Adolescents’ experiences with substance use: risks, protective factors and interventions

Abstract

Background

This study aimed to explore adolescents’ experiences with substance use and to identify risk, preventive, and protective factors, as well as the intervention processes from their perspective.

Methods

Adopting a phenomenological qualitative approach, in-depth semi-structured interviews were conducted with 21 adolescents (ages 14–18) who had been using substances (excluding cigarettes and alcohol) for over one year. Participants were selected using criterion and snowball sampling methods. The data were analyzed through thematic analysis.

Results

Analysis revealed four main themes and twelve sub-themes: Risk Factors (including peer influence, family dysfunction, and trauma/psychosocial adversity). Preventive Factors (such as adolescent awareness, family recognition, and school-based teacher leadership). Protective Factors (including social skills, intrinsic/extrinsic motivation, and positive family interaction). Interventions (involving parent education, psychosocial interventions, and psychotherapies).

Finding

Findings indicated that adolescents’ substance use is influenced by complex individual, familial, and environmental interactions. Moreover, the results highlight that both international literature and literature from Turkey converge in showing the negative biopsychosocial impacts of substance use among youth.

Conclusion

The study underscores the multifaceted nature of substance use among adolescents, pointing to the importance of developing culturally informed, multi-level interventions that target risk, reinforce protective mechanisms, and enhance access to treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-025-03125-w.

Introduction

About 5.1% of people worldwide has alcohol use disorders (AUDs) [1], and about 35 million people has druguse disorders [2]. Meanwhile, about 37.9 million adults suffer from SUDs that is marked by repeated abuse of drugs and/or alcohol and result in mental and behavior impairment [3]. With regard to the situation in Turkey, the report, which was based on data from 31,406 people “reporting ever having used a substance” in 2022, shows that 31.6% of substance users have at least a high school education. Average age at first use is 21.99, and average and most frequent age at relapsing is 20 [4]. According to the 2022 report by the Turkish Monitoring Centre for Drugs and Drug Addiction (TUBIM), the average age of first substance use in Turkey is 21.99 years. However, the 15–24 age group remains the most vulnerable, accounting for 69.6% of new users in 2022 [5]. While these statistics reflect nationwide trends, data specific to the province of Bingöl is relatively scarce in the academic literature. Nevertheless, reports from the Bingöl Provincial Police Department and local healthcare institutions indicate an increasing trend in substance use disorder, particularly among high school-aged adolescents. The 2023 Annual Activity Report of the Bingöl Provincial Health Directorate indicates that 22% of adolescents referred to mental health services in the province were referred due to substance use disorder-related problems [6]). This risk appears to be especially pronounced in socioeconomically disadvantaged neighbourhoods within the urban centre, where parental supervision is limited, social support mechanisms are inadequate and school disengagement rates are high. In addition to these data, what is more worrying is that in the Global Burden of Disease (GBD) study conducted among adolescents and adults in 2016, it was stated that approximately 14% of the total health burden in young men was due to alcohol and drug use [7]. Adolescents are the most vulnerable group to addiction [8]. It has been stated that the most critical age to start using drugs is adolescence, and the maximum drug use is seen in young people between the ages of 18 and 25 [9].

Adolescence is a time of high experimentation, curiosity, susceptibility to peer pressure, rebellion against authority, risk of danger, emotional instability, and low self-worth. Because of these characteristics, adolescents may be vulnerable to drug use [7]. On the other hand, adolescence has been suggested to be the birth of adult addiction, with more than 90% of adult addicts initiating substance use disorder during adolescence [10]. Similarly, adolescent substance use disorder is associated with psychosocial or mental health problems in adolescence and adulthood [11]. For example, in a study of 12,000 adolescents, profiles of substance use disorder and emotional and behavioral mental health symptoms were identified [12]; approximately 20% of adolescents were in profiles high in both substance use disorder and mental health concerns (combining three profiles that differed in heavy drinking, cannabis, and tobacco smoking patterns), 20% was in profiles high in mental health symptoms only (i.e., depression and anxiety), and 60% was in profiles low in both. This study shows that a significant proportion of adolescents use more than one substance and also experience a variety of emotional and behavioral symptoms. In addition to direct health risks, substance use disorder has been associated with self-harm and suicide [13] and risky sexual behavior [14].

Theories suggest that the emotion and reward systems (e.g., amygdala, nucleus accumbens) develop before the cognitive control systems (e.g., prefrontal cortex), and thus the propensity to engage in risky behaviors, including substance use disorder, during adolescence creates an “imbalance” in brain development [15]. In particular, alcohol and cannabis use during adolescence has been associated with a range of poor cognitive outcomes. In a study of a sample of 243 healthy adolescents aged 13–17 years, greater alcohol and cannabis use was associated with poorer verbal memory, visual and spatial functioning, and problems with psychomotor speed [16]. Indeed, a longitudinal study of adolescents who used cannabis and alcohol reported that substance users performed worse than non-users on tests of attention, memory, processing speed, and visuospatial functioning, including performance in various cognitive domains [17]. Although adolescent substance use disorder has been associated with a number of structural and brain changes (reduced gray matter volume, particularly in the frontal and temporal regions) and has been reported to affect abnormal neurodevelopmental trajectories, research has emphasized that it causes emotional (e.g., depression), interpersonal (strained relationships), physical (accidental injuries), and poor academic performance [18, 19]. It is even reported that adolescents are not only unable to learn in the school environment due to addictive substances, but are also at risk of long-term cognitive and memory loss.

There are many risk factors that contribute to substance use disorder among adolescents. These factors include family dysfunction, parental substance use, mental health issues, peer pressure, and traumatic experiences at an early age. Familial risk factors include childhood maltreatment (including abuse and neglect), parental or family substance use disorder, parental marital status, parental education level, parent-child relationships, family socioeconomic status, and the child’s perception that parents approve of substance use disorder [20]). In addition to parental and peer influences, schools also play an important role in shaping adolescent substance use disorder behaviors [21]. Schools are an important social context that creates opportunities for social learning about substance use disorder behaviors because teachers, peers, school staff, and policies promote social norms related to substance use disorder [22]. This social context is not only conducive to adolescents’ mental health and development, but it can also create an environment that is conducive to addiction. In fact, it has been emphasized that adolescents who attend schools where substance use disorder among students is common are more likely to use substances and more likely to attempt to use substances [23, 24].

Past maltreatment of adolescents has been found to be positively associated with their substance use, and a history of past physical abuse has been found to be associated with adolescent substance use disorder, although the evidence is limited to the female gender [25]. In fact, being a victim of physical or sexual assault has been reported to increase the risk of substance use disorder involvement by a factor of two to four [26]. Other important risk factors for substance use disorder among adolescents include early exposure to traumatic life events [27], lack of parental supervision and monitoring [28], high levels of impulsivity [29], involvement in romantic relationships at an early age [30], and co-occurring psychopathology, including ADHD and depression, has been shown to significantly increase the risk of alcohol use in adolescents [31, 32]. On the other hand, posttraumatic stress disorder (PTSD) has also been found to be associated with an increased likelihood of developing a substance use disorder, particularly with cannabis or hard drugs [33].

Previous studies examining the associations and risk factors for substance use disorder has identified many variables that is associated with a reduced risk of substance use disorder. These variables is referred to as “protective factors. For example, it has been emphasized that high self-esteem, religiosity, courage, peer factors, self-control, parental supervision, academic competence, anti-drug policies, strong neighborhood ties, positive family relationships, and attachment can prevent initiation of drug use [34–39]. On the other hand, the absence of protective factors and the presence of risk factors may predispose youth to substance use disorder. Therefore, protective factors is crucial to help adolescents reach their full potential and be healthier in the transition to adulthood. In this context, this study will shed light on the latest trends in risk and protective factors and lead to key focus areas for prevention and control programs. While it is important to focus on risk and protective factors in adolescent substance use disorder, the treatment and therapy processes of adolescent substance abusers should not be ignored. It is well known that an addicted adolescent creates multiple users. In other words, while risk, preventive and protective factors is important, intervention (treatment and therapy) also has an important place in the process of combating addiction. All of these processes indicate that adolescents need significant support in both protecting their mental health and in the educational environment in which they find themselves. In order to provide this support, it is important to first identify this period and the important risk and protective processes of this period.

Multiple treatments for adolescent substance use disorder is effective, including cognitive-behavioral therapy (CBT), the adolescent empowerment approach, family-focused treatments (FFT), motivational enhancement therapy (MET), and a combination of CBT, MET, and various FFTs [40, 41]. Because adolescent substance use disorders is heterogeneous and multidetermined, treatment approaches that address multiple biopsychosocial goals is often indicated [42]. However, there are a number of important issues that need to be addressed if young people with substance misuse problems are to benefit from these treatments. First, because of stigma, adolescents with substance abuse may face barriers in many areas, from seeking treatment to participating in social life. In recent years, research on stigma among adolescents with substance dependence has shown that the stigma perceived by these adolescents in their social environment and families can negatively affect their recovery process. Studies comparing levels of internalised stigma in people with different mental disorders show that people with substance use disorders experience the highest levels of stigma [43, 44]. This stigma may negatively affect individuals’ motivation to engage in treatment and the level of social support they perceive. In fact, a study conducted by Tanrıverdi et al. [45] found that treatment motivation and perceived social support among individuals with substance use disorders were at moderate levels. In addition, family relationships were found to have a significant effect on adolescents’ self-efficacy to protect themselves from substance use [46]. Another concern is the risk that adolescents will not complete the treatment programmes in which they participate. This is because most of these adolescents enter treatment due to external pressure from the school or juvenile justice system. Therefore, it has been reported that adolescents with low motivation to change do not perceive treatment as appropriate for them [47]. On the other hand, it has been suggested that practical concerns such as comfort, convenience, preparation, time, and transportation are also important barriers to benefiting from treatment, and the way to address these barriers is to bring mental health and substance abuse treatment into school [48]. In addition, school-based treatment can remove some of these barriers and improve treatment access and completion rates, leading to better clinical outcomes. In this context, the purpose of the study is described below.

This study occupies a unique position in the literature as it is conducted within the sociocultural context of Turkey and examines the experiences of adolescents who have used substances, as recounted by the adolescents themselves. These experiences are influenced by the indirect interventions of mental health professionals working in the field. Cultural values, family structures, social norms and service models that are unique to Turkey directly influence the visibility and functionality of risk and protective factors related to substance use. In this context, the study not only addresses experiences at the individual level, but also reveals how these experiences are interpreted within adolescents’ social environments, including family, school and neighbourhood settings. Furthermore, conducting the research in a socioeconomically disadvantaged province in eastern Turkey adds significance, enabling a contextual analysis of how regional and cultural differences shape risk, protection and intervention processes. For these reasons, the present study aims to generate original findings at micro (individual) and macro (cultural and structural) levels, contributing to the limited body of culturally informed research on substance use disorders within the national context.

The primary aim of this study is to conduct an in-depth examination of the experiences of adolescents with substance use in a socioeconomically disadvantaged province in the Eastern Anatolia Region. The study will focus on the risk, preventive and protective factors that influence this process, as well as the intervention processes that the adolescents have experienced, as recounted in their own narratives. The secondary objectives are structured as follows:

Identifying individual, familial and environmental risk factors influencing the initiation of substance use among adolescents.

To describe the protective and preventive factors experienced by adolescents in relation to substance use prevention.

To reveal the psychosocial and therapeutic intervention processes that adolescents have undergone.

The study will also contribute to the development of culturally sensitive prevention and intervention strategies based on the research findings.

Method

Research design

This study was designed as qualitative phenomenological research to explore in depth the experiences of adolescents with substance use, including the associated risk and protective factors, and intervention processes. Phenomenology is a qualitative approach that focuses on the subjective experiences of individuals and the meanings they attribute to specific phenomena [49]. In this context, the study aimed to uncover how adolescents describe and make sense of their experiences of substance use.

The research was grounded in a constructivist epistemological framework, which posits that knowledge is co-constructed through individuals’ social, cultural and personal experiences. According to constructivism, reality is not fixed, but shaped by multiple perspectives and contextual interpretations [50, 51]. Accordingly, this study aimed to understand how participants construct and interpret their substance use experiences within their specific socio-cultural contexts. The constructivist paradigm is particularly well-suited to researching sensitive and socially complex issues, such as addiction, trauma or social exclusion, because it emphasises the co-constructed nature of meaning and recognises the active role of researcher-participant interaction [52]. This approach closely aligns with the research questions and objectives of the current study.

Participants and study group

The study group consisted of 21 Turkish adolescents (12 females and 9 males) aged between 14 and 18, all of whom reported substance use disorder (excluding cigarettes and alcohol) or a history of substance dependence. In line with the principles of qualitative research, particularly studies focusing on hidden or stigmatised populations, purposeful sampling was employed. Specifically, a combination of criterion and snowball sampling techniques was employed [53].

In the first stage, criterion sampling ensured that all participants met the following inclusion criteria: (1) being aged 14–18; (2) holding Turkish citizenship; and (3) having engaged in non-alcohol/non-nicotine substance use disorder, either currently or in the past. In the second stage, snowball sampling was employed to recruit additional participants via referrals from those already involved in the study. This method is particularly valuable for reaching vulnerable groups who might otherwise be inaccessible due to stigma or institutional barriers [54]. To ensure ethical and coordinated access to participants, the study was conducted in collaboration with school counsellors and the school administration in selected public high schools. These professionals helped to identify eligible students based on the sampling criteria and facilitated contact with families. Ethical approval was obtained from the Scientific Research and Publication Ethics Committee of Bingöl University (approval no. E33117789/730.08/140964, date: 12/01/2024), and all procedures were carried out in accordance with the ethical standards of the Declaration of Helsinki [55].

This ethical framework aimed to protect the rights, dignity and autonomy of underage participants involved in research on sensitive topics [56, 57]. The collaborative recruitment process involving school counselling staff also ensured that participants had access to psychosocial support during or after the research process if needed.

Prior to participation, written informed consent was obtained both from the adolescents and their parents or legal guardians. The informed consent forms explained the purpose of the study, its voluntary nature, the confidentiality of the data and the participants’ right to withdraw at any time without consequence. Additionally, all participants explicitly consented to the publication of their direct quotations on the condition that their identities remain confidential. Upon request, it was clearly stated that all data collected would be used solely for the purposes of this research and would not be shared with third parties. Participants’ identities and any potentially identifying information were anonymised during transcription and reporting. Additionally, the demographic characteristics of the participants including age, gender, education level, living environment, family structure and duration of substance use are presented in detail in Table 1.

Table 1.

Demographic data of participants

Participant Code	Age	Gender	Education Level	Living Environment	Family Structure	Duration of Substance Use
P1	17	Female	11th Grade	Urban – Low SES	Divorced parents	2 years
P2	15	Male	9th Grade	Rural	Nuclear family	1 year
P3	16	Female	10th Grade	Urban – Middle SES	Extended family	1.5 years
P4	18	Male	High school graduate	Urban – Low SES	Single parent (mother)	3 years
P5	14	Female	Middle school graduate	Rural	Nuclear family	1 year
P6	17	Female	11th Grade	Urban – Low SES	Divorced parents	2 years
P7	15	Male	9th Grade	Urban – Middle SES	Nuclear family	1.5 years
P8	16	Female	10th Grade	Rural	Single parent (father)	2 years
P9	17	Male	11th Grade	Urban – Low SES	Extended family	2 years
P10	14	Female	Middle school graduate	Rural	Nuclear family	1 year
P11	15	Male	9th Grade	Urban – Low SES	Divorced parents	2 years
P12	16	Female	10th Grade	Urban – Middle SES	Nuclear family	1.5 years
P13	17	Male	11th Grade	Urban – Low SES	Single parent (mother)	3 years
P14	18	Female	High school graduate	Rural	Extended family	2.5 years
P15	15	Male	9th Grade	Urban – Middle SES	Nuclear family	1 year
P16	17	Female	11th Grade	Urban – Low SES	Divorced parents	2 years
P17	16	Female	10th Grade	Urban – Low SES	Single parent (father)	1.5 years
P18	14	Male	Middle school graduate	Rural	Extended family	1 year
P19	18	Female	High school graduate	Urban – Middle SES	Nuclear family	2 years
P20	16	Male	10th Grade	Urban – Low SES	Divorced parents	2 years
P21	17	Female	11th Grade	Rural	Single parent (mother)	2 years

Table 1 presents data from 21 adolescents (11 females and 10 males) aged between 14 and 18 years old. Most participants are currently enrolled in high school (n = 17), while the remaining four have either completed middle school or high school. 12 live in urban low SES areas, 5 in rural areas, and 4 in urban middle SES areas. Family structures include 8 nuclear families, 6 divorced parents, 4 single parents, and 3 extended families. The duration of substance use disorder ranges from 1 to 3 years, with an average of approximately 1.9 years.

Data collection tools and procedures

Within the scope of the research, it is necessary to meet the criteria of the research (being in the age group of adolescents (between 14 and 18 years old), being a Turkish citizen, and being a substance user (except cigarettes and alcohol) or substance addict). Qualitative interviews were conducted with 21 participants. In order to conduct in-depth interviews, a semi-structured interview form was prepared by the author, a psychological counselor and a psychologist specialized in substance use disorder. Some questions in this form is as follows can you briefly tell us about your process of getting involved with the substance? What was the reasons that led you to use substances - What do you think is the greatest risks? What would has prevented you from becoming an addict or user? What prevented you from getting worse (ability to manage and regulate emotions, religious beliefs, importance of faith and authoritarian parenting)? What has substance use disorder done to your life (what has changed)? What do you need to stop? How has new lifestyles and trends influenced your substance use disorder? What recommendations do you has for your peers? In addition, the sample size was set at 21 to ensure data saturation and in-depth analysis due to the nature of qualitative research. In qualitative studies, information density and diversity of participants are more important than sample size [58]. In this study, a sample of 21 participants was considered sufficient by selecting participants who were appropriate for the purpose of the research, experienced and able to offer different perspectives. Furthermore, it was observed that this number was appropriate due to the emergence of recurring themes and lack of new information (saturation) during the data collection process [59]. The interview form used in the study was developed for this study and has not been previously published elsewhere.

Prior to data collection, a pilot interview was conducted (by the author) with 2 people who met the participant criteria to evaluate the interview form. After the pilot study, no changes was made to the interview form and the people who participated in the pilot interview was not included in the study. The pilot study was conducted with two participants who were not included in the main research sample and had the same demographic characteristics as the target group, and was designed to assess the clarity of the interview questions, their fit with the research objectives, and time management [60]. Based on feedback from the pilot, two technical terms were supplemented with simple definitions, one question was narrowed and rephrased, and interview time was optimized [61]. However, the open-ended question structure was retained because it added qualitative depth, prominent themes in the literature were kept in the form because of their theoretical importance, and the order of the questions was not changed because it did not make a statistically significant difference [62]. Contributions of the pilot study to the main study included having an invalid response rate of less than 5%, strengthening the ethical emphasis, and ensuring methodological transparency [63]. This process was considered a critical stage that increased the validity of the research. After the pilot study, in-depth interviews was conducted with the participants. In-depth interviews was considered the most appropriate method to understand the experiences of adolescents who use substances, as they provide information about the risks adolescents face in relation to substance use disorder, protective factors, and intervention processes to protect themselves or be protected by various institutions in this process. All interviews was conducted face-to-face. Each interview lasted about 20 min. All interviews was audio-recorded and then transcribed verbatim by the author.

Data analyses

In this study, the data obtained from the participants was analyzed using thematic analysis. Thematic analysis is a systematic approach that aims to identify and interpret common themes in the data [64]. In this study, following the quality standards suggested by Braun and Clarke [65], a team of three researchers developed a codebook that combined inductive (data-driven, discovering new themes based on recurring patterns in the data) and deductive (theory-driven, creating codes based on a predetermined theoretical framework or concepts in the literature) approaches. In the inductive process, themes were derived from the natural structure of the data rather than from predetermined categories. In the first stage, open coding was used to mark important statements and then similar codes were grouped to form main and sub-themes. At this stage, by adopting the open-ended exploratory approach to data emphasized by Braun and Clarke [65], patterns in the transcripts were carefully examined and 12 new sub-themes emerged. In the deductive coding phase, four main themes (risks, prevention, protective factors and interventions) were defined as initial codes in line with the predetermined theoretical framework, a pre-coding template was created in MAXQDA software, and the data (e.g., interview transcripts and open-ended questionnaire responses) were screened according to this template [66]. The integration of the mixed method was designed to reflect the dialectical relationship between literature-based codes and data-based findings, and strategies such as reflexive note-taking and peer review suggested by Braun and Clarke [64] were employed to minimize researcher bias in this process. To ensure reliability of coding, team members independently coded three separate transcripts and then discussed the points of disagreement to achieve intercoder agreement. As a result of these discussions, the codebook was revised and finalized. The analysis process was completed at the point of data saturation where no new themes emerged [59]. The validity of the study was strengthened by 85% coder agreement, negative case analysis, and the analytical tools of MAXQDA. This approach was able to provide original findings that reflected the experiences of the participants, while maintaining theoretical depth.

The strategy for ensuring validity and reliability in qualitative research is expert or expert review [67]. In addition, an attempt was made to ensure the validity of the research by explaining the categories obtained by using the one-to-one statements of the interviewed participants [68]. On the other hand, in order to ensure the validity of the written interview questions prepared by the researcher and other experts, the form was submitted to expert opinion in terms of comprehension and level of coverage of the researched topic, and necessary corrections was made according to the feedback received. In terms of reliability, as emphasized by Creswell [69], the transcriptions of the data was checked by comparing them with the recordings. Some of the participants’ responses to the questions was presented as direct quotations. In the direct quotations, the information about the participants is given as participant number, participant group, and gender.

Results

Four themes and 16 sub-themes was identified as a result of the interviews with the participants and the data obtained from the interviews. Risk Factors, Preventive Factors, Protective Factors and Treatment. Information about the themes and sub-themes is shown in Fig. 1.

Fig. 1.

Themes and sub-themes

Sub-themes was created based on the analysis of the central themes that intersected with the axes deductively defined in each major dimension of the original model. Each subtheme was related to the main theme (Fig. 1). The results is presented below using verbatim quotes from the participants’ narratives.

Risk factors

This topic discussed various factors that increase the risk of adolescents becoming substance abusers, such as negative relationships within the family, the adolescent’s interaction with other peers, psychosocial events the adolescent has been exposed to in his or her past life, and new trends brought about by age. These risk factors, which negatively affect both the cognitive and emotional systems of adolescents, was found to significantly contribute to substance use disorder and increase the risk of developing this disorder. In almost all of the interviews with the participants, their relationships with themselves and others and the negative psychosocial events they experienced were mentioned as risk factors that directly influenced their substance abuse. This theme includes the following sub-themes: Peer Network, Family Risks, and the Impact of Psychosocial Events.

Peer network

During adolescence, the social groups in which adolescents often find themselves can influence their behavior, identity, and the values they discover. Changes in the emotional state of adolescents, especially during this time, can often make them reactive and prone to risk-taking. They may perceive social and family rules as an obstacle to their own development and therefore take on the responsibility of group dynamics in order to spend time with their peers and maintain their association with them, even if this involves risks and dangerous processes in some cases. “I started using substances because of my social friends and my environment. My family did not spend time with me, they did not teach me good things, they always stayed away from me, so I looked for attention from my friends outside and did what they told me to do” (P1). “The fact that the people around me made drugs innocent, that I was surrounded by people who used drugs all the time, and that it made me curious, made me use drugs and I became addicted’’(P2). One of the participants also explained that loneliness is not something that can be endured all the time and that drug use sometimes relieves loneliness and that it feels good to be treated as a human being by others: ‘’My close friends were using, so I learned from them, recognized them and started using. I couldn’t live my childhood, I was always beaten by my father after the age of eight, so I couldn’t live my childhood. When I got a little older, I started to turn to my friends. They showed more interest, so I got close to them and started using this substance (P3).

Family risks

This subtheme included descriptions of negative behaviors created by the experience of substance use disorder or addiction related to arguments, fights, family conflicts, family crises, and overprotective and overly demanding parental attitudes. Participants reported family miscommunication, parental indifference, oppressive family relationships, and a variety of disturbing and distressing behaviors and emotions that damaged important family relationships. In the long term, dysfunctional family relationships may imply a risk for substance use disorder and addiction in the dimension of ‘relating to others’. First, they talked about being unsupported and even ignored by their parents because of the difficulties they faced in adolescence. For example, “How a parent teaches his child good things, spends time with his child, but I did not experience these things. Emotionally, I always lived far away from my parents, I never received any attention from my parents. In short, I could not live my childhood to the fullest(P4). Similarly, one of the participants “When I came home from school in the evening, my father always warned me, saying, ‘You are a child, you should not come home late,’ and he used violence against me and my mother remained silent (P5). On the other hand, during this period, the adolescent’s desire to declare his or her independence and to get rid of the pressure of the family directs him or her to the external environment. This causes anxiety and worry in the family. For example, “My father was very conservative about spending time with my friends, he would say: ‘You are a teenager, you cannot be trusted, I am watching you, you cannot communicate with anyone without my knowledge. This caused me pain, but I don’t want pain and suffering in my life (P7).

Impact of psychosocial events

This subtheme refers to youth’s experiences and narratives about the psychosocial events that led to their substance use disorder or addiction. In their stories, participants talked about previous experiences of bullying, abuse, being a child of a broken family, having a substance abuser in the family, and being incarcerated for various crimes. Psychosocial events can put adolescents at risk for substance use disorder and accelerate the process. This can be a process associated with psychosocial events and at the same time an indicator of new risks for the adolescent. For example, one of the participants described his process as follows: “I went to jail for a crime. I met people in prison who were serving time for drugs, fraud, murder. I was bullied by them, and after I got out of prison, I couldn’t get the bullying out of my mind. I started using substances, which is the easiest way to calm my mind” (P9). On the other hand, one of the participants was the child of a broken family and described his situation as follows: ‘‘He explained that life was a great pain for him, a process that destroyed all his skills, talents and hopes for life. It was the pain, loneliness and orphanhood I experienced here that led me to the substance’’ (P11).

Prevention factors

This theme includes narratives detailing the measures that can be taken to prevent adolescents from becoming addicted and substance users from worsening their situation, as well as the vital efforts made to overcome addiction. In a sense, it is to emphasize the preventive mental health of adolescents who are substance users or addicts and to take measures to address it. Preventive factors, on the other hand, is aimed at adolescents who are already using substances and serve to reduce or stop substance use and prevent other risky behaviors. That is, these factors target individuals who are at high risk for future substance use because of personal or environmental factors, such as being a child of addicts or living in a neighborhood or school environment where drugs is readily available. This theme includes the following sub-themes: Adolescent Awareness, Family Awareness, and School-Based Teacher Leadership.

Adolescent awareness

This subtheme includes statements related to adolescents’ awareness of their ability to achieve goals that is important to them and to protect their mental health. Participants’ statements reflect the importance of learning meaningful things in their lives in order to feel useful and responsible. This could be related to overcoming a challenge, such as becoming a substance abuser, or achieving a goal that provides personal satisfaction, both in terms of recognizing their strengths and recognizing their weaknesses and being able to correct them in order not to become a substance abuser or addict. The participants emphasized the importance of recognizing their strengths and abilities in order to achieve positive results with their knowledge in the field of substance abuse. ‘’I play football very well, I want to be recognized and improve in this field. If there were experts who could both help me and make me realize my potential in terms of my skills, I don’t think I would be like this (i.e., I wouldn’t be addicted)’’ (P6). Similarly, “I don’t know how to get away from the negative environment of friends around me who use substances, or how to get healthier information about the harms of substances. If I had this information, I wouldn’t be so curious about drugs and I wouldn’t envy those who use them (P8). As stated here, it is recommended that comprehensive awareness-raising activities targeting adolescents, parents and other family members should be carried out in schools and social settings in order to recognize the harmful factors of frequent substance use among adolescents and to contribute to preventive factors to stop substance use before it becomes a habit.

Awareness of family

This sub-theme aims to determine whether parents has knowledge or awareness of substance use among substance-dependent adolescents. Adolescent substance use has been found to affect adolescents in two ways. One is the parents’ attitudes and behaviors specific to substance use, which are important links to adolescent substance use, and the other is the lack of parental awareness of adolescents who use substances. At some point during the interviews, almost all participants expressed that their substance use was not only a self-destructive behavior, but also that their parents was not aware of the situation, lacked parental support, had suicidal thoughts, and were psychologically negatively affected. Ahmet, who was constantly under the influence of substances and also suffered from impulse control disorder, said: “I can’t concentrate during the day, sometimes I resort to violence because I can’t control myself, but my parents don’t know about it and I can’t tell them. However, if my parents had paid attention to some of my behaviors, they would have known that I was not well” (P13). “My parents didn’t care about me, they didn’t realize that I was suffering’’(P10).

School-based teacher leadership

This sub-theme includes narratives that students who is failing, disinterested in school, absent, and unable to develop and maintain relationships with teachers is more likely to use substances. In this case, teacher competence, the teaching-learning process in the classroom, and substance prevention processes in the school environment come to the fore. On the one hand, the teacher’s self-efficacy in the educational processes, on the other hand, the teacher’s high awareness of substance abuse and therefore taking initiatives towards students who is addicts or users is important in terms of preventing substance abuse. In this regard, it is important for teachers to have adequate training on substance abuse and to lead both their school’s prevention program and classroom-based instruction. One of the participants, a student, said the following about teachers “Teachers can talk about the harms of substances in the classroom, it would be healthier if they talk openly about the negative aspects of substance use instead of hiding them. It is forbidden and illegal to use it at school, and because it is illegal, people quickly fall into that trap’’ (P12). Similarly, one of the participants, who is constantly truant and absent from school, said: “Teachers need to learn about the social, psychological and environmental problems that adolescents face and the new trends that these problems bring with them. New trends in particular attract more attention because of the illegal nature of the substance and the high level of acceptance among friends (P14). Other narratives suggest that the use of substances to be socially accepted by others and to be appreciated by peers is seen as intense. This is where the role of the teacher becomes very important. ‘’Drugs are made innocent and shown to people as something relaxing. They make drug use look like an achievement. However, teachers do not intervene or warn against this situation’’ (P15). In addition to all this, it was emphasized that the supervisory role of teachers in schools should be brought to the forefront. He said the following about the role of teachers in supervision “There should be more supervision in schools. If not once a week, then once a month, children should be given a blood test (done by health workers through the teacher) and then friends who use substances will inevitably come out. In this way, they can be given both psychological support and normal family support” (P15).

Protective factors

This theme includes variables associated with reduced risk of substance use, narratives that reduce the likelihood of substance misuse, and increased individual resilience to substance use. Participants indicated that they had some strong characteristics that prevented the negative effects of substance use (e.g., impaired personality, worsening mental health, poor self-perception) from worsening. Participants was asked, “What prevents or protects you from getting worse?” and the responses showed that there is situations that protect them. On the other hand, participants reported that their personal experiences and the education they received at school or in the family helped them to protect themselves and to reduce the pain and suffering caused by the substance to some extent. This theme includes the following sub-themes: social skills, the role of intrinsic and extrinsic motivation, family-based interaction.

Social skills

This sub-theme includes narratives that refer to the ability to communicate openly, the ability to overcome shyness, initiating social interactions, saying no, rediscovering oneself through social activation, meeting new people, making new friends, building healthy relationships, making demands, rejecting negative and unreasonable demands, and defending one’s rights. Almost all the participants spoke about the process of reorganizing their lives and overcoming the experience of drug abuse. On the other hand, they also mentioned some individual characteristics that protected them from developing substance abuse habits. These protective factors included self-confidence, religiosity, courage, self-control, parental supervision, academic achievement, and strong neighborhood ties. One of the participants spoke about the need for a process of self-regulation and the development of positive social relationships: “The most important turning point for me was that the local authorities created appropriate spaces for me to engage in social activities and sports and to develop my skills in this area“(P16). Similarly, ‘’After I got addicted and as long as I didn’t use, I felt sad, frustrated and angry. I would regret it all the time, but I would use again. Despite all this negativity, and despite the fact that it was destroying my mental health, sometimes using made me feel good. When my father realized this and told me that it was religiously forbidden and that Allah would punish those who engage in haram, I started to move away from using substances (P18). On the other hand, one of the participants talked about a communication skills course he attended and how it helped him develop new thoughts and behaviors, which in turn gave him new skills: “I rediscovered myself as an individual. My self-confidence improved, I learned how to say no. In fact, these realizations increased my academic success (P2). One of the participants also mentioned religious faith as an important protective factor that can prevent adolescents from getting involved in drug use: “I grew up in a strict religious family. I thought about what my family would say if they found out I was using drugs. I decided to stop so as not to disappoint them, and I reduced my use significantly. My faith influenced me (P2).

Family-based interaction

This sub-theme is defined as the interaction between family members and the adolescent who uses substances that is based on a solid foundation and at the same time strengthens the relationship between parents and adolescents, and even parents who support the adolescent against substance use. They explained that if the adolescent spends enough time with family members, especially parents, and feels understood by family members, it will protect them from getting worse while using substances. “Spending time with my family and especially with my parents, when I spent time with them, they told me about their beliefs and how to protect myself from negativity. They often told me what to look for when choosing my circle of friends (P17). Similarly, one of the participants said the following: “When you use substances, you don’t care about school anymore. You don’t want to go to school, even if you do, you sleep, you are academically disconnected from education. Both my drug use and my family’s negative attitude towards me, the fights between us, my growing loneliness and loss of socialization within the family, made me change. Over time, I became closer to my family and they adopted me, which brought about many changes (P9).

The role of intrinsic and extrinsic motivation

Motivation is the desire to restore impaired life functions. In addition to the processes that motivate addicted adolescents to use substances, there is also certain motivational processes in the decision to quit. In this subtheme, there is narratives about the ability to realize the pleasure of regaining impaired life functions and the ability to enjoy daily life. In particular, participants associated intrinsic motivational processes with the desire to regain impaired life functions and to reengage in life. One of the participants explained that the desire to re-engage in life enabled her to learn new things and value her own life, contrary to how she had felt before: “Later, when I used it around friends, I realized that I was always falling behind, I could not present my ideas on topics. If I had an idea, I was always reluctant to present my ideas. Maybe it was wrong, or my friends would misunderstand it, it somehow helped me and calmed me down. Then I would think about it and decide that it would not go that way. In fact, the fact that the substance affected me badly helped me in a way to wake up and look at life differently (P21).’’ On the other hand, One of the participants stated that extrinsic motivation is as important as intrinsic motivation when it comes to quitting the substance, saying: “I can say that my emotional control is better, but the most important thing is that a person can love and fall in love. I mean, I experienced something like that, I fell in love, and the person I fell in love with asked me to stop using, and I stopped using (P4). Sometimes, when substance use affects the individual’s mental and physical health, the individual may feel the need to stop, or the fact that the affected aspects is ridiculed by those around them may also lead to quitting. For example, “After a while, when I started using substances, I started having problems sleeping, eating and drinking. In fact, the substance I was using stimulated my appetite and I started eating more and more. I started to get fatter and uglier and my friends started to make fun of me. This situation became an incentive for me and I stopped using. Although it is not the same as before, I occasionally use again (P19).

Treatment

This theme includes narratives about the elements of substance abuse treatment, participants’ experiences with treatment, family support and education, and psychosocial support. During the interview process, participants talked about the pain and psychological damage caused by substance abuse and the themes that helped them reconnect with life. The following sub-themes are included in this theme: Parent education, psychosocial interventions, and psychotherapies.

Parent education

Parent education has an important place in the prevention of substance abuse among adolescents or as a preventive measure for adolescents who abuse substances. In addition, parental education has an important place in the intervention or treatment of adolescents who are addicted to substances. The important turning point here is that while intervening with the addicted adolescent, the parents of the addicted adolescent should also be educated so that they can actively participate in the treatment process. For example, the course of the relationship between the drug-using adolescent and the parents, the management of conflicts between the parents and the adolescent, the monitoring of the process by the parents, and especially the training of parents who smoke and drink alcohol on how to manage the process can increase the likelihood of treatment success. One of the participants explained the effects of substance use on mental and physical health, the involvement of parents in the process as an important element in restructuring the recovery process, and that this process further increases the desire to seek treatment: “In order to quit, first of all you need the support of the family, and of course the family needs to be educated on this issue. Then the person has to be determined to get off the substance. In the beginning, when my family said something to me, I couldn’t answer. Actually, my answer was ready, but I couldn’t give it to my family. Because they silenced me. I didn’t want to tell my family that I was using drugs in case they got upset. The center where I was being treated called my family and invited them to the center and explained the situation. That’s when my family started supporting me. “It was like a miracle for me (P20).

Psychosocial support

In this sub-theme, there are statements about the support that substance-dependent adolescents receive from various institutions. Participants talked about the changes in health, close relationships and good friendships related to their addiction that occurred after substance use processes. One of the participants explained how important the support he received at a psychosocial support center he visited two years after he started using drugs was in his psychological recovery process: “If I had not received this support from the institution I went to, maybe I would not be at this stage now, maybe I would be in a worse situation. My life is better now, my circle of friends and my social circle are getting better and better. “All this happened thanks to the experts of the institution I went to and the people who received support there like me (P15).” On the other hand, one of the participants said, “She reduced the use of substances and even came to the point of quitting, thanks to the coping skills taught by the experts of the institution in another institution she went to for support” (P19).

Therapeutic process

This subtheme includes narratives about the psychological support and therapeutic process provided by mental health professionals, whether or not related to the substance use experience. Several of the participants had been treated by mental health professionals for problems related to substance abuse or other issues. Those who had been in therapy for substance abuse problems stated how important and useful the treatment they had received had been, not only in helping them to process their experiences, but also in increasing their hopes for their future and thus taking initiatives to increase their satisfaction with life and themselves. One of the participants said that the therapy process changed her perspective on drug use and enabled her to make important decisions for the future: “I highly recommend it to anyone who is like me to go to a specialist and feel that you are doing well (P5).

Discussion

This study focuses on risk factors, preventive and protective factors, and interventions by mental health professionals related to substance use disorder experiences of adolescents with substance dependence living in a province of the Eastern Anatolian region of Turkey. Data obtained from adolescents with substance dependence showed that risk factors such as negative family relationships, the social environment in which adolescents live, and psychosocial events that they has been exposed to earlier in their lives (such as disasters, abuse, peer bullying) cause them to start using substances and become addicted. Studies on substance use disorder prevention, which also support the findings of the current study, have found that schools, peer groups, and family risks increase adolescent substance use disorder [70]. Similarly, it has been emphasized that there is similar risks in peer and school environments, with general characteristics of the environment (e.g., deviant peer group, weak ties established with school) and substance-specific characteristics of the environment (e.g., substance use disorder among close friends, large number of students in school and class) [71]. On the other hand, many believe that peer influence has the greatest impact on adolescent substance use disorder behavior [72].

In another study that supports the finding that one of the most prominent risks in the process of initiating or becoming addicted to substances in the current study is the social network to which the adolescent belongs, peer influence processes play an important role in the development of substance use disorder in adolescence, and the link between peer substance use disorder and adolescent substance use disorder is confirmed in the empirical literature. It has been noted that it has become established [36]. The peer network is the result of two interacting and often reciprocal processes: peer networking and peer socialization. Peer selection and socialization is inherently intertwined, as the direction of peer socialization depends on which friends adolescents choose [73, 74]. In fact, substance use disorder within an adolescent’s peer group has been universally identified as the single factor most likely to predict current substance use disorder. This suggests the existence of an “epidemic” process facilitated by same-age peers to explain the increasing prevalence of substance use disorder among adolescents [75]. In summary, peer network factors that contribute to an increased risk of adolescent substance use disorder include peer relationships, the desire to belong to a group, and peer bullying.

Peer and family influences can often occur simultaneously. While one meta-analysis study highlighted poor family management practices or weak parent-child bonds as risk factors for substance use disorder [76], familial risks include childhood traumatic experiences, parental or family substance use disorder, and parental education. It has been stated that these factors include the level of addiction, parent-child relationship, socioeconomic status of the family, and the child’s perception that their parents approve of substance use disorder [20]. On the other hand, according to the findings of the current study, one of the significant risks leading to adolescent substance use disorder is the psychosocial events experienced by the adolescent. Supporting the current study’s findings, prior research links adverse experiences, such as childhood sexual victimization [77] or frequent bereavement [78] to increased risk of substance use among adolescents.

Another finding that emerged from the current study is the need to determine what preventive factors are needed for adolescents with substance dependence in order to prevent the existing situation from worsening and to prevent various tendencies toward the substance. In this context, sub-themes such as adolescent awareness, family awareness, and school-based teacher leadership emerged. Because substance use is often associated with a range of other problem behaviors, including truancy, drinking and speeding, violent behavior, and general delinquency, it is important to intervene early with adolescents who substance use disorder. Such behavioral consequences has been consistently associated with adolescent substance use disorder in global studies [79, 80]. Awareness raising among adolescents who substance use disorder can therefore prevent their tendency and attempts to use substances. Particularly in school-based prevention studies, certain programs are used, and these programs aim to create a lasting resilience that will help adolescents who substance use disorder to cope with future negativity. From this perspective, in a study that analyzed the content of 15 effective substance use disorder prevention programs for children and adolescents, it was found that at least five out of six application areas corresponded to basic resilience factors (problem solving, coping skills, communication, self-confidence, and social skills) [81]. In conclusion, it has been found that preventing substance use disorder in adolescents provides a portfolio of improved resilience that persists for more than 15 years, resulting in reduced impairment in functioning during an acutely stressful period. It has been suggested that increased resilience allows participants to regulate their peer and family relationships and use less alcohol [82]. On the other hand, the middle and high school years are a particularly high-risk period for initiating substance use disorder, as adolescents transition from one type of education to another and face many challenges [81]. Therefore, after implementing a two-year series of family and school-based prevention programs, it was found that by the end of the second year, adolescents who participated in the program had better problem-solving skills and self-confidence, as well as better relationships with parents and fewer relationships with risky peers [83]. These studies, which also support the findings of the current study, show that education of adolescents who use substances is an important step in preventing their use. Not only awareness studies for adolescents who use substances, but also awareness studies for families are important in terms of preventive factors. One systematic review provides some support for the effectiveness of parent-based programs. These programs found that helping parents improve parent-child communication and monitor adolescent behavior was a preventive step against adolescent substance use disorder [84]. Another similar study found that family programs had a small but consistent preventive effect on adolescent substance use disorder [85].

Another theme in the study is variables related to reducing the risk of substance use disorder, reducing substance abuse, and increasing the individual’s resistance to substances; social skills, the role of intrinsic and extrinsic motivation, and the importance of family-based interaction [86]. The data obtained from the participants’ stories show that the focus of protecting adolescents from substance addiction is social skills, the internal and external motivation that the adolescent should has and the interaction that the adolescent has with his/her family, which has also been the subject of previous studies [87–89]. Studies on the protective element of social skills against substance use disorder has provided important arguments for adaptive social skills and problem solving by engaging high-risk adolescents and well-controlled adolescents in social activities together. It has also been suggested that motivational methods should be used before teaching specific skills, and that increased social competence has protective effects for high-risk youth [90]. However, it has also been emphasized that coping motives for substance use (e.g., gaining more self-confidence, reducing negative emotions, relieving boredom) are an important predictor of adolescent substance use disorder problems [91]. However, in the current study, internal and external positive motivations were found to protect adolescents from substance use disorder and addiction.

The last topic of the research is the intervention process for adolescents with drug addiction. The intervention process was obtained from the statements of the participants. In this context, they talked about the factors that help addicted adolescents reconnect with life after the pain they have experienced. The most important of these elements are parent education, psychosocial interventions, and psychotherapy. Research has shown that training for parents of substance-using adolescents increases parental monitoring of addicted adolescents and also reduces adolescent substance use disorder [92]. On the other hand, psychosocial interventions provided by some agencies to addicted adolescents has been found to be effective. Psychosocial interventions is defined as educational or interpersonal activities or techniques designed to address cognitive, emotional, behavioral, environmental, or interpersonal problems in order to improve functioning and overall health, and it is stated that they reduce the tendency to use substances in adolescents who use substances [93, 94]. However, other studies have stated that the most well-established effective treatments include ecological family therapy, group cognitive-behavioral therapy (CBT), and individual CBT, while fair evidence supports behavioral family therapy and motivational enhancement therapy (MET) [42, 95].

The current study has several limitations. First, there is a widespread difficulty in finding adolescents with substance dependence, which facilitated the outreach process through School Counsellors in the schools where the participants were located. Second, participants were recruited through qualitative interviews and the results obtained through qualitative interviews may have been conditioned [96]. As a result, only adolescents with addictions may have personal narratives, which may result in an incomplete picture of the situation. Third, due to the nature of qualitative research, the findings are based on the researcher’s interpretation of the participants’ narratives, which may be influenced by their own subjective experiences and assumptions, but this risk was mitigated through triangulation.

Furthermore, due to the homogeneity of the sample, the participants in this study were between 14 and 18 years old, which is a narrow age range. This limits the generalisability of the results of this study, as emerging adolescents are aged between 14 and 19 years old [97]. Therefore, it would be appropriate to select participants to cover the entire age range of emerging adolescents in order to increase the generalisability of the results. Therefore, to increase the generalisability of the results, it would be appropriate to select participants to cover the entire age range of emerging adults.

Conclusion

One of the most important risk factors for adolescents who use or abuse substances may be the peer network in which the adolescent is embedded. Another important risk factor for adolescents who use or abuse substances may be a previous psychosocial event (e.g. abuse, domestic violence, peer bullying and other disasters). The most important preventive factor for adolescents who use or abuse substances is reported to be school-based teacher leadership. It can be said that one of the most important protective factors for adolescents who use or abuse substances is family-based interaction. However, parental education, psychosocial interventions and psychotherapies were identified as the most important interventions for substance-using adolescents.

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Abbreviations

AUDs

Alcohol Use Disorders

SUDs

Substance Use Disorders

TUBIM

Turkish Monitoring Centre for Drugs and Drug Addiction

GBD

Global Burden of Disease

ADHD

Attention Deficit Hyperactivity Disorder

PTSD

Posttraumatic Stress Disorder

CBT

Cognitive-Behavioral Therapy

FFT

Family-Focused Treatment

MET

Motivational Enhancement Therapy

SES

Socioeconomic Status

MAXQDA

Maximum Qualitative Data Analysis

e.g.

Exempli gratia

Author contributions

“M.A. wrote the main manuscript text. All authors reviewed the manuscript.”

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Procedure of the present study was performed according to the Declaration of Helsinki. In addition, according to the letter dated 12.01.2024 and numbered E-33117789/730.08/140964 from the Rectorate of Social and Human Sciences, University of Bingöl Scientific Research and Publication Ethics Board, the research entitled “Adolescents’ Experiences with Substance Use: Risks, Protective Factors and Interventions” has been ethically evaluated by our board. As a result of the evaluation, the study in question was evaluated within the framework of the principles of the Ethics Committee Directive of our University and it was unanimously decided that it was “Approved” in terms of research ethics.

Consent for publication

Written informed consent was obtained from all participants prior to data collection. Additionally, all participants explicitly consented to the publication of their direct quotations on the condition that their identities remain confidential.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.