Attention-Deficit/Hyperactivity Disorder (ADHD)

Caffeine has stimulant-like properties that may improve attention and executive functioning in individuals with ADHD. A study in rodent models showed that caffeine improved memory and attention through enhanced dopaminergic signaling in the prefrontal cortex, paralleling the effects of prescription stimulants (Pandolfo et al., 2013). Human trials are limited, but a double-blind study in children with ADHD found that caffeine modestly improved behavior and attention, although not as effectively as methylphenidate (Lara et al., 2010). Nevertheless, caffeine may disrupt sleep—a significant concern for individuals with ADHD, as sleep impairment exacerbates core symptoms.

Depression

Caffeine’s psychostimulant properties and dopaminergic activation suggest potential antidepressant effects. A large prospective cohort study found that women who consumed ≥4 cups of caffeinated coffee daily had a 20% reduced risk of depression compared to those consuming little or none (Lucas et al., 2011). This protective effect is attributed to caffeine’s anti-inflammatory properties and its modulation of brain-derived neurotrophic factor (BDNF) (Kaster et al., 2015). However, excessive use may mask depressive symptoms or contribute to mood instability, especially when withdrawal effects are misinterpreted as depressive episodes.

Anxiety Disorders

Caffeine is a known anxiogenic agent, particularly in susceptible individuals. At high doses (e.g., >400 mg/day), caffeine can induce symptoms consistent with generalized anxiety or panic disorder, including restlessness, insomnia, palpitations, and irritability (Boulenger et al., 1984). A randomized trial demonstrated that patients with panic disorder were significantly more sensitive to caffeine’s stimulatory effects, exhibiting heightened cardiovascular and subjective anxiety responses (Charney et al., 1985). Clinical guidelines generally recommend limiting or avoiding caffeine in individuals with anxiety disorders.

Bipolar Disorder

Caffeine’s effects on mood stability in bipolar disorder are complex. While it may transiently alleviate depressive symptoms, its stimulant properties can disrupt sleep and potentially trigger manic or hypomanic episodes. Disrupted circadian rhythms are central to bipolar pathophysiology, and caffeine—especially when consumed late in the day—can exacerbate this vulnerability (Wehr et al., 1987). A study by Leibenluft and colleagues found that individuals with bipolar disorder frequently use caffeine during depressive phases but reported increased agitation during manic episodes (Leibenluft et al., 1996). Clinical prudence suggests moderating caffeine intake, especially during manic or mixed states.

Psychosis and Schizophrenia

Individuals with schizophrenia often consume caffeine at rates exceeding those of the general population. This may reflect attempts to counteract sedation from antipsychotic medications or cognitive dulling (Gurpegui et al., 2004). However, caffeine’s dopaminergic effects pose theoretical risks of exacerbating psychotic symptoms. Lucas et al. (1990) found that high caffeine intake was associated with increased positive symptoms, particularly in patients taking clozapine. Furthermore, caffeine is metabolized by cytochrome P450 1A2, the same enzyme responsible for metabolizing several antipsychotics, including olanzapine and clozapine, potentially leading to drug interactions (Carrillo et al., 2000).

Substance Use Disorders

Caffeine interacts with reward pathways implicated in substance use. While moderate caffeine use may not pose harm, energy drink consumption (often containing high caffeine doses) has been associated with increased risk of alcohol and stimulant misuse among adolescents and young adults (Arria et al., 2011). Caffeine also carries its own dependence potential, with recognized withdrawal symptoms such as headache, fatigue, and irritability (Juliano & Griffiths, 2004). Screening for problematic use patterns is warranted, particularly in individuals with comorbid SUDs.

Conclusion

Caffeine is a psychoactive substance with condition-specific effects on mental health. While it may offer mild symptomatic relief in ADHD and depression, it can also exacerbate symptoms in anxiety, bipolar disorder, and psychosis, or complicate treatment in substance use disorders. Mental health and primary care providers should assess individual caffeine consumption patterns, explore patient motivations for use, and provide tailored guidance based on psychiatric diagnosis, comorbidities, and medication interactions.

References

1. Vázquez JC, et al. Effects of Caffeine Consumption on Attention Deficit Hyperactivity Disorder (ADHD) Treatment: A Systematic Review of Animal Studies. Nutrients. 2022;14(4):739. https://doi.org/10.3390/nu14040739News-Medical
2. Grosso G, et al. Coffee, tea, caffeine and risk of depression: A systematic review and dose-response meta-analysis of observational studies. Mol Nutr Food Res. 2016;60(1):223-234. https://doi.org/10.1002/mnfr.201500620
3. Lara DR. Caffeine, mental health, and psychiatric disorders. J Alzheimers Dis. 2010;20 Suppl 1:S239-48. doi: 10.3233/JAD-2010-1378. PMID: 20164571. https://journals.sagepub.com/doi/abs/10.3233/JAD-2010-1378
4. Juliano LM, Griffiths RR. A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features. Psychopharmacology (Berl). 2004;176(1):1-29. https://doi.org/10.1007/s00213-004-2000-x
5. Charney DS, Heninger GR, Jatlow PI. Increased anxiogenic effects of caffeine in panic disorders. Arch Gen Psychiatry. 1985 Mar;42(3):233-43. doi: 10.1001/archpsyc.1985.01790260027003. PMID: 2983630. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/493529
6. Lucas PB, Pickar D, Kelsoe J, Rapaport M, Pato C, Hommer D. Effects of the acute administration of caffeine in patients with schizophrenia. Biol Psychiatry. 1990 Jul 1;28(1):35-40. doi: 10.1016/0006-3223(90)90429-6. PMID: 2375945. https://linkinghub.elsevier.com/retrieve/pii/0006322390904296
7. Carrillo JA, Benitez J. Clinically significant pharmacokinetic interactions between dietary caffeine and medications. Clin Pharmacokinet. 2000 Aug;39(2):127-53. doi: 10.2165/00003088-200039020-00004. PMID: 10976659. Gurpegui M, et al. Caffeine consumption in schizophrenia: associations with clinical and sociodemographic features. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28(5):945-951. https://link.springer.com/article/10.2165/00003088-200039020-00004
8. Meredith SE, et al. Caffeine Use Disorder: A Comprehensive Review and Research Agenda. J Caffeine Res. 2013;3(3):114-130. https://doi.org/10.1089/jcr.2013.0016
9. Fredholm BB, et al. Actions of caffeine in the brain with special reference to factors that contribute to its widespread use. Pharmacol Rev. 1999;51(1):83-133. https://pubmed.ncbi.nlm.nih.gov/10049999/

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Vista Hill Native American SmartCare Program

The Stages of Change Model

The Stages of Change model comprises five primary stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. A sixth stage, Termination, is often included but is less applicable to adolescent substance use due to the chronic nature of substance use disorders. The fluidity of these stages, with possible progression and regression, underscores the importance of continuous assessment and individualized intervention strategies.

1. Precontemplation: Adolescents in this stage are not considering change, either due to denial of the problem, lack of awareness, or perceived invulnerability. This stage is particularly challenging as adolescents may not perceive their substance use as problematic, or they may resist change due to peer influence and a desire for autonomy.
2. Contemplation: At this stage, adolescents acknowledge the potential risks associated with their substance use but are ambivalent about change. They may weigh the pros and cons of their behavior, often resulting in prolonged deliberation. This stage is critical for clinicians to build rapport and enhance motivation through motivational interviewing, a technique that helps resolve ambivalence by eliciting the adolescent’s own reasons for change.
3. Preparation: Adolescents in the preparation stage have made the decision to change and are planning to take action in the near future. At this point, specific goals and strategies for change should be developed collaboratively between the clinician and the adolescent. Interventions might include the development of coping strategies, addressing environmental triggers, and fostering supportive relationships that encourage sobriety.
4. Action: This stage involves the implementation of change, where the adolescent actively alters their behavior and environment to reduce or eliminate substance use. Clinicians play a crucial role in supporting adolescents during this stage by providing ongoing reinforcement, addressing challenges and setbacks, and ensuring that the strategies devised in the preparation stage are effectively employed.
5. Maintenance: In the maintenance stage, the focus shifts to sustaining the changes made during the action stage and preventing relapse. Adolescents are at risk of relapse due to the persistent nature of cravings, social pressures, and emotional triggers. Long-term success in this stage often requires continued counseling, participation in support groups, and ongoing monitoring by healthcare providers.

Clinical Application

Effective utilization of the Stages of Change model in adolescent substance use requires a thorough assessment of the adolescent’s current stage, followed by the implementation of stage-appropriate interventions. Physicians and counselors must be adept at identifying the subtle indicators of each stage and tailoring their approach to match the adolescent’s readiness to change.

1. Assessment and Rapport Building: Initial assessment should focus on understanding the adolescent’s perception of their substance use, their readiness to change, and any co-occurring mental health issues. Building rapport is essential, as adolescents are more likely to engage in treatment when they feel understood and respected. Tools such as the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) can be used to gauge the adolescent’s stage of change.
2. Motivational Interviewing: Motivational interviewing is particularly effective in the precontemplation and contemplation stages. This client-centered, directive method facilitates the exploration of ambivalence and strengthens the adolescent’s intrinsic motivation for change. Key techniques include expressing empathy, developing discrepancy between the adolescent’s goals and their current behavior, rolling with resistance, and supporting self-efficacy.
3. Tailored Interventions: Interventions should be stage-specific. For example, adolescents in the precontemplation stage may benefit from psychoeducation and discussions about the consequences of substance use, while those in the preparation stage might require help with developing actionable plans and identifying triggers. In the action stage, clinicians should focus on skill-building and problem-solving to navigate real-world challenges.
4. Relapse Prevention: Maintenance strategies should incorporate relapse prevention techniques, such as cognitive-behavioral therapy (CBT), which helps adolescents identify and challenge cognitive distortions that could lead to relapse. The use of contingency management, where positive behaviors are reinforced through rewards, has also shown efficacy in maintaining long-term sobriety.

Conclusion

The Stages of Change model offers a comprehensive framework that enables clinicians to deliver personalized care in the treatment of adolescent substance use. By aligning interventions with the adolescent’s stage of change, physicians and counselors can more effectively support the adolescent’s journey toward recovery. Continued research and training in the application of this model are essential to improving outcomes in this vulnerable population.

References

1. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
2. DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3-24). Springer US.
3. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.
4. Moyer, V. A., & US Preventive Services Task Force. (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 159(3), 210-218.
5. Wagner, E. F., & Ingersoll, K. S. (2013). Beyond cognitions: Broadening the treatment of adolescent alcohol and drug use. In E. F. Wagner & H. B. Waldron (Eds.), Innovations in adolescent substance abuse interventions (pp. 171-188). Elsevier.
6. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334.
7. Liddle, H. A., & Dakof, G. A. (1995). Efficacy of family therapy for drug abuse: Promising but not definitive. Journal of Marital and Family Therapy, 21(4), 511-543.
8. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33(3), 511-525.
9. Kaminer, Y., & Godley, S. H. (2010). Adolescent substance use disorders: Developmental considerations. In Y. Kaminer & K. C. Winters (Eds.), Clinical manual of adolescent substance abuse treatment (pp. 1-24). American Psychiatric Publishing.
10. Connors, G. J., Donovan, D. M., & DiClemente, C. C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. Guilford Press.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Theoretical Framework and Application of MI in Adolescence

Motivational interviewing was developed by Miller and Rollnick in the early 1980s as an approach to address ambivalence in clients with alcohol use disorders. Rooted in humanistic psychology, particularly the work of Carl Rogers, MI emphasizes empathy, respect for autonomy, and the therapeutic alliance. MI operates on the premise that behavior change is more likely when individuals feel they are in control of their decisions and are supported in exploring their reasons for change. This approach aligns well with the developmental stage of adolescence, characterized by an increased desire for autonomy and identity exploration.

Adolescents often present with ambivalence about changing their substance use behaviors. On one hand, they may recognize the negative consequences associated with their use, while on the other, they may view substance use as a means to achieve social acceptance or cope with stress. MI is particularly suited to addressing this ambivalence, as it provides a non-confrontational space for adolescents to express their thoughts and feelings, ultimately helping them to articulate and strengthen their motivation for change.

Efficacy of MI in Treating Adolescent Substance Use

The efficacy of MI in treating adolescent substance use has been supported by a growing body of research. Meta-analyses have demonstrated that MI is associated with small to moderate reductions in substance use among adolescents, with some studies indicating that MI may be particularly effective when used in combination with other therapeutic approaches, such as cognitive-behavioral therapy (CBT) (Barnett et al., 2012; Jensen et al., 2011). The adaptability of MI across diverse settings, including primary care, schools, and juvenile justice facilities, further underscores its utility in addressing adolescent substance use (Hettema et al., 2005).

One of the strengths of MI lies in its ability to engage adolescents who may be resistant or avoidant to treatment. Traditional approaches that emphasize confrontation and directive advice are often met with resistance, particularly among adolescents who may perceive such tactics as threats to their autonomy. In contrast, MI’s emphasis on collaboration and respect for the adolescent’s perspective fosters a sense of empowerment, making it more likely that the adolescent will engage in the treatment process (D’Amico et al., 2015).

Mechanisms of Change in MI

The mechanisms through which MI effects change in adolescent substance use are multifaceted. Central to MI is the concept of change talk, or the client’s verbal expressions that favor movement toward change. Research has shown that the frequency and strength of change talk during MI sessions are predictive of subsequent behavior change (Moyers et al., 2007). By eliciting and reinforcing change talk, clinicians can help adolescents build a stronger commitment to change.

In addition to change talk, the therapeutic alliance in MI is another key mechanism of change. The quality of the relationship between the adolescent and the clinician has been consistently linked to positive outcomes in substance use treatment (Karno & Longabaugh, 2005). MI’s focus on empathy, active listening, and unconditional positive regard contributes to the development of a strong therapeutic alliance, which in turn enhances the likelihood of successful outcomes.

Implementation and Integration into Practice

For physicians and counselors working with adolescents, the integration of MI into clinical practice requires both skill development and ongoing supervision. Training in MI typically involves workshops, role-playing, and feedback, with an emphasis on developing proficiency in MI techniques, such as reflective listening, summarizing, and eliciting change talk (Miller & Rollnick, 2013). Additionally, ongoing supervision and fidelity monitoring are essential to ensure that MI is being delivered as intended and to maintain clinician competency over time.

Physicians, in particular, may find MI to be a valuable tool in brief interventions during routine clinical encounters. Given the limited time available in most medical settings, MI’s brevity and focus on specific behavior change goals make it an efficient approach for addressing substance use. Moreover, the incorporation of MI into primary care settings has been shown to enhance patient engagement and improve outcomes in adolescent substance use (D’Amico et al., 2015).

Challenges and Considerations

Despite its demonstrated efficacy, the implementation of MI in adolescent substance use treatment is not without challenges. One significant barrier is the variability in clinicians’ adherence to MI principles, which can impact treatment outcomes. Additionally, the effectiveness of MI may be influenced by the adolescent’s readiness to change, with those at higher stages of readiness potentially deriving greater benefit from MI (Prochaska & DiClemente, 1983). Furthermore, while MI has been shown to be effective across diverse populations, cultural factors should be considered when applying MI in different contexts, as cultural values and norms can influence the adolescent’s perceptions of substance use and change.

Conclusion

Motivational interviewing represents a promising approach to addressing substance use among adolescents. Its emphasis on autonomy, empathy, and the therapeutic alliance makes it particularly well-suited to the developmental needs of adolescents, who may be ambivalent about change. While challenges exist in its implementation, MI’s adaptability and evidence base make it a valuable tool for physicians and counselors working to reduce substance use in this vulnerable population. Continued research and training efforts are essential to maximize the potential of MI in adolescent substance use treatment.

References

1. Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational interviewing for adolescent substance use: A review of the literature. Addiction Research & Theory, 20(4), 329-342.
2. D’Amico, E. J., Miles, J. N. V., Stern, S. A., & Meredith, L. S. (2015). Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment, 50, 46-53.
3. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.
4. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. Journal of Consulting and Clinical Psychology, 79(4), 433-440.
5. Karno, M. P., & Longabaugh, R. (2005). What do we know? Process analysis and the search for a better understanding of Project MATCH’s anger-by-treatment matching effect. Journal of Studies on Alcohol, 66(5), 644-652.
6. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
7. Moyers, T. B., Martin, T., Houck, J. M., Christopher, P. J., & Tonigan, J. S. (2007). Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment, 32(2), 197-206.
8. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
9. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23(4), 325-334.
10. Wagner, E. F., & Ingersoll, K. S. (Eds.). (2012). Motivational interviewing in the treatment of psychological problems. Guilford Press.

AUTHOR:

Shawn Singh Sidhu, MD, DFAPA, DFAACAP

Co-Medical Director, Vista Hill Foundation

Vista Hill Native American SmartCare Program

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

• Impulsiveness: This trait goes hand-in-hand with ADHD.
• Anxiety sensitivity: Linked to panic disorder, anxiety sensitivity can be seen in individuals who are hyper-vigilant and scared of physical signs of anxiety.
• Hopelessness: When a person feels hopeless, they are often depressed. Depression is a very common trait and precursor to addiction.
• Sensation-seeking: Though not linked to mental health issues, people who enjoy thrills and intense experiences, will also generally like drugs and alcohol.

The opioid epidemic is occurring because of multiple factors: deaths related to overdose, lost employment, effects on families and relationships and the cost for treatment. There are multiple risks for long-term opioid misuse. Mortality from all causes is 10x greater than the general population. There is an increased risk in suicide and violence, as well as 3x greater risk of dying from a car accident. There is a known increased risk in engaging in crime to pay for the substance that is being misused. If a person advances to IV drug use, there is a risk of infection including hepatitis, HIV and endocarditis.

Prior to the 1980s opioids were rarely prescribed. Pain was looked at differently. People used to look at pain with the mantra “What doesn’t kill you makes you stronger”. That view of pain has changed over time and there is more of a drive to stop pain and help the body avoid pain with external means. Also because of concern about addiction, providers were uncomfortable with prescribing opioid medications for patients. In recent years, that view has shifted in large part to pharmaceutical companies providing misinformation about newer pain medications. Some of the myths include that these medications are effective for chronic pain; that no dose is too high, meaning that tolerance is not something to worry about; and that very few patients with chronic pain actually develop an addiction because they are using the medication “correctly”. In reality, after one month of use of opioid pain medications, tolerance develops which increases the risk for addiction. Also addiction can develop even if a patient is taking the medication for an actual pain disorder.

The opioid epidemic is seen by many as a symptom of a faltering health care system. Opioids are prescribed across medical specialties. Most people who are addicted to opioids access their opioids directly or indirectly from providers, not off the street. Studies have shown that people of low socioeconomic status are accessing opioid prescriptions as a “treatment” for non-medical, financial and social problems. So how did we get here?

Providers generally have a fast-paced schedule and it can become challenging to find time to have difficult conversations with patients. The current health care reimbursement system weighs heavily in favor of providers doing procedures and prescribing medications. Additionally, the practice of medicine has moved away from the doctor-patient relationship and has become more based on customer service with a focus on patients liking providers versus trusting them.

The question of where do we go from here involves a longer conversation, but there are some practical steps to start with. It starts with limiting access to opioids to situations when it is appropriate (not effective for certain pain syndromes like fibromyalgia and not needed in every post-operative situation). It is important to prescribe the smallest dose for the shortest length of time (ideally 1 month or less) with careful psycho-education about the use and risks of opioid medications. There is a need for incentives for providers to not prescribe. There is a need for time and training on motivational interviewing for providers to help patients with an addiction become interested in sobriety. There is a need for de-prescribing clinics and providers who understand the need for slow taper off long-term opioid medication use. Ideally, co-location of rehabilitation services and mental health services allows for co-treatment. And there is a need for a chronic care model which brings back the primacy of the doctor-patient relationship as important to healing.

Part 2 of this series will be discussing some of these in more detail.

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.

The opioid epidemic has become a national emergency because of multiple factors: deaths related to overdose, lost employment, harm to families and relationships, and the cost for treatment. The US now consumes 80% of the world’s opioids.

Prior to the 1980s opioids were rarely prescribed. Pain was looked at differently. People used to look at pain with the mantra “What doesn’t kill you, makes you stronger”. That view has changed over time and there is now more of a drive to stop pain by external means. Previously, because of concerns about addiction, providers were uncomfortable with prescribing opioid medications. That view shifted in large part due to misinformation about newer pain medications, including (1) that these medications are effective for chronic pain; (2) that no dose is too high; and (3) that very few patients with chronic pain actually develop an addiction. In reality, after one month of use of opioid pain medications, tolerance develops which increases the risk for addiction even when a patient is taking the medication for an actual pain disorder.

The opioid epidemic is seen by many as a symptom of a faltering health care system. Opioids are prescribed across medical specialties and most people who get addicted first access these medications directly or indirectly from providers, not off the street. So how did we get here?

Providers generally have a fast-paced schedule and are challenged to find time to have difficult conversations with patients. The current health care reimbursement system weighs heavily in favor of providers doing procedures and prescribing medications. As a result, the practice of medicine has moved away from the doctor-patient relationship and has become more based on customer service with a focus on patients liking providers versus trusting them.

The question of where do we, as prescribers, go from here involves a longer conversation, but there are some practical steps to start with. It starts with limiting access to opioids to situations when it is appropriate (they are not effective for pain syndromes like fibromyalgia and not needed in every post-operative situation). It is important to prescribe the smallest dose for the shortest length of time (ideally 1 month or less) with careful psycho-education about the use and risks of opioid medications. There is a need for time and training on motivational interviewing for providers to help patients with addiction become invested in sobriety.

There is a need for de-prescribing clinics and providers who understand the need for slow taper off long-term opioid medication use. Co-location of rehabilitation, mental health and general healthcare services would allow for better coordination and team based treatment. Ultimately, there is a need for a chronic care model which brings back the primacy of the doctor-patient relationship as important to healing.