From the perspective of many adults, all adolescents who use drugs, including alcohol and tobacco, have a drug problem. In contrast very few teenagers, including those who are suffering adverse consequences of drug use, will either admit that they have any problem with drugs, or seek medical attention for drug-related concerns. The truth would appear to lie somewhere between these two extremes. As health care professionals it is important that we attempt to define for ourselves, for our teenage patients and their parents, and for our communities, what constitutes an adolescent drug problem, how it can be evaluated and what prevention and management alternatives are available.
PATTERNS OF SUBSTANCE USE
The initial step in the evaluation of the teenager with a potential drug abuse problem is a determination of the nature and extent of his or her drug involvement. It is most helpful to begin by defining the pattern of substance use exhibited by the adolescent. This pattern of use most clearly defines the risks to the teenager and the goals and strategies for intervention. Although any pattern of drug use has some potential risk and therefore cannot be ignored, certain patterns are clearly more hazardous and disruptive, thus mandating an attempt at intervention. Patterns of substance use by adolescents would include experimental, recreational, problematic and addictive.
Experimentation with new and different life experiences is a normal part of adolescence and, in many cases, must be tolerated as part of the maturation process. Many drugs are used on an experimental basis by young people. This type of use usually does not interfere appreciably with their lifestyle or expose them to significant risk of adverse consequences. There is always the risk, however, of the isolated tragic episode occurring in the life of the otherwise well adjusted teenager following the experimental use of a psychoactive substance. An additional risk of experimentation is that it may lead to contact with more regular drug users and then the pattern of use may change to one which would put the teenager in greater jeopardy.
The recreational use of intoxicants and stimulants, mainly alcohol, caffeine, and nicotine is widely accepted within our culture. Incorporation of some of these behaviors as part of the social developmental maturation process from childhood to adulthood is to be expected. However, it is difficult to consider recreational substance use by teenagers as a benign process. The main recreational drugs for the adolescent population are alcohol and marijuana. A 1977 United States National Survey of High School Seniors found that 93% had tried alcohol, while 56% had tried marijuana.' Of those high school seniors, 31% reported using alcohol and 20% reported using marijuana on more than 6 occasions in the 30 days preceding the survey. Both drugs, while posing tittle immediate physiologic danger to the user, do cause intoxication with impaired judgment and delayed reaction time. Accidents (mostly automotive) remain the leading cause of death among adolescents in the United States.1 Alcohol and marijuana are factors in many, if not most, of these automotive fatalities. The teenager who is doing well in all aspects of his or her life but is using alcohol or marijuana recreationally is at risk of being injured or killed as a driver or passenger. In addition to this immediate risk, both drugs are capable of causing serious long-term sequelae including damage to the respiratory, neurologic, and hepatobiliary systems. Unfortunately, knowledge of the possibility of adverse health consequences in the distant future makes virtually no impact on the behavior of young people (nor on that of many adults).
A major risk involved with recreational drug use in teenagers is that it may evolve to a pattern of problematic use with significant disruption in the life of the adolescent. Two of the major tasks of adolescence involve preparation for economic independence by acquiring an appropriate education, and developing the social skills necessary to survive and reproduce in a highly complex world. Recreational use becomes problematic when it interferes with these developmental tasks. Donovan and Jessor's study of adolescent problem drinking defined problem drinkers as those teenagers who had been drunk six or more times in the past year and / or had experienced two or more negative consequences of their drinking behavior in the past year in at least three of the following areas: difficulties with police, teachers, dates, friends or driving.1 In this study, which reports the analysis of questionnaires given to a national sample of high school students in the United States in 1978, 23.1% of boys and 14.8% of girls fell into the category of problem drinkers. This same type of definition can be applied to other recreational drugs such as marijuana. When considering problem substance use by teenagers, it is helpful to remember that teenagers have a narrower margin for error than adults. Adolescents are less developed socially and cognitively and less experienced in many technical skills and are therefore more likely to make errors when their judgment is even mildly impaired. The most frequently cited example is the inexperienced driver/ inexperienced drinker combination, the norm for adolescents, which is the direct or indirect cause of many of the previously mentioned automotive accidents. It is important to understand that the large numbers of teenagers defined as problem drinkers or problem marijuana smokers are neither alcoholics nor are they addicted to marijuana. They are, however, teenagers who are at significant risk for developmental disruption and various types of accidents.
Certain populations of teenagers would appear to be at greater risk of becoming problematic drug users. Donovan and Jessor more recently gave evidence that problem drinking and problem marijuana smoking as well as other problematic adolescent behaviors such as delinquency and early sexual experience are more likely to occur in teenagers who show a certain pattern of psychosocial attributes.4 These adolescents tend to have lower expectations for academic achievement than their peers and to place greater value on independence than on academic success. They have a greater tolerance for deviance, report being less influenced by parents as compared to friends and show less compatibility between parents and friends. They report a greater involvement in other problem behaviors and less participation in conventional activities. These and other investigators suggest that there is an adolescent syndrome of "proneness to problem behavior" and that it is, perhaps, less productive to address the specific behavior which emerges as the dominant problem, such as substance abuse, than it is to address the underlying psychosocial issues.
In order to identify a "problem prone" adolescent, the health professional should pay particular attention to certain historical points. School performance is one of the more important areas to explore. An adolescent who reports poor school performance, lack of interest in school and feelings of failure and dissatisfaction in that area of his or her life is at high risk for problem behaviors. This poor school performance can occur for many reasons, such as a specific learning disability, frequent absence from school, major family or environmental stress, economic problems, and chronic physical or emotional illness. It rarely occurs because of lack of intellectual ability. A second area which requires exploration is that of deviance. A family history of alcoholism or other deviant behaviors or a history of delinquency or sexual acting out in the teenager would help to place the adolescent in the problem prone group. A third area worthy of attention is the teenager's social development. The type of adolescents who become involved in problem behavior often show accelerated social maturity. The young adolescent in the 11- to 14year-old range may dress as if he or she is much older, be involved in dating behavior and move within a heterosexual peer group rather than the isosexual peer group which would be more common at this age. These adolescents value independence over education and are less influenced by parents than by peers, often because there are no parents or the available parents are inadequate. A final area which requires careful exploration by the health care professional is the adolescent's mood. Problematic substance use as a manifestation of underlying depression is not uncommon. Questions about sleeping and eating patterns, feelings of sadness, helplessness, hopelessness and suicidal ideation are important in making this identification.
A final pattern of substance use is that of addiction. Addiction implies physical dependence upon a substance where abstinence will cause physiologic distress. The most common addictive drugs used by teenagers are opiates, barbiturates, and alcohol. Both adolescents and adults may become psychologically dependent upon other substances, such as tobacco or marijuana, but they are not truly addictive. Clearly, addiction represents the most serious, but least common, pattern of substance abuse among adolescents. Beyond the physiologic consequences from the drug itself are illnesses secondary to the method of drug administration (i.e., hepatitis, cellulitis, and bacterial endocarditis from intravenous use), disruption secondary to a lifestyle designed to support an expensive drug habit, and all those areas of dysfunction experienced by the problematic drug user. Fortunately, opiate addiction among adolescents is now far less common than« it was in the early 1970s and barbiturate or alcohol addiction remain relatively rare among teenagers/ Occasionally, a young person will present for medical attention because of addiction or because of an illness secondary to drug use. These adolescents will require intensive intervention for not only the management of an abstinence syndrome but also the attempted prevention of subsequent drug abuse.
GOALS OF INTERVENTION
Having defined both the nature and pattern of substance use exhibited by the adolescent, decisions can now be made regarding the goals of intervention. These goals would include stopping the behavior, attempting to modify or control the behavior, or postponing the behavior to some later date. Which goal is chosen at any particular time would depend on the age and developmental stage of the adolescent, the substance in question and the pattern of use.
The most frequently encountered situations are adolescents who are exhibiting a pattern of either experimental or recreational drug use and are not experiencing any significant disruption of behavior or performance. Particularly when the drugs involved are either alcohol or marijuana, most teenagers and many parents do not regard such drug use as a health issue. A goal for the health professional should be to define for the teenager and the parents the risks involved in even experimental and recreational drug use, and by so doing modify the behavior in a manner which will decrease the health risks to the adolescent.
Those adolescents who are using alcohol or marijuana with frequency or who are suffering disruption of their academic or vocational progress because of such drug use and, by our definition, are problem drinkers or marijuana smokers are clearly in need of professional attention. For the young adolescent in the 12- to 15-year-old range, a reasonable minimum goal would be to attempt to postpone these behaviors. For the older adolescent involved in problematic substance use, a more achievable goal may be to try to modify and control these behaviors. In that minority of teenagers who are addicted or who are using any of the more dangerous drugs (opiates, amphetamines, barbiturates, and hallucinogens) a primary goal of intervention must be to stop the drug use behavior. Other goals for both problematic drug users and addicted teenagers would include remediation of disrupted areas of function (i.e., educational, vocational, and social dysfunctions), and addressing the underlying psychosocial issues which are so often encountered in these adolescents.
CONSIDERATIONS FOR INTERVENTION STRATEGIES
Having defined the problem and determined the goals of intervention, the health professional must decide on the strategy which is most likely to result in a successful outcome. Strategies would include: individual or family counseling by the primary care health professional, individual or family psychotherapy by a specialist, peer counseling and other self-help groups within the school or · larger community, environmental manipulation and drug treatment programs, and other therapies which special circumstances might warrant.
For the adolescent who is involved in the experimental or recreational use of such substances as alcohol and marijuana, the goals of postponing or modifying this behavior can often best be accomplished by the primary care health professional. It is important that the health professional emphasize those deleterious effects which may have an immediate effect upon the adolescent's health. Neither alcohol nor marijuana are safe drugs for teenagers. As noted previously, the leading cause of death in the adolescent population is accidents and many of these accidents involve a motor vehicle with intoxication being a contributing factor in the majority of such deaths. It is imperative that the counselor help the adolescent and the family to develop strategies for preventing such accidents. Discussions of alternatives to driving while intoxicated or being driven by an intoxicated friend should be prompted with the teenager and the family. Marijuana carries with it additional hazards for teenagers besides its role as an intoxicant in the morbidity and mortality from accidents. One of the immediate effects of marijuana intoxication is to interfere with short-term memory.6 This has an obvious deleterious effect on the teenager who attempts to learn in school while high on marijuana. For those teenagers who are interested in succeeding at school, this knowledge may help to persuade them to stop smoking marijuana or to confine its use to weekends. There are preliminary indications that heavy marijuana smoking may interfere with growth and pubertal development in young adolescents.7 This information is sufficiently disturbing to many young teenagers that it serves as a strong inducement to postpone marijuana smoking until they have completed their growth.
For the smaller, but highly significant population of adolescents who can be defined as problem drinkers or problem marijuana smokers, a more intensive intervention is often necessary. Treatment for these adolescents can best be accomplished by addressing issues in the teenager's life other than the substance -use itself. Individual psychotherapy may be indicated if there is an underlying depression or other major psychological disturbance in the teenager. Psychological testing may be indicated if learning disabilities are suspected as a reason for poor school performance leading to feelings of inadequacy and increased substance use. Family therapy may be needed where there is significant family pathology and lack of support for the adolescent. The health care professional must become familiar with the range of treatment modalities available in the community. There are often peer support groups affiliated with schools, religious institutions or community centers that may be very helpful in the treatment of problem prone adolescents.
For the rare adolescent who is addicted or seriously involved in hard drug use, hospitalization for detoxification or a drug treatment program, either residential or on a daily basis is advisable. In this instance, consultation with a professional who has special knowledge of these types of drug abuse problems is often very helpful in planning the intervention strategy and treatment program.
With the emergence of recreational alcohol and marijuana use as normative behaviors in the older adolescent population, and the recognition of both addictive and problematic drug use as issues which impact upon teenagers, the health care professional has been left no option but to participate in the prevention of morbidity and mortality related to the use of psychoactive drugs. This participation requires knowledge of the role of these intoxicants in contributing to developmental dysfunction, family stress and accidents in the teenage population. By applying the interviewing skills, preventive health strategies and counseling techniques which have been used successfully in other aspects of childhood health care, health professionals should be well equipped to identify teenagers at risk from drug use and devise achievable goals and appropriate intervention for the reduction of illness secondary to such drug use.
1. Johnston LD, Bachman JG.O'MalleyPM: Drug use among American high school students, i975-1977. US Dept of Health, Education, and Welfare publication No. (ADM) 78-619. National lnstilute on Drug Abuse, 1977.
2. Facts of life and death, US Dept of Health, Education, and Welfare publication No. 79-1222. National Center for Health Siatistics, i978.
3. Donovan JE, Jessor R: Adolescent problem drinking. J Stud Alcohol 39:1506-1524, 1978.
4. Jessor R, Chase JA, Donovan JE: Psychosocial correlates of marijuana use and problem drinking in a national sample of adolescents. Am J Public Health 70:603-613, 1980.
5. Hein K. Cohen Ml. Litt IF: Illicit drug use among urban adolescents: A decade in retrospect. Am J Dis Child 133:38-40, 1979.
6. Dornbush RL: Marijuana and memory: Effects of smoking on storage. Transactions of the New York Academy of Sciences, Series 11:36:94-100, 1974.
7. Copeland KC, Underwood LE, Van Wyk JJ: Marijuana smoking and pubertal arrest. J Pediair 96:1079-1080, 1980.