Policy on Substance Misuse in Adolescent Patients

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that substance misuse in adolescents is a significant health, social, and familial issue in the United States. The increasing prevalence of substance misuse among adolescents obligates dental personnel to identify behaviors characteristic of active use, recognize clinical signs and symptoms of active use or withdrawal, modify dental treatment accordingly, and facilitate referral to medical providers or behavioral addiction specialists. This policy addresses the harmful effects of alcohol and drug misuse in the adolescent and the dental provider’s role in recognition, initiation of appropriate interventions, and referrals.

Methods

This policy, developed by the Council on Clinical Affairs and adopted in 2016¹ , is based upon a review of current dental and medical literature, including a literature review through the PubMed®/MEDLINE database using the terms: adolescent substance abuse, adolescent substance misuse, substance use in adolescents, alcohol use in adolescents, illicit drug and alcohol use in teenagers, adolescent alcohol and/or drug abuse, and prescription drug use/misuse in teenagers; fields: all; limits: within the last five years, humans, English, birth through age 18. The search resulted in 741 papers that were reviewed by abstract and title. Papers for review were chosen from this list and from the references within selected articles. Websites and documents from select healthcare and public policy organizations, as well as governmental agencies, also were reviewed.

Definitions

Adolescence: “11 to 21 years of age, dividing the group into early (ages 11-14 years), middle (ages 15-17 years), and late (ages 18-21 years) adolescence.”²

Binge or heavy episodic drinking: “pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent – or 0.08 grams of alcohol per deciliter – or higher. For a typical adult, this pattern of excessive alcohol use corresponds to consuming four or more drinks (female), or five or more drinks (male) in about two hours. Research shows that fewer drinks in the same timeframe result in the same BAC in youth; only three drinks for girls, and three to five drinks for boys, depending on their age and size”.³

Substance misuse: “used to distinguish improper or unhealthy use from use of a medication as prescribed or alcohol in moderation. These include the repeated use of drugs to produce pleasure, alleviate stress, and/or alter or avoid reality. It also includes using prescription drugs in ways other than prescribed or using someone else’s prescription”.⁴

Substance use disorder (SUD): “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems”. ⁵

Withdrawal syndrome: “the development of a substance-specific maladaptive behavioral change, usually with uncomfortable physiological and cognitive consequences, that is the result of a cessation of, or reduction in, heavy and prolonged substance use”. ⁶

Background

Many physical, social, and behavioral changes occur during the adolescent years. The developing adolescent may encounter difficulties and pressures without effective coping skills or maturity. Unfortunately, some teenagers do not have familial, peer, or other support systems to provide help and guidance in adjusting to changes or with decision making. As a result, they may turn to alcohol or drugs to seek comfort and reduce the stresses associated with this erratic time in their lives.⁷

Substances misused by adolescents include alcohol, inhalants, opiates, amphetamines, cocaine, marijuana, barbiturates, benzodiazepines, hallucinogens, and anabolic steroids.⁸ In a 2019 survey of eighth, tenth, and twelfth grade students, trends revealed alcohol use at 7.9, 18.4, and 29.3 percent respectively in the previous 30 days, reflecting a five-year decreasing trend in comparison to survey results from 2014.⁹ Prevalence of binge drinking in the past 30 days demonstrated a five-year decline, reported at 3.8, 8.5, and 14.4 percent.⁹ Use of any illicit drug was reported to be 8.5 percent for eighth graders, 19.8 percent for tenth graders, and 23.7 percent for twelfth graders.⁹

Findings from the 2019 Monitoring the Future (MTF) survey demonstrate the strong desire for vaping in adolescence, as seen in the increased prevalence of marijuana use as well as nicotine vaping.⁹ Past-month marijuana vaping among twelfth graders nearly doubled in a single year from 7.5 to 14 percent.⁹ Marijuana was the most commonly used illicit drug among teenagers.⁹ A national sample study of adolescents and young adults demonstrated use of electronic nicotine delivery systems (ENDS) and coupled use of ENDS and cigarettes are significant underlying risk factors for coronavirus disease 2019 (COVID-19).¹⁰ Association of the prevalence of individuals who vaped (vapers) in each United States state and daily number of COVID-19 cases and deaths per state suggested vapers may be more susceptible to COVID-19 cases and deaths.¹¹ The MTF survey found rates remaining unchanged for other illegal drug use in this population, including methamphetamine, cocaine, and overthe-counter cough and cold preparations.⁹ A 2015 survey found more than 2.3 million youth aged 12-17 years were current (i.e., in the past 30 days) users of illicit drugs, equivalent to 9.4 percent of adolescents.¹² In 2015, alcohol use was higher, reported at 11.5 percent, corresponding to 2.9 million adolescents, with binge drinking shown to occur in 6.1 percent.¹² Among the same age group, current marijuana use was at 7.4 percent (approximately 1.8 million adolescents).¹² Misuse of prescription drugs (i.e., analgesics, stimulants, anxiolytics, sedatives) for non-medical purposes was reported by 2.6 percent of adolescents.¹² Based on a 2019 survey, alcohol use among adolescents reduced to 9.4 percent, and the percent of binge drinkers reduced to 4.9 percent.13 Despite the decrease, about one in 11 adolescents was a current alcohol user, and one in 21 adolescents was a current binge drinker in 2019.¹³ Approximately one in six (17.2 percent) adolescents aged 12 to 17 in 2019 was a past-month illicit drug user.¹³ Between 2015 to 2019, the percentage of adolescents who used illicit drugs in the past year ranged from 15.8 to 17.2 percent.¹³

In 2019, 4.5 percent of adolescents (one in 22 adolescents) had SUD, which was lower than five percent of adolescents diagnosed in 2015.¹³ Similarly, the percentage of adolescents with alcohol use disorder decreased from 2.7 percent in 2015 to 1.7 percent in 2019.¹³ Adolescents regularly and frequently consume caffeine-containing beverages, considered harmless and non-addictive, such as coffee, tea, cocoa, carbonated beverages, energy drinks, and energy shots.¹⁴ Though caffeine use disorder is not officially classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), caffeine intoxication and caffeine withdrawal are listed disorders.⁵

Prescription drug monitoring programs (PDMPs) have been implemented in most states and have been effective in reducing the number of prescriptions and opiates available for misuse by adolescents.¹⁵ However, many adolescents are resorting to heroin and fentanyl.¹⁶ In 2017, misuse of prescription opioids, heroin, and fentanyl analogs increased the overall death rate (per 100,000) to 12.6 in adolescents and young adults, up from 3.7 in 2000.¹⁷ Drug use at an early age is an important predictor of development of a SUD later in life.⁷ Of people who started drinking by age 14, 15.2 percent eventually developed an alcohol use disorder as compared to just 2.1 percent of those who waited until they were 21 years or older.¹⁸ Thirteen percent of those who developed an SUD began using marijuana by the time they were 14 years of age.¹⁸ Of individuals who misused prescription drugs at age 13 or younger, 25.3 percent developed a SUD at some time in their lives.¹⁹ Recurrent use of drugs or alcohol causes significant clinical and functional impairment such as health issues, disability, and failure to fulfill important responsibilities at work, school, or home.²⁰

Due to the prevalence of substance misuse, it would not be uncommon for the dental provider to encounter signs of substance misuse. Staff should be attentive to similar signs displayed by the parent. Clinical presentations of substance use may include odor of alcohol on breath, odor of marijuana on clothing, impaired behavior, slurred speech, staggering gait, visual hallucinations, disorientation, rhinitis, scratching, physical injuries including lacerations, needle marks, cellulitis, diaphoresis, tachycardia, sensory impairment, and pupillary dilation or constriction.²¹ Cognitive and behavioral manifestations may present as mood changes or emotional instability, loud obnoxious behavior, laughing at nothing, withdrawn/ depressed affect, lack of communication/silence, hostility/ anger/uncooperative behavior, inability to speak intelligibly or to focus, rapid-fire speech, hyperactivity, and unusually elated mood.^21,22 Perioral and oral signs may include sores around the mouth, continual wetting or licking of lips, clenched teeth, bruxism, trismus, enamel chips or coronal fractures, neglected/ poor oral hygiene, multiple cervical caries lesions, gingivitis, gingival ulceration, periodontitis, pale mucosa, leukoplakia, and intraoral burns.^8,21,23 Adolescents experiencing withdrawal syndrome may demonstrate behaviors such as altered mental status, agitation, irritability, restlessness, increased anxiety or panic, and inattentiveness.^6,8 Clinical signs and reported symptoms of substance withdrawal include rhinorrhea, tachycardia, elevated temperature, yawning, tremors, hallucinations, and seizures.^6,8

Adolescent substance misuse frequently co-occurs with mental disorders.^5,7,8,24,25 SUD often coexists with psychiatric conditions such as depression, anxiety disorders, attentiondeficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, bipolar disorder, post-traumatic stress disorder, bulimia nervosa, social phobia, and schizophrenia.^4,25-27 Substance use may induce the deterioration, emergence, or reoccurrence of psychiatric disorders, or it may work in reducing, masking, or enabling an adolescent to cope with symptoms.^24-26,28 Behaviors consistent with both SUD and mental disorders may be confusing to dental providers. Professionals must be cautious not to assume clinical signs are associated with substance misuse when, in fact, they are presentations consistent with mental disorders and vice versa.^7,8,25-27 Such caution prevents inaccurate diagnoses and judgment or labelling of an adolescent patient, which could lead to emotional harm and diversion from necessary treatment.^25,26,28

Dentists are in a position to identify clinical manifestations of substance misuse, present brief interventions, and provide referrals to medical providers or behavioral health or addiction specialists. They also can assist the patient and family in finding treatment facilities, self-help groups, and community resources which address alcohol and drug misuse specific to adolescents.^7,8,29-31 When substance misuse is suspected or confirmed, an empathetic, non-judgmental style of discussion facilitates a trusting patient-doctor relationship.^8,31 Asking open-ended questions may garner more information as they tend to be less threatening to the patient.⁸ Brief interventions may include educating the patient or family, or both, on health risks of use or misuse of alcohol or other drugs, strong encouragement for avoiding drugs and alcohol, motivational interviewing,^27,32 and initiating referrals for assessment and treatment by other health care providers.^7,8,29-31,33 Although the dental practitioner may grant patient confidentiality, he must abide by state laws when treating minors.⁸ Involvement of the parent and other authorities is imperative when substance misuse places the adolescent patient or others in a high-risk or lifethreatening situation.^8,34 In such circumstances, the patient should receive notification when disclosure of confidential information will occur and be provided an opportunity to join the conversation.³⁴

When providing treatment to a patient suspected of substance use, the dentist may need to modify sedation procedures, administration of local anesthetics, and prescribing practices. Administration of nitrous oxide or anxiolytic or sedative medications to an adolescent who is actively using or has a current history of substance misuse can lead to unfavorable drug interactions, over-sedation, or respiratory depression.^8,29 Use of these agents during remission/recovery from a SUD can predispose a patient to relapse.^7,8,25 Dentists should use local anesthetics containing vasoconstrictors judiciously in patients who misuse stimulant medications such as methylphenidate, amphetamine and dextroamphetamine, methamphetamine, and cocaine.³⁰ Drug interactions between vasoconstrictors and stimulants can cause tachycardia, hypertension or hypotension, palpitations, hyperthermia, cardiac dysrhythmias, myocardial infarction, and cerebrovascular accidents.^8,35-37 Dentists should be knowledgeable of the various SUDs (e.g., alcohol, opiate, benzodiazepine) when recommending or prescribing medications.³⁰ When pain management is necessary, an adolescent with an opioid use disorder should receive non-opioid analgesics (e.g., acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDS]).^6,8 Prior to prescribing medications that have the potential to be misused, the practitioner should assess adolescent patients with risk factors such as active substance use, past SUD, current medications, and a family history of SUD.^7,38 For patients at high risk, the dentist should consider prescribing alternative medications with less abuse potential, closely monitoring the patient, reducing length of time between visits for refills, prescribing smaller amounts of liquid medications or fewer pills, and educating both patients and parents about proper use and potential risks of prescription medications, including the risk of sharing them with others.⁷

Policy statement

The number of adolescents who misuse alcohol, drugs, or both is a public health problem.^9,13 The AAPD recognizes providing dental care to adolescents with substance use disorders requires awareness of clinical manifestations and implementation of different treatment approaches. Therefore, the AAPD encourages dental professionals to:

• gain knowledge of SUD and associated behavioral, physiological, and cognitive effects in adolescents.
• use a specific adolescent medical history documenting past history, current use, and previous treatments for SUD.
• recognize behaviors, clinical signs, and symptoms of adolescent substance misuse.
• provide brief interventions to educate the adolescent and his family regarding the risks of substance misuse.
• provide brief interventions for encouragement, support, and positive reinforcement for avoiding substance use.
• provide referrals to primary care providers or behavioral health or addiction specialists for assessment and/or treatment of SUD in adolescents when indicated.
• be familiar with community resources, such as self-help groups and treatment facilities, specific to adolescents with SUD.
• use local anesthetics containing vasoconstrictors with caution in patients having a stimulant use disorder.
• limit or decline use of nitrous oxide and anxiolytic or sedative medications in adolescents with SUD.
• recommend non-opioid analgesics or prescribe noncontrolled medications with a low potential for misuse when medications are indicated for disease management/ pain control.
• if non-controlled medications are ineffective, prescribe only small amounts of medications that have the potential to be misused, preferably with no refills.
• respect patient confidentiality in accordance with state and federal laws.