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Pediatric Substance Abuse

By Santa J. Bartholomew M.D. FAAP, FCCM

See Corresponding Case Study: Pediatric Substance Abuse

The recreational use of drugs, including alcohol, is an underrecognized cause of mortality and morbidity in children and adolescents. It is, in fact, a public health priority. Although annual surveys of drug use by children and adolescents may show fluctuation, the underlying rates remain high.  Numerous adverse consequences accompany use, not the least of which is the increased risk of dependence among those who began smoking, drinking, and using drugs before 18 years of age. 

Alcohol is the substance most frequently abused by children and adolescents in the United States. Its use is associated with the leading causes of death and serious injury at this age (ie, motor vehicle accidents, homicides, and suicides). Among youth who drink, the proportion who drink heavily is higher than among adult drinkers, increasing from approximately 50% in those 12 to 14 years of age to 72% among those 18 to 20 years of age.

Pediatric Substance Abuse

Among youth who drink, the proportion who drink heavily is higher than among adult drinkers increasing from approximately 50% in those 12 to 14 years of age to 72% among those 18 to 20 years of age.

Adolescence is a time of exploration and limit testing; therefore, it is no coincidence that this is the chief period for initiating substance use. Alcohol is the substance most frequently used by children and adolescents in the United States, and its use in youth is associated with the leading causes of death and serious injury at this age (i.e., motor vehicle accidents, homicides, and suicides). Drinking levels that may cause little or no problem for adults may be dangerous for adolescents. Recent studies indicate that alcohol use during this period of growth may interrupt key processes of brain development, possibly leading to cognitive impairment and an elevated risk of developing a chronic alcohol use disorder.

The NIAAA ( The National Institute of Alcohol Abuse and Alcoholism) has defined binge drinking as the pattern of drinking that brings a person’s blood alcohol concentration (BAC) to 0.08% or greater, which derives from concentrations for drunk driving for those 21 years or older (the legal intoxication level for adults in all 50 states in the United States). A quantitative definition of drinking makes results comparable across studies and is also important from a clinical point of view because binge drinkers are more likely to experience alcohol-related problems than drinkers who do not binge. Studies show that youth may underestimate the resulting harm and because they typically weigh less than adults, they are likely to reach a BAC much higher than 0.08% with five drinks in a 2-hour period.

Binge drinking in adolescents is a serious issue, in a 2013 report 23% of Americans 12 years and older reported binge drinking in the 60 days before the survey. Rates of alcohol use and binge drinking in girls and young women have been increasing, although still lower than in their male counterparts. LGBT youth are at elevated risk of alcohol misuse with drinking patterns increasing linearly over time.

Risk Factors for Binge Drinking

  • “Positive expectancies”: advertising directed at youth that portrays drinking as a normal part of adolescent life.
  • Personality traits such as sensation seeking, low inhibitory control, and impulsivity.
  • Peer use: social experience of drinking in a group.

Physiology of Intoxication

As alcohol enters the bloodstream, it must be metabolized by the liver. This occurs at a fixed rate. So, if the volume of alcohol consumed is greater than the liver’s ability to metabolize, the individual begins to feel a sense of inebriation as the BAC rises from 50 to 150 mg/dl (euphoria, incoordination, imbalance, sleepiness, loss of social inhibitions, depression, hostility). Alcohol readily crosses over into the brain so the concentration of alcohol in the brain parallels that of the bloodstream.

When the BAC (blood alcohol level) is greater than 150 mg/dl the individual has more depressant qualities. They experience lethargy, bradycardia, hypotension, and respiratory depression.

Alcohol poisoning occurs around a medial of 450 mg/dl and causes stupor, coma, respiratory depression, and death.

Blackouts are based on the amount of alcohol consumed , are more common in adolescents than adults, and during these times, the drinker often engages in highly dangerous or risky behaviors: swimming on dares, high-speed car chases and unprotected sex.

  • 50% of all adolescent head injuries are associated with alcohol.
  • Alcohol use is involved in all major sources of mortality in adolescence, including accidents, suicides and homicides
  • 1/3 of all fatal car crashes involve alcohol.

Marijuana Use in Adolescents

Marijuana is a psychoactive drugs, one of the most commonly used in the United States. In recent years the THC (tetrahydrocannabinol) content has increased 6 to 7 fold and there has been a proliferation of alternative forms for consumption such vaping, oral products (gummies), in addition to smoking marijuana cigarettes. In 2017, the Centers for Disease Control and Prevention Youth Risk Behavior Survey found that 19.8% of youth of high school age reported past-month marijuana use, and 35.6% had ever tried marijuana, down from a peak rate of 47.1% in 1997.

With legalization, marijuana use during pregnancy has become more common, with 7.1% of pregnant women reporting marijuana use in the past month and 3.1% reporting daily use even though the impact on the neurodevelopment of the fetus is not completely known but thought to be harmful to the unborn. Animal studies of prenatal THC exposure provide strong evidence for these adverse effects.  In a review of several studies on prenatal marijuana use, investigators found a dose-response effect on fetal growth; increased use was associated with decreased growth. Marijuana exposure has also been associated with NICU admissions as well as with increased respiratory and neurologic infections and hematologic morbidity.

Positive attitudes toward school, parental monitoring, and strong disapproval of peers have been found to be protective factors against substance abuse disorders.

There was an increase from 10.5% in 2017 to 20.8% in 2018 for the past 30-day use of vaping devices among 12th graders. Furthermore, there was an increase from 21.6% in 2017 to 34.5% in 2018 for the past 12 months of use of marijuana via vaping devices among 12th-grade marijuana users. Additionally, there were significant associations between vaping device use and marijuana vaping, between vaping device use and marijuana use, between vaping device use and synthetic cannabinoids use, and between marijuana use and synthetic cannabinoids use from 2016 to 2018. Adolescent marijuana users have a higher incidence of using synthetic cannabinoids as well.

Population-based surveys from the 1990s revealed that most cannabis users were co-users of tobacco. Until the recent electronic cigarette (e-cigarette) or JUUL epidemic, there had been a steady decrease in self-report of tobacco use in youth. However, youth who smoke tobacco remain more likely to report marijuana use.  Co-users in this study had lower academic performance compared with cannabis-only users and were more likely to be male than female.


Cannabis is a naturally occurring plant, the leaves of which are dried to smoke, make tea, and add to other drugs, and the oils of which are used to make other cannabinoid products. The liver metabolizes cannabinoids via the P450 system. CBD inhibits cytochrome oxidases that metabolize other drugs and can, therefore, interfere with other commonly used medications, such as anti-seizure drugs. Since cannabinoids are lipophilic are rapidly absorbed and can act as CB1 and CB2 receptors in the brain. CB2 receptors are also found in smooth muscle, the heart, and the vascular system in some white blood cells. Synthetic cannabinoids are used for medicinal purposes such as nausea and vomiting associated with chemotherapy, cancer pain, and inflammatory bowel disease in adults.

Adverse Effects from Cannabis Use

  • Distorted perception
  • Poor concentration
  • Psychosis
  • Hyperemesis Syndrome
  • Addiction
  • Cardiotoxicity
  • Sedation
  • Respiratory depression
  • Impaired neurocognitive functioning in adolescents
  • Generally lower cognitive function compared to non-using counterparts.
  • Adverse effects on IQ and executive function.
  • Marijuana use has also been associated with increased use of opioids, and marijuana users are 2.8 times more likely to have Opioid use disorder

Spice & K2 (SC's)

Popular recreational substances that are plant-derived and similar to THC are readily available for purchase in shops specializing in marijuana sales. They are marketed as safe natural herbal blends; however, these products are not naturally produced. They are mass-produced outside the U.S.A., then dissolved and mixed with dried vegetation in imprecise dosing processes. They can be contaminated with bacteria, chemicals, and heavy metals.

In 2018, 70 individuals in Connecticut experienced a serious drug overdose with SCs contaminated with rat poison.

Unlike THC, SC’s are full agonists of CB1 and CB2 accounting increased potency and increased morbidith and mortality.

Toxicities Include

  • Cardiac abnormalities
  • Long lasting bleeding disorders
  • Acute myocardial infarction in adolescents
  • Acute kidney injury requiring dialysis
  • Strokes, seizures, suicidal ideation and psychosis

SCs can also be mixed with other psychoactive drugs, such as bath salts and ecstasy,making medical detection and therapy difficult.

Other Common Drugs of Abuse:

Over-the-Counter Medications: Dextromethorphan (dexing, robo-tripping, triple Cs): is a weak opioid receptor drug that acts at the υ-receptor. Toxicity can include altered mental status, hyperreflexia, tachycardia, hyperthermia, hypertension

Inhalants: Abuse of inhalants remains popular among adolescents and an estimated 9% of the US population 12 years and older have abused or misused an inhalant for psychoactive properties, more than any other age group. Other terms for inhalation include “huffing,” “bagging,” and “dusting.” Most inhalants are organic compounds containing hydrogen and carbon, or hydrocarbons. They are commonly used as solvents and diluents in various household products including cleaners, aerosols, fuels, and essential oils. The onset of psychoactive effects is rapid. Hydrocarbons diffuse through the pulmonary system, readily cross the blood-brain barrier, and affect neurotransmitters, which include glutamate/NMDA, GABA, dopamine, and opioid receptors. Toxicity includes CNS depression, tachycardia, angioedema, kidney failure, and myocardial depression.

Hallucinogens: Hallucinogens are a diverse group of substances (LSD, peyote, mushrooms) that alter and distort perception, thought processes, and mood. In 2016, the NSDUH reported that 1.4 million Americans older than 12 years were current users of hallucinogens. Physiologic abnormalities include hallucinations such as tachycardia, high blood pressure, nausea, flushing, and, in some cases, severe hyperthermia, rhabdomyolysis, liver necrosis, bleeding disorders, breathing problems, coma, and death. The vast majority of morbidity associated with hallucinogens occurs from secondary trauma such as imagining you can fly or walk on water.

Stimulants ( MDMA (Ecstasy), Methamphetamine): these drugs release catecholamines, particularly dopamine, norepinephrine, and serotonin from presynaptic terminals resulting in a hyperadrenergic state. This can cause life-threatening side effects such as stroller, seizures, myocardial infarction, abnormal fatal heart arrhythmias, severe high core body temperature, and loss of pregnancy.

Users of MDMA report it enhances pleasure, heightens sexuality, and expands consciousness without the loss of control. Negative effects reported with acute use included ataxia, restlessness, confusion, poor concentration, and impaired memory.

Cocaine: contained in the leaves of the Eryhroxylum coca in Columbia, Bolivia, Peru, West Indies, and Indonesia. It can be inhaled, ingested, insufflated, or injected and causes the excitatory amino acid concentrations in the user’s brain to increase by blocking the reuptake of serotonin, dopamine, epinephrine, and norepinephrine. It can primarily affect many different organ systems including the heart and vascular system, lungs , muscles. Toxicity include: abnormal and fatal heart rhythms, hyperthermia, extremely high blood pressure, stroke, rhabdomyolysis (breakdown of muscle), and vascular occlusions.

Opioids: The adolescent population is no exception when it comes to the opioid misuse and abuse epidemic. In 2016, almost 900,000 adolescents (3.6%) reported misusing opioids in the past year. The number increases to over 2 million between ages 18 and 25 years. Opioids are alkaloids naturally derived directly from the opium poppy plant. These include morphine, codeine, thebaine, and noscapine. Opioids are a broader class of substances capable of binding to opioid receptors. Semisynthetic opioids, such as heroin and oxycodone, are created by chemical modification of an opiate. A synthetic opioid is a chemical that is not derived from an opiate and is capable of binding to an opioid receptor and producing opioid effects clinically. Depending on the opioid or opiate, the onset of action and duration of action can be quite variable. Toxicity can be reversed with naloxone via various routes: intranasal, intramuscular and intravenous. Toxicity includes mental status depression, respiratory failure, poor bowel function, eliminated carbon dioxide drive to breathe, hypotension, and seizures.

The Role of the Pediatrician

  • Prevention, prevention, prevention
  • Ask questions starting at about 9 years old:
    • Friends drink?
    • How much? How often? What kind of alcohol?
    • Drugs?
    • Does the patient drink?
  • Talk about the dangers of drinking, drugs, and risk-ridden behaviors.
  • Provide a safe place for children and adolescents to ask questions.
  • In older age groups drug and alcohol questionnaires.


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Testing for Drugs of Abuse in Children and Adolescents

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COMMITTEE ON SUBSTANCE ABUSE Pediatrics (2014) 133 (6): e20140865.

Marijuana and the Pediatric Population

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Common Substances of Abuse

George Sam Wang, MD; Christopher Hoyte, MD. Pediatr Rev (2018) 39 (8): 403–414.