Psychiatric Annals

CME Article 

Substance Use in Adolescents: Diagnostic Dilemma with Case Examples

Edore Onigu-Otite, MD; Biren Patel, MD; Iqra Ansari, MD; Kelash Rai, MD; Sandy Lee, MD; Asim A. Shah, MD

Abstract

Substance use in adolescents is a public health problem that poses many challenges for health care providers. Adolescents frequently abuse multiple substances simultaneously, further confounding the symptoms and signs of their presentation. Adolescents with substance use disorders often have co-occurring mental health problems predating or resulting from substance use, complicating their diagnoses and treatment. Additionally, many adolescents who use substances do not perceive their own need for treatment or acknowledge their level of functional impairment, which influences their symptom report. In this article, we use case examples to review common drug and alcohol problems present in adolescents and the challenges to diagnosis and treatment. [Psychiatr Ann. 2019;49(6):263–268.]

Abstract

Substance use in adolescents is a public health problem that poses many challenges for health care providers. Adolescents frequently abuse multiple substances simultaneously, further confounding the symptoms and signs of their presentation. Adolescents with substance use disorders often have co-occurring mental health problems predating or resulting from substance use, complicating their diagnoses and treatment. Additionally, many adolescents who use substances do not perceive their own need for treatment or acknowledge their level of functional impairment, which influences their symptom report. In this article, we use case examples to review common drug and alcohol problems present in adolescents and the challenges to diagnosis and treatment. [Psychiatr Ann. 2019;49(6):263–268.]

Substance use disorders (SUD) are a leading cause of morbidity and mortality in the United States and are becoming increasingly prevalent in the adolescent population. Nonmedicinal use of prescription medications is a concern as 5.5% of high school seniors report nonmedical use of the prescription stimulant amphetamine/dextroamphetamine mixed salts in the past year.1 Recently, vaping of nicotine and cannabis has become increasingly prevalent among youth, with 37.3% of high school students vaping in the past month.1 Additionally, opioids are a leading cause of death from unintentional drug overdose in adolescents age 15 to 19 years.2,3

Adolescence is a critical neurodevelopmental period for brain maturation that is marked by rapid and overlapping changes in a person's biological, psychological, and social life. Adolescents are at increased risk of drug use due to their marked emotional drives, which often override their ability to regulate impulsive actions, increasing their risk of initiating of drug use. Additional risk factors include peer pressure and heritability, which can be reinforced by environmental factors that place the adolescent at imminent risk for initiation, continuation, and relapse of substance use.4 Parental involvement and supervision often serve as a moderator between adverse peer influence and substance use. Attentive and authoritative parenting styles have a positive impact on preventing substance use in adolescents and can affect peer influence.5

Robust evidence shows co-occurring mental health disorders in 61% to 88% of adolescents with SUD.6 In adolescents, mental health disorders often precede substance use, and substance use often worsens the underlying psychiatric condition.7–9 Conversely, a lack of treatment of the underlying psychiatric symptoms makes it difficult for adolescents to stop using substances.10 Comorbid conditions associated with substance use in adolescents include attention-deficit/hyperactivity disorder (ADHD), conduct disorder,11–13 major depressive disorder,14 eating disorder,15 and exposure to interpersonal violence.16,17 Individual and cumulative measures for adverse life events are associated with increased odds of early substance initiation, binge drinking, tobacco use, alcohol use, and marijuana use, even after adjusting for demographics.18

Substance use in adolescence is associated with negative medical and psychosocial outcomes, including increased risk of sexually transmitted infections, vehicular fatalities, and juvenile delinquency.19 At least 20% percent of all traffic crashes of 16- to 20-year-olds involve alcohol,20 and about 28% of completed suicides in youth age 9 to 15 years can be directly or indirectly attributed to alcohol use.20 Early onset of sexual activity, more sexual partners, engaging in unsafe sex, and sexually transmitted infections are more prevalent in youth with substance use, including those in the juvenile system.21 Permanent cognitive impairment may result from binge drinking and cannabis use, affecting frontal, temporal, and cerebellar parts of the brain.22,23 Abnormalities in brain white matter quality and activation to cognitive tasks has been found in youth with as little as 1 to 2 years of drinking 20 drinks per month, especially if more than 4 to 5 drinks are consumed in one sitting.24 Binge drinkers who are female show less activation and poorer sustained attention and working memory performances when compared to their male counterparts.25 Adolescents who are regular cannabis users did poorer on performance tests of learning, visual scanning, error commission, working memory, and cognitive flexibility.26 Interventions are required at multiple stages to prevent adolescents from engaging in such detrimental activities. The National Institute of Drug Abuse emphasizes the importance of family, school, and community prevention programs to address SUDs.27 Primary care providers play an essential role in prevention, early detection via screening tools, and prompt referral to youth treatment centers.28

Illustrative Case 1

A 14-year-old boy presents to an adolescent addiction outpatient specialty clinic for his first psychiatric evaluation. He attends drug rehabilitation class twice a week and completes a drug test twice a week at a juvenile center. Due to repeated positive drug tests, his probation officer referred him to the clinic. The patient first used drugs at age 12 years when he experimented with marijuana, eventually progressing to daily use. He was also experimenting with other substances including cigarettes, alcohol, lysergic acid diethylamide (LSD), nonmedical use ofprescription opioids, cocaine, 3,4-methylenedioxymethamphetamine (MDMA), mushrooms, benzodiazepines, amphetamine and dextroamphetamine mixed salts, and promethazine with codeine cough syrup. His first encounter with the law also began at age 12 years after he was brought to the emergency department because of physical aggression on school grounds. A urine drug screen (UDS) was positive for cannabis, opiates, and benzodiazepines. He was placed on probation, ordered to attend rehabilitations, and had multiple jail sentences. As part of a routine adolescent mental health evaluation, he was screened for depression. His patient health questionnaire revealed a score of 23, indicating significant depressive symptoms. On further questioning, he admitted to experiencing depression after a break-up with his girlfriend, which led him to attempt suicide.

The patient was diagnosed with severe major depressive disorder, without psychotic features; moderate cannabis use disorder; and unspecified substance use disorder due to intermittent use of multiple substances. Due to extensive substance use on the patient's maternal side, his mother was determined to provide care for her son's mental health needs. She faithfully brings him to appointments, and he engages in treatment. The patient is prescribed fluoxetine and titrated to 30 mg daily and participates in “motivational enhancement” group therapy. His depressive symptoms resolve as well as his multiple substance use. Over the next year, he remained abstinent from drugs as evidenced by self-report and parental report and negative UDS. He is now more involved in his education, participates in prosocial hobbies, surrounds himself with positive peer relationships, and is planning on attending college.

Case 1 Discussion

This case illustrates the critical importance of conducting a full psychiatric evaluation on adolescents with early onset substance use. Adolescents may experiment with drugs but most move on to live drug-free lives. Adolescents with untreated mental health conditions often self-medicate with drugs. The case demonstrates the importance of early psychiatric treatment and the need for complementary biological-driven treatments within systems that are heavily psychosocially driven.29 The patient had several encounters with the law spanning several years before he received psychiatric care. The patient achieved substance use remission with the onset of fluoxetine within a few months, an outcome he was unable to achieve with rehabilitation alone in 2 years. Attention to the mental health of adolescents with substance use could significantly reduce the economic cost of recidivism in youth with substance use concerns. Specifically, it may be more cost effective and productive to increase funding for evidence-based policies and programs. Effectively responding to SUDs in the adolescent juvenile delinquent population may enhance adherence to probation, prevent recidivism, and improve public safety.30 Chronic juvenile offenders are more likely than other juvenile offenders have SUDs. Substance use and offending at one age is a predictor of continued offending at a later age.31 There is strong association between serious offending and substance use in youth.32

Illustrative Case 2

A 16-year-old girl presents to the adolescent addiction clinic for an evaluation. Six months prior, her pediatrician completed a HEADSS (Home, Education and employment, Activities, Drugs, Sexuality, Suicide/Depression) screening examination revealing excessive alcohol use at parties and subsequently having unprotected sex. Her pediatrician ordered a sexually transmitted infection (STI) panel and counseled the patient on substance abuse and safe sex practices. Several months later, after not showing up at follow-up appointments, she requested another STI screen and a pregnancy test because she had been working in the sex trade and had been sexually assaulted. Child Protective Services were consulted and the patient was referred to the emergency department for examination by a sexual assault nurse examiner. The patient was also referred to community addiction resources and received “wrap-around services” from the local YMCA. She began to see the school counselor regularly for supportive therapy and was referred to the child and adolescent psychiatry clinic for a psychiatric evaluation.

At her initial psychiatry appointment, she revealed adverse childhood experiences pertaining to a father who was an alcoholic and emotionally abusive to her, physically abusive to her mother, and had been incarcerated multiple times. The patient disclosed first using alcohol at age 13 years and experimenting with cocaine, benzodiazepines, and pain pills. While under the influence of alcohol and drugs, she was sexually assaulted by a group of older boys and developed posttraumatic stress disorder (PTSD) symptoms. Her drug use increased to the point of binge drinking on the weekends and using cocaine at least once a week to improve her mood and to feel better about herself. She reported having depressive symptoms for more than 2 years and disclosed a suicide attempt by overdose 1 year prior to her sexual assault. The patient was diagnosed with severe major depressive disorder, without psychotic features; PTSD; and polysubstance use. Her initial UDS was positive for cannabis, cocaine, and benzodiazepines. She completed a 90-day inpatient drug rehabilitation program and then transferred to an adolescent addiction outpatient specialty clinic.

By engaging in biweekly appointments in the addiction clinic, her qualitative and quantitative UDS remained negative. Progressively, she disclosed more PTSD symptoms of daily nightmares and flashbacks. She had a recurrence of suicidal ideation when mocked about her sexual trauma at school and she required hospitalization two times. For 6 months, she was trialed on medications including fluoxetine, mirtaza-pine, quetiapine, and aripiprazole. She responded well to sertraline (150 mg/d) and clonidine (0.2 mg/d). The patient was referred for trauma-focused cognitive-behavioral therapy. Having progressed successfully in her recovery from substance use, she now faces the lifelong journey of recovery from the trauma.

Case 2 Discussion

Adolescent girls with substance use often present with complex psychosocial situations and require services tailored to their needs. In adolescent girls who binge drink, alcohol acts as a central nervous system depressant leading to difficulty sustaining attention, poorer working memory,22 and possible engagement in high-risk sexual behavior.33 Adolescents who continue to drink may have increased rates of alcohol-related “blackout” events as they age. Some studies have shown 15-year-olds who binge drink to lose consciousness as often as 30% of the time, and this can increase to 74% in 19-year-olds who binge drink.34 The inability to recall details related to an assault may affect the victim's ability to pursue legal action against her assailants. Unprotected and unplanned sexual intercourse while under the influence of alcohol or drugs highlights the need for sexual education.33

Abstinence from drugs and alcohol for more than 6 months can be trauma-protective. Patients with alcohol or illegal drug use have a higher frequency of trauma compared to patients without alcohol or drug use even when age, gender, and previous psychiatric disorders are taken into account.35 The patient in this case no longer engaged in prostitution during her period of sobriety, and thus she did not further increase her trauma burden. Attention to trauma recidivism is a major part of her treatment, and this patient would likely benefit from trauma-focused cognitive-behavioral therapy.

Illustrative Case 3

A 15-year-old boy presents to the outpatient psychiatry clinic a week after his second psychiatric hospitalization for psychosis. In his first psychiatric hospitalization he was diagnosed with schizophrenia, started on quetiapine, then discharged to a drug rehabilitation facility. After 2 months, he convinced his mother to sign him out of the rehabilitation facility. Later, he was seen by his pediatrician for worsening depressive symptoms and his mother expressed concern for self-inflicted cuts on his forearms. This is when he was referred to the child and adolescent psychiatry department.

In the initial psychiatric evaluation, he reported a 4-year history of daily cannabis use interspersed with alprazolam, cocaine, and MDMA use in the past year. His behavioral concern started in elementary school where he struggled academically. At age 10 years, he first used marijuana that he obtained from his older brother. By middle school he developed relationships with peers who used and engaged in selling drugs. He obtained nonprescription amphetamines to improve his focus. He reported using drugs to help with his irritability and anxiety, but he was unsure if he was depressed. Drugs helped him with “being upset.” He was irritable but not sure if he felt depressed. He knew he was anxious but had a difficult time describing his anxiety symptoms because he had always been this way. Regarding his psychiatric hospitalization, he says, “I guess they thought I was schizophrenic because I was talking a lot about demons.” He denies current psychotic symptoms, and there is no evidence of delusions or paranoia.

The patient was diagnosed with depressive disorder unspecified, anxiety disorder unspecified, and polysubstance use. He was started on fluoxetine and restarted on quetiapine. Over the next month, he felt more positive, less irritable, and he began attending school more often. His grades improved and he passed a state-wide examination given to high school students. He decreased his marijuana use, his quantitative cannabis level dropped to 32 ng/mL, and he abstained from alprazolam and cocaine for 2 months.

Two months later, his mother brought him in with concerns about his rapidly shifting moods. A diagnosis of bipolar disorder unspecified was given, and the patient tried several mood stabilizers before he was eventually stabilized on lithium. The fluoxetine was discontinued, and he was transitioned to escitalopram and mirtazapine to help with sleep. Lisdexamfetamine at a dose of 20 mg daily was also started for inattention. He was eventually referred to the adolescent addiction outpatient specialty clinic due to sporadic use of cannabis, alprazolam, cocaine, and MDMA. He was given a diagnosis of moderate severity cannabis use disorder; severe major depressive disorder with psychotic features; anxiety disorder unspecified; and substance use unspecified.

After a brief period of stability, he presented to the clinic with fresh cuts on his forearms after a break-up with his girlfriend. He disclosed discontinuing his medications (except for lisdexamfetamine) and revealed that he was often noncompliant with medications, particularly when using drugs. Only quetiapine was restarted but the patient continued to skip school to use drugs with his peers. His mother transferred him to a new school, but he found new friends with whom to use drugs. The patient reported enjoying the “high” for recreational use and he used increasing amounts of cannabis, alprazolam, LSD, and methamphetamines, and also binged on alcohol.

Ongoing assessment included regular UDS, which remained positive for marijuana, and its quantitative levels increased from 32 ng/mL to 1,100 ng/mL. Intermittently, he would test positive for benzodiazepines and amphetamines, presumed to be from prescription lisdexamfetamine. Due to increased substance use, lack of adherence with medications, and decline in function, outpatient care program was deemed insufficient to meet his needs. Inpatient rehabilitation was recommended but the patient declined to attend. He did not have any legal charges up to that point, except for truancy.

Case 3 Discussion

Substance use presents with multiple mental health symptoms and when combined with complex psychosocial circumstances, this may obscure accurate diagnoses. The patient exhibited psychotic symptoms while using cannabis and was given a diagnosis of schizophrenia. While in treatment, he presented with elevated mood leading to a diagnosis of bipolar disorder, so treatment with mood stabilizers was started. Given his use of cocaine, methamphetamine, and LSD, the bipolar presentation could have been substance-induced. Nonadherence with prescribed medications while using illegal substances made his true diagnoses and symptom-response difficult to decipher. His cessation of stimulant use could have resulted in decreased elevated mood symptoms perceived to be the treatment result of mood stabilizers.

The lack of early identification in elementary school was a missed opportunity to treat his inattention. The patient had been self-medicating for symptoms of inattention, depression, and anxiety, and may have exacerbated his drug use while contrarily potentiating the same symptoms. Youth who use cannabis have 10 times the odds of exceeding the threshold for internalizing or externalizing problems.36 The treatment plan to highlight the benefits of abstinence, such as increased engagement in school, improved attention, and mood, was lacking in appeal when compared to the patient's desire to become intoxicated. Despite his mother's effort to bring him to appointments, her permissive parenting style contributed to the patient's regression.

Discussion

The identification and optimal treatment of co-occurring mental health conditions is critical in decreasing substance use in adolescents. Individual risk factors should be taken into account during the initial interview.37 Contrary to previous assumptions, ADHD often continues into adulthood (if left untreated) and increases the risk of addictive disorders.38 In people with ADHD, early onset and longer duration of stimulant treatment for ADHD are associated with a risk of substance use during adolescence that is similar to that in the general population.39,40 In effect, treatment with stimulants may not increase, and in fact might lower, the risk of subsequent SUD.

Early identification and interventions to address mental health disorders are pivotal to interrupt the initiation and progression of substance use in adolescents. Low levels of mental health service use may act as a barrier to treatment.36 Exposure to adverse childhood experiences, trauma, and psychosocial stressors can push the adolescents who are vulnerable into using substances. School-based substance use prevention programs may increase drug abstinence education and provide access to social and mental health services.41 The juvenile justice system could serve as a point of initiation of psychiatric services and facilitate entry into drug rehabilitation programs. Services for youth who have experienced maltreatment should also incorporate prevention strategies to reduce risk for substance use.42

Conclusion

Adolescent substance use is a common but modifiable health behavior that is often indicative of an underlying mental health condition. This article emphasizes the need to take a developmental approach to addressing substance use in adolescents. There is a critical need for age-targeted efforts to prevent and delay substance use and to promptly intervene. Addiction-informed education in the medical and mental health pediatric field is needed to identify and advocate for adolescents with SUDs.43 Promoting adolescent addiction outpatient specialty clinics could provide prevention, identification, and treatment of substance use and may effectively provide specialized care to this patient population.

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Authors

Edore Onigu-Otite, MD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Biren Patel, MD, is an Addiction Psychiatry Fellow, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Iqra Ansari, MD, is a Medical Officer, Children's Hospital Karachi. Kelash Rai, MD, is a Medical Officer, Ziauddin University. Sandy Lee, MD, is a Child and Adolescent Psychiatry Fellow, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Asim A. Shah, MD, is a Professor and the Executive Vice Chair, Menninger Department of Psychiatry and Behavioral Sciences; and a Professor, Department of Community and Family Medicine, Baylor College of Medicine.

Address correspondence to Edore Onigu-Otite, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS350, Houston, TX 77030; email: Edore.Onigu-Otite@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190507-03

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