Adolescent substance use: Challenges and opportunities related to COVID-19

Abstract

Adolescent substance use is a significant public health concern within the United States that remains largely undertreated. The COVID-19 pandemic has exacerbated many preexisting risk factors for adolescent substance use, such as early life stress, social isolation, school connection, and boredom. Other effects include the potential for arrest in adolescent development, which can occur when there is disruption in expected developmental milestones. New cohorts of adolescents who may not otherwise initiate substances may now be at risk. The pandemic is also straining family systems, with potential for increased conflict and relapse that can occur in a bidirectional fashion. In parallel, the way in which we treat substance use disorders in youth has also shifted, with a dominance in digitally based platforms for delivery of most outpatient treatment. Challenges to utilizing virtual technology include fewer means of monitoring substance use remotely; privacy concerns; and ease of nonadherence with treatment by signing off the computer. Practitioners can utilize considerable opportunities for virtual care to reach adolescents at risk of developing a substance use disorder and/or those who may already have relapsed. Primary care providers and other general practitioners who frequently interface with youth should increase their baseline screening of youth.

The COVID-19 pandemic has caused a significant disruption to everyday life for individuals of all ages. In addition to adverse health outcomes directly associated with the virus, the world has suffered devastating secondary effects, including increasing rates of unemployment, a disruption to food supply chains, and a conversion from in-person to virtual communication. We are only at the beginning of witnessing the long-term psychological consequences for our population. While the pandemic has undoubtedly afflicted all sectors of society, there is growing concern of more persistent, lifelong effects that youth may experience. This brief commentary seeks to address the potential impact of the COVID-19 pandemic on the prevalence and treatment of adolescent substance use.

1. Changing risk and protective factors for substance use

Adolescence spans a period of great change across areas of physical, cognitive, and social/emotional development. This transitional stage can also be a time of significant psychiatric vulnerability. Early life stress, social isolation, and boredom are known external risk factors for the development of depression and substance use disorders (SUDs) in youth (Hall-Lande et al., 2007; Kirsch et al., 2020; Wegner & Flisher, 2009). In attempts to contain the pandemic, many normally developing adolescents have had limited engagement in socially meaningful activities. Initial reports indicate that the frequency of alcohol and cannabis use in some adolescent populations has increased in the context of social distancing during the pandemic (Dumas et al., 2020).

Research has found that school life and how connected an adolescent perceives themselves to be to their academics and to their school environment influence the likelihood of developing an SUD in late adolescence (Bond et al., 2007). High school graduations were cancelled or held virtually, music concerts and sporting events are not taking place, and large social events have been postponed or cancelled. Many of these events serve as developmental milestones and represent a way of marking the passage of time and symbolize increasing independence, achievement, and individuation for youth. Youth who have experienced an arrest in their development during critical time periods are at greater risk of using substances as a perceived way of coping (Andersen & Teicher, 2009). Unfortunately, the social and developmental impact of the pandemic may be creating a new cohort of youth at risk for substance use and in eventual need of services, while exacerbating use in those already at elevated risk of an SUD.

Many youth have spent an increasing amount of time within their household as a measure of reducing the risk of infection from COVID-19. Exposure to the use of alcohol and other drugs, especially in the family system, can be both a risk factor and trigger for adolescent substance use. An estimated 1 in 8 U.S. children aged 17 and younger already live in a household where at least one parent has an SUD (Lipari & Van Horn, 2017). Early data indicate an additional surge in substance use behaviors among adults during the pandemic, including opioid overdoses (Slavova et al., 2020). The risk of one person's relapse impacting another's sobriety is further compounded by the medical risk associated with the lack of social distancing. Suddenly, one member's relapse now carries with it both a medical (COVID-19) and psychiatric risk (relapse, safety concerns) for others in the home.

Conversely, while the pandemic is likely to largely negatively impact youth, there are some potential advantages for a small subset of at-risk adolescents. Research has shown social networking to be a significant means for initiation and continuation of substance use (Balsa et al., 2011; Cheadle et al., 2015; Christakis & Fowler, 2008). Some adolescents observing social distancing may inadvertently remain protected from social situations that would have otherwise lead to an initiation of substance using behaviors. Access to substances may also be limited for some who are sheltering in place at home, leading to a potential reduction in use of substances for a minority of adolescents.

2. Potential opportunities and future considerations

Adolescent SUDs remain prevalent and significantly undertreated (Substance Abuse and Mental Health Services Administration, 2019). Only about 8% of adolescents between the ages of 12 and 17 who meet criteria for at least one SUD receive specialized treatment each year (Substance Abuse and Mental Health Services Administration, 2019). The advent of the COVID-19 pandemic will likely exacerbate an already critical need for treatment during adolescence. New cohorts of teens at risk must be identified and referred for treatment. Pediatricians and other primary care physicians should be vigilant in their screening for substance use during routine, annual check-ups and vaccinations. Practitioners should also regularly administer 12-panel urine screens to assist with identifying those who may require further intervention. Resilience building (Hodder et al., 2017) and increased therapeutic support in the form of weekly group treatment or referral for individual therapy can assist youth who are otherwise healthy, but find themselves unexpectedly at a crossroad.

Many adolescents with SUDs are likely to first present to treatment for other difficulties, such as their anxiety or depression, or through the criminal justice system (Aarons et al., 2001). Given the scarcity of treatment resources available within specialized programs, general psychiatrists or adolescent practitioners must be creative in implementing basic substance-related programming, such as adding a motivational interviewing group or a relapse prevention group into existing psychiatric care. Efforts to engage family members or support parents through skills-based learning can also assist indirectly with treating adolescents with SUDs (Godley et al., 2014). This is an opportunity to utilize a dual diagnosis model of treatment to meet the demand.

A switch to virtual care also provides a hidden opportunity to expand access to adolescents who might not otherwise be able to reach such programming in person. Many states are waiving licensure requirements and allowing licensed medical practitioners to provide telehealth treatment to patients residing in other states (American Psychiatric Association, 2020). Institutions and groups of practitioners should be encouraged to consider investment in group-based virtual programming, such as a short-term, partial hospital program or establishing intensive outpatient services (AMA, 2020). Some insurance companies are also providing flexible reimbursement for such virtual services, which cannot be safely delivered in person at the moment. The Drug Enforcement Agency (DEA) has also modified guidelines around buprenorphine prescribing to allow practitioners to evaluate patients with opioid use disorders via telehealth, without requiring them to first be seen in person prior to prescribing buprenorphine (DEA, 2020). Unfortunately, there has been a dearth in available treatment centers that offer medication for opioid use disorder to adolescents (Hadland et al., 2020). Virtual services can potentially expand access to adolescent patients with opioid use disorders to the critical treatment that they need.

Creative collaboration efforts and new guidelines might help to overcome some of the current challenges in providing care for this age group through the use of virtual platforms. Sensitive conversations about drug use may be more difficult when other family members are present in the household and can impede the ability of the examiner to create a strong therapeutic alliance with the patient. Adolescents also have the option of easily signing off if they do not wish to engage or avoid direct discussion of their substance use. Traditional monitoring of urine toxicology screens has largely become unavailable. The use of home administered urine drug screens for adolescents is somewhat controversial, due to a perceived invasiveness, loss of privacy, and boundary violation between parent and adolescent. Parents are also often unequipped to interpret results. Some potential solutions to these challenges include requiring an adult to be present in the home while administering virtual programming, collaborating with primary care physicians to obtain urine toxicology screens, and clarifying expectations with families about privacy prior to the start of any virtual care.

Youth may need to consider more restrictive treatment options if parents cannot safely manage or monitor them at home using virtual services. Many residential programs have remained open and available for adolescents who need to be treated away from home and in a more structured setting. Youth with co-occurring mood disorders, executive functioning disorders, substance use, and/or safety concerns may be more likely to necessitate such interventions. Inpatient care is reserved for patients with both acute safety concerns, as well as ongoing risk factors within the home setting, such as a high likelihood of relapse or accidental overdose.

Future data and research will be necessary to fully discern the impact this pandemic has had on a new generation of adolescents. In the interim, treatment considerations should focus on adolescents who are most at risk of relapse or of an exacerbation of their use. This includes identifying families who may be at higher risk, by virtue of multiple members within the same household having an identified SUD. Practitioners should consider any and all means of accessing and interfacing with these youth and their families, including with virtual programming and addressing other co-occurring psychiatric symptoms, such as depression and anxiety.

CRediT authorship contribution statement

Author 1 (Corresponding author): Dana Sarvey, MD

Conceptualization, writing-original draft preparation, writing-reviewing and edits

Author 2: Justine W. Welsh, MD

Conceptualization, writing-reviewing and edits

Declaration of competing interest

Dr. Justine W. Welsh had received consulting fees from Analgesic Solutions and training fees from Chestnut Health Systems.