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Old 10-13-2011
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Poison Substance Abuse

A healthy 16-year-old adolescent male arrives at your office with his parents, who are concerned about his several months' history of erratic behavior. At times he has a great deal more energy, decreased appetite, and less sleep requirement than usual; at other times he sleeps incessantly and is lethargic. He is doing poorly in school. Last evening he appeared flushed and agitated, he had dilated pupils, and he complained "people were out to get him." The family notes that he has been skipping school occasionally, and they reluctantly report that he was arrested for burglary 2 weeks previously. You know he is in good health and he previously has been an excellent student. Today he appears normal.

What is the most likely diagnosis?
What is the next step in the evaluation?
What is the long-term evaluation and therapy?

Substance abuse: Alcohol or other drug use leading to impairment or distress, causing failure of school or work obligations, physical harm, substance-related legal problems, or continued use despite social or interpersonal consequences resulting from the drug's effects.

Substance dependence: Alcohol and other drug use, causing loss of control with continued use (tolerance requiring higher doses or withdrawal when terminated), compulsion to obtain and use the drug, and continued use despite persistent or recurrent negative consequences.

Clinical Approach
Experimentation with alcohol and other drugs is common among adolescents; some consider this experimentation "normal." Others argue it is to be avoided because substance abuse is often a cause of adolescent morbidity and mortality (homicide, suicide, and unintentional injuries). In all cases, a health-care provider is responsible for discussing facts about alcohol and drugs in an attempt to reduce the adolescent's risk of harm and for identifying those requiring intervention.

Children at risk for drug use include those with significant behavior problems, learning difficulties, and impaired family functioning. Cigarettes and alcohol are the most commonly used drugs; marijuana is the most commonly used illicit drug. Some adolescents abuse common household products (inhalation of glue or aerosols); others abuse a sibling's medications (methylphenidate, which is often snorted with cocaine).

Pediatricians can ask about alcohol or drug use during the adolescent's annual health examination or when an adolescent presents with evidence of substance abuse. Direct questions can identify drug or alcohol use and their effect on school performance, family relations, and peer interactions. Should problems be identified, an interview to determine the degree of drug use (experimentation, abuse, or dependency) is warranted.

Historical clues to drug abuse include significant behavioral changes at home, a decline in school or work performance, or involvement with the law. An increased incidence of intentional or accidental injuries may be alcohol or drug related. Risk-taking activities (trading sex for drugs, driving while impaired) can be particularly serious and may suggest serious drug problems. Alcohol or other drugs users usually have a normal examination, especially if the use was not recent. Needle marks and nasal mucosal injuries are rarely found.

An adolescent with recent alcohol or drug use can present with a variety of findings (Table 11). A urine drug screen (UDS) can be helpful to evaluate the adolescent who (1) presents with psychiatric symptoms, (2) has signs and symptoms commonly attributed to drugs or alcohol, (3) is in a serious accident, or (4) is part of a recovery monitoring program. An attempt to obtain the adolescent's permission and maintain confidentiality is paramount.

Table 11 Clinical Features of Substance Abuse

Treatment of life-threatening acute problems related to alcohol or drug use follows the ABCs of emergency care: manage the Airway, control Breathing, and assess the Circulation. Treatment then is directed at the offending agent (if known). After stabilization, a treatment plan is devised. For some, inpatient programs that disrupt drug use allow for continued outpatient therapy. For others, an intensive outpatient therapy program can be initiated to help develop a drug-free lifestyle. The expertise necessary to assist an adolescent through these changes is often beyond a general pediatrician's expertise. Assistance with this chronic problem by qualified health professionals in a developmentally appropriate setting can maximize outcome. Primary care providers can, however, assist families to find suitable community resources.

Cigarettes and alcohol are the most commonly used drugs in adolescence.
Marijuana is the most common illicit drug used in adolescence.
Substance abuse behaviors include drug dealing, prostitution, burglary, unprotected sex, automobile accidents, and physical violence.
Children at risk for drug use include those with significant behavior problems, learning difficulties, and impaired family functioning.
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