• Substance use by an adolescent should be identified and the individual’s situation and any other mental symptoms examined comprehensively before deciding on any further measures.
• To obtain the adolescent’s trust, it is important to have a neutral, interested and non-patronizing attitude when encountering them and investigating substance use.
• Identify any suicidal tendencies or psychotic symptoms, and refer to adolescent psychiatric emergency care, if necessary.
• Do not hesitate to submit a child welfare notification if the situation of an adolescent below the age of 18 years arouses concern, even if substance use appears to be only occasional.
• In minors, the patient’s capability for independent decision-making should always be assessed and entered in the patient records.
• Adolescents usually give permission to contact their parents if you explain the reasons for this.

• For epidemiological data on various intoxicants (including alcohol, nicotine products, electronic cigarettes, cannabis and other drugs), see
  • Local sources for local epidemiology
  • Europe
    • European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) https://www.emcdda.europa.eu/topics/young-people_en
    • European School Survey Project on Alcohol and Other Drugs (ESPAD) http://espad.org/ https://www.emcdda.europa.eu/about/partners/espad_en https://pubmed.ncbi.nlm.nih.gov/34537468/
  • USA
    • Centers for Disease Control and Prevention (CDC) https://www.cdc.gov/healthyyouth/data/topics/ https://www.cdc.gov/healthyyouth/substance-use/ https://www.cdc.gov/mmwr/volumes/73/wr/mm7305a1.htm
    • National Institute on Drug Abuse (NIDA) https://nida.nih.gov/news-events/news-releases/2023/12/reported-drug-use-a...
    • Office of Population Affairs (OASH) https://opa.hhs.gov/adolescent-health/substance-use-adolescence
  • Global
    • OECD https://www.oecd-ilibrary.org/sites/92f5c3dd-en/index.html... https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-g...
    • WHO Global Information System on Alcohol and Health (GISAH) https://www.who.int/data/gho/data/themes/global-information-system-on-alco... https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/youth-an...

• Even though experimenting with substances is common among adolescents, most of them will not develop addiction or substance abuse problems.
• Identify the adolescents whose experimenting with substances has already become or is at risk of becoming a problem.
• The adolescent's overall life situation should be assessed comprehensively before deciding on further measures.

Laboratory tests

1. Phosphatidyl ethanol, PEth, in blood is specific for alcohol use (not age-dependent),
   • In minors, PEth levels suggesting even moderate consumption are worrying.
   • A single episode of binge drinking will not raise PEth levels above the reference range unless there is alcohol in the blood when taking the sample.
   • PEth levels below the reference range do not exclude the possibility of alcohol problems in adolescents.
2. Supervised urine drug screening test (which must include the analysis of potential test manipulation to ensure reliability of the sample) can give some idea of the extent of substance abuse in adolescents. Various narcotics show up, however, differently in the screen – a negative screening result does not rule out the possibility that the adolescent is using illegal drugs.
3. Other laboratory tests (such as liver values) are of little benefit in the diagnosis of substance use disorder in adolescents.

Questionnaires

• Ask directly about intoxicant abuse and about various substances separately.
• You can use the AUDIT test , for example, to assess alcohol consumption, the CRAFFT tool https://crafft.org/ for screening, the DUDIT test https://www.emcdda.europa.eu/drugs-library/drug-use-disorders-identificati... to assess risks of illegal drug use or the ADSUME test https://pubmed.ncbi.nlm.nih.gov/17456127/ for adolescents to assess intoxicant abuse. In the AUDIT test, a lower cut-off point (4 points) for high-risk consumption should be used than for adults.
• Also discuss the questions because written answers are not always truthful.

• Adolescents’ experiments with intoxicants should be addressed calmly but it is important for all adults to consistently convey the message that intoxicant abuse is harmful for adolescents. In adolescents, intoxicant abuse that is becoming more regular increases the risk of later intoxicant and mental health problems and social exclusion.
• Brief intervention works for adolescents, too (Brief interventions for risky use of alcohol).
• Brief intervention should be available where adolescents are first seen because of intoxicant abuse, such as in school health care or in emergency services.
• Bringing up the topic, assessing the adolescent’s resources and follow-up of intoxicant abuse form sufficient intervention after the first experiments.
• More extensive brief intervention should be used if high-risk use is already becoming more regular.
• The younger the patient and the more associated problems (related to school attendance, high-risk behaviour, social relationships) there are, the more readily they should be referred for further treatment at a unit specializing in treating substance use disorders in adolescents, along with assessment by child welfare.
• Forms of treatment that are effective in adolescents include family therapy (such as Multidimensional Family Therapy, MDFT) and cognitive-behavioural psychotherapy, for example.
• Check where therapy is provided in your region. Larger urban centres have youth stations (age limit eg. 13–23 years) or other treatment centres that specialize in substance abuse.
• Elsewhere adolescents' substance problems are handled as part of other health care and social services. Institutional care is generally arranged through child welfare services.
• Substance use is often only part of a larger set of problems among patients in youth psychiatric wards.

Co-morbidity

• Most young substance abusers also have other mental problems, most commonly a behavioural problem (Conduct disorders in children and adolescents), an attention deficit–hyperactivity disorder (ADHD) or a mood disorder (see (Depression in adolescents) (Risk of suicide in adolescence)).
• Assess other mental symptoms comprehensively and start active treatment when withdrawing intoxicants already.

Medication

• The choice of pharmacotherapy for an adolescent is guided by other mental problems, such as symptoms of depression or anxiety or sleeping disorders.
• Due to the strong potential for dependence, benzodiazepines should be avoided in adolescents, particularly. Their use should be restricted to institutional rehabilitation of substance dependence. In adolescents, non-pharmacological skills for tolerating distress should be emphasized.
• Opioid substitution therapy should only be used by units specializing in the method.
• If an adolescent below the age of 18 years cannot stop intoxicant abuse with the support of outpatient care and child welfare, and such abuse continues on a harmful level, measures that are based on legislation can be taken, including involuntary treatment. Check locally relevant criteria, policies and legislation where relevant themes may include child welfare, social work with intoxicant abusers, or mental health.
  • Presence of self-destructiveness or psychotic symptoms (including a risk to health/safety and unsuitability of outpatient care) are also important in these considerations.

• Emergency clinics usually submit a notification to child welfare authorities of any child or adolescent below the age of 18 who is under the influence of intoxicants when presenting at the clinic. Check local policies and practices.
  • It is advisable that treating units agree on the policy of cooperating with child welfare services.