Substance use among teenagers remains a pervasive and multifaceted issue, eliciting concern from healthcare professionals, educators, and parents alike. Adolescence, a period marked by rapid physiological, psychological, and social changes, is often associated with experimentation and changes in behavior and personality, including the experimental use of substances such as alcohol, tobacco, and illicit drugs. While some teens may use experimentally and then discontinue use, others may develop patterns that progress towards lifelong addiction. Also, even the experimental use of substances can be dangerous, as in the case of the recent rise in accidental fentanyl overdoses in teens. This article is part of a series that will take a deeper dive into teen substance use and potential treatment options.

Epidemiology

Approximately 2% of teenagers will develop full criteria for an Alcohol Use Disorder (tolerance, dependence, withdrawal), while approximately 4% will develop full criteria for an Illicit Drug Use Disorder. While these percentages may seem small initially, in a high school of 2000 teens, this would equate to approximately 80 teenagers whose use is so severe and so regular that it causes tolerance, dependence, and withdrawal. Rates of use without dependence, or “experimental use,” is much higher, with approximately 30% of 12^th graders reporting “any illicit drug use in the past year.” While this type of use may initially seem less dangerous, fentanyl overdoses are increasing in teens, and thus even single use or binge use can be dangerous (National Institute on Drug Abuse).

Psychological Factors

One significant contributor to adolescent substance use is the presence of psychological distress, including conditions such as trauma, depression, anxiety, and stress. Adolescents experiencing emotional turmoil may turn to substances as a coping mechanism to alleviate their symptoms. The self-medication hypothesis suggests that individuals use substances to manage negative emotional states, albeit with unintended consequences to their body (Khantzian, 2013). For instance, a study published in the Journal of Adolescent Health found a positive correlation between depressive symptoms and the use of substances such as alcohol and marijuana among teenagers (Hussong et al., 2017). The tendency to self-medicate can lead to a cycle of dependence, exacerbating the initial psychological issues, and adding additional traumas, negative life events, and decreased self-esteem along the way.

Social and Environmental Influences

The social environment plays a crucial role in shaping adolescent behavior, including substance use. Peer pressure or fear of missing out is often cited as a primary driver, where adolescents may engage in substance use to gain social acceptance or avoid ostracism (Piko & Kovács, 2010). Teens may use on social media as a way of projecting an image online. Additionally, familial factors, such as parental substance use and lack of supervision, significantly impact teenagers’ propensity to experiment with substances. Adolescents who perceive low parental monitoring or who have parents that use substances are more likely to engage in similar behaviors (Ryan et al., 2010).

Moreover, the socio-economic environment can influence substance use. Adolescents from disadvantaged and underserved backgrounds may face increased exposure to environments with intergenerational trauma and other barriers, increasing the use of substances (Patrick et al., 2020). In so called “food deserts,” it can be easier to find alcohol, tobacco, cannabis, and drugs than it can be to find fresh fruits and vegetables. Conversely, teenagers from families with greater means might still use substances as a means of coping with academic and social pressures, or from a feeling of disconnect with others when their parents and siblings may be unavailable due to family and career obligations. For example, “a sense of emptiness” has anecdotally been cited as a reason for use, and thus, teenagers feeling a genuine sense of meaning, a positive connection to their family and community, social and cultural supports, spiritual supports, and therefore a strong sense of identity may be at far lower risk for the development of a substance use disorder.

Neurobiological Factors

Adolescence is a critical period for brain development, particularly in regions associated with decision-making, impulse control, and reward processing. The underdeveloped prefrontal cortex, responsible for executive functions, coupled with a highly responsive reward system, renders adolescents more susceptible to risky behaviors, including substance use (Casey et al., 2008). To use a driving metaphor, a highly responsive reward system “pushes the gas pedal” while an underdeveloped prefrontal cortex “lets the foot off the brakes.” The heightened sensitivity to rewards can amplify the perceived benefits of substance use, overshadowing the potential long-term consequences. This neurobiological framework helps explain the propensity for experimentation and the difficulty in abstaining from substance use once initiated. Moreover, the neurotransmitters (dopamine, serotonin, norepinephrine, cannabinoids, opioids, etc.) that are released produce a highly euphoric effect; however, each subsequent use provides a smaller effect, rendering the use “chasing the high” they first felt but never able to achieve it. Meanwhile, their resting state neurotransmitters have been depleted, resulting in irritability and withdrawal.

Genetic Predisposition

Genetic factors also play a significant role in the likelihood of substance use among teenagers. Studies have identified specific genetic variations that can increase susceptibility to substance dependence. For example, variations in genes encoding dopamine receptors and transporters have been linked to increased risk of addiction (Ducci & Goldman, 2008). Adolescents with a family history of substance use disorders are at higher risk, indicating a hereditary component (up to 40-70% heritable). The interplay between genetic predisposition and environmental triggers creates a complex landscape where both nature and nurture contribute to substance use behaviors, and this explains why some teens use briefly and experimentally while others develop potentially lifelong substance use disorders.

Media and Cultural Influences

The portrayal of substance use in media and popular culture can significantly influence adolescent attitudes and behaviors. Glamorization of alcohol, tobacco, and drugs in movies, television shows, and social media can create a perception of substance use as socially desirable and relatively harmless (Strasburger et al., 2010). Adolescents are particularly vulnerable to media influence, given their developmental stage and the importance they place on social identity and acceptance. Exposure to substance use in media can normalize these behaviors and reduce the perceived risks associated with them.

Preventive Measures and Interventions

Addressing substance use among teenagers requires a multifaceted approach, incorporating preventive measures and targeted interventions. Educational programs that focus on enhancing awareness of the risks associated with substance use, promoting healthy coping mechanisms, and building resilience can be effective. Family-based interventions that foster open communication, improve parental monitoring, and address familial substance use are crucial in mitigating risk factors (Kumpfer et al., 2010).

Moreover, community-based initiatives that provide safe recreational activities and support networks for adolescents can reduce the allure of substance use. Alternative peer groups who are sober are an absolute must for teens to achieve sobriety or even harm reduction, as is the necessity for a home environment without substances present. This requires a culturally-sensitive, inter-generation, and family-centered approach that prioritizes empathy and compassion rather than shame, judgment, and stigma. Healthcare professionals play a vital role in early identification and intervention, employing screening tools and providing counseling and resources to at-risk youth.

Conclusion

Substance use among teenagers is a complex phenomenon influenced by a convergence of psychological, social, neurobiological, genetic, and cultural factors. Understanding these underlying causes is essential for developing effective prevention and intervention strategies. By adopting a holistic approach that addresses the multifaceted nature of adolescent substance use, healthcare providers, educators, and families can work together to mitigate this pervasive issue and promote healthier developmental trajectories for adolescents.

References

1. Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124(1), 111-126.
2. Ducci, F., & Goldman, D. (2008). Genetic approaches to addiction: genes and alcohol. Addiction, 103(9), 1414-1428.
3. Hussong, A. M., Ennett, S. T., Cox, M. J., & Haroon, M. (2017). A systematic review of the link between stress, substance use, and adolescent development. Journal of Adolescent Health, 61(3), 288-294.
4. Patrick, M. E., Schulenberg, J. E., Martz, M. E., Maggs, J. L., O’Malley, P. M., & Johnston, L. D. (2020). Socio-economic status and substance use among US adolescents: Findings from a nationally representative sample. Addiction, 115(8), 1467-1477.
5. Strasburger, V. C., Jordan, A. B., & Donnerstein, E. (2010). Health effects of media on children and adolescents. Pediatrics, 125(4), 756-767.

AUTHOR:

Shawn Singh Sidhu, M.D., DFAPA, DFAACAP

​Medical Co-Director, Vista Hill Foundation

CBD oil or cannabidiol oil is one of 113 active compounds found in cannabis. It accounts for up to 40% of the plant’s extract, depending on which strain is being grown.

The reason there is interest in potential medical properties of this compound is that it appears to not have the psychoactive (or “high”) effects such as those caused by tetrahydrocannabinol (THC). There is thought that CBD oil might have a down regulating effect on disordered thinking and anxiety and even might be neuroprotective. This is very different than THC’s effects on the brain – long-term use has been shown to have detrimental effects on IQ and executive function.

It is currently being studied for treatment for addiction, chronic inflammatory and neuropathic pain syndromes, and epilepsy. Currently, most of these studies are small and involve animal subjects.

People using CBD oil can experience side effects, such as somnolence, diarrhea, vomiting, fatigue, and abnormal liver function. There are also possible drug interactions to be aware of, like an interaction with valproate. There is evidence that CBD can reduce THC clearance, which can increase the THC effects in a dose-dependent manner. It is important to help patients considering using these products to be aware that even “natural supplements” can have adverse effects and drug interactions. Many people are not aware of this and assume if something is “natural” that it cannot have side effects on interact with their other prescribed medications.

Recreational marijuana typically has a lower relative concentration of CBD and higher relative concentration of THC because users prefer cannabis strains that are more mind-altering. Medical marijuana standards are not very strict, but in general require lower relative THC concentration and higher relative CBD concentration. Still it will be important to distinguish between medical marijuana (which would still have THC and therefore can have psychoactive properties and have negative effects on brain function) and medical CBD oil. Any part of a cannabis plant that has a THC concentration of 0.3% or less is referred to as industrial hemp. Typically CBD extract is made from industrial hemp and therefore has a very low THC concentration.

Another challenge is that CBD products are not regulated by the FDA or any authorizing agency. Many companies are adding CBD oil to food items and claiming neuroprotective features for those products. There is no standardization on the amount of CBD in a product or the bioavailability of the active ingredient. The only limitation for referring to a product as CBD is that there is a restriction on the amount of THC in the product.

The take home messages are that there is still a lot to be learned about the role that CBD could play in medicine. More research is being conducted now that marijuana has been legalized in many states and there is more and more public pressure to understand the possible medical benefits of cannabis. It is important for primary care providers to maintain the vow to first “do no harm” by strongly recommending against using cannabis that is high in THC, recommending avoiding cannabis use in general until adulthood, and avoiding daily use.

There has been a clear and steady increase in the number of adults reporting use of cannabis since 2000. Interestingly and fortunately, there is not an increase in the number of teens using cannabis, nor are there findings of teens starting to use at younger ages, but teens who are using are using more frequently than in the past and the potency of current supplies are greater than in the past, raising significant risk concerns.

Following are suggested harm reduction recommendations that seem appropriate to use with patients of any age to minimize potential negative consequences of cannabis use.

1. Using it less frequently and avoiding daily use
2. Delaying starting it until adulthood
3. Using safer sources and routes
4. Avoiding driving or being driven by someone under the influence

Although research findings are still somewhat limited, several studies have looked into the negative effects of cannabis use in adolescence which include: increased risk of psychosis, increased risk of substance dependence, and reduction of cognitive skills. Regular cannabis use can increase the risk of subclinical psychotic symptoms, and these symptoms can persist even after a long period of abstinence. Additionally, for patients with schizophrenia, using cannabis can move up the onset of schizophrenia up to 3 years earlier than for patients who do not use cannabis. Regular and heavy cannabis use in adolescence can lead to a permanent loss of IQ points, something that is not seen with cannabis use that starts in adulthood. Regular cannabis use in teens has been shown to impair learning, problem-solving skills and short-term and long-term memory. Studies also suggest downward socioeconomic mobility in people who started to use cannabis at a young age. The take home message is that if a teenager is using or at risk of using cannabis, they should be encouraged ideally to wait until adulthood or, absent abstinence, to avoid using it routinely because of these risks.

It is important for all patients, regardless of their age, to be aware of the sources of cannabis they are using and the route they are ingesting it by. It is particularly important for them to avoid products that are very high in THC (trans-Δ9-tetrahydrocannabino) and to avoid concentrates, which can be made in unsafe environments, and especially synthetic cannabinoids, which can be very potent and can have significant negative psychological impacts. Edibles and vaporized cannabis can be safer routes, because they do not irritate the respiratory system, but again, psychological impacts remain an obvious concern as dosing may be higher than anticipated, especially for new users.

It is recommended that providers discuss these issues in a fact oriented and non-judgmental manner just as one might inquire about alcohol or other substance use/abuse.  In the face of the changes in social attitudes and the change toward the legality of using cannabis for those over the age of 21, establishing and maintaining an active dialogue with all patients about substance use issues is recommended as part of routine care.

Patients acknowledging problems with dependence or misuse of cannabis should be referred for treatment to a mental health provider or a cannabis specific treatment program.

The San Diego Access and Crisis Line can offer options for your patients seeking treatment.  1-888-724-7240

References:

http://www.psychcongress.com/article/managing-cannabis-use-and-its-potential-risks