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Twenty-five percent of individuals who begin abusing prescription drugs before the age of 14 will eventually develop a substance use disorder (SUD) later in life, according to results from a national study, as reported by the National Institute on Drug Abuse (NIDA, 2014). And, NIDA reports, the majority of people with a substance use disorder started using before age 18 and developed their disorder by age 20.

Patricia Nisbet, DNP and Psychiatric Mental Health Nurse Practitioner (PMHNP) Program coordinator, who is also a PMHNP in an integrated primary care pediatric practice, primarily sees adolescents for psychiatric assessment and medication management. After observing a high prevalence of substance use issues among patients, Nisbet identified through literature review that as many as 82 percent of adolescents who are hospitalized for psychiatric disorders also have a substance use disorder, and 60 percent in community samples have co-occurring SUD’s and a psychiatric disorder.

“This complicates treatment because an SUD and a psychiatric disorder are often not treated concurrently,” explains Nisbet. “Because substance use and psychiatric disorders often mimic each other, it is difficult to tease apart the symptoms and determine if the patient is presenting with a psychiatric disorder, substance use disorder or both.”

Adolescents are particularly vulnerable to substance use issues – with an immature pre-frontal cortex but simultaneous rapid brain changes and developments occurring up to the age of 25, adolescents and young adults are more prone to poor impulse control and decision making. They are more susceptible to SUDs, regardless of a psychiatric diagnosis.

“Adolescents do not have the same triggers as adults that tell them they’ve had too much to drink, for example. They do not experience the same motor disability as adults do when intoxicated,” Nisbet says.

What makes individuals with psychological disorders particularly susceptible to SUDs, according to Nisbet, is that areas of the brain that are affected by psychological disorders are the same areas of the brain that are affected by SUDs. Neurotransmitters, like dopamine, that are involved with SUDs are also involved with major depressive disorder and attention deficit disorder, for instance.

Nisbet emphasizes the importance of integrated care, with psychiatric and primary care practitioners working together to ensure early intervention. While adolescents who are identified as being at high risk of engaging in risk-taking behaviors, they often do not meet the DSM-5 full criteria for SUDs – Nisbet asserts these adolescents are, in fact, at high risk for dangerous consequences, such as intoxicated driving or harming themselves, necessitating substance use screening.

Nisbet now employs the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble – key words in the second section of the assessment tool), a NIDA recommended screening questionnaire for substance use for adolescents presenting with a psychiatric assessment. This series of questions screens for all substances, not just alcohol, and provides an opportunity to start a productive (and preventative) discussion.

Early intervention and education are key to prevention, Nisbet says, because this normalizes the conversations both parents and practitioners can have with their children about substance use and abuse. She adds that subsequent coordinated and integrated treatment will ensure these adolescents are receiving treatment for both their psychiatric disorder and substance use with improved prognosis.

And, the CRAFFT screening, Nisbet says, can be utilized by advanced practice nurses and RNs alike in a variety of settings. “No matter what population nurses are treating, we need to assess for substance use disorders because it’s a prevalent problem in our society. It contributes to or is the underlying cause of many psychiatric and medical diagnoses.

“Especially with the current opioid and opiate crisis in the U.S., and the ‘slippery slope’ that is substance abuse, it is even more vital for nurses to be aware of substance use issues, particularly among vulnerable adolescents,” explains Nisbet. “They’re looking for that ‘high adventure’ and like to take risks, so it is very important to be vigilant about what is happening in their lives regarding substance use. As nurses, we have the skills and opportunity to arm adolescents and their parents with the tools and the knowledge to keep themselves healthy.”

-SARAH GOLDTHRITE