Chapter 14: Health and Wellness
Substance Use and Abuse
Substance Use and Abuse
Adolescence is a time of rapid change and maturation. It is also a time of experimentation—with new hairstyles, clothes, attitudes, and behaviors. Some of these experiments are harmless. Others, such as using alcohol or other drugs, can have long-lasting harmful consequences. There are several reasons why it is important to identify and treat adolescent substance use.
Substance use is common among adolescents, though it has generally gone down in recent years. Alcohol, marijuana, and nicotine products are the substances most commonly used by youth (Johnston et al., 2024), and alcohol often is the first substance to be used (Miech et al., 2024). The percentage of young people who have used alcohol increases with age. By the end of eighth grade, approximately 15% of students have tried alcohol, and 6% have been drunk at least once; by the end of 10th grade, 28% of students have tried alcohol, and 16% have been drunk at least once (Miech et al., 2024). In 2023, 29% of students in grades 9 through 12 reported ever having used marijuana, which is down over 10% from the decade prior (40.7% in 2013; CDC, June 2025). Approximately 17% reported having used marijuana in the preceding 30 days (CDC, June 2025). According to a survey published in 2024, only 14% of students in grades 9 through 12 reported having tried cigarettes, which is down from 70% in the late 1990s. Though cigarette usage has decreased, electronic vapor products, such as e-cigarettes, vape pens, and other nicotine vapor products, have become quite popular. Nearly one-third of high schoolers surveyed indicated they had used electronic vapor products at least once, with 17% using them within the past 30 days (CDC, June 2025). Approximately 1 in 10 adolescents report misuse (i.e., use without a prescription) of prescription medication (CDC, June 2025), and most commonly indicated that they got them from a prescription they had or were given them by a friend (Miech et al., 2024).
Why do Adolescents use Drugs?
As we read above, many adolescents will use drugs or alcohol before reaching adulthood; however, the reasons for use can vary greatly. A popular model for understanding the reasons and levels of drug use involves viewing the behavior as a continuum. This continuum includes non-use and experimental drugs, casual, habitual, and compulsive drug use.
A non-user is someone who has never misused drugs. An experimental user has used drugs a few times out of curiosity. Using substances may make them feel ‘grown-up,’ or they may do it as a form of rebellion against authority or rules. Using may be exciting for this teen. Typically, experimental users have no significant problems with drug use, and adults are not likely aware of the use.
When substance use becomes more common among peer groups, teens are more likely to engage in social use. Using drugs or alcohol might be a way of fitting in with some social groups or with friends. Teens may feel that they are more outgoing or social when under the influence of substances. Furthermore, some teens may use substances for fun or out of boredom. There may also be circumstantial-situational reasons for substance use, such as increasing awareness or creativity and lowering inhibitions. These casual users might engage in regular drug use, maybe 2 to 4 times per week. They still associate drug use with feeling excited or stimulated, and they make efforts to maintain control of their use. Their substance use may be frequent enough that the behavior is difficult to hide from parents and school officials. Casual users may experience decreased school performance, loss of interest in previously enjoyed activities that do not involve drug use, and other atypical behaviors for the adolescent (e.g., increased lying).
As we see substance use intensify, the concern for the teen’s health and safety increases. A habitual user is likely to use drugs daily, often with a particular group of friends who are also using. Drug use may be part of the group’s norms and identity. Teens may also use substances to escape or to self-medicate. At this level of use, the teen may not necessarily lose control but experiences significant school and family problems. Drug use may no longer bring the excitement and stimulation previously sought. Instead, the adolescent may become impulsive, erratic, guilt-ridden, and depressed.
A compulsive user has lost control over their drug use. The person is using drugs several times per day, and they spend a significant part of their day in the procurement, maintenance, and use of a regular drug supply. These adolescents engage in behaviors that put their health and safety at risk. Their emotional state is often disorganized. Individuals in the last three categories – casual, habitual, and compulsive – are most likely to qualify for a substance use disorder diagnosis.
Risk Factors and Outcomes of Substance Abuse
Adolescent substance use poses both short-term and long-term risks. In the short term, drinking, for example, can result in unintentional injuries and death, suicidal behavior, motor vehicle crashes, intimate partner violence, and academic and social problems (e.g., Brown et al., 2008; Calvert et al., 2010; Spear, 2018). These outcomes occur because excess alcohol consumption leads to decreased cognitive abilities, inaccurate perception of risk, and impaired bodily control. These effects, in combination with the fact that compared to adults, adolescents tend to be more physically active when under the influence of alcohol, put adolescents at greater risk of harm. For example, at blood alcohol concentrations greater than zero, adolescents are at increased risk of being fatally injured or involved in fatal crashes in single, two, and more vehicles compared with sober male drivers ages 21-34 (Voas et al., 2012). Marijuana use is associated with diminished lifetime achievement (Meier et al., 2012). Tobacco use results in poor health in the short and long term, and it can be a gateway to the use of other drugs (Sims, 2009). The risk of substance use is compounded because it is associated with other risky behaviors, such as unplanned, unprotected sex, which can result in pregnancy (Levy et al., 2009; Ritchwood, 2015). Adolescents who misuse prescription opioids are at high risk of transitioning to injection drugs and overdosing (McCabe et al., 2019). Any level of substance use can be harmful to adolescents—no amount is safe.
Adolescence is a long period of intense neurodevelopmental growth and maturation. As a result, the adolescent brain is particularly vulnerable to the toxic effects of alcohol and other drugs and to the potential for addiction. Persistent marijuana use in adolescence, for example, is associated with neuropsychological impairments across a range of functional domains (Meier et al., 2012). Moreover, stopping use does not fully restore neuropsychological functioning, suggesting particular harm to the adolescent brain.
Use tends to increase over time. National estimates of the prevalence of drinking indicate that older youth drink more and drink more heavily than do younger youth. This fact makes it all the more important for pediatricians to start early with screening and brief intervention in order to prevent or delay alcohol use for as long as possible.
Substance use in adolescence is associated with harm in adulthood. The earlier an adolescent begins using substances, the greater their chances of continuing to use and of developing substance use problems later in life. For example, compared to people who do not start drinking until they are young adults, people who begin to drink before age 15 are 5 times as likely to develop alcohol dependence or abuse (Chambers et al., 2003; Grant & Dawson, 1997; Hingson & Zha, 2009). Compared with adolescents who first try marijuana at age 18, those who begin using at 14 or younger are 6 times as likely to meet the criteria for illicit drug dependence or abuse later in life (SAMHSA, 2014). More than 80% of adults who smoke tobacco began before they were 18 (Sims, 2009).
Adolescents who report weekly or more frequent substance use are likely to have a severe substance use disorder. In some cases, by the time an adolescent has reached this point, parents are already aware of the drug use, although they may underestimate the seriousness of the problem. Adolescents with serious substance-use disorders require more-intensive care as soon as possible, including a comprehensive evaluation by a substance use specialist, assessment for co-occurring mental health disorders, and referral to treatment.
Prevention of Substance Abuse
Prevention of substance abuse during adolescence should be a multipronged and long-term approach that involves the education of youth, families, and the community. Prevention education should begin as early as preschool and be specific to the target population (i.e., ethnicity, gender), establishing a culture against substance abuse. Effective programs for teens involve interactive education, such as peer discussions and role-playing, and focus on risk-reduction and fostering good decision-making skills.
D.A.R.E. – the drug prevention program that never worked
The primary goal of Drug Abuse Resistance Education (DARE) was to teach effective peer resistance and refusal skills so that adolescents can say “no” to drugs and their friends who may want them to use drugs. The secondary goals of the program were to build students’ social skills and enhance their self-esteem, as these are believed to be linked to adolescent drug use.
DARE was developed in 1983 as a joint effort between the Los Angeles County (Calif.) School District and the Los Angeles Police Department. In 1986, the U.S. Congress passed the Drug-Free Schools and Communities Act to promote drug abuse education and prevention programs across the country, and DARE spread rapidly, with many school districts adopting it for their students. By 1994, DARE was the most widely used school-based drug prevention program, showing up in all 50 states in the United States and spreading to six foreign countries.
Several large scale studies assessed the effectiveness of the DARE program. The findings consistently found no effects. There were no statistically significant differences between students participating in the DARE program and those that did not when comparing rates of drug use, attitudes toward drug use, or self-esteem.
Check Your Understanding.
