal of time is spent in activities necessary to obtain the
inhalant substance, use it, or recover from its effects.

Craving, or a strong desire or urge to use the inhalant substance.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
23

Recurrent use of the inhalant substance resulting in a failure to fulfill
major role obligations at work, school, or home.

Continued use of the inhalant 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 inhalant substance.

Recurrent use of the inhalant substance in situations in which it is
physically hazardous.

Use of the inhalant 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:
o A need for markedly increased amounts of the inhalant
substance to achieve intoxication or desired effect.
o A markedly diminished effect with continued use of the same
amount of the inhalant substance.
Clinicians are guided in the DSM-5 to specify the particular inhalant and,
when possible, the particular substance involved should be named.
The chemicals inhaled during the process are also damaging to the body; the
chemicals enter the bloodstream and can lead to toxic levels that eventually
affect tissue perfusion and proper organ function. Typically, high levels of
chemicals in the bloodstream cause toxicity that leads to poor concentration,
slowed response times, and mental status changes. For a teen who is still
going through neurological development, this is particularly damaging to the
brain and central nervous system. Growing teens also suffer the physical
effects of brain hypoxia after using inhalants, affecting their abilities to study
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
24
or participate in sports or games. Inhalants are also dangerous because it is
difficult to control how much a person takes in each time; the person using
the inhalant can easily overdose and take in too much, causing them to lose
consciousness or even die after one use.
Long-term use of inhalants can lead to nerve damage after breakdown of the
myelin sheath covering some of the nerves. Brain hypoxia also occurs from
chronic inhalant use, which leads to memory problems and delays in thinking
and processing, which can make it difficult to hold a conversation or make
quick decisions. This may cause problems with movement, such as
maintaining a normal gait or performing daily activities. Further health
problems include chronic muscle weakness, liver failure, and aplastic
anemia.10
Inhalants are one of the earliest forms of drug use among teens that start
abusing drugs. According to the National Institute on Drug Abuse, younger
teens are more likely to use inhalants when compared to older teens, and a
greater percentage of 8th graders admit to using inhalants in the past month
when compared to 10th or 12th graders.10 Inhalant use is often not
something that occurs once or twice; often, the teen who experiments with
inhalants to get high tends to repeat its use, which may lead to chronic,
long-term abuse of inhalants.
Poisoning or Ingestion
In addition to inhaling toxic substances, some teens may get high by
ingesting other products that are commonly found around the house. Spices,
kitchen items, mouthwash, and perfume are just some of the items that
adolescents have used for their effects when taken in large amounts.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
25
It may seem unlikely, but kids have been known to abuse everyday kitchen
spices for their effects. Some teens have found that snorting large amounts
of nutmeg produces sensations similar to smoking marijuana. It is believed
that nutmeg contains a component known as myristicin, which is also found
in Ecstasy and is responsible for some of its psychedelic properties.
Ingesting large amounts of nutmeg impacts the central nervous system,
neurotransmitters in the brain, and the cardiovascular system. Nutmeg
causes hallucinations that can last for several hours and in some cases, can
go on for several days.
Nutmeg is often snorted through the nose, but a person can get some of the
same effects by eating large amounts of the spice. Even one tablespoon of
nutmeg consumed all at once has been shown to produce symptoms similar
to anticholinergic toxicity.12 Although it may appear that nutmeg is harmless
because it is a commonly used spice, teens who ingest excess nutmeg to get
high are in danger of its toxic effects, which can include hyperthermia,
breathing difficulties, anxiety, aggression, rapid pulse, and delirium.
Another method that some teens use to get access to alcohol is by drinking
extracts, which are flavorings used for baking and cooking. One of the most
commonly used extracts in the kitchen is vanilla; pure vanilla extract
contains up to 35 percent ethanol and can be a source of alcohol for some
people who have no other access to getting it.13 Vanilla extract falls in the
same category as other products found in the home that contain ethanol,
such as mouthwash, hand sanitizer, or some types of perfumes.
A case report found in The Internet Journal of Family Practice showed that
teens and young adults may likely ingest extracts and other household
products containing ethanol with the desire to get high, but these
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
26
substances can cause harmful effects to the cardiovascular system.
Ingestion of ethanol depresses the central nervous system and produces
effects of intoxication similar to that of drinking too much beer or wine. The
person may also experience an upset stomach and may vomit, the skin
becomes flushed, and the person can develop hypotension and a low body
temperature.13 Unlike drinking beer or wine, the amount of alcohol found in
some household products is at a much higher concentration; the teen who
gains access to alcohol by drinking vanilla extract is more likely to
experience a much more rapid and dangerous period of ethanol intoxication
that warrants medical attention, when compared to becoming intoxicated by
drinking alcoholic beverages.
Many teens use household products as substances for the experience of a
rush or getting high because they are often more accessible than illegal or
prescription drugs or alcohol. Adolescents may believe that it is safer to use
household items than it is to use drugs or alcohol because, after all, these
items are safe to have in the home; the truth, however, is that abusing
household substances, whether by using inhalants or by ingesting toxic
items in the home, can cause significant physical effects, can lead to chronic
use that is damaging to the body, and often serves as a gateway to other
forms of substance use disorder, such as with illegal drugs or alcohol.
Tobacco
There was a time when tobacco use was common and even encouraged
among adults and adolescents; society was unaware of the dangers of
tobacco use and people smoked everywhere, including in public places and
in their homes. This trend has changed with more information about the
effects of tobacco use, including long-term negative health consequences.
The effects of tobacco use have been taught in schools throughout the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
27
United States and many more people are now aware of the dangers of longterm tobacco use.
This has not necessarily stopped some adolescents from trying tobacco and
eventually using it on a regular basis. The U. S. Department of Health and
Human Services Office of Adolescent Health states that almost 4 million 14to 17-year olds have smoked cigarettes and one in 15 high school seniors is
a daily smoker. Smoking is also more common among white adolescents
when compared to black or Hispanic teens; and adolescents who live in the
South and Midwest regions of the country are also more likely to smoke.48
Tobacco comes from a plant that is grown in various parts of the world,
including within the United States. Tobacco leaves are cut from the plant and
dried, where it is then packaged into different forms depending on its use.
Cigarettes contain shredded tobacco that is rolled in paper; shredded
tobacco can also be loosely placed in pipes. Cured tobacco makes up
smokeless tobacco, also called dip that some teens use by placing a pinch of
it on the inside of the cheek next to the gums. Ground tobacco is made into
snuff, which is used by snorting it into the nose.
Tobacco is addictive because it contains nicotine, which causes changes in
the brain; after using tobacco, a person can become addicted and crave
more of the nicotine, in which he will continue to use the tobacco. Among
teens, the most common method of using tobacco is by smoking
cigarettes.48 Tobacco causes a number of negative effects on various body
systems, and cigarette smoking is responsible for approximately 480,000
deaths each year in the United States.68 Smoking contributes to such longterm illnesses as cardiovascular disease, lung cancer, and stroke, among
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
28
many other potential complications that can cause sickness and can lead to
death.
Teens who smoke and become addicted to tobacco are putting their bodies
at risk of developing health problems associated with tobacco use. Cigarette
smoke has been shown to contain more than 7,000 chemicals, many of
which are toxic to the body and can cause cancer. Further, addiction to
nicotine is controlling for the teen who tries to continue smoking cigarettes
during school or work, finding someone to buy cigarettes for him or her if
underage, and spending the money to buy packs of cigarettes.
Tobacco-related disorders is defined in the DSM-5 as “a problematic pattern
of tobacco use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12-month
period”, and the criteria are listed as:77

Tobacco 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 tobacco use.

A great deal of time is spent in activities necessary to obtain or use
tobacco.

Craving, or a strong desire or urge to use tobacco.

Recurrent tobacco use resulting in a failure to fulfill major role
obligations at work, school, or home (i.e., interference with work).

Continued tobacco use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of
tobacco (i.e., arguments with others about tobacco use).

Important social, occupational, or recreational activities are given up
or reduced because of tobacco use.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
29

Recurrent tobacco use in situations in which it is physically hazardous
(i.e., smoking in bed).

Tobacco use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by tobacco.

Tolerance, as defined by either of the following:
o A need for markedly increased amounts of tobacco to achieve
the desired effect.
o A markedly diminished effect with continued use of the same
amount of tobacco.

Withdrawal as manifested by either of the following:
o The characteristic withdrawal syndrome for tobacco (refer to
Criteria A and B of the criteria set for tobacco withdrawal)
o Tobacco (or a closely related substance, such as nicotine) is
taken to relieve or avoid withdrawal symptoms.
Cigarette smoking contributes to poor lung function, and a teen who smokes
may have a longer period of healing if he or she becomes ill with colds or the
flu because of the lung damage incurred from smoking. Cigarette smoking
can also reduce a person’s stamina and ability to perform daily activities,
leading to potential problems completing work, maintaining responsibilities,
or participating in sports.
Electronic cigarettes, also called e-cigarettes are forms of smoking in which
tobacco is delivered through a vapor that the person inhales. The vapor is
created through an electronic device that can also deliver other flavors of
vapor for the person to inhale and use. E-cigarette use by teens increased
significantly between 2010 and 2014, with rates of use jumping from 4
percent to over 17 percent.48
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
30
It is illegal for many teens to buy tobacco products in the United States, with
most states requiring that a person be at least 18 years old to purchase it;
although there are a couple of states that require a person to be at least 19
years old before purchasing tobacco. Cigarettes, cigars, loose tobacco, and
dip can all be purchased over the counter; many products are available at
grocery stores, pharmacies, and specialty shops, although many teens would
be required to show proof of age with identification to purchase. E-cigarettes
may be purchased at specialty shops that sell many types of vapors for
smoking; many of these shops require that a person be at least 18 years old
to even enter the store.
Some people may consider tobacco abuse to be not as harmful as other
types of drugs or alcohol, yet quitting smoking and overcoming nicotine
addiction can be extremely difficult. There are many adults who started
smoking while in their teens and have never been able to successfully quit
permanently because the cravings for nicotine are so great. Smoking is often
a social activity in addition to the physical changes it causes, which means
that many teens who smoke may do so in groups; later, when trying to quit,
it can be difficult to be around others who are smoking and to abstain.
Smoking is associated with alcohol use, which also the case with teens that
smoke. When it comes to using tobacco, there is no safe amount and teens
should be encouraged to avoid any type of tobacco to protect their health in
the future and to avoid becoming addicted to a substance that is extremely
difficult to let go.
Contributing Factors To A Substance Use Disorder
In most cases, a drug and alcohol use disorder does not develop in isolation.
There are a number of elements in the environment and within a person that
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
31
contribute to the risk of a teen developing a substance use problem. Some
factors can be controlled, or at least can be minimized; for instance, a teen
may watch his parents consume alcohol to excess and may make a
conscious choice never to become intoxicated himself. Alternatively, there
are other factors, such as genetic background or mental health issues that
cannot necessarily be controlled, and it is up to the adolescent to make
positive choices to decrease his risk for developing a substance use disorder.
Family and Social Environment
The environment in which a teen is raised plays a significant role in the risks
of developing drug or alcohol problems. The home and family environment
sets a certain amount of values that impact whether a teen will choose to
experiment or use drugs or alcohol or whether he or she will abstain. Teens
grow up in diverse family environments, with various types of family
structures, such as a nuclear family, single parent family or various other
structures of family relationships.
As a child grows through adolescence, the importance of family relationships
significantly impacts his growth and development. Relationships with parents
and caregivers are important in predicting which teens will more likely
struggle with substance abuse and which teens will choose to avoid alcohol
or drugs. Teens who have supportive caregivers, who experience less
conflict and arguments with their parents, and who are able to communicate
openly with their parents are less likely to turn to drugs or alcohol because
they may feel more support at home. Alternatively, teens may more likely
struggle with substance use and mental health disorders when they feel
misunderstood, have frequent conflict with parents or caregivers, or have
home lives that are chaotic or violent.18
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
32
The social environment and the community in which a teen grows up also
impact whether he or she is more likely to get involved with drugs or
alcohol. Many factors affect whether a teen chooses to experiment with
substances and although family plays a significant role, the teen often must
also be familiar with how to access drugs or alcohol, must have money to
buy these items, and typically knows which of his or her friends are using
drugs and which friends are not. When drugs and alcohol are easily available
to teens within a community, there will be more instances of adolescents
abusing these substances. Teens who know who to contact to access drugs
or alcohol will more likely engage in using these substances compared to
those who do not know how to get drugs.
A teen that has friends who talk about drugs and alcohol and who use them
frequently is at higher risk of also engaging in these activities. A teen’s
friends or acquaintances may talk about certain items at school, while
playing games or sports, or just when hanging out together. The adolescent
may view drug or alcohol use when visiting another teen’s home or when
attending parties. Although parents may talk about avoiding drug and
alcohol use and may not use these substances in front of their children,
teens can be exposed to drug and alcohol use because of their social
environments; another friend’s parents may not monitor their child as
carefully and the teen may know that drugs or alcohol are used in other
homes.
The complete lack of family or a supportive care environment also plays a
negative role in increasing the risk of a substance use disorder. A study
found in the journal Contemporary Nurse demonstrated that homeless teens
that have aged out of the foster care system are at higher risk of developing
a substance use disorder and mental illness.17 Youth who have run away
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
33
from home and who are living in shelters or are homeless may abuse drugs
or alcohol because of several factors, including to avoid some of the pain in
their lives from living alone and without support, to stay awake at night and
avoid being assaulted, or to cope with the difficulties of living on the street.
The availability of family members to provide a source of support can also
help a teen to cope with a substance use disorder and to overcome an
addiction. Often, through treatment, a patient requires substantial help and
support for when he leaves an inpatient environment and returns to working
or going to school without using drugs or alcohol. During this time, the
family dynamic plays a significant role in a teen’s ability to overcome
addiction and to heal; alternatively, a family environment or community that
is not supportive could cause the patient to relapse or make overcoming
addiction much more difficult.
It is important for parents to continue to monitor the activities of their teen;
while many parents fear being intrusive into the life of their teen, it is better
to be aware of a teen’s activities, his or her friends, and how the teen
spends time instead of inadvertently finding out that their teen has a
substance use disorder. Although it is a parent’s job to raise a child to
eventually become independent, frequent parental monitoring teaches a
teen that someone cares and pays attention to whether or not he or she
engages in risky behaviors. Setting limits, keeping an organized home, and
maintaining supportive communication with teens is important for parents to
reduce the chance that their teen will turn to drugs and alcohol for support
instead of their family.
Mental Health Disorders
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
34
Mental health issues are a common theme associated with substance use
disorders. Approximately 70 percent of adolescents in treatment for a
substance use disorders have co-occurring depression; approximately 33
percent also have some form of anxiety disorder.20 Many teens suffer from
dual diagnosis, which occurs when a patient is diagnosed with both a
substance use and a mental health disorder. Co-occurring mental health
conditions may range from depression and anxiety to issues with anger,
post-traumatic stress, or violence. Many adolescents seeking treatment for a
substance use disorder have already undergone therapy for mental health
problems or have served some time in the juvenile justice system because
of their behavior; however, a significant number of teens who need
treatment for a substance use disorder remain undiagnosed for having
mental illness.
A substance use disorder has also been associated with other mental health
issues, including diagnosis of ADHD and depression with suicidal ideation. A
teen may abuse drugs or alcohol to avoid feeling some of the pain or
confusion associated with a mental health diagnosis. Often, conditions such
as depression, anxiety, or post-traumatic stress leave a teen feeling sad,
isolated, and apprehensive. Using drugs or alcohol may provide some shortterm relief for the teen who feels overwhelmed by these feelings. Mental
health problems may also contribute to a substance use disorder when a
teen feels angry or upset because of the relationship with his or her parents
or friends; the teen may use substances as a method of coping with painful
or difficult feelings, or as a form of self-medication that brings temporary
relief by numbing pain and feelings.
Theoretically, substance use disorders are a form of a mental health issue,
as addiction causes changes in the structure of the brain that can lead to
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
35
many symptoms that are found in mental health diagnoses, such as
impulsivity, depression, poor concentration, and mood alterations. When
mental health issues occur as comorbidity with a substance use disorder, the
adolescent may develop both conditions at the same time, or one condition
may precede the other. In many cases, a mental illness diagnosis occurs
before a substance use disorder and it is the cause of the teen using drugs
or alcohol. This is not the case in every situation, however, and careful
assessment and intervention is essential for determining both the timeline of
when each type of mental illness occurred and for how each condition
contributed to the other.
The National Institute on Drug Abuse states that a teen that struggles with
both a mental health diagnosis and substance abuse may have shared
factors in which each condition contributes to the other.21 For instance, a
teen may have a genetic predisposition to developing substance abuse and
may also have a family history of mental illness. There may be factors in the
environment that contribute to an increase in symptoms of mental illness,
substance abuse, or both; such as, trauma triggers from PTSD causing
anxiety, fear, and the teen turning to drug use to self medicate. A significant
percentage of adults who become addicted to drugs or alcohol started using
these substances as teenagers, during the time when the brain is still
undergoing developmental changes as part of maturity. When a teen is
exposed to drugs or alcohol at a young age, such as during adolescence, the
effects of substance use on the brain can lead to changes that are similar to
or that contribute to later mental illness.21
It is important for clinicians to recognize the frequent pairing of a substance
use disorder and mental health diagnoses, and to consider potential signs or
symptoms of each situation when caring for the adolescent patient.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
36
Behavioral therapies and medications exist to help affected adolescents
control one or both of these conditions when they are accurately diagnosed
and can receive proper treatment.
Genetics
Genetics, or the inherited characteristics a person receives from his or her
family, plays an important role in whether a teen will develop a substance
use disorder. Substance use disorders tend to run in families, with
development of drug addiction or alcoholism occurring between members of
the same family and noted patterns of use between parent and child,
grandparent and grandchild, or other family associations. Not only is the
potential for a substance use disorder genetically related but the amount of
use, whether to the level of experimentation with substances or of a
diagnosed addiction, as well as the type of substance use, all have genetic
components as well.22 When discussing the genetic predisposition to a
substance use disorder, it is important to note that a person who has a
genetic tendency toward substance use and addiction is more likely to
become addicted after using drugs, but is not necessarily set on becoming a
user. The genetic component describes an adolescent’s vulnerability toward
addiction, in that if he or she chooses to try drugs or alcohol, there may be a
greater risk of becoming addicted.23 Alternatively, despite having a genetic
predisposition for addiction, if a teen never tries drugs or alcohol then the
addiction will not develop because the teen has not succumbed to the
vulnerability present in his or her genetic state.
Despite this fact, many teens can and do try alcohol and drugs and, when a
genetic predisposition for addiction is present, it can cause harm and longterm substance use problems that may require treatment before an
adolescent even reaches young adulthood. Twin studies are useful methods
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
37
of measuring genetic influences on people who were born together but have
grown up in different environments. Twin studies demonstrate how genetics
affect people who have inherited many of the same characteristics but who
do not have the same environmental stimuli to affect their behavior. Linda
Spear, author of the book The Behavioral Neuroscience of Adolescence,
states that according to several twin studies, the genetic contribution toward
alcohol dependence is 50 to 60 percent, while the genetic contribution for
the risk of drug addiction is up to 80 percent.23
Further studies have shown that genetics also play differing roles when
comparing whether a teen will try a drug in the first place, versus becoming
addicted to a drug after continued use.23 For example, a teen may have a
genetic predisposition that increases his or her risk of trying certain drugs
when faced with a situation where there is the ability to use them.
Alternatively, another teen may have genetic background that increases the
risk of becoming addicted, but only after he or she has used drugs or alcohol
for a period of time.
The genetic contribution that increases risk of trying substances before even
becoming addicted appears to affect more teens trying illegal drugs, not
necessarily alcohol. Teens who excessively use alcohol do not necessarily
have an increased risk of trying alcohol based on genetic influence. Instead,
teens tend to try alcohol more because of environmental influence, such as
when they see a parent using alcohol regularly. However, there still is a
genetic link between alcohol addiction after continuous drinking.23 A teen
who starts to drink alcohol regularly may choose to begin drinking based on
environmental influences, but may become addicted to alcohol based on
genetic components.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
38
The specific genes that cause alcohol or drug addiction have not necessarily
been identified; in fact, many studies have had a difficult time narrowing
down which specific genes are related to a drug and alcohol use disorder and
addiction. In the area of alcohol, studies have shown that there are
differences in the genes related to enzymes that metabolize alcohol when
comparing people who are alcoholics and those who are not. Also, certain
forms of genes have been shown to be associated with increased use of
certain substances, including marijuana and tobacco, when present in some
groups of teens, with less substance use and addiction in those of whom the
altered gene is not found. Other gene variations have been found in the
neurotransmitter GABA, glutamate, and mu opiate receptor genes that are
related to an increased susceptibility of a drug and alcohol use disorder.23
Adolescence is a critical time of brain growth and neurodevelopment, yet it is
also a time when many adolescents begin to experiment with drugs and
alcohol. Although parents and healthcare providers cannot always know if a
teen is genetically predisposed to developing a substance use problem,
caregivers should continue to work to prevent substance abuse through
counseling and education, as well as demonstrating appropriate behavior, so
that a teen at risk will be more likely to make better choices about his or her
health, regardless of whether the teen has a genetic risk or not.
Family History
Family history of a substance use disorder plays a strong role in the
development of substance use problems in the adolescent, even if the teen
does not directly witness substance use by a family member, as genetic
factors also play a significant role.15 However, when a teen witnesses a
family member using drugs or alcohol, he or she may be more likely to
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
39
develop substance use problems because of the example set by the parent
or family member.
The relationship a teen has with his or her parents and the home
environment are important factors in preventing a substance use disorder.
When a teen has little supervision, lives in a disordered or chaotic
environment, and witnesses his or her parents or family members using
drugs or alcohol, the teen is more likely to use substances as compared to
adolescents who do not live in these types of environments.15
Whether or not a teen decides to start using drugs or alcohol is often related
to the messages the teen receives in the home, as well as his or her home
and community environment. However, after using and abusing certain
substances, the risk of the adolescent becoming addicted is related to family
genetics. A teen may become addicted to drugs or alcohol if his or her body
is genetically predisposed to addiction to these substances. That is not to
say that a person who does not have drug addiction and alcoholism in his or
her genetic background will not become addicted if using too many drugs or
too much alcohol; instead, it means that drug addiction and alcoholism “runs
in the family” for teens who have a family history of substance abuse. Such
teens are at much greater risk of becoming addicted to substances.16
The decision of a teen to engage in harmful behaviors is a combination of
nature and nurture: the teen does not have a choice as to whether his or her
family history contains genetic factors that increase the risk for alcoholism or
drug addiction, but the teen can make choices against abusing substances,
regardless of the environment and associated triggers. While it is true that
an adolescent who becomes an alcoholic has had a higher risk of becoming
so, if the family history includes alcoholism or drug addiction the increased
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
40
risk in alcohol use could also be related to the individual’s exposure to drugs
or alcohol within the family.
Parents should remember that their actions send a much more powerful
message to their children than their words. A parent may tell their teen that
it is important to avoid alcohol and drugs and may talk about the dangers of
substance use, but the teen will be much more affected and likely to misuse
substances if he or she sees the parent doing it. Alternatively, a parent who
models appropriate behavior is likely to be more successful in teaching their
child about the importance of avoiding a substance use disorder when
compared to simply talking about it.
Trauma
A traumatic event can be painful and frightening for the adolescent patient
who may continue to suffer through memories of what happened. Trauma
can be both physically and emotionally debilitating; although a person who
experiences a traumatic event may come through the event alive, he or she
may suffer long-term physical damage that requires rehabilitation and the
emotional effects of the event can last for the rest of his or her life.
Traumatic events impact many youth of today, with estimates of
approximately 25 percent of teens experiencing some form of trauma by 16
years of age.14
Trauma is any event or series of events that are overwhelmingly frightening
and harmful to a person. A traumatic event may be such circumstances as
the loss of a loved one, an experience in which a teen is gravely injured or
assaulted, a situation in which a person endures an act of violence, or a
natural disaster. After living through trauma, a person may then suffer from
traumatic stress, which occurs as continued feelings of guilt, shame, anger,
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
41
or fear about an event. For example, a teen may have lived through a
natural disaster and survived the event, only to be plagued by traumatic
stress for years afterward, in which he or she feels terror every time there is
an adverse weather condition.
During a traumatic event, the body responds with a stress reaction, which is
known as the fight-flight-freeze phenomenon, designed to help the body
counter the threat. During this time, the person experiences such sensations
as a rapid heart rate, difficulty swallowing, nausea, and sweating. The
person may also feel detached from his or her surroundings or feel a sense
of displacement in which the body does not seem to be part of the
environment. These responses are the body’s method of protecting itself in
the face of danger.
Traumatic memories may trigger outbursts or temporary changes in
behavior that cause the teen to act out in harmful ways, which may include
substance use. A teen that has suffered a traumatic event may experience
triggers in the environment, which are stimuli that can release memories or
thoughts about the event. The person may have profound memories of the
feelings he or she experienced during the trauma and may not be able to
control behavior. Triggers that cause traumatic memories to return may lead
some adolescents to feel angry and hypervigilant in their surroundings, and
they may want to avoid others.14 Trauma triggers can also lead a person to
crave substance use, whether he or she has an addiction or has been using
drugs or alcohol to numb some of the pain of the trauma.
Post-traumatic stress disorder (PTSD) occurs when an individual continues to
experience psychological problems related to a traumatic event; it is
associated with increased substance use and addiction to drugs or alcohol.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
42
PTSD causes a person to experience feelings and physical symptoms similar
to what occurred during the traumatic event, in a sense, he or she is “reliving” the event in this way. The person may also experience a state of
hyperarousal, hypervigilance, and fear that the event or something like it
will occur again.
A substance use disorder is a response as part of PTSD when a person tries
to avoid the feelings connected to the trauma. The teen with PTSD may turn
to alcohol or drugs in order to feel numb against the pain of remembering
the traumatic event. The use of substances works temporarily as a method
of self-medicating some of the feelings experienced. Using drugs or alcohol
may help the affected person to control some of the intensity of emotions
that may be happening. Over time, the person can become addicted to the
substance when he or she turns to using it every time the effects of a
trauma trigger are felt. The teen then needs treatment not only for
managing the intense feelings associated with the trauma, but also for a
substance use disorder, which has developed as a response.
Signs And Symptoms Of A Substance Use Disorder
Many teens are susceptible to the risks associated with drug and alcohol use
because of pressure from friends and because they are often easily
influenced by the behavior of adults. Because many adults who have become
addicted to drugs or alcohol began by experimenting with substances when
they were teens, it is extremely important for parents and caregivers of
teens to recognize the signs and symptoms that may demonstrate that their
youth are using drugs or alcohol.
Before becoming addicted to a certain substance, an adolescent will most
likely go through a time of regular use. During this time of substance use,
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
43
parents may find that their child is behaving differently, has experienced a
change in attitude, or is pursuing new or unhealthy relationships.24 If a
parent, friend, or healthcare provider notices differences in a teen’s behavior
or attitude and is concerned that he or she may be using drugs or alcohol, it
is important to intervene, even if the suspicions are not correct. By gently
approaching the teen and acting in a non-threatening manner, the caregiver
can communicate concern for the individual and might be able to discuss the
situation further with the affected teen. If the symptoms are associated with
a substance use disorder, this opening conversation can be the beginning of
getting help for the adolescent.
Changes in Appetite
Adolescents often demonstrate changes in appetite as a result of growing;
changes associated with growth and puberty may cause a teen to eat more.
Boys, in particular, may eat much more food as adolescents when compared
to how much they ate during childhood. Teen boys are typically growing
taller and developing more muscle mass that causes an increase in appetite
and they often eat much more food. Alternatively, an adolescent affected by
drug or alcohol use may demonstrate changes in appetite such that the
changes may depend on the type of drug being used. For example,
stimulants such as methamphetamines or cocaine cause the adolescent to
lose weight over time and to eat less. Stimulants often work as an appetite
suppressant, and chronic use may cause the person using them to feel less
hungry and therefore eat less and lose weight.
Ecstasy may cause symptoms of nausea and the person who uses this type
of drug consistently may experience jaw clenching. Both of these symptoms
can make it difficult for the person to eat and he or she may eat less
because of the discomfort. Heroin use also may cause nausea, which can
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
44
cause a change in appetite when the person feels uncomfortable and doesn’t
want to eat. Heroin crosses the blood-brain barrier very quickly and enters a
person’s system at a rapid pace. The drug slows down cognitive function
because, as it enters the brain, it is converted into the chemical morphine
and binds to opioid receptors.26 The person then experiences a rush, but
with it also comes a heavy or dragging feeling, slowed thinking, dry mouth,
and nausea.
Too much alcohol use can also lead to changes in appetite; the person who
struggles with alcohol addiction may experience a decrease in appetite as a
result of changes in cortisol production, which affects appetite. According to
an article in ABC Science, two hormones, dehyrdoepiandrosterone
sulfate (DHEAS) and cortisol, affect the appetite, as well as cognitive
function and memory. The body needs to produce sufficient cortisol in order
to feel hungry, but consuming too much alcohol can suppress the body’s
ability to release cortisol.25 As a result, the person who drinks too much
alcohol will have a decreased desire for food, even if he or she hasn’t been
eating.
The release of hormones will depend on the type of alcohol consumed. The
hormone DHEAS, which is also responsible for appetite control, has been
shown to fluctuate in levels depending on the type of drink consumed. In the
study noted, participants drank different types of alcoholic beverages and
their levels of DHEAS and cortisol were measured afterward. The people who
drank beer had low levels of DHEAS initially, but then their levels increased,
which actually increased their appetites. Alternatively, participants who
drank wine had lower levels of cortisol and DHEAS, which reduced their
appetites.25 The type of alcohol a teen consistently drinks may then depend
on whether he or she has an increased or a decreased appetite.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
45
There are some drugs that increase a person’s appetite. A teen that uses
some of these drugs may want to eat more and may experience weight gain
from eating too much. Marijuana tends to cause a person to crave sweets,
and the individual using marijuana may eat more desserts and sweet foods
after smoking it. Using marijuana also increases appetite so that the person
who smokes it eats more overall, particularly when feeling high. One known
aspect of marijuana use is that it causes a person to be hungry, and teens
that smoke marijuana may also then eat large amounts of food, go out for
meals, or binge on snacks.
In many cases, a person who has been using drugs or alcohol or has
developed an addiction will demonstrate changes in appetite, as well as
weight loss, because the drug or the alcohol often replaces food intake. As a
result, the teen who uses drugs or who drinks alcohol may not eat for long
periods of time while feeling high and then again during the time afterward.
The teen may not feel hungry if the body has replaced the effects of the
drugs and alcohol with food. The affected person may then experience
significant weight loss, muscle wasting, and malnutrition over time because
he or she is not taking in enough food or nutrients. The person’s body then
exhibits changes that may appear as symptoms that others may notice as
weight loss or wasting.
Changes in Sleep Patterns
A teen who abuses drugs or alcohol may experience changes in sleep
patterns as a result of the substance use. Although the amount of sleep
required changes as a teen grows from childhood into adolescence, teens
still need about 9 ½ hours of sleep at night. Delayed sleep phase syndrome,
a condition in which a person has trouble falling asleep until very late at
night and has difficulty with getting up in the morning, is much more
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
46
commonly found among adolescents than among adults or children. Teens
may be more likely to stay up late and may sleep late in the morning if they
do not need to rise for school or work. Because of these patterns, it may be
difficult to determine if a teen is exhibiting changes in sleep patterns as a
result of drug use or if he or she is going through more common alterations
in sleep schedules that are typically seen among adolescents.
People who suffer from substance abuse disorders are 5 to 10 times more
likely to struggle with sleep difficulties.27 The most common sleep issues
related to drug and alcohol use are insomnia and difficulties with staying
asleep once a person has fallen asleep. Drugs that act as depressants, such
as alcohol and benzodiazepines, can make a person feel sleepy initially, so
that he or she may fall asleep rapidly at first. In fact, many benzodiazepines
are prescribed for sleep difficulties to help an affected person to fall asleep
more easily. The difficulties arise when the individual uses CNS depressants
inappropriately; he or she will more likely suffer from sleep disruption by
taking too many of these drugs.
Alcohol, for example, will initially cause a person to feel sleepy, which is the
depressant effect. However, after having several drinks, the person may fall
asleep quickly or pass out, only to wake up much earlier than normal, during
the second half of the sleep period. The person’s body reacts to the ingestion
of alcohol by altering the cycles of REM sleep and deep sleep, which makes
sleep unrefreshing, and the person awakens more often. Increased alcohol
use can further perpetuate the cycle, in which the person experiences poor
sleep after drinking too much alcohol but then spends longer periods being
awake, eventually becoming sleep deprived. Over a short period of time, the
person develops tolerance to the sedative effects of alcohol and its use no
longer induces sleepiness. Alcohol use has been shown to contribute to other
types of sleep disorders in addition to insomnia, including worsening of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
47
symptoms of obstructive sleep apnea and causing further episodes of
restless leg syndrome.27
Unfortunately, sleep problems may continue once they have developed,
even if the person has undergone treatment and has overcome a substance
use disorder. Studies have shown that a person who suffers from insomnia
as a result of drug use may continue to have trouble sleeping, even when he
or she no longer uses the drug.27 Parents and caregivers who suspect that
their teen is struggling with substance use should be aware of changes in
sleep patterns that may develop from the effects of substances on the brain.
Withdrawal from Activities
Many teens are notoriously busy with activities and school work; often, an
adolescent may remain busy with school, hold down a part-time job, play
sports, or stay involved in clubs and groups that keep him or her active
almost all of the time. When a parent or provider notices that a teen is
withdrawing from normal activities, it can be a sign of a problem.
One of the warning signs that indicate a substance use disorder is when a
teen demonstrates a loss of interest in normal activities. What the teen once
considered enjoyable and kept him or her busy may become uninteresting,
leading to avoidance of the groups that once held the teen’s attention. The
affected teen may spend more time alone or may spend more time away
from home, but not necessarily keeping up with hobbies or friends. The teen
may spend time with new friends and hang out with groups of people that he
or she has not been with before. What was once normal and active behavior
from a teen may be replaced with more secretive activities.
Parents of teens who use drugs or alcohol also have stated that their teen is
caught lying more often and avoiding certain social interactions. Normal
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
48
friendships may go by the wayside to be replaced with spending more time
alone, demanding more privacy, sneaking out of the house, or keeping doors
locked.69 Parents may also worry about their teen’s friends and wonder with
whom the teen is spending time. When an adolescent is normally involved in
regular activities, such as hobbies or sports, parents are often much more
aware of who the teen is spending time with and they know that he or she is
keeping busy. Withdrawal from normal activities is a red flag that something
is wrong, as this indicates that the teen would rather spend time doing
something else — which could be using drugs or alcohol — instead of staying
engaged with activities that used to bring the teen joy.
Changes in Appearance
It is normal and common for teens to experiment with their appearance.
Adolescence is a time when many teens evolve in what they wear and how
they present themselves. Adolescence is also a time for increased selfexpression, when a teen can communicate some individual beliefs or ideas
through choosing a style of clothing and appearance.
Once a teen has developed a style of appearance, sudden changes in how
the teen presents in their appearance toward others are a warning sign that
something may be wrong. A teen who normally bathes regularly and wears
relatively clean clothes and who suddenly changes or stops taking care of his
or her appearance may be struggling to keep up with self-care measures
because of substance abuse.
Teens often experiment with changing their appearance. It is not uncommon
for an adolescent to decide to pierce a body part or change hair color or
style. Parents may have a difficult time accepting what their teen decides to
wear or present in his or her appearance. However, these methods do not
necessarily reflect a lack of self-care; to the contrary, a teen may use
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
49
various methods of changing personal style as a matter of self-expression.
The cause for concern, rather, arises when the teen clearly does not seem to
care about his or her appearance and no longer takes measures to care for
their own body or health.
Further, a teen that has been using drugs or alcohol may demonstrate other
physical changes beyond those in dress or grooming. Parents may notice
that their teen is losing weight, often has bloodshot eyes, or has been
injured without a good reason. These physical signs and changes in the
teen’s health status are danger signals that a teen could be having a
significant problem of a substance use disorder.70
Changes in Personality
Some people use drugs or alcohol because of the impact these substances
have on their personalities. For example, someone who is normally shy may
enjoy feeling less inhibited after drinking alcohol and may choose to drink
more because it makes them feel popular and social. Alternatively, drug or
alcohol use can bring out many negative behaviors among teens. A person
who struggles with anger or violence may become even more aggressive
after using drugs, while someone with a diagnosis of depression may have
overwhelming symptoms that are difficult to overcome.
A teen often has fluctuating moods and it is not uncommon for a teen to
experience the highs and lows of adolescence that cause mood fluctuations.
A teen may feel happy and carefree one minute and then may experience
anger, confusion, or frustration the next. Adolescence is a time when teens
are solidifying the work of controlling their emotions so that when they
become young adults they are better able to manage their behavior.
However, a teen who seems to have a consistent personality and who
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
50
exhibits sudden changes in temperament could be struggling with a
substance use problem.
Personality changes that may be exhibited with drug or alcohol use include
increased lethargy, moodiness, anger, and irritability.71 This may be the
result of the effects of the drug or it may occur when the teen is
experiencing feelings of withdrawal when trying to stop taking the drug.
Drug and alcohol use that lead to changes in social activities may also lead
the adolescent to experience personality changes. A teen who normally has
a solid group of friends and who abandons them to spend more time using
drugs with a new set of friends may be more irritable or depressed because
he or she misses those who were once close.
Unfortunately, certain types of drug use may change a person enough so
that he or she no longer has the same personality or temperament, even
after quitting the drug use. For example, chronic use of marijuana during
adolescence has been shown to decrease IQ levels that are never recovered,
even after the person later stops smoking marijuana.28 A teen that uses
drugs or alcohol may develop personality changes that make him or her
difficult to be around because of impaired social interactions or an inability to
understand certain social cues; these traits may never resolve even if the
teen stops using drugs, and the negative personality changes could
potentially remain into adulthood.
Neglecting Responsibilities
When an adolescent has many activities to be involved with, he or she may
become quite busy and active, leaving less time for family or time spent at
home. Because adolescence is a time of growth by being involved in hobbies
and activities, it is normal to see this time of recreation as a method of
keeping a young person active and busy. When an adolescent fails to keep
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
51
up with normal responsibilities and drastically changes his or her normal
routine, parents have a cause to worry.
A teen that is struggling with a substance use disorder may be less able to
keep up with normal responsibilities, especially if he or she reaches the point
of craving drugs or alcohol enough that it consumes the teen’s time. The
teen might be involved with drugs to the point that it is all that is thought
about and the teen’s normal responsibilities, whether at home, work, or
school, fall by the wayside. Parents may notice that their teen, once
responsible enough to study regularly and maintain good grades, is failing
classes and has been disciplined at school. Some parents notice that their
teen becomes more reclusive at home and does not participate in family
activities or take up their share of home responsibilities, such as taking part
in house or yard work.
Neglecting normal responsibilities can be an ominous sign and is quite
detrimental to the affected adolescent. A teen normally stays involved with
activities to learn responsibility so that he or she can be a productive adult
who contributes to society. When a teen starts to neglect responsibilities
because of drug use, he or she is hurting their own ability to learn and to be
dependable, which are skills needed in the future when working or managing
their own family. The teen may also lose out on important contacts or tasks
that could have worked out well. For instance, a teen may have a job that
requires the teen to act responsibly and to show up to work on time, and
has also given the teen the chance to earn money, to meet others, and to
have a reference for future employment.
When the teen starts neglecting responsibilities because of drug or alcohol
use, he or she could potentially damage these connections and hamper
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
52
future outcomes. Parents cannot always know when their teen is acting
responsible or if they are upholding their duties to school, work, or
friendships, but parents should be familiar with their child’s normal schedule
of activities and monitor for changes that signify that something could be
wrong.
Co-occurring Mental Illness And Addiction
Mental illness includes a wide range of potential health conditions that affect
a person’s emotional or psychological state. Mental illness can range from
severe and debilitating, in which the affected person is unable to function in
society, to a struggle with signs or symptoms that can be managed through
behavioral therapy or medications. Mental illness is more commonly seen
among patients who have substance abuse disorders, and those diagnosed
with a type of mental illness have been shown to be more likely to use drugs
or alcohol when compared to those without mental illness.1
Depression
Depression is one of the most common forms of mental illness among adults
and adolescents. According to Substance Abuse and Mental Health Services
Administration (SAMHSA), 2.2 million teens age 12 to 17 had at least one
major depressive episode in 2012.1 Depression describes a condition in
which a person experiences feelings of sadness or despair, has difficulty
completing tasks or performing everyday activities, and feels a loss of joy or
hope in life. Depression may occur as one of several different types,
including major depression, persistent depressive disorder, seasonal
affective disorder, psychotic depression, or bipolar disorder.72 Depression,
while very common when associated with substance abuse, often remains
underdiagnosed among teens. While the signs and symptoms may be
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
53
present, parents and caregivers may not be familiar enough with what to
look for or who to contact for help for their child.
Drugs and alcohol can lead to feelings of depression because of their effects.
Some drugs cause a feeling of depression when the high goes away; for
example, a person who uses certain stimulants that rapidly increase levels of
dopamine in the brain to cause feelings of pleasure may suffer a rebound
effect of depression after the drug wears off. People who become intoxicated
or high while using drugs may become depressed after engaging in foolish or
dangerous activities. And, a teen who struggles with a drug or alcohol use
disorder and who has tried to quit may become depressed when he or she is
unable to stop using.73
A teen that is already depressed before developing a substance use disorder
may suffer from sad feelings, grief, anger, irritability, and may be unable to
find pleasure in any activities. Alternatively, using drugs or alcohol may
bring feelings of pleasure and euphoria that can make up for some of these
negative feelings, even if it is only for a short period of time. The teen may
eventually develop a substance use disorder because of continuing to crave
the effects of using drugs, and may use drugs to self-medicate in order to
deal with negative feelings. The teen may believe that using drugs brings
short-lived positive feelings that can replace some of the sadness and
negativity he or she experiences with depression. Parents and their teens
can be immensely helped when informed that depression is treatable when a
teen is properly assessed and diagnosed. Adolescents who suffer an episode
of a mental illness are more likely to have better outcomes if intervention is
provided early, in particular, shortly after experiencing the first episode of
mental illness. When a teen patient receives comprehensive and focused
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
54
care either during an acute episode of mental illness or shortly following the
first episode, he or she has a greater chance of a positive health outcome.1
Parents can monitor their children for signs or symptoms of depression,
particularly when their teen experiences significant changes in his or her
normal personality. Early intervention can mean a diagnosis of depression,
but even if the teen is not actually diagnosed, it is helpful to seek out care
and support for symptoms of depression because they can be quite
debilitating to the affected teen. Once a diagnosis has been made, there are
a number of options for treatment, including pharmacological therapies,
behavioral interventions, and some types of brain stimulation therapies that
can potentially bring relief of symptoms. Because of the close connection
between a substance use disorder and depression, when a teen is suffering
from symptoms of either condition, it is important for the provider to
consider both conditions and to provide treatment to help the adolescent
manage the pain of a mental health condition.
ADHD
Another mental health issue that is commonly associated with substance
abuse is attention deficit hyperactivity disorder (ADHD). ADHD is the most
common neurobehavioral disorder of childhood; it causes difficulties with
attention and hyperactivity, as well as symptoms of impulsivity and lack of
control. According to the Centers for Disease Control and Prevention (CDC),
11 percent of people ages 4 to 17 have been diagnosed with ADHD as of
2011.4
According to an article in The American Journal of Psychiatry, because of
their neurodevelopment, teens already possess a drive to experiment with
new situations, such as with drugs or alcohol; but, a teen with a mental
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
55
health background that affects impulsivity, such as with a diagnosis of
ADHD, is at even higher risk of engaging in risky and impulsive behaviors
that can lead to addiction and substance use.7
ADHD is a chronic condition, and teens that use drugs or alcohol and who
also have ADHD may be even more likely to struggle with impulsive and
reckless behavior. This can increase the risk of injuries from poor judgment.
Alternatively, a teen may use drugs or alcohol as a form of impulsive
behavior because of having ADHD. Some teens with ADHD may be more
likely to develop substance use disorders because they have a common
genetic factor that is associated with both conditions; this theory is still
being investigated for its accuracy.74
Under normal circumstances, ADHD is treated with stimulants, such as
methylphenidate, which work by affecting the brain’s neurotransmitters and
relieving some of the symptoms of disorganization and hyperactivity.
Unfortunately, though, some of the stimulants used to treat ADHD can also
increase a teen’s risk of substance use because they are commonly abused
substances as well. Therefore, prescription stimulants should be used and
monitored very carefully when administered to a teen with a substance use
disorder who has concurrent ADHD. Alternatively, a clinical report in the
journal Pediatrics showed that early treatment of ADHD with stimulants and
psychological counseling, such as before adolescence or within the early
years of adolescence, may reduce the risk of a teen later developing a
substance use problem. The caveat is that the teens involved in the reported
study received treatment for ADHD with stimulant medications at a young
age and not as older adolescents.74 The early recognition of ADHD symptoms
and onset of interventions is much more likely to help teens who struggle
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
56
with impulsivity and hyperactivity of ADHD before they move on to develop
substance use disorders.
Bipolar Disorder
It is normal and common for teens to experience fluctuating levels of moods.
Many adolescents transition between levels of happiness and despair on any
given day. When a teen has difficulty performing usual tasks and is unable
to carry out routine activities because of highs or lows in moods, parents
may need to consider whether there is an underlying mental illness present,
such as bipolar disorder.
Bipolar disorder is more commonly seen and diagnosed among children and
adolescents. It is a type of mental illness that causes intense fluctuations in
mood and emotions for the affected person. The moods a person
experiences are different from his or her normal personality; high moods,
referred to as mania, may include being overly silly, feeling extremely
happy, talking fast, sleeping less, and engaging in risky behaviors. The
person may also experience the opposite effects of depression, in which
there may be feelings of prolonged sadness or guilt, and the person may eat
more and sleep more often, may not show interest or pleasure in routine
activities, and may be at risk of suicide.75
Teens with bipolar disorder are at higher risk of developing substance use
disorders. Boys seem to be more susceptible to these co-occurring
conditions happening together when compared to girls. Teens who have a
history of suicide attempts because of bipolar disorder may also be more
likely to develop substance use disorders.76 As with depression or other
forms of mental illness, teens may develop a substance use disorder after
routinely using drugs or alcohol to self-medicate their conditions. The high
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
57
produced from substance use often feels better for a short time instead of
struggling with mania or depression. Over time, the teen with bipolar
disorder may continue to turn to drugs or alcohol to feel better but may find
that he or she has developed a craving for the substance and needs it. When
this occurs, the teen then faces the difficulties of having co-occurring bipolar
disorder and a substance use problem, both of which often require intensive
management.
The good news is that treatment of bipolar disorder tends to decrease the
risk of a substance use disorder as a comorbidity.76 Teens are more likely to
manage their conditions and avoid developing substance use problems when
they receive mental health treatment, particularly when the intervention is
early in the disease. When screening an adolescent for signs or symptoms of
mental illness, the provider should consider the possibility of substance use
as well and perform an assessment. Parents and caregivers, as with other
forms of mental illness, should be alert to the symptoms associated with
bipolar disorder and seek to get help for their teen as soon as possible.
Other Brain Disorders
The crucial time of neurodevelopment during adolescence is an important
factor in developing substance abuse disorders when a teen experiments
with or uses drugs and alcohol. During adolescence, the brain still has a
certain amount of neuroplasticity, in which the brain is able to change and
adapt to circumstances. Some areas of the brain have matured more than
others, so a teen may have some thoughts and feelings that are more
established than others. For example, an individual may seek pleasurable
activities and seek rewards through dangerous activities because the part of
the brain that manages these emotions matures before other parts of the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
58
brain that control such activities as making decisions, controlling impulses,
and assessing harmful situations.28
Because the brain of an adolescent remains immature until he or she has
had more time to grow, even experimenting with drugs can lead some youth
to quickly become addicted because of the brain’s response to the drugs. An
adolescent may make a poor decision to try a certain drug at a party and the
high from the drug causes a significant increase in the release of dopamine,
in which the person feels intense pleasure associated with the release of the
neurotransmitter.
The release of dopamine caused by the drug is much greater than what is
produced during other activities that do not involve drugs. Because of this
rush of dopamine, the teen finds that there is a desire to have the feeling
and the experience again, so he or she seeks out a chance to try the drug
another time. Each time the teen uses the drug, it reinforces the pleasurable
feelings associated with the release of dopamine, but the teen’s brain may
not be mature enough to recognize that this is abnormal.28 Eventually, the
teen may engage in drug-seeking behavior and the desire for the drug has
transcended other activities because his or her brain wants the continued
rush that comes from excess dopamine release when taking the drug. When
the adolescent becomes addicted to a drug, he or she is no longer able to
turn away from the drug, even if there is the desire to do so, because the
drug has affected the person’s levels of impulsivity and ability to make
decisions.
As a result of drug use, many teens are at risk of mental health issues that
develop as co-occurring conditions. These comorbidities may have been
present before the substance use began but were not diagnosed or they may
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
59
develop as a result of substance use. Often, when a teen begins using drugs
or alcohol, he or she may experience symptoms similar to mental illness,
such as intense rage, impulsive behavior, or changes in cognition.
Alternatively, a patient may have underlying symptoms of a mental illness
that cause the teen to seek drugs or alcohol as a form of self-medication to
help with managing the symptoms.
There are some conditions that may also have overlapping factors as to why
they develop together. For instance, a person who is genetically predisposed
to a certain type of mental illness may have the same genetic variants that
increase his or her risk for substance use. Some types of mental illnesses
that have been shown to be more likely to develop as comorbidities to
substance use disorders include anxiety disorders, schizophrenia, and posttraumatic stress disorder.77
The DSM-5 addresses co-occurring substance use and mental disorders
under various sections of the manual. For example, a depressive disorder
that occurs during or as a result of intoxication is specified under the section
Substance/Medication-Induced Depressive Disorder. Symptoms that may
occur during intoxication or withdrawal are defined. The main classes of
substance/medication induced depression that may be assigned to a
diagnostic code are: alcohol, phencyclidine, other hallucinogen, inhalant,
opioid, sedative, hypnotic, or anxiolytic, amphetamine (or other stimulant),
cocaine, other (or unknown) substance. The other (or unknown) substance
category is not specifically covered in this study but basically it involves a
section in the DSM that allows the clinician to identify a substance use
disorder not specified under the main categories raised above. Similarly,
when reviewing the DSM-5 section on bipolar and related disorders as a cooccurring condition with a substance use disorder, the diagnostic code
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
60
remains dependent on whether or not there is a comorbid substance use
disorder present for the same classes of substances. These main categories
of substance use disorders occurring in the setting of comorbidity resonate
throughout each section in the DSM-5 where a specific condition and
symptoms of a mental illness are described.
As with other types of mental illness and co-occurring substance use,
treatment of one condition often affects the other. A person who seeks
treatment for a mental illness, such as a diagnosed anxiety disorder, may be
at lower risk of developing another type of mental illness, including
substance use disorder.77 There are many treatments available for
adolescents who struggle with mental health issues. Often, diagnosis is the
first hurdle to overcome when a person is seeking help for either a
substance use disorder or a mental health issue.
Substance Use Disorder Treatment
When it comes to a substance use disorder, adolescents are not merely
smaller adults, and they should not be treated as such. Instead, they need
to be recognized as having distinctive needs associated with their age group,
as they are still growing and maturing in their neurological, emotional, and
physical developments. The transitions associated with adolescence pave the
way for experimentation with different substances, the presence of peer
pressure from fellow students and friends, and the continued progression
toward maturity that make this timeframe not only difficult but also more
prone to testing and experimenting with substances can lead to
inappropriate use.
As with other forms of chronic illness, the patient who struggles with a
substance use disorder may take positive steps in treatment of his or her
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
61
addiction but then may later have setbacks and periods in which there are
relapses. When relapse occurs, the clinician and the affected teen should not
consider the situation as a failure; rather, the clinician may need to work
with the patient and the patient’s family to come up with another method of
treatment that may be beneficial and more successful for the patient.
Regular monitoring by parents or caregivers is important to prevent relapse.
In many cases, the teen patient requires regular communication with a
caregiver and close monitoring for changes in behavior or other symptoms
that signify that a relapse has occurred. Further ongoing support, such as
through 12-step groups that meet on a regular basis may provide help and
encouragement that can prevent relapse after the teen has completed a
treatment program.
Unfortunately, because they are younger and have fewer experiences during
their shorter lives, teens may be less likely to seek treatment or to see the
importance of treatment. Despite struggling with substance use and
addiction, some adolescents may still not believe that substance use can be
life threatening or may not be aware of the harmful effects of these
problems. They may not want to get involved in a treatment program
because they have not necessarily experienced some of the terrible effects
that can occur as a result of chronic substance use. Because of their limited
experiences with substance use when compared to adults, teens may not be
as cooperative in seeking treatment or in maintaining the work needed to
successfully complete a treatment program. Further, a number of teens
undergo treatment for a substance use disorder because they are required
to participate due to their behavior and legal action taken against them.
A teen may only attend treatment sessions because they are required to
participate, but they may not necessarily believe in the seriousness of the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
62
consequences associated with a substance use disorder. These situations
require extensive patience on the part of the caregiver who must work with
the teen to help him or her recover when the teen does not want to. The
teen who does not believe that he or she needs substance use addiction
treatment, or who is only undergoing treatment because of a mandatory
requirement to attend sessions, can still overcome his or her addiction and
may not necessarily revert back into abusing substances again after the
sessions are complete. Most teens do not seek help for a substance use
disorder on their own; they enter into treatment usually after being referred
by a parent, healthcare provider, or through law enforcement. Even when
the teen is unwilling to go to treatment early on, he or she can still have a
successful treatment program and may still heal from their addiction.28
When determining the best course of treatment for the adolescent who
struggles with a substance use disorder, the provider must consider several
aspects of the patient’s situation to determine the best and most appropriate
form of treatment. Factors to consider include the type of substance the
patient has become addicted to, how long he or she has been using it,
whether or not the patient has family support during the treatment process,
and whether the patient has a co-occurring mental or physical illness that
must also be managed.
A teen does not have to be classified as being addicted to a drug or to
alcohol before undergoing treatment for substance use. Many teens benefit
greatly from treatment programs in which interventions were made at
relatively early points in the process of illness; in the case of an adolescent
who is struggling with a mild substance use disorder, early treatment is
better than waiting for the teen to be showing signs of a severe disorder or
complete addiction to a substance. The teen will have a much greater
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
63
likelihood of succeeding through treatment when the problem is detected
and managed early on.
Treatment programs are available in both inpatient and outpatient formats;
many of them are specifically designed for the unique needs of teen
patients. A teen who struggles with drug or alcohol substance use may need
to be treated with inpatient intervention in which he or she stays in a
treatment center for a designated period of time to go through periods of
withdrawal and detoxification, receive education and counseling about
addiction, and be treated for other health issues. Alternatively, outpatient
treatment programs can deliver counseling and support through groups or
individual therapy. The type of program the adolescent needs depends on
his or her situation and the type of social support available. Unfortunately,
although treatment is extremely important for the recovering teen substance
user, only about 10 percent of teens with substance use disorders receive
adequate treatment.29
The decision of whether to treat an adolescent as an inpatient or within an
outpatient facility is determined by the amount of care needed, as well as
other factors affecting the patient. The American Society of Addiction
Medicine (ASAM) has developed a set of criteria that may be used to
determine the length and intensity of treatment for the adolescent with a
substance use disorder. The ASAM criteria are divided into six dimensions of
assessment that help the provider to establish the most appropriate level of
care to provide for the adolescent client. The six dimensions include:30

Dimension 1: Acute intoxication or the potential for significant
withdrawal symptoms

Dimension 2: The presence of co-occurring medical conditions or
complications
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
64

Dimension 3: Whether emotional, cognitive, or behavioral
conditions or complications are present

Dimension 4: The patient’s readiness to change

Dimension 5: The potential for relapse or continued problems with
abstinence

Dimension 6: The patient’s living environment and support available
By reviewing these six dimensions, the provider is better able to assess the
patient’s background and determine his or her needs for support through
treatment. The criteria were developed to prevent adolescents from
receiving treatment that is inadequate in length or intensity, or that does not
consider the complex needs of adolescents when being treated for a
substance use disorder.
When determining the type of treatment needed during withdrawal from a
substance disorder, the DSM-5 generally specifies the phase of remission
(early or sustained), and the patient’s type of use and environment, i.e.,
whether the patient is on maintenance therapy or using in a controlled
environment. In early remission, a substance use disorder has met full
criteria to diagnose a problem but none of the criteria for a disorder have
been met for at least 3 months but for less than 12 months or longer. In
sustained remission, after full criteria for a substance use disorder were
previously met, none of the criteria for the disorder have been met any time
during a period of 12-months or longer. The severity of use is coded
according to the ICD-10-CM codes, and most disorders are categorized as:

Mild – the presence of 2 - 3 symptoms

Moderate – the presence of 4 – 5 symptoms

Severe – the presence of 6 or more symptoms
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
65
Substance use disorders and addiction recovery programs are highly
specialized area of mental health care. This course primarily focuses on the
criteria to diagnose a substance use disorder according to the DSM-5;
however, it is necessary for the clinician to be familiar with the general
definitions of symptom severity within each category of a substance use
disorder to be able to plan referrals and treatment programs for patient
recovery. Determining the type of treatment indicated by the patient’s
diagnosis and level of severity of a substance use disorder and withdrawal is
beyond the scope of this study and a topic worthy of further focused review,
which the interested learner is recommended to pursue. The following
sections discuss types of inpatient and outpatient treatment programs and
venues through which the patient can continue to follow a recovery
treatment plan for a substance use disorder.
Inpatient Treatment Programs
Treatment for adolescents with substance use disorders differs from that of
treating adults with the same problems. When caring for adolescents who
are recovering from addiction, the healthcare provider must view the
treatment from a neurodevelopmental perspective, as the teen is still going
through stages of development, he or she has not yet reached adulthood,
and is not necessarily established in individual thought and behavior
patterns.29 Inpatient treatment for adolescents suffering from substance use
disorders is considered for those who are in danger; and, for those who have
co-existing psychiatric or medical complications, not otherwise responded to
more conservative treatments, little to no social supports in place, and
suffering from severe effects of acute withdrawal during the detoxification
process.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
66
Detoxification is the process of getting rid of a certain substance from the
body. Many patients who suffer from a substance use disorder and addiction
will experience symptoms of withdrawal when the drug or alcohol is stopped;
withdrawal can cause severe symptoms that are not only uncomfortable, but
could also cause serious complications. Common symptoms of withdrawal
include sweating, nausea, muscle aches, diarrhea, fever, and insomnia;3
withdrawal symptoms may also lead to life-threatening situations that also
include seizure activity and changes in the patient’s level of consciousness.
Because of this, the adolescent patient who is going through detoxification
should be monitored carefully for signs and symptoms of withdrawal from
the substance, and the clinician may need to provide medications for
comfort and sedation until the severe symptoms have passed. It is therefore
important that a teen undergoing detoxification be monitored through an
inpatient treatment facility where he or she can receive continuous care if
having severe symptoms of withdrawal, if suffering from an infectious illness
or from symptoms of a co-occurring psychiatric illness, and if the teen does
not have a support person who can help.
The process of detoxification for a teen is somewhat similar to detoxification
in an adult patient. Inpatient rehabilitation centers may be located at standalone centers that have been developed for treatment of substance use
disorders; they may also be found within hospitals or mental health centers.
The adolescent patient is checked into the inpatient center where he or she
will stay for several weeks. The amount of time required for a patient to stay
as an inpatient depends on the program itself and the patient’s health status
and needs for therapeutic treatment. The typical process of inpatient
treatment involves an initial assessment where the teen undergoes
psychiatric and physical health evaluations to determine the extent of care
needed during the teen’s stay. For instance, upon review of the patient’s
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
67
history, the clinician may find out that in addition to a substance use
disorder, the teen also has a co-occurring mental health diagnosis for which
he or she will need routine medications while staying as an inpatient.
Following the initial evaluation, the teen may need to go through
detoxification, in which the teen’s health will be managed, particularly if he
or she is suffering from severe symptoms of withdrawal. After the
detoxification process, the teen inpatient then has continued counseling and
behavioral interventions, as well as medications administered to help control
the addiction recovery process. Finally, the caregivers at the inpatient center
focus on equipping the patient with resources and tools so that he or she can
be integrated back into the community. This may mean setting up services
for ongoing outpatient therapy with a trained counselor or helping the
patient access information about local 12-step programs that can be
attended.
One concept that has been used successfully in helping some teens
overcome substance addiction is the implementation of therapeutic
community living. A therapeutic community (TC) is a program located away
from the typical area where the teen’s drug or alcohol use has occurred. The
members of the TC live together in a group setting where they must uphold
certain behavioral expectations and may need to contribute to the ongoing
maintenance of the home. The members of the community also go through
therapeutic interventions while living in the TC, in which they attend support
groups, participate in community-based learning, and practice role-playing.
Throughout a person’s stay in a TC, it is expected that he or she will
continue to grow in responsibility until becoming a role model for other
members. People move into and out of each TC; some have substance use
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
68
problems but have had experience with holding jobs or maintaining other
responsibilities, while others may have significant deficits in social
functioning or may be suffering from severe symptoms of mental illness. The
ultimate goal of living in a TC is to help the affected person learn coping
skills for dealing with a substance use disorder, and to learn to manage
feelings, live and cooperate with others, and live a respectful and
responsible life away from substance addiction.45
Some teens may have contracted infectious diseases or other illnesses as a
result of their drug and alcohol use. It is well known that using certain drugs
increases the risk of some infectious diseases, such as human
immunodeficiency virus (HIV) or hepatitis B, when the person engages in
activities that promote the spread of these infections. Drug use also may
increase unsafe sexual behavior on the part of the teen and he or she may
have a sexually transmitted infection as a result. The clinician may need to
provide treatment interventions for some of these conditions when a teen is
receiving inpatient treatment for a drug or alcohol use disorder. This may
involve administering medications, such as antibiotics for the treatment of
some sexually transmitted infections, testing for infections, and
administering antiviral medications to manage chronic illnesses, such as HIV
infection.
Inpatient treatment programs are not as common as outpatient programs in
the setting of teen substance use. However, they can be extremely beneficial
in providing a solid base for which an addicted teen can recover from initial
symptoms of withdrawal and then learn strategies for dealing with cravings
and a substance use disorder. Inpatient programs are often successful at
equipping patients to return to their normal environments; a teen cannot
live as an inpatient in a facility forever, but the tools the teen learns during
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
69
his or her stay in one of these facilities may help the teen to engage in
responsible activities and learn to live a normal life upon return home.
Outpatient Treatment Programs
Outpatient programs are the main form of treatment for most adolescents
with substance use disorders. Studies have shown that outpatient
treatments can be effective for adolescents with less severe addictions as
well as those who suffer from severe symptoms of dependence and who
have co-occurring mental health issues.28 Outpatient services can vary in
intensity and length and can range from the patient meeting with a provider
once or twice a week to intensive therapy that lasts several hours a day.
The most successful programs of outpatient treatment for a substance use
disorder consider the needs of the teen patient as a whole person, including
the teen’s medical background, the presence of any co-occurring mental
health issues, the level of family support available, living arrangements,
whether or not the teen has a job or is in school, and if the teen has
transportation to get to outpatient treatment appointments. The healthcare
provider must take a comprehensive approach when assessing the teen
patient’s needs while he or she is undergoing treatment instead of focusing
solely on the teen’s use of drug or alcohol.
Among adolescents, behavior interventions have been shown to be one of
the most effective forms of treatment for substance use. Behavioral
therapies may consist of such practices as cognitive-behavioral therapy,
motivational interviewing, support groups, or family therapy, which provide
education and direction for the teen as well as allow the teen to talk about
issues and their use of substances. Behavioral intervention also helps the
teen to develop stronger interpersonal relationships so that he or she will be
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
70
more likely to turn to friends or family for help instead of using drugs or
alcohol during times of need. The teen patient may learn more about coping
skills, in which solutions are readily available to turn to when the teen is
struggling with mental health issues, relationships, or personal problems so
that he or she will better understand how to manage feelings and behavior
instead of using substances to self medicate.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a form of psychotherapy in which the
adolescent patient meets with a counselor for treatment one or more times
per week. Cognitive-behavioral therapy works when the therapist teaches
the client to consider how his or her thoughts affect behavior. The patient
then works on changing his or her thoughts and to replace thoughts with
realistic thinking. For example, a teen may meet with a therapist to undergo
CBT regarding use of marijuana. Throughout the discussion, the teen may
recognize that negative encounters with the teen’s parents cause the teen to
feel deficient or guilt, and the teen may feel that he or she has not been
successful in achieving good grades or being active in school. Whenever the
teen starts to feel this way, he or she smokes marijuana to help feel better
and not think about the negative interactions had with the teen’s parents.
The therapist can work with the teen to come up with alternative solutions
for when he or she is feeling like a failure or when negative encounters occur
with the teen’s parents, instead of smoking marijuana.
Cognitive behavioral therapy has been shown to be effective in reducing
substance use among teens, improving coping skills and communication, and
increasing self-monitoring activities. A study from the journal Addiction
demonstrated that among the drug-using youth studied, participants showed
a significant decrease in frequency of cannabis use and a marginally
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
71
significant decrease in alcohol use when they underwent CBT.31 The use of
CBT can be extremely beneficial in helping adolescents with substance use
disorders to cope with the difficulties of adolescence instead of turning to
drugs or alcohol to self-medicate. The individual can continue to use the
coping skills learned through CBT over a long period of time as new
problems and issues develop, in order to reduce or eventually eliminate drug
or alcohol use.
Motivational Interviewing
Motivational interviewing is another form of outpatient treatment that has
been shown to be successful among some adolescent patients who struggle
with substance use disorders. Motivational interviewing (MI) is a technique
in which a caregiver or provider meets with a patient and works together
with the patient to collaborate on how best to elicit change in the patient’s
life.32 It does not involve the practitioner teaching the patient about what he
or she should or shouldn’t do, and it is not used to treat all forms of
substance use. Instead, it is designed as a method of respectfully working
with a patient to consider what aspects of the patient’s life need to change
and how he or she can go about making those changes.
Motivational interviewing may be successful when used with teens because it
is often used in situations where a client does not necessarily want to
change or does not see the need for change. Through the principles of
motivational interviewing, the practitioner explores with the patient his or
her feelings of ambivalence about making life changes. The clinician is not
confrontational about the change; instead, the clinician uses the principles of
empathy and support to help the client to see his or her own self-efficacy to
make changes.33 This is done by talking through the situation with the
patient, using “change talk,” which involves discussing the impetus for
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
72
change and the patient’s ambivalence toward it, and helping the teen patient
to understand that the provider is available to listen and to talk regardless of
whether the patient decides to change.
There is some variation in how MI is delivered and how often the patient
should undergo sessions of meeting with a therapist for the MI. In severe
cases, the teen may need to meet with the practitioner on a frequent basis
for many months to go through the process of change. Alternatively, MI has
also been used in very brief episodes in the primary care provider’s office or
the emergency department and has also shown benefits. Motivational
interviewing has been demonstrated to be successful in helping both adults
and teens to overcome tobacco use and to quit smoking.33
Motivational interviewing also plays a key role as another type of
intervention that may be used as follow up to traditional therapy for a
substance use disorder. In these situations, MI may provide the benefit of
helping an adolescent to significantly reduce his or her use of alcohol or
drugs, but not necessarily to promote complete abstinence. MI may also
help an adolescent to make changes in the coping skills he or she has
developed as part of treatment, even if the adolescent does not completely
give up using drugs or alcohol. For example, a teen that has gone through
substance use treatment and has learned to use certain coping skills in place
of using drugs may use motivational interviewing to develop a plan for
utilizing these coping skills when he or she wants to use drugs instead.
Although the teen may not commit to abstaining from drugs completely
during the process of MI, it can produce enough of an effective change that
the teen will commit to using coping skills, which can drastically reduce his
or her use of drugs.
Outpatient Support Groups
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
73
Other outpatient groups are beneficial for teens when they are able to meet
together with others for support and to discuss their circumstances. SMART
Recovery® is an outpatient teaching program that educates teens about
how to change their behavior when they make poor choices, such as
engaging in drug use or smoking. SMART is an acronym that stands for Self
Management And Recovery Training.34 The program provides a group where
teens can meet with others who have similar issues for discussions and peer
support. It is an alternative to other 12-step programs that are typically
available as outpatient support groups.
SMART Recovery is based on a 4-point process: the group focuses on the
motivation for change, developing coping skills for dealing with impulsive
behavior that leads to drug or alcohol use, determining how to manage
difficult feelings and how to control behavior, and learning how to live an
organized and balanced life, such as by setting goals and finding new
interests outside of drug or alcohol use.34 SMART Recovery is one option for
outpatient treatment for a teen who can benefit from continuing treatment
by meeting with others for small group support; it is considered a nonreligious group that usually meets the requirements designated by the legal
system when a teen has been ordered to attend meetings by the court.
Meetings are also a place where teens can feel support from others in similar
situations, make new friends, and have good discussions facilitated by a
trained leader.
Twelve-step groups are another choice for some teens to attend ongoing
support groups with others who have similar substance use problems. These
programs are free and typically have meetings at a number of locations,
making them relatively easy for teens to access. Some groups consist of
both adults and teens, while others may be centered specifically on the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
74
unique needs of adolescents. A 12-step program is based on 12 steps of
change and recovery, in which the person with the problem admits that he
or she has a problem and turns over control of the problem to a Higher
Power. Other steps include admitting to others about the wrongs committed,
making a list of people who have been hurt by the behavior and making
peace with them, pursuing meditation and reflection about the changes that
have been made in the teen’s life, and teaching others about the steps to
recovery.35
There are various types of 12-step programs, and each is centered on the
specific item or act that affected individuals are trying to overcome; as such,
each type of group is so-named according to the topic needing change and
then followed by the term “Anonymous” because the groups agree not to
share personal information outside of the group and to respect the
confidentiality of those in the group. Groups range from broad categories,
such as Alcoholics Anonymous or Narcotics Anonymous, to specific types of
substances or items needing to be changed, including Heroin Anonymous or
Marijuana Anonymous.
Although teens can attend groups where there are also adults struggling
with addiction and dependence, The Partnership for Drug-Free Kids states
that 12-step programs are often more effective when they are tailored to the
needs of adolescents.36 Some 12-step programs have been modified to meet
the developmental needs of teens and they offer friendship with other teens
who are in similar situations. Still, some people are uncomfortable with the
spiritual component of 12-step programs and recognizing a Higher Power as
part of the process. They may not want to continue in this type of treatment
if they feel awkward about attending meetings. However, there are many
teens who succeed in abstaining from substance use by utilizing 12-step
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
75
programs. They are paired with a sponsor, who is usually someone else who
has overcome addiction, and who acts as a mentor to provide support during
the process. Having someone at the meetings and discussing aspects of
treatment is an important social outlet for many teens and helps them to
make new friends in place of their former friends who may still continue to
use drugs or alcohol.
Family Therapy Groups
Family therapy is important for treatment of teen substance use; often, a
teen still lives at home with family and if these family members can attend
family therapy groups, the counselor can help everyone to work together.
The family is a significant source of support for the teen both during the time
that the teen is attending outpatient therapy and later when he or she goes
forward into life as a recovering drug or alcohol addict. When family
members attend group therapy with the teen, they learn to talk about issues
present that may have contributed to the substance abuse, discuss their
feelings regarding the patient’s problems with drugs or alcohol, and talk
about their home life together. Family therapy is also a time to learn better
forms of communication that will continue to serve the members of the
family so that they can talk when issues arise in the future and work
together to solve problems as a family.
Parents and other family members of the teen who has a substance use
disorder also benefit from family therapy in that the group can provide ideas
about coping methods to use when their teen is struggling. It can be difficult
for family members to watch their child spiral out of control into drug or
alcohol use; this often causes feelings of hurt, pain, confusion, and anger for
others in the family. Family therapy can be a resource for those who must
live with the teen patient to help them cope with difficult feelings associated
with drug and alcohol use and their teen’s behavior. When family members
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
76
have coping skills and resources for dealing with a substance use disorder,
they can better help their child who is struggling.
Many teens that have gone through inpatient treatment programs need
continued care and monitoring after being discharged from inpatient care.
These outpatient treatment programs are designed to follow up on the
principles used during inpatient treatment so that the patient can continue to
practice what he or she has learned. They are also designed to reduce the
risk of relapse that may be more likely to occur among teens. Despite going
through inpatient treatment programs, many adolescents later return to
alcohol or drugs after a period of abstinence. This is often because the teen
who receives intensive treatment for a drug or alcohol problem is learning
about how to cope and recover from a situation that affects his or her life as
a teen. The teen’s current lifestyle revolves around school, a job, peers, and
activities that are related to adolescence, not necessarily adulthood. As the
teen continues to grow and reaches adulthood, the teen’s life changes and
he or she takes on different responsibilities and reaches a new stage of
development.
Because a teen’s responsibilities become different as an adult, the person
who received substance use addiction treatment as a teen may not
necessarily be able to use the same coping measures once learned. The
individual’s problems have changed and he or she may respond differently
by returning to drugs or alcohol as methods of self-medicating for adult
issues. Alternatively, just because a teen does not complete outpatient
sessions after an inpatient treatment program does not mean that he or she
is destined to have a lifelong addiction to drugs or alcohol. Because noncompletion of a long-term outpatient program is more common among youth
than adults, an affected adolescent may also be more likely to re-enter a
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
77
program for help with a substance use disorder. While this may need to
occur a number of times during adolescence and into adulthood, it is still
possible that the teen or young adult eventually gets the treatment needed
to succeed.29
Medical Intervention
Although there are a number of medications to treat addiction, which are
available for adults, there are few, if any, medications approved by the U.S.
FDA for the treatment of adolescent substance users. In most cases, these
drugs are not approved because of their potentially negative effects on the
developing brain of an adolescent. Still, there are some providers who
continue to prescribe some medications for drug or alcohol addiction in
teens, in which the drugs are considered to be “off label” use. These
medications are often indicated more for older teens who are closer to
entering young adulthood, compared to very young teens with substance
use addiction.
Methadone
Methadone is a drug that is sometimes used for the treatment of addiction to
painkillers or heroin. Methadone itself is an opioid analgesic and provides
pain relief as well as many similar symptoms associated with heroin or
opioid use, but its onset of action is much slower when compared to other
drugs. As part of treatment for addiction, a teen may receive methadone,
which binds to the same receptors as heroin or other opioid drugs.37
Methadone may be administered in controlled settings known as methadone
clinics, in which the provider determines the appropriate amount of the drug
needed and then administers it in a controlled environment where the
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
78
patient can be monitored. The teen patient is given a dose of methadone
and then the dose is slowly decreased over time to reduce the person’s
dependence on opioids.
Methadone use is not without risks. Although it has been used as part of
substance use treatment for thousands of people, a person who takes
methadone as part of treatment may still become addicted to it. Methadone
may also be given as a prescription to be taken on an outpatient basis as
part of detoxification. This presents a potentially dangerous situation in
which the teen is at greater risk of becoming addicted to the methadone if
he or she takes it inappropriately. For instance, a person with a methadone
prescription may not feel the effects of the drug right away because of its
slower onset when compared to heroin. He or she may then take more
methadone to try and achieve the same effects, which could result in an
overdose.
Methadone is typically administered as an oral tablet, although in some
methadone clinics, it may also be given as an oral liquid. The drug is given
to block the effects of opiates and has been shown to reduce cravings for
drugs such as heroin in addicted individuals.37 Among adolescents,
methadone may be used for treatment of 16- to 18-year olds who have
documented cases of other forms of failed drug treatments or opioid
detoxification. The teen must also have consent signed by a parent or
guardian to undergo methadone treatment.28
Buprenorphine
Buprenorphine is another type of narcotic analgesic that has been approved
for use for people undergoing withdrawal from heroin or painkiller addiction.
Buprenorphine is a partial opioid agonist, so it is less likely to cause
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
79
dependence and symptoms of withdrawal when it is discontinued. This
makes it different from methadone, as people who take buprenorphine are
less likely to become addicted to it as part of the drug withdrawal process. It
has been shown to reduce cravings for heroin and opioid analgesics because
it blocks the effects of other opioids when administered correctly.28,29
A patient who takes buprenorphine may still experience some effects such as
euphoria, but may not experience them to the full extent as with taking
other types of opioids. Although it is available as an analgesic (Buprenex®),
it is administered as Suboxone® for use as an opioid withdrawal treatment,
which has been approved for the management of opioid addiction by the
U.S. FDA, although not for adolescents.38 Suboxone is a combination of
buprenorphine and naloxone, which is an opioid antagonist that has been
added to protect against inappropriate administration of Suboxone; for
instance, the person who injects Suboxone intravenously will experience
negative side effects of a withdrawal reaction. Although it is technically not
approved for pediatric use, some practitioners have been approved for inoffice treatment with Suboxone for opioid or heroin addiction for teens; its
use is typically regulated to older adolescents.28
Naltrexone
Naltrexone is an opioid antagonist medication that may be administered to
some patients as part of treatment for drug and alcohol use. Naltrexone
(Vivitrol®) works by blocking opioid receptors so that the person who takes
an opioid medication does not experience the pleasant effects and euphoria.3
It may be administered as oral tablets or as a preparation given by injection.
Extended-release naltrexone may be given as an injection, in which the drug
is slowly released into the system over a longer period of time when
compared to oral tablets. A study in the Journal of Substance Abuse
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
80
Treatment showed that patients who used extended-release naltrexone in
injectable form in the physician’s office were more likely to continue their
treatment of substance use over a longer period of time when compared to
those who only used naltrexone as oral tablets. Naltrexone extended-release
injections are more expensive than taking oral tablets, but patients who take
the injections may more likely stay committed to treatment protocols and
stay with their programs. The study determined that those who used the
extended-release injections of naltrexone had shorter periods of
detoxification and withdrawal and shorter stays in inpatient treatment
facilities.39
Naltrexone is also used for the treatment of an alcohol use disorder and may
be given to some teens that struggle with alcohol addiction. In this type of
treatment, it is also given as an oral tablet or as an injectable medication.
Other drugs are also specifically designed for the treatment of alcohol
addiction; two of the most common forms used among adolescents are
acamprosate and disulfiram. As with other forms of medications used for
drug withdrawal, medications used for alcohol withdrawal among
adolescents have not been extensively studied for this population and may
not be entirely safe. However, they are still often prescribed, particularly in
areas where adolescents do not respond to other forms of alcohol use
treatment, such as through behavioral therapy.
Benzodiazepines
A teen that is undergoing acute symptoms of withdrawal, including delirium
tremens, may be treated with benzodiazepines. Delirium tremens may occur
during the acute stage of withdrawal as the affected person stops using
alcohol; symptoms include sweating, high fever, seizures; and altered
mental status that can include hallucinations, delusions, and significant
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
81
confusion.40 Benzodiazepines may be given as treatment for delirium
tremens, but these drugs are used carefully because they may also increase
the risk of dependence and addiction. Therefore, benzodiazepines are
typically used on a short-term basis during an acute withdrawal period when
they can be closely monitored.
Benzodiazepines act on the GABA receptors in the brain, so they reduce
many of the hemodynamic and peripheral symptoms associated with alcohol
withdrawal. They are most often effective when given as needed (PRN) for
symptoms of delirium tremens, as opposed to scheduled, continued doses on
a fixed basis.41 However, when benzodiazepines are given PRN for alcohol
withdrawal symptoms, they require frequent and close monitoring by
medical staff to ensure that affected patients receive the right amount when
needed for symptoms and also to ensure that the benzodiazepines are
working as they should. Diazepam and lorazepam are two types of
benzodiazepines that may be administered intravenously for treatment in
these cases.
Acamprosate
Acamprosate (Campral®) is another type of medication that may be
administered for treatment of alcohol addiction. As stated, Campral has not
been studied extensively among teen populations, but it has been used in
this group of patients for significant alcoholism and among older teens.28
Acamprosate reduces cravings for alcohol among addicted persons; it works
by inhibiting the neurotransmitter GABA in the brain. It often works more
effectively for patients who use it in combination with behavioral counseling
and therapy for their alcohol addiction. Campral has been shown to reduce
instances of alcohol consumption when taken appropriately, even among
those who suffer from a severe alcohol substance use disorder.40
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
82
Disulfiram
Drugs known as aversion medications may also be used for the treatment of
alcoholism. One of the most commonly known aversion medications is
disulfiram (Antabuse®). Disulfiram works by blocking the enzyme aldehyde
dehydrogenase, which disrupts how the body metabolizes alcohol. When a
person drinks alcohol after taking disulfiram, the body is unable to process it
and acetaldehyde builds up in the bloodstream.42 This causes the person to
experience severe flushing, dizziness, nausea, and vomiting when a person
drinks even a small amount of alcohol. As a result, the person is less likely
to want to drink again, causing a psychological aversion to using alcohol
because of the effects of the drug.
Disulfiram must be carefully controlled for its use by teens with an alcohol
use disorder. The effects of the drug last up to 2 weeks, so a patient may
take a dose and then continue to receive outpatient treatment for alcohol
abuse at home. It is important for the healthcare provider to consistently
remind the patient not to drink any alcohol after taking disulfiram and that
the effects can occur 1 to 2 weeks after taking the dose. Overdose effects
can cause a drastic drop in blood pressure, leading to hypotension, as well
as chest pain and shortness of breath.40 Patients who take disulfiram seem
to be more successful when they have continued monitoring through
outpatient therapy, 12-step support groups, or frequent follow-up visits with
a healthcare provider.
DSM-5 Criteria In The Diagnosis Of A Substance Use Disorder
The American Psychiatric Association (APA) Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) provides the latest criteria for
clinicians in the evaluation and diagnosis of mental illness and a substance
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
83
use disorder. This is discussed in the DSM-5 chapter on “Substance-Related
and Addictive Disorders” which categorizes a variety of substance use
disorders (SUDs). While earlier DSM editions identified “substance abuse”
and “substance dependence,” as separate categories, the DSM-5 eliminated
those separate categories and identifies SUDs as one (1) category with
changes to the diagnostic criteria that identify addictive behaviors along a
continuum. Although professional studies and guidelines may continue to
widely use terms interchangeably as relates to substance addiction, abuse
and dependence, working committees and authors of the DSM-5 clearly
identified how those terms had often been used inappropriately and tended
to confuse the diagnosis of a substance related disorder or addiction.
The important distinction made in the DSM-5 for clinicians to understand as
it relates to a SUD diagnosis and, importantly, in the education of patients
with an addiction problem, is that prior criteria of “dependence” and “abuse”
are no longer considered mutually exclusive disorders with one being a less
serious disorder as compared to the other. There are levels of severity
associated with SUDs in the DSM-5, and the criteria apply to the level of
severity identified with a specific SUD diagnosis. The new DSM-5 criteria
guiding the diagnosis of a SUD are outside the scope of this study, however,
it is important for clinicians to have a basic familiarity with the new criteria
and to adapt practice to incorporate DSM-5 criteria when considering a
patient’s treatment plan for a substance use disorder. Additionally, in a
therapeutic milieu, application of the DSM-5 criteria relative to SUDs will
support clinicians and care teams to avoid some of the earlier pitfalls of
confusing and stigmatizing language associated with the diagnosis of a
substance use disorder.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
84
Summary
Adolescent substance use addiction is a dangerous situation that is often
overlooked as being a real problem. Consequently, many teens that are
struggling with a substance use disorder do not receive the treatment they
need. Parents and caregivers of teens should be aware of the signs and
symptoms of a substance use disorder and should learn to recognize when
their teen is behaving differently, which can indicate a problem. When
healthcare providers give time and attention to assessment of the needs of
the adolescent who is struggling with substance use, the affected teen may
be able to heal from this condition by receiving appropriate care.
REFERENCES
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
85
1.
Substance Abuse and Mental Health Services Administration. (2014,
Oct.). Prevention of substance abuse and mental illness. Retrieved from
http://www.samhsa.gov/prevention
2.
Monti, P., Colby, S., O’Leary T. (Eds.). (2001). Adolescents, alcohol,
and substance abuse: Reaching teens through brief interventions. New
York, NY: The Guilford Press
3.
Lilley, L., Collins, S., Snyder, J. (2011). Pharmacology and the Nursing
Process (7th ed.). St. Louis, MO: Elsevier Mosby
4.
National Institute on Drug Abuse. (2014, Jan.). Drug facts: Stimulant
ADHD medications: Methylphenidate and amphetamines. Retrieved
from http://www.drugabuse.gov/publications/drugfacts/stimulant-adhdmedications-methylphenidate-amphetamines
5.
NIDA for Teens. (2015, Feb.). Drug facts: Methamphetamine (meth).
Retrieved from http://teens.drugabuse.gov/drugfacts/methamphetamine-meth
6.
Muir Wood. (2015). Teen cocaine abuse: How cocaine affects your teen
and how to find help. Retrieved from
http://www.muirwoodteen.com/teen-cocaine-abuse/
7.
Chambers, R., Taylor, J., Potenza, M. (2003, Jun.). Developmental
neurocircuitry of motivation in adolescence: A critical period of addiction
vulnerability. The American Journal of Psychiatry 160(6): 1041-1052.
Retrieved from
http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.160.6.1041#_i8
8.
NIDA for Teens. (2015, Feb.). Drug facts: MDMA (ecstasy or Molly).
Retrieved from http://teens.drugabuse.gov/drug-facts/mdma-ecstasyor-molly
9.
National Institute on Drug Abuse. (2011, Oct.). Prescription drugs:
Abuse and addiction. Retrieved from
http://www.drugabuse.gov/sites/default/files/rrprescription.pdf
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
86
10. NIDA for Teens. (2015, Feb.). Drug facts: Inhalants. Retrieved from
http://teens.drugabuse.gov/drug-facts/inhalants
11. Hayes, G., Talley, M. (2011). Drugs and your teen: All you need to
know about drugs to protect your loved ones. Philadelphia, PA: Omni
Publishing House
12. Addictionblog.org. (2011, Aug.). Can you get high off nutmeg?
Retrieved from http://drug.addictionblog.org/can-you-get-high-offnutmeg/
13. Mazor, S., DesLauriers, C., Mycyk, M. (2013). Adolescent ethanol
intoxication from vanilla extract ingestion: A case report. The Internet
Journal of Family Practice 4(1). Retrieved from
https://ispub.com/IJFP/4/1/3199
14. The National Child Traumatic Stress Network. (n.d.). Understanding
traumatic stress in adolescents. Retrieved from
http://www.isbe.net/learningsupports/pdfs/traumatic-stress-factsheet.pdf
15. Hazen, E., Goldstein, M., Goldstein, M. (2011). Mental health disorders
in adolescents: A guide for parents, teachers, and professionals. New
Brunswick, NJ: Rutgers University Press
16. National Council on Alcoholism and Drug Dependence, Inc. (n.d.).
Family history and genetics. Retrieved from https://ncadd.org/forparents-overview/family-history-and-genetics
17. Hudson, A., Nandy, K. (2012). Comparisons of substance abuse, highrisk sexual behavior and depressive symptoms among homeless youth
with and without a history of foster care placement. Contemporary
Nurse 42(2): 178-186.
18. Sacks, V., Moore, K., Shaw, A., Cooper, P. (2014, Nov.). Research
brief: The family environment and adolescent well-being. Retrieved
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
87
from http://www.childtrends.org/wp-content/uploads/2014/11/201452FamilyEnvironmentRB.pdf
19. Partnership for Drug-Free Kids. (2012, Oct.). Nurses can help reduce
substance abuse in homeless youth, study finds. Retrieved from
http://www.drugfree.org/join-together/nurses-can-help-reducesubstance-abuse-in-homeless-youth-study-finds/
20. Hoffman, N., Estroff, T., Wallace, S. (n.d.). Co-occurring psychiatric and
substance disorders. Retrieved from
http://www.dualdiagnosis.org/resource/co-occurring-psychiatric-andsubstance-disorders/
21. National Institute on Drug Abuse. (2011, Mar.). Drug facts:
Comorbidity: Addiction and other mental disorders. Retrieved from
http://www.drugabuse.gov/publications/drugfacts/comorbidityaddiction-other-mental-disorders
22. Yule, A., Wilens, T. (2011, Oct.). Familial influences on adolescent
substance use. Psychiatric Times. Retrieved from
http://www.psychiatrictimes.com/child-adolescent-psychiatry/familialinfluences-adolescent-substance-use
23. Spear, L. (2010). The behavioral neuroscience of adolescence. New
York, NY: W. W. Norton & Company, Inc.
24. White, D. (2012). Symptoms of teen substance abuse. Psych Central.
Retrieved from http://psychcentral.com/lib/symptoms-of-teensubstance-abuse/00012664
25. Phillips, N. (2009, Aug.). Not all alcoholic drinks are the same.
Retrieved from
http://www.abc.net.au/science/articles/2009/08/25/2662698.htm
26. Bellum, S. (2011, Jun.). Real teens ask about effects of heroin.
Retrieved from http://teens.drugabuse.gov/blog/post/real-teens-askabout-effects-heroin
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
88
27. Vimont, C. (2013, Jul.). Sleep problems and substance use disorders:
An often overlooked link. Retrieved from http://www.drugfree.org/jointogether/sleep-problems-and-substance-use-disorders-an-oftenoverlooked-link/
28. National Institute on Drug Abuse. (2014, Jan.). Principles of adolescent
substance use disorder treatment: A research-based guide. Retrieved
from http://www.drugabuse.gov/sites/default/files/podata_1_17_14.pdf
29. Kaminer, Y., Winters, K. (Eds.). (2010). Clinical manual of adolescent
substance abuse treatment. Arlington, VA: American Psychiatric
Publishing, Inc.
30. American Society of Addiction Medicine. (2015). What is the ASAM
criteria? Retrieved from http://www.asam.org/publications/the-asamcriteria/about/
31. Child Trends. (2012, Feb.). Cognitive-behavioral therapy for drug
abuse. Retrieved from
http://www.childtrends.org/?programs=cognitive-behavioral-therapyfor-drug-abuse
32. Naar-King, S., Suarez, M. (2011). Motivational interviewing with
adolescents and young adults. New York, NY: The Guilford Press
33. Headspace. (2012). Evidence summary: The effectiveness of
motivational interviewing for young people engaging in problematic
substance use. Retrieved from
http://www.headspace.org.au/media/326688/motivational_interviewing
_for_young_people_engaging_in_problematic_substance_use_headspac
e_evsum.pdf
34. SMART Recovery. (2015). The SMART Recovery teen & youth support
program. Retrieved from http://www.smartrecovery.org/teens/
35. Teen Addiction Anonymous. (2014). Teen AA’s 12 steps. Retrieved from
http://www.teenaddictionanonymous.com/the12steps
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
89
36. Vimont, C. (2012, Jun.). Adapting 12-step programs for teenagers.
Retrieved from http://www.drugfree.org/join-together/adapting-12step-programs-for-teenagers/
37. Center for Substance Abuse Research. (n.d.). Methadone. Retrieved
from http://www.cesar.umd.edu/cesar/drugs/methadone.asp
38. The National Alliance of Advocates for Buprenorphine Treatment. (n.d.).
What exactly is buprenorphine? Retrieved from
http://www.naabt.org/faq_answers.cfm?ID=2
39. Hartung, D., McCarty, D., Fu, R., Weist, K., Chalk, M., Gastfriend, D.
(2014). Extended-release naltrexone for alcohol and opioid
dependence: A meta-analysis of healthcare utilization studies. Journal
of Substance Abuse Treatment 47(2): 113-121.
40. University of Maryland Medical Center. (2013, Mar.). Alcoholism.
Retrieved from
http://umm.edu/health/medical/reports/articles/alcoholism
41. Burns, M. (2014, Aug.). Delirium tremens (DTs) medication. Retrieved
from http://emedicine.medscape.com/article/166032-medication#2
42. Skinner, M., Lahmek, P., Pham, H., Aubin, H. (2014). Disulfiram
efficacy in the treatment of alcohol dependence: A meta-analysis. PLoS
ONE 9(2): e87366. Retrieved from
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.00873
66#s1
43. National Institute on Alcohol Abuse and Alcoholism. (n.d.). College
drinking. Retrieved from http://www.niaaa.nih.gov/alcoholhealth/special-populations-co-occurring-disorders/college-drinking
44. National Institute on Alcohol Abuse and Alcoholism. (n.d.). Underage
drinking. Retrieved from http://www.niaaa.nih.gov/alcoholhealth/special-populations-co-occurring-disorders/underage-drinking
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
90
45. National Institute on Drug Abuse. (n.d.). Research report series—
Therapeutic community. Retrieved from
http://archives.drugabuse.gov/researchreports/Therapeutic/Therapeutic
3.html#structure
46. National Institute on Drug Abuse. (n.d.). Monitoring the Future Study:
Trends in prevalence of various drugs. Retrieved from
http://www.drugabuse.gov/trends-statistics/monitoringfuture/monitoring-future-study-trends-in-prevalence-various-drugs
47. NIDA for Teens. (2015, Feb.). Drug facts: Marijuana. Retrieved from
http://teens.drugabuse.gov/drug-facts/marijuana
48. U. S. Department of Health and Human Services Office of Adolescent
Health. (2015, Feb.). Trends in adolescent tobacco use. Retrieved from
http://www.hhs.gov/ash/oah/adolescent-health-topics/substanceabuse/tobacco/trends.html
49. McGuire, K. (2009, Mar.). Abandoned. Retrieved from http://artemistwitches.deviantart.com/art/Abandoned-116038029
50. Flickr.com. (2009, May). USAG-Humphreys. Retrieved from
https://www.flickr.com/photos/usaghumphreys/3568673346/in/set72157618756925735
51. Nicholson, T. (2010, Oct.). Smoking woman Kelsey. Retrieved from
http://commons.wikimedia.org/wiki/File:Smoking_woman_Kelsey.jpg
52. Flickr.com. (2006, May). Cheers to Friday. Retrieved from
https://www.flickr.com/photos/reinrache/475174170/
53. Hansen, T. (2008, Feb.). Marijuana joint. Retrieved from
https://www.flickr.com/photos/torbenh/2298921212/
54. Wikipedia Commons. (2006, Jun.). Ritalin SR. Retrieved from
http://commons.wikimedia.org/wiki/File:Ritalin-SR-20mg1000x1000.jpg
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
91
55. Wikipedia Commons. (2007, Feb.). Cocaine lines on the mirror.
Retrieved from
http://commons.wikimedia.org/wiki/File:Cocaine_lines_2.jpg
56. Hacker, M. (n.d.). Inhalants. Retrieved from
http://commons.wikimedia.org/wiki/File:USMC-07664.jpg
57. Wikipedia Commons. (2005, May). Nutmeg nuts. Retrieved from
http://commons.wikimedia.org/wiki/File:Muscade.jpg
58. Wikipedia Commons. (2011, Mar.). Symptoms of ADHD described by
the literature. Retrieved from
http://commons.wikimedia.org/wiki/File:Proposed_Symptoms_of_ADHD
.PNG
59. Bezrukov, V. (2008, May). Reflected sadness. Retrieved from
http://commons.wikimedia.org/wiki/File:Reflected_sadness.jpg
60. Wikipedia Commons. (n.d.). Students need sleep in order to study.
Retrieved from
http://commons.wikimedia.org/wiki/File:Sleeping_while_studying.JPG
61. Ku, M. (2011, Feb.). Sad girl. Retrieved from
https://www.flickr.com/photos/james_sickmind/5448338240/
62. Maksymenko, A. (2013, Nov.). Training in Ukraine. Retrieved from
http://en.wikipedia.org/wiki/Positive_psychotherapy#mediaviewer/File:
Positive_Psychoterapy.jpg
63. Durfey, J. (2010, Dec.). Grunge. Retrieved from
https://www.flickr.com/photos/pdworkman/galleries/721576453049604
13/
64. Flickr.com. (2012, Jun.). Lonely boy. Retrieved from
https://www.flickr.com/photos/littlesourire/12989897375/in/photolistkMSBVR-91mpev-9uE2M5-qmcFYA-fkAWKF-9uE2LS-53xYuM-dsEsdZfkAz5z-56vLHQ-bVnhoQ-6PTBd4-5gktq
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
92
65. Csonka, N. (2009, Jul.). Teen angst. Retrieved from
https://www.flickr.com/photos/53395511@N04/galleries/72157625559
248452/#photo_3685178495
66. Wikipedia Commons. (2013, May). Dr. Bob’s house. Retrieved from
http://commons.wikimedia.org/wiki/File:Dr._Bob%27s_House.jpg
67. Flickr.com. (2009, Jun.). Urrghh… Retrieved from
https://www.flickr.com/photos/dm-set/3651344537/in/gallery52238172@N07-72157629538596506/
68. Centers for Disease Control and Prevention. (2014, Feb.). Health effects
of cigarette smoking. Retrieved from
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/
effects_cig_smoking/
69. Robinson, L., Smith, M., Saisan, J. (2015, Feb.). Drug abuse and
addiction. Retrieved from
http://www.helpguide.org/articles/addiction/drug-abuse-andaddiction.htm
70. National Council on Alcoholism and Drug Dependence, Inc. (n.d.). Signs
and symptoms. Retrieved from https://ncadd.org/learn-aboutdrugs/signs-and-symptoms
71. Narconon.org. (2013, Aug.). How drugs can change your personality.
Retrieved from http://www.narconon.org/blog/drug-use-2/how-drugscan-change-your-personality/
72. National Institute of Mental Health. (n.d.). What is depression?
Retrieved from
http://www.nimh.nih.gov/health/topics/depression/index.shtml
73. Achieve Solutions. (2014, Apr.). Alarming trends in teen substance use
and depression. Retrieved from
https://www.achievesolutions.net/achievesolutions/en/Content.do?cont
entId=22386
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
93
74. Harstad, E., Levy, S. (2014, Jul.). Attention deficit/hyperactivity
disorder and substance abuse. Pediatrics 134(1): e293-e301. Retrieved
from http://pediatrics.aappublications.org/content/134/1/e293.full
75. National Institute of Mental Health. (2012). Bipolar disorder in children
and adolescents. Retrieved from
http://www.nimh.nih.gov/health/publications/bipolar-disorder-inchildren-and-adolescents/index.shtml
76. Elements Behavioral Health. (2013, May). Bipolar disorder and
substance abuse among teens. Retrieved from
http://www.elementsbehavioralhealth.com/adolescent-issues/bipolardisorder-and-substance-abuse-among-teens/
77. American Psychiatric Association (2013). Desk Reference To The
Diagnostic Criteria From DSM-5. Washington, D.C.; pp. 233-234, 239240, 239-240, 267-268, 274-275.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
94