Adolescent Substance Abuse (Case 2)

A healthy 16-year-old adolescent male arrives at your office with his par-ents, 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?

Summary: A 16-year-old previously healthy adolescent with recent behavior changes and declining school performance.

Most likely diagnosis: Drug abuse (probably cocaine, possibly amphetamines).

Next steps in evaluation: History, examination, urine drug screen, and screening for other commonly associated drug abuse consequences (sexually transmitted infections [STIs], hepatitis).

Long-term evaluation and therapy: Threefold approach: (1) detoxification program, (2) follow-up with developmentally appropriate psychosocial sup-port systems, and (3) possible long-term assistance with a professional trained in substance abuse management.



1. Learn the pattern of behavior found among drug-abusing adolescents.

2. Know the signs and symptoms of the more common drugs of abuse.

3. Understand the general approach to therapy for an adolescent abusing drugs.


Rarely, a brain tumor could explain an adolescent with new onset of behavior changes. In general, however, an adolescent’s new-onset truant behavior, depression, or declining grades is more commonly associated with sub-stance abuse. A previously undiagnosed psychiatric history (mania or bipolar disease), too, must be considered. A history, family history, physical examina-tion (especially the neurologic and psychological portions), and screening laboratory will help provide clarity. Information can come from the patient, his family, or from other interested parties (teachers, coaches, and friends). Direct questioning of the adolescent alone about substance abuse is appropri-ate during routine health visits or when signs and symptoms are suggestive of abuse.


SUBSTANCE ABUSE: Alcohol or other drug use leading to impairment or distress, causing failure of school or work obligations, physical harm, sub-stance-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.


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 prob-lems, learning difficulties, and impaired family functioning. Cigarettes and alco-hol 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 2–1). A urine drug screen (UDS) can be helpful to evaluate the






Euphoria, grogginess, impaired short-term memory, talkativeness, vasodilation, and at high serum levels, respiratory depression

7-10 h (blood) or

10-13 h (urine)


Elation and euphoria, impaired short-term memory, distortion of time perception, poor performance of tasks requiring concentration (such as driving), and loss of judgment

3-10 d for occasional users or up to 2 mo for chronic users


Euphoria, increased motor activity, decreased fatigability, dilated pupils, tachycardia, hypertension and hyperthermia; sometimes associated with paranoid ideation; physical findings might include changes in nasal mucosa

2-4 d

Methamphetamine and methylenedioxymetham phetamine (ecstasy)

Euphoria, increased sensual awareness, increased psychic and emotional energy, nausea, teeth grinding, blurred vision, jaw clenching, anxiety, panic attacks, and psychosis

2 d

Opiates including heroin, morphine, and codeine

Euphoria, decreased pain sensation, pinpoint pupils, hypothermia, vasodilation, and possible respiratory depression; physical findings might include needle marks over veins

2 d

Phencyclidine (PCP)

Euphoria, nystagmus, ataxia, and emotional lability; hallucinations affecting body image that can result in panic reactions, disorientation, hypersalivation, and abusive language

8 d


Sedation, pinpoint pupils, hypotension, bradycardia, hypothermia, hyporeflexia, as well as central nervous system and respiratory depression

1 d for short-acting agents; 2-3 wk for long-acting agents

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 ado-lescent’s permission and maintain confidentiality is paramount.

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, inpa-tient 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.

Comprehension Questions

2.1 A 14-year-old has ataxia. He is brought to the local emergency depart-ment, where he appears euphoric, emotionally labile, and a bit disori-ented. He has nystagmus and hypersalivation. Many notice his abusive language. Which of the following agents is most likely responsible for his condition?

A. Alcohol

B. Amphetamines

C. Barbiturates

D. Cocaine

E. Phencyclidine (PCP)

2.2 Parents bring their 16-year-old daughter for a “well-child” checkup. She looks normal on examination. As part of your routine care you plan a urinalysis. The father pulls you aside and asks you to secretly run a urine drug screen (UDS) on his daughter. Which of the follow-ing is the most appropriate course of action?

A. Explore the reasons for the request with the parents and the ado-lescent, and perform a UDS with the adolescent’s permission if the history warrants.

B. Perform the UDS as requested, but have the family and the girl return for the results.

C. Perform the UDS in the manner requested.

D. Refer the adolescent to a psychiatrist for further evaluation.

E. Tell the family to bring the adolescent back for a UDS when she is exhibiting signs or symptoms such as euphoria or ataxia.

2.3 A previously healthy adolescent male has a 3-month history of increas-ing headaches, blurred vision, and personality changes. Previously he admitted to marijuana experimentation more than 1 year ago. On examination he is a healthy, athletic-appearing 17-year-old with decreased extraocular range of motion and left eye visual acuity. Which of the following is the best next step in his management?

A. Acetaminophen and ophthalmology referral

B. Glucose measurement

C. Neuroimaging

D. Trial of methysergide (Sansert) for migraine

E. Urine drug screen

2.4 An 11-year-old girl has dizziness, pupillary dilatation, nausea, fever, tachycardia, and facial flushing. She says she can “see” sound and “hear” colors. The agent likely to be responsible is which of the fol-lowing?

A. Alcohol

B. Amphetamines

C. Ecstasy

D. Lysergic acid diethylamide (LSD)



2.1 E. PCP is associated with hyperactivity, hallucinations, abusive lan-guage, and nystagmus.

2.2. A. The adolescent’s permission should be obtained before drug test-ing. Testing “secretly” in this situation destroys the doctor–patient relationship.

2.3 C. Despite previous drug experimentation, his current symptoms and physical findings make drug use a less likely etiology. Evaluation for possible brain tumor is warranted.

2.4 D. LSD is associated with symptoms that begin 30 to 60 minutes after ingestion, peak 2 to 4 hours later, and resolve by 10 to 12 hours, including delusional ideation, body distortion, and paranoia. “Bad trips” result in the user becoming terrified or panicked; treatment usually is reassurance of the user in a controlled, safe environment.

Clinical Pearls

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 prob-lems, learning difficulties, and impaired family functioning.


Heyman RB. Adolescent substance abuse and other high-risk behaviors. In: McMillan

JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:579-584. Jenkins RR, Adger H. Substance abuse. In: Kleigman RM, Behrman RE, Jenson HB,

Adolescent Substance Abuse (Case 2) Adolescent Substance Abuse (Case 2) Reviewed by WebofPediatric on December 15, 2021 Rating: 5

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