Substance Use by Adolescent Patients

Board takeaway

• Ask adolescents about substance use without judgment, recognize possible intoxication or withdrawal, and connect concerns with assessment and treatment.
• Medication safety: Review interactions and relapse risk before dental medications; acetaminophen or NSAIDs remain first-line options for mild to moderate pain when appropriate.
• Confidentiality: Explain confidentiality and its legal limits, including circumstances of serious risk that require parent or authority involvement.

Scope and evidence

• Adolescence: early 11–14, middle 15–17, late 18–21 and beyond.
• Substance use disorder (SUD) involves cognitive, behavioral, and physiologic changes with continued use despite significant substance-related problems.
• This literature-informed policy addresses recognition and dental care, not a detailed diagnostic or emergency-treatment protocol. Recommendations have no formal certainty grades.

Risk, protection, and changing substances

• Risk is multifactorial: family, peers, school, community, and individual vulnerabilities interact. Early use predicts later SUD.
• Strongly replicated risks: parental substance use, limited parental monitoring, family conflict; also substance-using peers, impulsivity, low self-esteem, and untreated mental illness.
• Protection: parental monitoring, supportive household relationships, maternal education, protective peer norms, self-regulation, emotional skills, academic achievement, and anti-drug attitudes.
• Adolescent brain development favors high-reward risk taking. Repeated use can impair health, development, and responsibilities.
• Common encounters: alcohol, cannabis, nicotine. Other categories include hallucinogens and steroids. Declining use prevalence does not eliminate overdose risk.
• Depressants include alcohol, prescription/illicit opioids, benzodiazepines, barbiturates, and inhalants. Fentanyl-contaminated pills create accidental overdose risk; friends/relatives with prescriptions are common initial opioid sources.
• Cannabis routes include vaping, dabbing, and edibles. High-potency concentrates are associated with more frequent use, cannabis use disorder, anxiety, panic, paranoia, and psychotic reactions.
• Nicotine pouches are easily concealed; the policy reports increasing youth use. Chronic caffeine use can produce dependence and health risks.
• Prescription stimulants may be misused for academic enhancement without evidence of improved performance in people without ADHD. Illicit stimulant use remains uncommon in adolescents.

Recognize signs without assuming a diagnosis

• Behavioral: impaired decisions/impulse control, hostility, emotional instability, hyperactivity, and functional impairment.
• Physical: slurred speech, unsteady gait, disorientation, hallucinations, injuries, or altered pupil size. Caregivers also may show signs.
• Oral clues: lip licking/sores, bruxism or clenching, trismus, dry mouth, chipped/fractured teeth, poor hygiene, cervical caries, and erosion.
• Other findings: gingivitis/ulceration, periodontal disease, pale mucosa, leukoplakia, leukoedema, candidiasis, and burns. SUD is associated with greater caries, oral infection, and oral/pharyngeal cancer risk.
• Psychiatric disorders frequently coexist, including mood/anxiety disorders, ADHD, disruptive behavior disorders, PTSD, eating disorders, and schizophrenia. Substances may worsen, precipitate, mask, or appear to relieve symptoms; distinguish substance-related presentations from primary mental illness.

History, brief intervention, and confidentiality

• Document past/current substance use, previous SUD treatment, current medications, active-use risks, and family SUD history.
• Use empathetic, nonjudgmental, open-ended discussion; oral findings provide a starting point for connecting behavior with health.
• Tools: Screening, Brief Intervention, and Referral to Treatment (SBIRT) and CRAFFT are validated approaches identified by the policy.
• CRAFFT domains: Car, Relax, Alone, Forget, Family/Friends, Trouble.
• Scope: No scoring threshold is supplied here.
• Educate about risks; encourage avoidance and reinforce positive choices. Refer suspected or confirmed SUD to primary care, behavioral health, or addiction specialists; know adolescent treatment facilities, self-help groups, and community resources.
• Follow state/federal confidentiality requirements. When use threatens the patient or others with high-risk or life-threatening harm, involve parents/authorities according to state law; notify the adolescent of disclosure and offer participation in the conversation.

Dental medications and follow-up

• Sedatives, anxiolytics, local anesthetics, and analgesics may need modification to prevent interactions or relapse. Specifically consider vasoconstrictor-containing local anesthetics, nitrous oxide, and sedatives.
• Prescription drug monitoring programs (PDMPs) can reduce prescriptions/opioids available for misuse; the policy provides no universal checking schedule.
• If medication with abuse potential is indicated for severe pain: monitor closely, shorten intervals between refill visits, limit liquid quantities/pill counts, and educate patients/caregivers about correct use, risks, and sharing/diversion.
• No doses, fixed refill intervals, drug-specific contraindications, or abstinence waiting periods are specified.

AAPD advocacy

• Support medical–dental collaboration, effective prevention legislation/policies, education campaigns, comprehensive addiction-medicine coverage, evidence-based pediatric analgesia, and research into effective non-addictive acute-pain treatments.

Common board traps

Answer aloud

A teen has cervical caries, dry mouth, and behavioral changes. How do you assess substance use?

Use a private, empathetic history and screening; these findings raise concern but do not diagnose a substance use disorder.

• Ask about substances, recent use, medications, past treatment, family history, and mental-health symptoms.
• Explain confidentiality and its legal limits; use open-ended questions.
• SBIRT and CRAFFT can support brief intervention and referral.
• Address dental disease and review interactions/relapse risk before medication or sedation.

How do you manage severe dental pain in a patient with a substance use disorder history?

Provide definitive dental care and select analgesia after reviewing interactions and relapse risk.

• Acetaminophen/NSAIDs are first-line for mild to moderate pain when appropriate.
• If an abuse-potential medication is indicated for severe pain, limit quantity and monitor closely.
• Shorten refill-visit intervals and counsel about correct use, risks, sharing, and diversion.

When may substance-use confidentiality require disclosure?

Follow state/federal law when high-risk or life-threatening danger to the patient or others requires parent or authority involvement.

• Explain confidentiality limits beforehand.
• Notify the adolescent when disclosure will occur and offer participation in the conversation.
• Do not promise absolute confidentiality.