Providers Can Help Identify Young People at Risk for Addiction

Addiction is 1 of the most costly and tragic diseases in the United States, in both financial and human terms.

Our nation spends around $740 million annually in costs on addiction-related crime, health care, and lost work productivity.¹ Tobacco product use alone is linked to an estimated 480,000 deaths a year.²

The real tragedy is that addiction disorders and substance use disorders (SUDs) are preventable, and the key is preventing youth initiation of substance use. There is no safe amount of any substance for children and teens. None. Never. No exceptions.

Decades of research across substances has shown that pre-teens and teens become addicted more easily and with less exposure than adults. In fact, 90% of people with drug dependency and addiction issues started using substances prior to age 18, with a significant number initiating use between the ages of 12 to 15 years.³ The earlier that use starts, the higher the risk. Multiple studies have shown many magnitudes higher lifetime risk for SUD with earlier initiation of substance uses.

Why is early substance use so risky? There is an amazing period of brain development and “rewiring” that starts at age 10 years and is not complete until about age 25 years.⁴ During that period, the brain is particularly vulnerable, and serious and often long-lasting injuries can be caused by substance use.

The limbic region of the brain (behavior, emotion, long-term memory, and motivation) develops faster than the prefrontal cortex (complex cognitive behavior, decision-making, moderating social behavior, and personality expression). This helps explain why pre-teens and teens are very motivated to be easily influenced by peers, take risks, and try novel experiences. At the same the areas of the brain that help them weigh risks are not fully developed. First-time use often occurs in social settings with easily accessible substances, such as alcohol and tobacco products, including high-nicotine-content e-cigarettes.

The young brain’s immature risk and reward system is particularly vulnerable to substance use. All drugs of abuse act directly and quickly on the brain’s reward system, flooding the brain with 2 to 10 times the amount of dopamine (the brain’s “feel good” chemical) as natural rewards from other pleasurable activities.⁵ The brain creates a memory of this intense satisfaction and quickly forms a conditioned response that causes the individual to repeatedly seek the same pleasure, shortening the path from use to abuse to addiction. Besides the risk of addiction, early drug use can alter the development of brain structures. Brain areas affected by substance use include the basal ganglia, extended amygdala, hippocampus, and pre-frontal cortex. Difficulties with concentration, impulse control, learning, and memory are well documented, with some deficits persisting into adulthood even if use ceases. Early substance use has also been linked to an increased risk for developing mood disorders, such as anxiety and depression.

Families and pediatric health care providers play a vital role in efforts to prevent the onset of substance use. Recognizing and addressing risk factors for substance use and enhancing protective factors are the hallmarks of effective prevention.

Adverse childhood experiences (ACEs), especially living with someone who has an alcohol or drug problem, are strongly linked to an increased risk of and increase risk for ACEs in the subsequent generations. Below are some risk factors.

• Environmental risk factors include
  • Academic failure and difficulties concentrating in school
  • Association with drug-using peers
  • History of childhood trauma
  • Poor coping and social skills
  • Prenatal exposure to alcohol, marijuana, or tobacco

• Family risk factors include:
  • ACEs, especially living with anyone with a problem with alcohol or drugs
  • Behavioral health concerns in children or family members, such as anxiety or depression
  • History of SUD
  • Ineffective parenting
  • Lack of attachment to and nurturing by caregivers and parents

Families also provide strong protections that offset risk including:

1. Accepting and open communication with children
2. Expressing disapproval of substance use and setting a good example
3. Forming strong loving and supportive bonds between children and parents
4. Increasing parental involvement in children’s activities and lives
5. Setting clear limits and consistently enforcing discipline

Health care providers play a vitally important role in identifying risk factors for substance use and helping families address them. Identifying family history of SUD and more widespread screening for ACEs is needed. The American Academy of Pediatrics recommends that health care providers routinely screen patients for substance use, provide brief interventions, and refer to addiction or behavioral specialists, as needed.⁶ The National Association of Pediatric Nurse Practitioners also has a position statement on exposure to tobacco products.⁷ The CRAFFT+N is a widely used substance screening tool that was recently modified to include nicotine.⁸ Anticipatory guidance should include providing prevention information and supporting effective parenting. It is especially important to address common parental misperceptions of youth substance use that are not supported by data, such as all kids experiment; at least it isn’t heroin; if I let them drink here and collect the keys, they will be safe; and they only listen to their friends. National surveys show that some children are already experiencing difficulties with substance use at age 12 or 13, so prevention and screening activities should start earlier at about age 10.³

The National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration (SAMHSA) are rich in information and resources, including tools to help build parents confidence and skills in discussing substance use with their children. In particular, the SAMHSA’s Talk. They Hear You. prevention campaign helps caregivers and parent start talking to their kids early about the dangers of alcohol and other drugs.⁹

The horrible price of addiction in both financial and human terms can be greatly reduced by delaying or stopping youth initiation of substance use. It is important to emphasize that increasing numbers and young people are making healthy choices to abstain from alcohol and drugs. Prevention works. Providers in partnership with families and parents are in a powerful position to identify those at most risk and intervene early.

Laura Searcy, MN, APRN, PPCNP-BC, FAANP, is a pediatric nurse practitioner at Marietta Neonatology in Georgia and the program coordinator of the Georgia Tobacco-Free Youth Project, and a member of the National Association of Pediatric Nurse Practitioners.

REFERENCES

1. National Institutes of Health. Costs of substance abuse. National Institute on Drug Abuse. April 6, 2020. Accessed December 8, 2020. https://www.drugabuse.gov/drug-topics/trends-statistics/costs-substance-abuse
2. CDC. Smoking & tobacco use. Updated May 21, 2020. Accessed December 8, 2020. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
3. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. August 2019. Accessed December 8, 2020. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
4. Arain M, Hague M, Johal L, et al. Maturation of the adolescent brain. Neuropsychiatr Dis Treat. 2013;9:449-461. 2013. doi:10.2147/NDT.S39776
5. National Institutes of Health. Drugs, brains, and behavior. National Institute on Drug Abuse. Updated July 2014. Accessed December 8, 2020. drugabuse.gov/sites/default/files/soa_2014.pdf
6. Levy SJL, Williams JF, Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211. doi:https://doi.org/10.1542/peds.2016-1211
7. National Association of Pediatric Nurse Practitioners, Daley AM, Searcy L, et al. NAPNAP position statement regarding the use and exposure to tobacco products in children, adolescents, and young adults. J Pediatr Health Care. 2020;34;630-634. doi:10.1016/j.pedhc.2020.07.007
8. Get the CRAFTT. CRAFTT. Accessed December 8, 2020. https://crafft.org/get-the-crafft/.
9. Talk. They Hear You. Substance Abuse and Mental Health Services Administration. Updated June 11, 2020. Accessed December 8, 2020.