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Addressing the Critical Health Problem of Adolescent Substance Use Through Health Care, Research, and Public Policy

      Abstract

      The use of addictive substances—tobacco, alcohol, and other drugs—during adolescence interferes with brain development and increases the risk of serious health and mental health conditions, including addiction. Yet, adolescents live in a culture in which family, social, community, and media influences regularly bombard them with pro-substance use messages, creating an environment in which substance use is considered an expected behavior, rather than a considerable health risk. To prevent the significant harm that falls to teens and young adults because of substance use, The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) undertook a study to explore how adolescent brain development relates to the risk of substance use and addiction; the cultural influences that create an environment in which substance use is considered normative behavior; individual factors that make some teens more disposed to substance use and addiction; and evidence-based prevention and treatment strategies for addressing this problem. The recently published report Adolescent Substance Use: America's #1 Public Health Problem concludes that risky substance use is a major public health problem that can be ameliorated through evidence-based public health measures, including education about the disease and its risk factors, screenings, and clinical interventions, and that addiction can be treated and managed effectively within routine health care practice and specialty care.

      Keywords

      Despite the tremendous toll that addictive substances take on the health and well-being of adolescents, three of four high school students ages 18 years and younger (75.6%, 10.0 million, based on census population estimates) report having ever used an addictive substance (includes cigarettes, alcohol, marijuana, and/or cocaine) by grade 12, with 82.3% of students reporting having done so [
      Census Bureau (US)
      State and County QuickFacts.
      ,
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009 [data file].
      ]. Alcohol is by far the most commonly used substance (72.5%), followed by cigarettes (46.3%) and marijuana (36.8%) [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009 [data file].
      ]. Among adolescents who use addictive substances, two-thirds (65.1%) are polysubstance users (prevalence rates are measured as lifetime use) [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ]. Among those who have ever used tobacco, alcohol, or other drugs, 19.4% meet the clinical diagnostic criteria for a substance use disorder (defined as meeting the Nicotine Dependence Syndrome Scale criteria for past-month nicotine dependence or the Diagnostic and Statistical Manual of Mental Disorders criteria for past-year alcohol/drug abuse or dependence), as do one-third (33.3%) of current users of these substances [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ]. In total, one in eight high school students (11.9%, 1.6 million) suffers from an addictive disorder [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ].
      The treatment gap for adolescents is unacceptably high. In 2009, only 6.4% of high school students who met clinical criteria for an alcohol or other drug use disorder received formal treatment (including treatment for alcohol and other drug addiction at hospitals, rehabilitation facilities, or mental health centers), and those who do receive treatment often receive substandard care [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ]. Fewer teens who needed treatment received it compared with any other age-group [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ].
      Although many effective and science-based prevention and treatment strategies are available, they rarely are implemented. The public is ill-informed about the dangers of teen substance use [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      Adolescent substance use: America's #1 public health problem.
      ]. Physicians seldom screen for adolescent substance use or discuss it with their patients or their parents [
      • Hingson R.W.
      • Heeren T.
      • Edwards E.M.
      • Saitz R.
      Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol.
      ,
      • Knight J.R.
      • Harris S.K.
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      • et al.
      Prevalence of positive substance abuse screen results among adolescent primary care patients.
      ,
      • Millstein S.G.
      • Marcell A.V.
      Screening and counseling for adolescent alcohol use among primary care physicians in the United States.
      ]. Even for teens who seek specialty care, there are few treatment programs that offer age-appropriate evidence-based services [
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      National Survey of Substance Abuse Treatment Services (N-SSATS): 2009. Data on substance abuse treatment facilities. DASIS Series: S-54.
      ].

      Adolescent Brain Development Is Strongly Linked to Substance Use Risk

      The initiation of substance use during adolescence is driven, in part, by biological factors. Addiction is a progressive and complex brain disease [
      • Volkow N.D.
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      • Fletcher B.W.
      Drug addiction as a brain disorder or disease [reply].
      ] that disrupts the functioning and structure of the areas of the brain responsible for pleasure, decision making, self-control, and survival, including motivation, risk and reward assessment, pleasure seeking, impulse control/inhibition, emotion, learning, memory, and stress control [
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      ,
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      The neuroscience of addiction.
      ]. Because the adolescent brain, particularly the prefrontal cortex and the reward pathways, is still developing [
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      • Op de Macks Z.A.
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      Adolescent risky decision-making: Neurocognitive development of reward and control regions.
      ], adolescents exhibit an increased proclivity toward taking risks, including the risk of smoking, drinking, or using other drugs [
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      Adolescent brain development: A period of vulnerabilities and opportunities.
      ,
      • Steinberg L.
      • Fletcher A.
      • Darling N.
      Parental monitoring and peer influences on adolescent substance use.
      ]. Moreover, addictive substances have a greater negative impact on the adolescent brain than the adult brain [
      • Chambers R.A.
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      • Crews F.
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      • Nixon K.
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      ], increasing the risk of further use, adversely influencing the development of the regions of the brain associated with judgment, attention, memory, and reward seeking, and increasing the risk of addiction [
      • Squeglia L.M.
      • Spadoni A.D.
      • Infante M.A.
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      • Tapert S.F.
      Initiating moderate to heavy alcohol use predicts changes in neuropsychological functioning for adolescent girls and boys.
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      ].
      The earlier an individual initiates substance use, the greater the likelihood of developing a substance use disorder [
      • Grant B.F.
      • Dawson D.A.
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      • Grant B.F.
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      • Placzek A.N.
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      ]. Analysis of data from the National Survey on Drug Use and Health indicates that 9 of 10 people who meet the clinical criteria for substance use disorders involving nicotine, alcohol, or other drugs began smoking, drinking, or using other drugs before they turned 18 [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ]. Individuals who begin using any addictive substance (including nicotine, alcohol, or other drugs) before age 15 are 6.5 times as likely to develop a substance use disorder as those who delay use until age 21 or older (28.1% vs. 4.3%) [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ] (Fig. 1) . These findings are particularly striking because the average age of initiation of substance use among high school students is between 13 and 14 years old [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of the National Survey on Drug Use and Health (NSDUH), 2009 [data file].
      ].
      Figure thumbnail gr1
      Figure 1Substance use disorders among persons aged 12 years and older, by age of first use.
      Source: CASA Columbia analysis of The National Household Survey on Drug Use and Health (NSDUH), 2009.
      Genetic factors also contribute to the early initiation and persistence of substance use, and the progression from use to addiction [
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      ].

      Cultural Factors Drive Adolescent Substance Use

      Although biology is a powerful influence, cultural and environmental factors play a critical role in setting the stage for adolescent substance use. Mixed messages generated by peers, family members, and communities regarding the acceptance of use; school environments and policies that contribute to student use; the widespread availability of tobacco, alcohol, marijuana, and controlled prescription drugs; pervasive advertising of addictive products; and media portrayals of substance use as glamorous, fun, or relaxing all contribute to the initiation and continued use of addictive substances among young people. These cultural influences, combined with the failure of the health care, education, social service, and justice systems to systematically identify risky use and intervene when it occurs, conspire to create a culture in which teen substance use is accepted as the norm.

      Parental influences

      Parents send mixed messages to their children, often unknowingly, through their tacit approval of teen substance use. Teens who believe their parents disapprove of their smoking, drinking, or using other drugs are less likely to do so, whereas those who believe their parents are tolerant of substance use are at higher risk of using [
      • Martino S.C.
      • Ellickson P.L.
      • McCaffrey D.F.
      Multiple trajectories of peer and parental influence and their association with the development of adolescent heavy drinking.
      ,
      Substance Abuse and Mental Health Services Administration
      Results from the 2008 National Survey on Drug Use and Health: National findings.
      ]. Many parents fail to set clear expectations that their children will not engage in these behaviors. For example, recent national surveys conducted by The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) found that 44% of parents think it is unrealistic to expect that their children will not try marijuana [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      National survey of American attitudes on substance abuse XIV: Teens and parents.
      ], and one in five parents (20.8%) believe that marijuana is a harmless drug [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of CASA's national survey of high school students, parents of high school students, and high school personnel XVI [data file].
      ]. In the absence of a clear and consistent “no use” message, adolescents may perceive such beliefs as tolerance.
      Some parents believe that allowing their children to drink at home, or under adult supervision, will teach their children to drink more responsibly; however, providing alcohol to children increases the risk of adverse consequences, as noted previously, and research indicates that allowing teens to drink at home increases the likelihood that they will drink outside of the home as well [
      • Abar C.
      • Abar B.
      • Turrisi R.
      The impact of parental modeling and permissibility on alcohol use and experienced negative drinking consequences in college.
      ,
      • Livingston J.A.
      • Testa M.
      • Hoffman J.H.
      • Windle M.
      Can parents prevent heavy episodic drinking by allowing teens to drink at home?.
      ].
      Parents' own substance-related behaviors are another powerful influence on children's substance use expectations and behavior [
      • Ennett S.T.
      • Bauman K.E.
      • Foshee V.A.
      • Pemberton M.
      • Katherine A.H.
      Parent-child communication about adolescent tobacco and alcohol use: What do parents say and does it affect youth behavior?.
      ,
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      The formative years: Pathways to substance abuse among girls and young women ages 8-22.
      ], and nearly half (45.4%, 33.9 million) of children aged <18 years live with a parent who engages in risky substance use (risky substance users include current smokers, underage drinkers, adult drinkers who exceed the U.S. Department of Agriculture guidelines of no more than one drink per day for women or two drinks per day for men, current users of any illicit drug, and/or current misusers of any controlled prescription drug). Living with a parent or other family member who is a risky substance user or who has a substance use disorder significantly increases the likelihood of adolescent substance use [
      • Li C.
      • Pentz M.A.
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      Parental substance use as a modifier of adolescent substance use risk.
      ,
      • Walden B.
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      Trajectories of change in adolescent substance use and symptomatology: Impact of paternal and maternal substance use disorders.
      ].

      The media

      One of the most persistent and pernicious sources of pro-substance use messages in adolescent culture is entertainment media. Adolescents spend more time in a typical day engaged in media use—television, Internet, radio, movies, magazines, and smartphones—than they spend with family, friends, or in school [
      • Rideout V.J.
      • Foehr U.G.
      • Roberts D.F.
      Generation M: Media in the lives of 8-18 year-olds. 2010 [cited March 22, 2011].
      ]. Most of these media are rife with messages that condone or promote substance use [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      Adolescent substance use: America's #1 public health problem.
      ]. These pervasive pro-substance use messages can make substance use seem normal; exposure to pro-substance use media content is linked to initiation of adolescent smoking [
      • Charlesworth A.
      • Glantz S.A.
      Smoking in the movies increases adolescent smoking: A review.
      ,
      • Gidwani P.P.
      • Sobol A.
      • DeJong W.
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      • Gortmaker S.L.
      Television viewing and initiation of smoking among youth.
      ,
      • Primack B.A.
      • Land S.R.
      • Fine M.J.
      Adolescent smoking and volume of exposure to various forms of media.
      ], drinking [
      • Sargent J.D.
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      • Gibson J.
      • Gibbons F.X.
      Alcohol use in motion pictures and its relation with early-onset teen drinking.
      ,
      • Van den Bulck J.
      • Beullens K.
      Television and music video exposure and adolescent alcohol use while going out.
      ], and marijuana use [
      • Primack B.A.
      • Kraemer K.L.
      • Fine M.J.
      • Dalton M.A.
      Media exposure and marijuana and alcohol use among adolescents.
      ]. Internet access and cell phones allow teens to discuss, read about, and view images of substance use, as well as even to purchase drugs, with relative privacy [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      CASA analysis of CASA's national survey of high school students, parents of high school students, and high school personnel XVI [data file].
      ,
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      National survey of American attitudes on substance abuse XV: Teens and parents.
      ].
      Advertising, marketing, and product promotions and placements by the tobacco and alcohol industries and pharmaceutical advertising are a pervasive influence on adolescents' substance-related attitudes and behavior. These industries devote vast resources to the effective promotion of their products and have significant financial incentives in expanding their customer base [
      • Califano J.A.
      High society: How substance abuse ravages America and what to do about it.
      ]. Tobacco and alcohol advertising and marketing—including print, television (alcohol only), and retail displays—have been linked to positive attitudes about substance use, initiation of use, and increased levels of use among adolescents [
      • Anderson P.
      • de Bruijn A.
      • Angus K.
      • Gordon R.
      • Hastings G.
      Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies.
      ,
      • Hanewinkel R.
      • Isensee B.
      • Sargent J.D.
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      Cigarette advertising and teen smoking initiation.
      ,
      • Smith L.A.
      • Foxcroft D.R.
      The effect of alcohol advertising, marketing and portrayal on drinking behavior in young people: Systematic review of prospective cohort studies.
      ,
      • Wellman R.J.
      • Sugarman D.B.
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      The extent to which tobacco marketing and tobacco use in films contribute to children's use of tobacco: A meta-analysis.
      ]. Advertising of controlled prescription drugs promotes a culture of medicating all ills and normalizes substance use as a way to alter mood, cope with stress, and improve performance [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      Under the counter: the diversion and abuse of controlled prescription drugs in the United States.
      ].

      Availability

      After the interest or desire is primed in them, adolescents have little problem accessing addictive substances. Teens report being able to get cigarettes, alcohol, and other drugs quickly and easily [
      • Johnston L.D.
      • O'Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      National survey results on drug use from the Monitoring the Future Study, 1975-2009 Volume 1: Secondary school students.
      ]. Very often, these drugs are available to them for free [
      • Johnston L.D.
      • O'Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      National survey results on drug use from the Monitoring the Future Study, 1975-2009 Volume 1: Secondary school students.
      ,
      Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality
      Young alcohol users often get alcohol from family or home [Internet]. 2011 [cited April 13, 2011].
      ]. Typically, they get these substances from friends and family members, in their own homes, at their friends' homes, or at parties [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      National survey of American attitudes on substance abuse XIV: Teens and parents.
      ].

      Individual Challenges Heighten the Risk of Substance Use and Addiction

      Some adolescents face personal circumstances or challenges that make them more susceptible to initiating substance use and more likely to progress from experimentation to addiction. A family history of substance misuse or addiction [
      • Walden B.
      • Iacono W.G.
      • McGue M.
      Trajectories of change in adolescent substance use and symptomatology: Impact of paternal and maternal substance use disorders.
      ,
      • Biederman J.
      • Faraone S.V.
      • Monuteaux M.C.
      • Feighner J.A.
      Patterns of alcohol and drug use in adolescents can be predicted by parental substance use disorders.
      ]; adverse childhood events, such as abuse, neglect, or other forms of trauma [
      • Dube S.R.
      • Felitti V.J.
      • Dong M.
      • et al.
      Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study.
      ]; mental health disorders [
      • Chan Y.-F.
      • Dennis M.L.
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      Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment.
      ,
      • King S.M.
      • Iacono W.G.
      • McGue M.
      Childhood externalizing and internalizing psychopathology in the prediction of early substance use.
      ,
      • Upadhyaya H.P.
      • Deas D.
      • Brady K.T.
      • Kruesi M.
      Cigarette smoking and psychiatric comorbidity in children and adolescents.
      ]; certain temperament traits [
      • Myers M.G.
      • Aarons G.A.
      • Tomlinson K.
      • Stein M.B.
      Social anxiety, negative affectivity, and substance use among high school students.
      ,
      • Wills T.A.
      • Sandy J.M.
      • Yaeger A.
      Temperament and adolescent substance use: An epigenetic approach to risk and protection.
      ,
      • Windle M.
      • Windle R.C.
      Adolescent temperament and lifetime psychiatric and substance abuse disorders assessed in young adulthood.
      ], such as low self-esteem [
      • Donnelly J.
      • Young M.
      • Pearson R.
      • Penhollow T.M.
      • Hernandez A.
      Area specific self-esteem, values, and adolescent substance use.
      ,
      • Taylor J.
      • Lloyd D.A.
      • Warheit G.J.
      Self-derogation, peer factors, and drug dependence among a multiethnic sample of young adults.
      ]; having experienced peer victimization or bullying [
      • Mitchell K.J.
      • Ybarra M.
      • Finkelhor D.
      The relative importance of online victimization in understanding depression, delinquency, and substance use.
      ,
      • Niemela S.
      • Brunstein-Klomek A.
      • Sillanmaki L.
      • et al.
      Childhood bullying behaviors at age eight and substance use at age 18 among males: A nationwide prospective study.
      ]; identifying as lesbian, gay, bisexual, or transgender or having same-sex attractions and relationships [
      • Austin S.B.
      • Ziyadeh N.
      • Fisher L.B.
      • et al.
      Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys.
      ,
      • Marshal M.P.
      • Friedman M.S.
      • Stall R.
      • Thompson A.L.
      Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth.
      ,
      • Russell S.T.
      • Driscoll A.K.
      • Truong N.
      Adolescent same-sex romantic attractions and relationships: Implications for substance use and abuse.
      ]; engaging in early sexual activity [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009 [data file].
      ]; unhealthy weight control [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009 [data file].
      ]; violence or aggression [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009 [data file].
      ]; and living in a divorced or single-parent family [
      • Deleire T.
      • Kalil A.
      Good things come in threes: Single-parent multigenerational family structure and adolescent adjustment.
      ,
      • Hemovich V.
      • Lac A.
      • Crano W.D.
      Understanding early-onset drug and alcohol outcomes among youth: The role of family structure, social factors, and interpersonal perceptions of use.
      ] are factors that compound the cultural or environmental risks for substance use and addiction. Adolescents with these individual life challenges are at much greater risk—as high as fourfold—of developing a substance use disorder [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
      Adolescent substance use: America's #1 public health problem.
      ] and require special vigilance by the adults in their lives to keep their substance use and risk for addiction in check.

      Costly Health and Social Consequences of Risky Substance Use

      Adolescent substance use is the largest preventable [
      • Horgan C.M.
      Schneider Institute for Health Policy, Brandeis University Substance abuse: The nation's number one health problem.
      ]—and most costly—public health problem in the United States [
      American Cancer Society
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      • Corso P.
      • Finkelstein E.
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      ,
      • Lloyd-Jones D.
      • Adams R.
      • Carnethon M.
      • et al.
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      ,
      • Volkow N.D.
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      ]. Its consequences are staggering in both the short and long term. The medical and health consequences include increasing the risk for mental and physical health problems, including addiction; death from substance-related accidents, homicides, and suicide; and engaging in other dangerous behaviors, such as risky driving, unsafe sex, and violence. Adolescent substance use also is associated with poor academic and career achievement and impaired social functioning. Beyond the tragic costs to individuals and their families, failure to prevent risky substance use and to treat addiction results in a tremendous economic burden on our health care, education, and justice systems. For example, the Pacific Institute for Research and Evaluation calculated that in 2007, underage drinking alone cost the nation approximately $68 billion in youth violence, traffic crashes, high-risk sex, property crime, injury, fetal alcohol syndrome among mothers aged 15–20 years, and alcohol-related poisonings and psychoses [
      Pacific Institute
      Problems and costs associated with underage drinking in the United States [Internet].
      ].
      Because addiction is a progressive disease and most people do not receive effective treatment, the costs of teen substance use and addiction can compound over a lifetime. U.S. government spending on the consequences of risky substance use and addiction amount to an estimated $467.7 billion each year ($1,500/year for every person in the United States), of which <2% is spent on prevention and treatment [
      The National Center on Addiction and Substance Abuse (CASA) at Columbia University
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      ].

      Integrating Substance Use Prevention/Intervention and Addiction Treatment Into Health Care Practice

      Like other public health problems, adolescent substance use can be prevented through evidence-based public health interventions designed to modify individual behaviors and reduce exposure to factors that encourage or increase the risk of use. The negative health consequences of adolescent substance use can be averted by identifying use and intervening early. Once manifested, the disease of addiction, like most other diseases with a behavioral component, can be treated effectively with both behavioral and pharmacologic therapies while simultaneously treating co-occurring health conditions.
      To effectively prevent and address adolescent substance use and addiction, CASA Columbia recommends the following changes in health care practice and policy (CASA Columbia's report provides additional recommendations for how parents, policymakers, researchers, and the media can effectively address the problem of adolescent substance use):

      Recognize addiction as a disease with origins in adolescence

      Because parents, schools, and communities have a tremendous influence on children's substance use behaviors, it is critical to educate the public about the dangers of adolescent substance use. This will require effective population-based public health campaigns.
      Health care providers should recognize addiction as a medical disease that, in most cases, stems from adolescent substance use and requires treatment and long-term management. They should reinforce this message by discussing the risk factors for adolescent substance use and the consequences of use with teens and their parents, encouraging the delay of initiation of substance use for as long as possible. Every interaction with parents, children, and adolescents is an opportunity to impart a clear message that substance use is particularly perilous for young people.

      Identify the problem and intervene early

      Given the link between age of initiation and lifetime incidence of addiction, identification and early intervention are vital. Health care practitioners should include screening, diagnosis, and early intervention for tobacco, alcohol, and other drug use as critical components of a prevention strategy that seeks to reduce the frequency of adolescent substance use and the progression of risky use to addiction. Although these techniques are effective among adolescents of high school age, they rarely are used [
      • Knudsen H.K.
      Barriers to treating alcohol and drug problems among adolescents knowledge asset [Internet].
      ]. Both the American Medical Association [
      American Medical Association
      Guidelines for adolescent preventive services (GAPS).
      ,
      • Kulig J.W.
      Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse.
      ] and the American Academy of Pediatrics [
      • Kokotailo P.K.
      Committee on Substance Abuse
      Alcohol use by youth and adolescents: A pediatric concern [policy statement].
      ] recommend that physicians screen adolescents for alcohol and other drug use; the American Academy of Pediatrics also recommends that pediatricians deliver brief interventions [
      • Kokotailo P.K.
      Committee on Substance Abuse
      Alcohol use by youth and adolescents: A pediatric concern [policy statement].
      ]. A variety of validated screening tools, including short written or orally administered questionnaires, are available [
      • Clark D.B.
      • Moss H.B.
      Providing alcohol-related screening and brief interventions to adolescents through health care systems: Obstacles and solutions.
      ,
      • Fournier M.E.
      • Levy S.
      Recent trends in adolescent substance use, primary care screening, and updates in treatment options.
      ,
      • Levy S.
      • Knight J.R.
      Screening, brief intervention, and referral to treatment for adolescents.
      ,
      National Institute on Alcohol Abuse and Alcoholism
      Assessing alcohol problems: A guide for clinicians and researchers: Michigan Alcoholism Screening Test (MAST).
      ,
      National Institute on Alcohol Abuse and Alcoholism
      Assessing alcohol problems: A guide for clinicians and researchers: Alcohol Use Disorders Identification Test (AUDIT).
      ].
      Substance use screenings can be administered to adolescents in primary care, emergency/trauma care, and mental health care settings; schools; foster care and other social service programs; and the juvenile justice system. When use is identified, evidence-based interventions (e.g., motivational interviewing) should be applied immediately [
      • Levy S.
      • Knight J.R.
      Screening, brief intervention, and referral to treatment for adolescents.
      ,
      • Miller W.R.
      • Rose G.S.
      Toward a theory of motivational interviewing.
      ,
      • Spirito A.
      • Monti P.M.
      • Barnett N.P.
      • et al.
      A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department.
      ,
      • Tait R.J.
      • Hulse G.K.
      A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug.
      ,
      • Walton M.A.
      • Chermack S.T.
      • Shope J.T.
      • et al.
      Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: A randomized controlled trial.
      ,
      • Winters K.C.
      • Leitten W.
      Brief intervention for drug-abusing adolescents in a school setting.
      ] and, when necessary, referrals to appropriate treatment services should be provided. Ideally, treatment should be tailored to the patient's age and gender, and should engage families where possible [
      • Brannigan R.
      • Schackman B.R.
      • Falco M.
      • Millman R.B.
      The quality of highly regarded adolescent substance abuse treatment programs: Results of an in-depth national survey.
      ].
      Health care providers, counselors, social workers, and others working with children and adolescents should be particularly vigilant for signs of substance use among adolescents with additional personal risk factors that make them more susceptible to risky substance use and addition. When risk factors are identified, appropriate treatment and support should be provided as necessary.

      Expand the number of providers trained to effectively prevent, screen, diagnose, and treat adolescent substance use and addiction

      Medical and other health professional training programs should incorporate information regarding the nature of addiction, the associated risk factors, comorbidities, symptoms, and consequences, as well as the range of treatment options, into their basic curriculum so that all health care professionals are equipped to conduct routine screenings for substance use, identify symptoms of substance use in patients, provide brief interventions, and treat or refer to specialty care when necessary. Many physicians and other health care professionals do not screen their adolescent patients for substance use problems or do so inadequately because they simply have not been properly trained to do so [
      • Van Hook S.
      • Harris S.K.
      • Brooks T.
      • et al.
      The “six T's”: Barriers to screening teens for substance abuse in primary care.
      ,
      • Ozer E.M.
      • Adams S.H.
      • Gardner L.R.
      • et al.
      Provider self-efficacy and the screening of adolescents for risky health behaviors.
      ]. Identifying and treating risky substance use and addiction must become a routine part of medical practice.
      To meet the demand for treatment, the number of specialists who are trained to diagnose and treat addictive disorders must be expanded. The American Board of Addiction Medicine currently is working to increase the number of residency training programs in addiction medicine, with the goal of having these programs accredited by the Accreditation Council for Graduate Medical Education within the next few years [
      • Quenqua D.
      Medicine adds slots for study of addictions.
      ].
      Effective practice tools, continuing education materials, and other resources also are needed to help health care providers who work with adolescents become educated in how to conduct screenings and brief interventions, diagnose substance use disorders, and treat or refer for specialty care as they would with any other health condition. Practitioners are strongly encouraged to seek out the tools that currently are available and incorporate best practices into routine care.

      Increase access to effective prevention and treatment services for adolescents

      Health care providers and billing specialists should take advantage of existing opportunities for billing for screening and treatment services and new opportunities that may become available as the Affordable Care Act (ACA) is implemented. Although there are Current Procedural Terminology (CPT), Medicare, and Medicaid billing codes for screenings and brief interventions, many health insurance plans, including some state Medicaid plans, do not reimburse practitioners for providing comprehensive screening and brief interventions to adolescent patients, and those that do may place limitations on the substances for which screening can be done and where and by whom such services can be offered [
      National Associates of Community Health Centers
      State policy report #34: Health center reimbursement for behavioral health services in Medicaid [Internet].
      ,
      SBIRT: If you don't ask: Addiction medicine educational series workbook [Internet]. 2011 [cited March 15, 2011]
      New York State Office of Alcoholism and Substance Abuse Services.
      ,
      Overview of SBIRT coverage and payment in Medicaid and Medicare: SAMHSA SBIRT Grantee Conference [Internet]. 2009 [cited November 4, 2009]
      Substance Abuse and Mental Health Services Administration.
      ]. The ACA aims to increase the number of Americans who are insured and to expand preventive and integrated care. Some of the proposed changes under ACA that are likely to improve access to treatment for those with substance use disorders include:
      • Expansion of Medicaid eligibility and an increase in the number of insured persons;
      • Mandatory prevention services for adolescents, including alcohol and other drug use assessments and depression screening, without a co-payment;
      • Mandatory benefits for addiction treatment in new exchange and Medicaid plans;
      • Limitations on cost-sharing requirements for patients in new exchange and Medicaid plans;
      • Focus on integrating care through medical homes;
      • Increased federal funding for qualified health centers; and
      • Application of the Mental Health Parity and Addiction Equity Act of 2008 to most group health plans and all Children's Health Insurance Program state plans [
        • Buck J.A.
        The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.
        ].
      Currently, addiction treatment is funded primarily through grant programs and is administered by state substance abuse authorities; the aforementioned provisions in the ACA are likely to shift the organization and delivery of such care into a more traditional fee-for-service model [
      • Buck J.A.
      The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.
      ]. This means that a greater range of health care providers, including nonspecialty care providers, will be able to provide and collect payment for these services [
      • Buck J.A.
      The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.
      ]. These changes—particularly the expansion of Medicaid, under which physician-directed treatment is generally mandated—may promote the integration of treatment into mainstream health care [
      • Buck J.A.
      The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.
      ].

      Expand research on effective prevention and treatment services

      Developing and evaluating innovative approaches to preventing and treating this health care problem are of critical importance. Health care and treatment providers should routinely document patient outcomes and, while protecting patient confidentiality, use such information to guide improvements in practice. More research is needed on the effectiveness of promising prevention programs, early interventions, and treatments tailored to teens of high school age, and of best practices for implementation. Given the unmet need for services, and the enormous costs resulting from our failure to address this problem, policymakers should invest in innovative solutions and ensure that they are rigorously evaluated for effectiveness. To help build demand for these increased investments, health care researchers should include cost-effectiveness arguments in their applications to federal and state governments for research funding.

      Conclusion

      Adolescent substance use is a widespread public health problem threatening the health, safety, and success of our youth and increasing their lifetime risk of the disease of addiction. Like other public health problems, it occurs frequently throughout the population, is driven by biological and cultural factors, and is linked to serious health and mental health outcomes. Many adolescents already suffer from addiction—a progressive brain disease with behavioral components—for which effective medical treatments are available. Despite a significant body of scientific evidence demonstrating these facts, this knowledge has not been translated broadly into public health and medical practice. It is time for the health care system to catch up with the science.

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