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Substance Use Disorders

Overview

Substance use disorders (SUDs) are characterized by recurrent use of alcohol or drugs that causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Substance use occurs on a continuum from experimental or non-problematic through addiction.
Small packet of white powder changing hands between two individuals
Public Health England/Science Photo Library
Addiction typically starts during adolescence and occurs when the reward system is upregulated or hyper-stimulated. This results in enhanced dopamine function in the nucleus accumbens, which is often associated with the forced release of other neurotransmitters. The massive dopamine shift results in euphoria; the release of neurotransmitters results in psychoactive and/or physical symptoms. The achieved euphoric state then becomes “reset” as the reward center’s benchmark for attaining pleasure. There is also a significant behavioral component to the addictive process.
The medical provider maintains an important role in screening for drug use and providing anticipatory guidance, education about drugs of abuse, brief interventions, referrals to substance abuse treatment, ongoing monitoring, and follow-up. SUDs are frequently associated with other mental health issues including mood disorders, anxiety disorders, ADHD, and impulse control disorders; therefore, identification of substance use warrants additional exploration and treatment of other mental health concerns.

Other Names & Coding

Addiction Dependence on drugs Substance abuse

ICD-10
Appropriate coding involves listing a specific substance, degree of dependence, and associated complications. Codes for specific substances are listed below, and the links lead to a comprehensive list of subcodes.
F10 (icd10data.com), Alcohol related disorders
F11 (icd10data.com), Opioid related disorders
F12 (icd10data.com), Cannabis related disorders
F13 (icd10data.com), Sedative, hypnotic, or anxiolytic related disorders
F14 (icd10data.com), Cocaine related disorders
F15 (icd10data.com), Other stimulant related disorders
F16 (icd10data.com), Hallucinogen related disorders
F17 (icd10data.com), Nicotine dependence
F18 (icd10data.com), Inhalant related disorders
F19 (icd10data.com), Other psychoactive substance related disorders.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) usually designates the same codes as the ICD-10, but its publisher, the American Psychiatric Association, prohibits including their codes or descriptions. [American: 2013]

Prevalence

The prevalence of SUDs among youth is difficult to estimate. First, many national studies only survey students, but a number of at-risk children do not regularly attend school. Additionally, surveys tend to rely on self-reports, which are often under-reported. Finally, clinicians may be using procedure codes for treating the symptoms of substance abuse instead of the codes for SUDs themselves. According to the 2020 Monitoring the Future Survey (NIH) for 10th graders, 37.3% had used an illicit drug other than marijuana (including marijuana increases the number to 52.1%), 41% had vaped, and 46.4% of students had tried alcohol in their lifetime. In 2014, about 21.5 million Americans ages 12 and older (8.1%) were classified with a substance use disorder in the past year. [Han: 2015] See Trends in Drug Use, which tracks prevalence of substance use in 8th, 10th, and 12th graders.
Other health problems, such as having a chronic disease or intellectual disability, may increase an adolescent’s vulnerability to substance use and its consequences and may place the youth at higher risk for future heavy or problem substance use. [Carroll: 2012] [Wisk: 2016]

Genetics

Family and twin studies [Laursen: 2017] suggest a genetic vulnerability to substance abuse initiation, continued use, and dependence. [Lynskey: 2010] Studies of the genetics of addiction have identified several regions [Yu: 2016] on chromosomes 4, 5, 9-11, and 17 that are likely to contain abuse susceptibility loci for multiple substances and involve vulnerabilities in the dopamine transporter system.

Prognosis

While many young people experiment with substances without adverse effects, those who progress to substance abuse often develop social, mental, and physical problems. Both the short- and long-term impacts of substance abuse result in neurological, cardiovascular, renal, and hepatic changes. Other long-term impacts may involve the hematopoietic, immunologic, endocrine, dermatologic, dental, and gastrointestinal organ systems.
In addition, those with substance dependence or addiction often are at higher risk for poor peer relationships, depression, anxiety, and poor self-esteem. Teens engaging in high-risk behavior and substance use may experience unintended consequences, such as overdose, injuries from accidents, physical altercations, school failure, legal difficulty, date rape, acquisition of sexually transmitted infection, and pregnancy. Adolescents who “experiment” by mixing drugs and pushing higher doses as their addiction progresses are at a particularly high risk for medical sequelae and death.

Practice Guidelines

Levy SJ, Williams JF.
Substance Use Screening, Brief Intervention, and Referral to Treatment.
Pediatrics. 2016;138(1). PubMed abstract / Full Text

Bukstein OG, Bernet W, Arnold V, Beitchman J, Shaw J, Benson RS, Kinlan J, McClellan J, Stock S, Ptakowski KK.
Practice parameter for the assessment and treatment of children and adolescents with substance use disorders.
J Am Acad Child Adolesc Psychiatry. 2005;44(6):609-21. PubMed abstract / Full Text

California Department of Health Care Services.
Adolescent Substance Use Disorder Best Practices Guideline.
(2020) https://www.dhcs.ca.gov/Documents/CSD_CMHCS/Adol%20Best%20Practices%20....

American Society for Addiction Medicine.
National practice guideline for the treatment of opioid use disorder 2020 update.
(2020) https://www.asam.org/quality-care/clinical-guidelines/national-practic....

Roles of the Medical Home

Roles of the medical home clinician include screening for drug use, providing anticipatory guidance, educating about drugs of abuse, offering brief interventions and or referrals for substance abuse treatment when necessary, and continuously monitoring and following-up.  [Levy: 2016]
The SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA) is a standardized approach used by primary care clinicians to target the reduction of and abstinence from substance use. [Babor: 2017] [Levy: 2016] [DelRosario: 2017] The program tenets are:
  • Screen with a short, well-tested questionnaire to identify risk (the screening section below provides links to validated screens).
  • Brief intervention is provided to reduce drug use and other risky behaviors. Intervention may involve education on how continued drug use may harm their brain, general health, relationships, and education (for a short table of intervention goals, please see Substance Use Spectrum and Goals for Office Intervention (AAP), which is Table 1 from [Levy: 2016]).
  • Refer for in-depth assessment, diagnosis, and treatment as needed (see Substance Use Disorder Outpatient Treatment (see NV providers [98]) and Services, at the end of this module, for a list of providers).
Motivational Interviewing (SAMHSA) is a technique used to explore and strengthen an individual’s personal motivation for change. This technique relies on a partnership between the patient and clinician, rather than the clinician or external authorities imposing or mandating change. It involves using empathy, open-ended questioning, and reflective listening to help the patient weigh the pros and cons of different behaviors. By working at the patient’s own pace, planning for (and achieving) small, realistic goals, and helping them understand that motivation to change fluctuates, the provider helps patients succeed and provides support during relapse. [Levensky: 2007] [Barnett: 2012] [Steele: 2020]
In addition, the medical home clinician should screen for comorbid physical and mental illnesses, provide ongoing preventive care, and communicate with the substance abuse and/or mental health treatment team to ensure that all providers have current information regarding both health and substance use status. For patients actively in treatment, clinicians can offer ongoing support of treatment participation and substance use abstinence during follow-up visits. [National: 2014]

Clinical Assessment

Pearls & Alerts for Assessment

Poor validity of CAGE assessment in adolescents

The CAGE questions include 4 parameters:

  • Feeling the need to Cut down on use
  • Feeling Annoyed when others comment on use
  • Feeling Guilty about use
  • Needing an Eye-opener (a drink first thing in the morning).

Although commonly used in adult populations for assessing alcohol use disorders, the CAGE screen has poor validity in children and adolescents. [Knight: 2003]

Disclosure laws: Strict adherence is mandated and serious financial penalties applied

Previously, federal law (42 CFR 2.14 - Minor Patients (LII) (PDF Document 22 KB)) prohibited the oral or written disclosure of any information that could identify a patient, adult or minor, as potentially having a substance use disorder. Thus, it protected such diagnostic information as urinalysis results, verbal communications, printed medical records, and any type of confirmation that a patient is receiving treatment in a federally-funded program without the patient’s consent to disclosure.
Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) enacted in 2020, some of the rules pertaining to records release, including those for substance use disorder treatment, have changed to more closely align with Part 2 of the Health Insurance Portability and Accountability Act (HIPAA). Healthcare information, including that pertaining to substance use disorder treatment, can be disclosed without the patient’s permission as part of healthcare operations, including insurance authorizations. Additionally, in some states, the rights of minors to protected health information have changed. Parents may elect to view their adolescent’s electronic medical record without the child’s consent. Providers can block access to parents viewing their minor child’s electronic health information if doing so is felt to be in the youth’s best interest (i.e., risk posed to the safety of the child if nformation were to be disclosed).
Providers should consider the risks and benefits in disclosing this information to their minor patients and families as part of discussion about confidentiality. Providers are strongly encouraged to

  • Understand the related capabilities and limitations of their electronic record systems
  • Research the state and federal laws about confidentiality in minors
  • Seek counsel from legal and medical records teams in situations that are unclear.

Suicide risk

SUDs are an independent risk factor for increased suicidality and suicide completion. [Mars: 2019] Suicide and Suicide Attempts in Adolescents (AAP) [Shain: 2016] has information about how clinicians can approach and evaluate youth who may be at risk for suicide. See also the Portal’s page on Suicidality & Self-Harm.

Screening

For the Condition

The American Academy of Pediatrics recommends that clinicians screen adolescents 10 years and older for substance abuse during routine clinical care. [Levy: 2016] These short, well-tested screens and the scoring instructions can be downloaded or printed for free: Early detection and intervention before the sensitive adolescent period is key to maximizing resilience and preventing substance use disorders. [Jordan: 2017] The choice of screen will depend on the practitioner’s experience with the tool. The Substance Abuse and Mental Health Services Administration recommends routine SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA). A 2019 RCT demonstrated that adolescents who underwent SBIRT had improved health care use, general health, mental health, and substance use outcomes. [Sterling: 2019] A 2013 report by SAMHSA found that only 10% of patients over age 12 with SUDs actually received specialty treatment. [Substance: 2014] Recent studies suggest that routine screening at all well-child and acute-care visits significantly increases SUD detection, [Monico: 2019] but the traditional screening tools still underestimate actual substance use among teenagers. [Gryczynski: 2019]

Of Family Members

A salient family history of addiction and mental health problems is often helpful, but no formal screening is currently recommended.

For Complications

SUDs are often comorbid and exacerbate underlying mental health issues, such as ADHD, antisocial personality disorder, major depression, eating disorders, post-traumatic stress disorder, and anxiety disorders. [Welsh: 2020] SUDs may also mimic symptoms of a mood or anxiety disorder. Screening for complications in a simplified and systematic manner can bring to light significant changes or ominous risk factors.
  • Screening for Complications of Drug Use (PDF Document 81 KB) provides screening ideas with sample questions.
  • HEEADSSS Assessment Guide (USU) (PDF Document 1017 KB) provides examples of open-ended questions the clinician can ask adolescents about Home; Environment, education, and employment; Eating; peer-related Activities; Drugs; Sexuality; Suicide/depression; and Safety from injury and violence.
  • SSHADESS (PDF Document 60 KB) is an interview framework that asks questions about Strengths, School, Home, Activities, Drug use, Emotions, Sexuality, and Safety. It underscores resiliency by identifying the patient’s perceived and realized strengths before exploring environmental context and risks.
For more tools that may be useful if additional concern is raised based on in-office questioning, see: Adolescents who use substances are at increased risk of engaging in other high-risk behaviors, and screening for pregnancy, [Dir: 2019] sexually transmitted infections, and other medical sequelae may also be warranted. Also, please see Dental and Oral Health Screening.

Presentations

Adolescents in the early stages of substance use typically have few adverse consequences but are at risk for acute intoxication due to rapid consumption of toxic quantities.
Symptoms of intoxication, acute use, and withdrawal: Signs of early substance use or experimentation:
  • Increased or decreased need for sleep
  • Changes in appetite with sudden weight loss or gain
  • Slurring of speech or impaired coordination
  • Engaging in secretive behaviors
  • Changes in school or work performance
  • Glazed or bloodshot eyes; unusually large or small pupils
  • Characteristic odor of alcohol, marijuana, or inhalants
  • Changes in peer group, activities, and hobbies
Signs in the later stages of substance abuse:
  • School failure or truancy
  • Changes in dress, behavior, and peer groups
  • Relationship difficulties
  • Injuries/motor vehicle accidents
  • Sexual assault or sexual acting out
  • Legal difficulties
  • Personality and emotional changes
  • Cognitive changes

Diagnostic Criteria

A SUD diagnosis is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria. Each SUD is divided into mild, moderate, and severe subtypes. A person who meets at least 2 criteria is diagnosed with SUD. The severity subtype of the disorder is determined by the specific number of the following criteria that are met:
  • Taking the substance in larger amounts or for a longer time than intended
  • Wanting to cut down or stop use, but not managing to
  • Spending a lot of time getting, using, or recovering from use of the substance
  • Experiencing cravings and urges to use the substance
  • Not managing responsibilities because of substance use
  • Continuing to use, even when it causes problems in relationships
  • Giving up important activities because of substance use
  • Using substances again and again even though it leads to being put in dangerous situations
  • Continuing to use while knowing a physical or psychological problem could have been caused or is made worse by the substance
  • Needing more of the substance to get the desired effect (tolerance)
  • Taking more of the substance to relieve withdrawal symptoms

Clinical Classification

Clinicians may encounter various levels of drug use or nonuse:
  • Abstinence: No use of any psychoactive substances
  • Experimental use: Occasional use of any psychoactive substance, used typically with peers
  • Non-problematic use: Intermittent, continuing use of alcohol or drugs without negative consequences
  • Problematic use: Adverse consequences occur as a result of substance use (school difficulties, relationship problems, injuries, legal difficulties); some can still reduce or stop their use with limited intervention.
  • Addiction: Encompasses not only physical dependence and cravings but also the maladaptive psychosocial consequences resulting from use and behaviors that an individual engages in to obtain a substance
  • Physical dependence: Physiologic changes that occur from continued use of a substance and drive cravings and ongoing use
  • Withdrawal: Occurs from abruptly stopping heavy or prolonged use
  • Remission: Cessation of use after diagnosis of a SUD

Differential Diagnosis

Differential diagnoses vary according to the presenting symptom(s):
  • Inattentiveness and a decline in school performance may be due to ADHD, anxiety, lead poisoning, depression, sleep disorder, abuse/trauma, chronic illness, or hypothyroidism. Dissociation, or an appearance of inattentiveness with a subjective feeling of being detached from oneself, may be seen with severe anxiety or trauma.
  • Hyperactivity, agitation, and irritability may be related to depression, anxiety, bipolar disorder, hyperthyroidism, hyperparathyroidism, abuse/trauma, iatrogenic effect, or ADHD.
  • Hallucinations and disorganized behaviors may be seen in mood disorders (depression or bipolar) with psychotic features, psychotic disorders such as schizophrenia, metabolic disturbances, delirium, catatonia, or neurological conditions.
  • Weight loss or gain may be seen with depression, anxiety, eating disorders, metabolic disorders, or endocrine problems.
  • Sleep changes may be due to depression, bipolar, anxiety, psychotic disorders, primary sleep disorders, metabolic problems, endocrine problems, and many other medical issues.
  • Consider unintentional ingestion of illicit substances in young children or patients with developmental disabilities, particularly if others in the home or the peer group use drugs.

Comorbid & Secondary Conditions

SUDs may cause or exacerbate underlying mental health conditions and vice versa. [Essau: 2011] Antisocial personality disorder is more common in men, while women have higher rates of major depression, posttraumatic stress disorder, and other anxiety disorders. [Jones: 2019] [Welsh: 2017] The coexistence of a SUD and at least 1 other psychiatric disorder is known as dual diagnosis. Approximately 70-80% of adolescents with SUDs meet criteria for dual diagnosis. [Kaminer: 2007]
Additional mental health disorders that are associated with SUDs include:
  • Anxiety disorders
    • ~30-35% of patients with generalized anxiety disorder will have a comorbid SUD [Simon: 2009]
  • Trauma-related disorders, such as post-traumatic stress disorder [Jaycox: 2004]
  • Attention-deficit/hyperactivity disorder, if untreated (children with ADHD that is diagnosed and treated appropriately are less likely to develop SUD than those with untreated ADHD) [Wilens: 2008]
  • Conduct disorder [Krueger: 2002]
    • >50% of children and adolescents with conduct disorder also meet criteria for SUDs [Reebye: 1995]
  • Depression (suicidality) [Esposito-Smythers: 2004]
  • Bipolar disorder
    • ~30-50% of children and adolescents with bipolar disorder will develop SUDs [Wilens: 2004]
  • Eating disorders
    • ~13% of patients with anorexia and 20% patients with bulimia and binge eating disorders have comorbid SUDs [Swanson: 2011]
  • Psychotic disorders
    • 3 to 5 times more likely than in the general population [Wu: 2011]
  • Autism spectrum disorder without ADHD or intellectual disability
    • 2 times the risk of substance use than the general population [Butwicka: 2017]
Comorbid medical conditions and high-risk behaviors related to SUDs include:
  • Pregnancy
  • Sexually transmitted infection (gonorrhea, chlamydia, herpes, syphilis, HIV, hepatitis B)
  • Hepatitis C and HIV transmission (with intravenous drug use)
  • Dermatologic abscesses
  • Thrombophlebitis and bacterial endocarditis
  • Organ impairment and damage (skin, heart, kidneys, liver, dental, nutritional stores)

History & Examination

Current & Past Medical History

When taking an interim medical history from the adolescent with a known SUD, consider asking about:
  • Access to substances, intercurrent use patterns, types of substances used, amount, and frequency
  • A detailed history of substance use patterns, such as age at first use, substances tried, current substances used, along with quantity and frequency
  • Accidents (individuals who abuse substances are more likely to ride in an automobile with a driver who had been abusing alcohol or drugs), injuries, or pregnancies
  • Symptoms or signs of mental health disorders such as depression, anxiety, ADHD, conduct disorder, bipolar disorder, and eating disorders
  • Sexually transmitted infection, infection with blood-borne pathogens (through needle sharing), thrombophlebitis, and endocarditis (in cases of intravenous drug use)
Risk factors associated with development or progression of SUDs should be explored. [Newcomb: 1995] [Burrow‐Sanchez: 2006] Consider asking about:
  • Chronic domestic violence and physical and emotional abuse
  • Sexual abuse
  • Early-onset mental health/behavioral disorders, such as ADHD, conduct disorder, mood disorders, anxiety disorders, and learning disorders
  • Association with drug-using peers and gang affiliation
  • Initiation of substance use at a young age
  • Academic truancy, drop-out, underachievement or failure
  • In-utero exposure to substances

Family History

Focus questions on substance abuse and mental health disorders in other family members. Parental alcohol or drug use is a strong predictor of substance abuse in offspring. Additionally, parental substance use may result in prenatal substance exposure, inadequate medical care, and significant psychosocial stressors related to substance use. [Smith: 2016] The presence of mental health disorders in family members (e.g., conduct disorder, bipolar disorder) may suggest comorbid psychopathology.

Pregnancy/Perinatal History

Ask about a history of or possibility of current pregnancy and intrauterine exposure to nicotine products, tobacco, alcohol, and other substances.

Developmental & Educational Progress

Inquire about general development and recent changes in school performance. Children with learning disabilities are at risk for substance abuse. Recent academic changes may signify progression to problematic use or raise concern for an associated mental health disorder.

Maturationalprogress

Evidence suggests that early pubertal development is associated with higher rates of substance abuse independent of age and school grade. [Patton: 2004] Identification of “early bloomers” with other risk factors for substance abuse may allow timely initiation of preventive counseling measures. In girls who use substances, menstrual cycles may become more erratic than expected for adolescence. Ask about amenorrhea, which may be due to alterations in hormonal cascades caused by heavy substance use.

Social & Family Functioning

Consider asking about the following factors as they pertain to substance use:
  • Impacts on physical and emotional health
  • Effects on school, family, and friends
  • Negative consequences of use (e.g., accidents, legal difficulties, injuries, altercations, school failure)
  • Use in risky situations, including driving while intoxicated
  • Risky sexual activity
  • Gang affiliation
  • Parental modeling of substance use, negative communication patterns, and lack of anger control in families
  • Relationships with peers and substance use in peer group - associating with friends who use drugs is a strong predictor of personal drug use.
  • Family relationships
  • Victimization by bullying
Parents may be interviewed as part of the substance abuse assessment, although parents generally underestimate the severity of substance abuse in their teenage children.

Physical Exam

“Designer drugs” (synthetic cannabinoids and bath salts, heroin, inhalants, MDMA, PCP, and androgenic-anabolic steroids) and other substances are associated with renal damage and failure, either directly or indirectly from dangerous increases in body temperature [National: 2017]

Vital Signs

Abnormalities in heart rate, blood pressure, and respiratory rate may represent complications of acute or chronic substance abuse.

Growth Parameters

Check growth - steroid use during childhood or adolescence, resulting in artificially high sex hormone levels, can signal the bones to stop growing earlier than they normally would have, leading to short stature, gynecomastia and decreased sperm counts in males, and masculinization in females. Some of these changes may be irreversible.

Skin

Examine for needle marks suggestive of intravenous drug use. Methamphetamine use may cause compulsive skin picking leading to scattered excoriations and ulcerations. Intravenous drug use may produce micro-emboli in nail beds.

HEENT/Oral

Pupillary constriction may be seen with intoxication from opioids or other depressants. Pupillary enlargement could indicate the use of stimulants or hallucinogens. Cannabis can cause conjunctival injection. Examine nasal mucosa for inflammation or erosion associated with nasal insufflation (snorting). Redness around the nares may be a sign of inhalant use (huffing). Poor dentition due to lack of dental hygiene is often associated with substance use. Methamphetamine use may lead to rapidly progressive dental decay due to alteration of salivary acid balance. Poor dental hygiene is common with SUDs and may lead to gingivitis, caries, and abscesses.

Chest

Smoking tobacco, marijuana, cocaine, or heroin may result in abnormal breathing sounds, such as wheezing, and lead to bronchitis.

Heart

A new murmur may suggest endocarditis due to venipuncture-associated bacteremia. Arrhythmia may suggest acute stimulant intoxication or effect from stimulant/cocaine-induced infarction. Several substances of abuse, particularly psychostimulants, may contribute to arrhythmias. Injection drug use can also lead to collapsed veins and bacterial infections of the blood vessels and heart valves. [National: 2017]

Abdomen

Palpate the liver for tenderness or enlargement suggestive of hepatitis. Constipation is associated with chronic opioid use.

Neurologic Exam

Altered mental status suggests acute intoxication or withdrawal symptoms. Cognitive problems may be noted with multiple substances of abuse. Persistent leukoencephalopathy and sensory neuropathy may be noted with prolonged inhalant use. [Brust: 2014]

Testing

Laboratory Testing

Random urine testing for substances of abuse may be an important component of a substance abuse treatment program. Urine specimens must be collected according to the Mandatory Guidelines for Federal Workplace Drug Testing Programs.
Initial testing is performed with immunoassay. Positive results must be confirmed with gas chromatography (GC) or mass spectroscopy (MS). Quantitative results may be helpful for some significant false positives (THC, alcohol, cocaine). Synthetically crafted opioids (i.e., opiates) will not be detectable on an opioid screen but will be identified with GC or MS.
If a clinician suspects abuse of a non-detectable substance, order a toxicology screen with the specific agent identified. No screens or labs are available to identify inhalants, except for hair analysis, which is rarely used. A thorough, confidential history is the most effective way to screen and diagnose SUDs. 
Obtaining laboratory studies without the consent of the competent adolescent is damaging to the doctor-patient relationship and should only be done in emergent situations. [American: 1996] [Knight: 2007] In general, drug screens should not be performed at the request of parents because the clinical information yielded from such testing is limited. False-positive results are common and can have significant medical and social consequences. [Moeller: 2008] The following link provides a summary of agents that contribute to false-positive screens for drugs of abuse by immunoassay: Drugs of Abuse, Cross Reactivity .
Other laboratory studies should be considered based on clinical findings or concerns (e.g., thyroid-stimulating hormone (TSH) and thyroxine if thyroid dysfunction is suspected as a cause for behavioral changes). Other studies may be helpful in identifying complications of substance abuse:
  • Labs for substance abuse include a comprehensive metabolic panel, complete blood count, TSH, free thyroxine (fT4), urinary analysis, gamma-glutamyl transpeptidase (GGT) for suspected alcohol abuse, and human chorionic gonadotropin (HCG) for women.
  • If engaging in unprotected sex is suspected, test for gonorrhea, chlamydia, HIV, syphilis, and hepatitis B (if not vaccinated).
  • If intravenous drug use is suspected, test for hepatitis C and HIV.
  • Risk factors for tuberculosis should be considered and tuberculin purified protein derivative (PPD) placed if concerned.

Imaging

A 12-lead EKG should be obtained in those with chest pain associated with known or suspected stimulant use (e.g., cocaine, methamphetamine, ecstasy) due to the risk of myocardial infarction. Extensive inhalant abuse is associated with cardiomyopathies. Echocardiography is indicated to identify intracardiac vegetations in known or suspected intravenous drug users who present with a new heart murmur.

Genetic Testing

Genetic testing for individuals with SUDs currently has little clinical value and is not recommended. [Mathews: 2012]

Other Testing

Perform a detailed psychosocial history if a patient receives a score of ≥2 on the Car, Relax, Alone, Friends, Forget, Trouble (CRAFFT 2.1/2.1+N) screen.

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see NV providers [37])

Consult if a comorbid mental health disorder is suspected or if pharmacotherapies for a SUD are needed.

Mental Health Evaluation/Assessment (see NV providers [9])

Refer for testing if a learning or intellectual disability is suspected. Testing may include the Millon Adolescent Clinical Inventory for an indication of defensive responding, client’s level of insight and awareness of the effects of their substance misuse, evidence of emotional pain, and relative risk of involvement with the legal/judicial system. Other tests may include the Minnesota Multiphasic Personality Inventory-Adolescent.

Treatment & Management

Pearls & Alerts for Treatment & Management

Comorbidities are the rule, rather than the exception

SUDs are frequently associated with other mental health issues, including mood disorders, anxiety disorders, ADHD, and impulse control disorders. Therefore, identification of substance use warrants additional exploration and treatment of other mental health concerns.

Treat comorbid psychiatric disorders, but be aware of medication abuse potential

Pharmacotherapy for primary mental health disorders may be safely and effectively be used for patients with substance abuse problems, but the clinician should recognize the potential for abuse when with any schedule II medication(s). Alternative agents for ADHD treatment with low abuse potential include atomoxetine and bupropion. Selective serotonin reuptake inhibitors and buspirone offer less potential for abuse than benzodiazepines in the treatment of comorbid depression and anxiety. Trazodone and melatonin may be helpful sleep aids with low abuse potential compared to hypnotics. Behavioral interventions should be considered as well. Evidence supports the integrated treatment of both SUD and comorbid psychiatric conditions. [Brewer: 2017]

Substance abuse and ADHD

Untreated ADHD is associated with a high incidence of SUDs, and adequately treating ADHD may decrease that risk. [Wilens: 2008] [Wilens: 2003] [Chadi: 2020]

Prescription Drug Monitoring Program Database

Most states have websites that allow authorized users to monitor dispensing of controlled substances. This helps track possible diversion and misuse of controlled substances. States vary in their laws regarding access to this information. Individual state contacts can be found at the Prescription Drug Monitoring Programs (NASCSA).

SUDs and Asthma

Some drugs of abuse cause breathing to slow and block air from entering the lungs, which exacerbates asthma symptoms.

How should common problems be managed differently in children with Substance Use Disorders?

Growth or Weight Gain

Although weight changes can be a direct effect of substance use, screening for contributing eating disorders and other psychiatric disorders is important. Individuals with fear of weight gain may abuse stimulant medications to lose weight. Individuals with SUDs may be more prone to nutritional deficiencies, such as thiamine (more commonly associated with chronic alcohol use but also can be seen with cocaine abuse), due to decreased intake of nutritive substances. [Sukop: 2016]

Development (Cognitive, Motor, Language, Social-Emotional)

SUDs should be considered in the differential diagnosis of any child or adolescent who experiences a change in academic performance, peer groups, or interpersonal functioning. Academic and cognitive testing may need to be delayed until a period of prolonged abstinence is achieved to provide more accurate results. Prenatal exposure to drugs of abuse may also affect cognitive development.

Viral Infections

Adolescents with SUDs may engage in high-risk behaviors, such as unprotected sexual intercourse and needle sharing, which increases risk for viral infections, including HIV and hepatitis; therefore, more intensive counseling and testing may be warranted.

Over the Counter Medications

Abuse of over-the-counter medications, such as cough syrup, is common. Families should be counseled to lock up all medications in the home to prevent unintentional overdose.

Common Complaints

Drug use (inhalants, MDMA, PCP, and steroids) may be the cause of muscle cramping and overall muscle weakness.

Systems

Other

Determining Level of Care
SUDs are a chronic condition with potential for relapse. Complications related to comorbid mental health disorders, medical issues, and social complications are common. Because of the complexity and potential for progression of these disorders, most adolescents will require referral to substance abuse services. 
The American Society of Addiction Medicine (ASAM) has placement guidelines for 4 levels of care (with sub-set levels):
  • Outpatient Treatment: No risk of withdrawal, no biomedical or emotional concerns, acceptance of and cooperative with treatment, good coping skills and internal resources, and a supportive environment
  • Intensive Outpatient or Partial Hospitalization (Day Treatment): No risk of withdrawal, mild biomedical or emotional concerns, some resistance to change, high risk of relapse, and an unsupportive environment
  • Residential Facility (clinically managed, low/medium/high intensity; 24/7 medically monitored and high intensity): Minimal to moderate risk of withdrawal, mild to moderate biomedical or emotional concerns requiring monitoring and behavioral and/or medical intervention, high risk for continued use, and an obstructive environment for recovery
  • Medically Managed Inpatient Services: Severe risk of withdrawal or moderate to severe biomedical and/or emotional concerns (dimensions 4-6, listed below, are obsolete for this level of care)
The recommended level of care is based on scores attained from 6 dimensions of assessment. The 6 dimensions are (1) potential for medical withdrawal; (2) bio-medical conditions; (3) emotional/behavioral disturbances; (4) acceptance or resistance to treatment; (5) potential for relapse; and (6) social/recovery environment.
More information about application of the ASAM guidelines can be found at ASAM Criteria (American Society of Addiction Medicine).
Care may also involve referral to:

Mental Health/Behavior

The Adverse Childhood Experiences Study (CDC) is the largest investigation ever conducted to assess associations among childhood maltreatment and later-life health and well-being. The ACE studies have documented robust associations among untreated childhood trauma and addiction, as well as chronic psychiatric and medical illnesses. Typically, in these cases, there is early onset and rapid progression of substance abuse with multiple types of substances, including opiate and/or stimulant-like substances (methamphetamine, cocaine, etc.).
Individuals with a SUD in the course of mental illness may require higher levels of care. SUDs can exacerbate and mimic psychiatric disorders, such as depression, anxiety, and psychosis. A detailed history of psychiatric symptoms during periods free from, or prior to, alcohol or drug use can help distinguish between a primary SUD and a primary mental health disorder. Patients with a primary mental health disorder often seek relief from symptoms by self-medicating with substances. Intoxication with multiple substances can result in mental status changes ranging from euphoria, excitation, and agitation to sedation and coma, either from direct effects or as consequences such as traumatic injuries from disinhibited behaviors.
Conduct disorder is the most common psychiatric disorder in adolescents who use alcohol, and it is a strong predictor of developing alcohol use or dependence. Conduct disorder is characterized by maladaptive behaviors, including disrespect toward authority figures, engagement in illegal activities, threats of violence or aggressive/assaultive behaviors, and a general disregard for the safety of others. However, features of conduct disorder may be present and secondary to a significant, untreated mental health disorder, including substance abuse. Therefore, conduct disorder should be diagnosed based on history and after resolution of the primary disorder. Chronic use of some drugs of abuse can cause long-lasting changes in the brain, which may lead to paranoia, depression, aggression, and hallucinations. 
Substance use is also a risk factor for suicide attempts and completions. For additional information, please refer to Suicidality & Self-Harm.
In addition to the services listed below, care may involve referral to:

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see NV providers [37])

Refer for diagnosis and treatment of comorbid psychiatric conditions and treatment if indicated.

General Counseling Services (see NV providers [209])

Refer for implementation of behavioral strategies applied in substance abuse treatment programs and engage the client and/or family in the therapeutic process.

Pharmacy & Medications

Detoxification occurs when the body fully eliminates substances. It is often accompanied by unpleasant and potentially harmful side effects; acute withdrawal from alcohol, benzodiazepine, and/or barbiturate dependence can potentially be lethal. Detoxification under medical supervision is typically recommended. Any adolescent who meets criteria for alcohol, opioid, or sedative-hypnotic dependence and who displays symptoms of physical dependence should be admitted to a hospital for medically supervised withdrawal (detoxification).
Medically supervised withdrawal treatment protocols vary according to substance(s) used and symptoms present. Medications are available to assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives and should be administered by a physician experienced in addiction treatment. No medications have been FDA-approved for the treatment of substance abuse in adolescents. Medications for substance abuse are best prescribed in collaboration with referral to a behavioral program.
Opioids: Methadone (full mu agonist) and buprenorphine (partial mu agonist) are long-acting opioid receptor agonists that reduce opioid withdrawal symptoms and cravings. Buprenorphine/naloxone (Suboxone) also contains naloxone, which blocks other opiates, resulting in less potential for overdose and may therefore be preferred over methadone; preliminary studies of its safety and efficacy in adolescents are encouraging. Naltrexone is a competitive antagonist at the mu and kappa opioid receptors. In patients with a chronic history of opioid use, acute reversal of opioid effects with naloxone, a related medication, may precipitate withdrawal symptoms, limiting its use to patients who have an opiate overdose. Naltrexone should not be used in patients with questionable compliance concerns.
Tobacco: Nicotine replacement systems are available as over-the-counter sprays, patches, gum, and lozenges. Bupropion and varenicline have received FDA approval for the treatment of nicotine addiction in adults. Bupropion inhibits the reuptake of norepinephrine and dopamine, resulting in a mild stimulant effect that reduces craving for nicotine. Varenicline has mixed agonist and antagonist effects at nicotine receptor subsets resulting in less nicotine craving.
Alcohol: Naltrexone, acamprosate, and disulfiram are FDA-approved for treating alcohol dependence in adults. Naltrexone is a competitive opiate receptor antagonist that blocks opioid receptors involved in the rewarding effects of drinking and thus lessens the craving for alcohol. It reduces relapse to heavy drinking during the first 3 months of treatment but is less effective for treatment maintenance. The exact mechanism of acamprosate is unknown. Acutely, it acts predominantly by regulating glutamate surges and may reduce protracted withdrawal symptoms, such as insomnia, anxiety, restlessness, and dysphoria, through upregulation of gamma-aminobutyric acid (GABA) (to which it is structurally similar). Disulfiram inhibits the enzyme (acetaldehyde dehydrogenase) responsible for degradation of acetaldehyde (a byproduct of alcohol metabolism) to acetic acid. This results in the accumulation of acetaldehyde, which leads to an unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Disulfiram is rarely used in adolescents for alcohol dependence. Intermediate- to long-acting benzodiazepines are used in medically supervised withdrawal from alcohol and sedative-hypnotic agents because this withdrawal syndrome can be life-threatening.

Specialty Collaborations & Other Services

Psychiatry/Medication Management (see NV providers [37])

Refer for diagnosis and treatment of comorbid psychiatric conditions and pharmacotherapeutic treatment if indicated.

Substance Use Disorder Inpatient and Residential Treatment (see NV providers [16])

A substance abuse treatment center may offer residential or outpatient treatment including individual, group, and/or family counseling. Pharmacotherapeutic management may be offered in centers staffed with a physician with experience and expertise in substance abuse management.

Gastro-Intestinal & Bowel Function

Among other adverse effects, many drugs of abuse have been known to cause nausea and vomiting soon after use. Cocaine and other psychostimulant use can also cause abdominal pain. [National: 2017] Constipation is a common side effect of prolonged opioid use (management information can be found at Constipation. Several drugs of abuse, including alcohol, heroin, inhalants, and anabolic-androgenic steroids, cause hepatotoxicity and/or transaminitis.

Nutrition/Growth/Bone

Stimulant medications may decrease appetite and growth. Chronic alcohol use and use of cocaine may contribute to vitamin deficiencies, particularly thiamine. A referral to Dieticians and Nutritionists (see NV providers [4]) may be warranted.

Funding & Access to Care

Inpatient hospitalization, prolonged residential treatment, and outpatient treatment programs can be very costly, particularly for the un- and under-insured. Most substance abuse treatment programs will have a social worker or case manager who can assist in exploring payment options for patients and their families. Insurance coverage for substance abuse treatment varies according to treatment center. The Substance Abuse Treatment Facility Locator (SAMHSA) has a detailed search to identify facilities that accept Medicaid programs, major insurance plans, and have sliding fee scales and payment assistance programs.
No Related Issues were found for this diagnosis.

Ask the Specialist

I have just identified a teen in my practice with a substance use disorder. What treatment facility can I refer them to?

The Substance Abuse Treatment Facility Locator (SAMHSA) lists facilities by zip code. Guardians may also request a list of authorized providers and/or facilities from their insurance provider. Services can also be found at:

What is my obligation in notifying parents of a patient with substance use?

Individual states mandate laws related to confidentiality about substance use screening results and toxicology reports. In general, experimental or nonproblematic use is not disclosed with a family without the child’s permission. If behavior associated with substance use compromises a child’s safety, consider breaking confidentiality and discussing this possibility with the patient. Regardless, the patient should always be encouraged to use the supports of parents or other healthy adult caregivers.

My patient with ADHD has had problems with marijuana and alcohol use. I am worried that they may start abusing their ADHD medications. Would it be in their best interest to stop using the ADHD medications to remove the temptation for abuse?

Although stimulant medications used to treat ADHD have the potential for abuse, studies have shown that the risk of substance abuse in those with ADHD is reduced if the ADHD is appropriately treated. The most common substance of abuse associated with untreated ADHD is marijuana and not stimulants.
Still, a small number of youth prescribed stimulants may abuse these medicines themselves or sell them to others. Clinicians are advised to monitor the use of these medications and the frequency at which refills are required. The formulation of some long-acting stimulant preparations (lisdexamfetamine or Vyvanse) limits the potential for misuse. Alternative ADHD medications that are not in the stimulant class include atomoxetine, clonidine, and guanfacine. The Medical Home Portal’s Attention-Deficit/Hyperactivity Disorder (ADHD) contains more information about management with prescribed medications.

How do I counsel parents who are interested in home screening their child for substance use?

Home drug screening kits are available, but they have limitations:

  • Not all substances are detected - particularly the newer synthetic agents.
  • The length of use (acute or chronic) affects how long a screen can detect a substance after last use.
  • False-positive results can occur.
The results of a drug screen must be considered in the context of an individual’s functioning, clinical presentations, and other familial and social factors.

What is the responsibility of the physician who is asked to perform a drug screen on a child without the child’s knowledge or consent?

In most states, teens have legal capacity to consent to or reject drug screening. It’s important to be aware of your specific state laws regarding a child’s right to know about both drug testing and substance abuse treatment. [Kerwin: 2015] Even if the physician can test the child without their consent or knowledge, the AAP [Levy: 2014] recommends against such practice - except in emergencies. The reasons against testing without the child’s consent include the risk it poses to the therapeutic relationship between the physician and child, the possibility of a false-positive or false-negative test, and the limited insight a solitary drug screen gives into the child’s patterns of behavior. Regardless of the physician’s ability to test, they should understand the parent’s concerns and reasons for desiring a drug screen on the child.

Resources for Clinicians

On the Web

Intoxication, Chronic, and Withdrawal Effects of Commonly Abused Drugs (PDF Document 258 KB)
A clinically useful chart organized by drug classification that lists the main effects of various drugs; Medical Home Portal.

Resources for Primary Care (AACAP)
A resource center for clinicians treating substance use disorders and mental health issues. Includes practice parameters, a guide for integrating mental health care into the medical home, and information about policy and advocacy; American Academy of Child & Adolescent Psychiatry.

American Academy of Addiction Psychiatry (AAAP)
A professional membership organization for clinicians interested in learning and sharing information about the art and science of addiction psychiatry treatment, advocacy, and training.

American Society of Addiction Medicine (ASAM)
A resource for clinicians and families that includes an ASAM addiction specialist locator, links to family support groups, patient guides, and practice guidelines.

Substance Abuse Treatment Facility Locator (SAMHSA)
A tool for people seeking (by ZIP Code) treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems; Substance Abuse and Mental Health Service Administration.

Motivational Interviewing (SAMHSA)
A list of online resources, webinars, and courses for clinicians interested in Motivational Interviewing; Substance Abuse and Mental Health Services Administration.

Tour of Motivational Interviewing - Free Online Course
Completing this course enables the learner to make an informed decision about whether to pursue more advanced training; prepared by the University of Missouri Kansas City School of Nursing and Health Studies Mid-America Addiction Technology Transfer Center.

Clinical Resources for Medical and Mental Health Professionals (NIDA)
Tools, resources, continuing education, training, clinical trials information, and other educational materials that may be downloaded or ordered; National Institute on Drug Abuse.

Helpful Articles

PubMed search for adolescent substance use, last 1 year.

Fadus MC, Squeglia LM, Valadez EA, Tomko RL, Bryant BE, Gray KM.
Adolescent Substance Use Disorder Treatment: an Update on Evidence-Based Strategies.
Curr Psychiatry Rep. 2019;21(10):96. PubMed abstract / Full Text

Gutierrez A, Sher L.
Alcohol and drug use among adolescents: an educational overview.
Int J Adolesc Med Health. 2015;27(2):207-12. PubMed abstract

Crowley R, Kirschner N, Dunn AS, Bornstein SS, Abraham G, Bush JF, Gantzer HE, Henry T, Kane GC, Lenchus JD, Li JM, McCandless BM, Candler SG.
Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper.
Ann Intern Med. 2017;166(10):733-736. PubMed abstract

Kulak JA, Griswold KS.
Adolescent Substance Use and Misuse: Recognition and Management.
Am Fam Physician. 2019;99(11):689-696. PubMed abstract

O'Connor E, Thomas R, Senger CA, Perdue L, Robalino S, Patnode C.
Interventions to Prevent Illicit and Nonmedical Drug Use in Children, Adolescents, and Young Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.
JAMA. 2020;323(20):2067-2079. PubMed abstract

Squeglia LM, Fadus MC, McClure EA, Tomko RL, Gray KM.
Pharmacological Treatment of Youth Substance Use Disorders.
J Child Adolesc Psychopharmacol. 2019;29(7):559-572. PubMed abstract / Full Text

Clinical Tools

Assessment Tools/Scales

Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (WHO)
The Alcohol, Smoking, and Substance Involvement Screening Test detects and manages substance use and related problems in primary care settings. It contains 8 main questions that relate to 10 substances; a clinician-administered version and a self-report version are provided. The screen and scoring instructions are available in 11 languages and can be downloaded or printed for free; developed for the World Health Organization.

Alcohol Use Disorders Identification Test (AUDIT) (WHO) (PDF Document 13 KB)
A 10-item screening tool that assesses alcohol consumption, drinking behaviors, and alcohol-related problems. The AUDIT Questionnaire and scoring instructions can be downloaded or printed for free; developed by the World Health Organization.

Car, Relax, Alone, Friends, Forget, Trouble (CRAFFT 2.1/2.1+N)
Brief screening tool for use with youth ages 12-21 recommended by the American Academy of Pediatrics. A clinician-administered version and a self-report version provided. The screen and scoring instructions are available in 17 languages and can be downloaded or printed for free upon request; Boston Children's Hospital and Harvard Medical School Teaching Hospital.

HEEADSSS Assessment Guide (USU) (PDF Document 1017 KB)
Examples of open-ended questions the clinician can ask adolescents about Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety.

Screening to Brief Intervention (S2BI) (PDF Document 126 KB)
Up to 7 questions about frequency of substance use - based on DSM-5 diagnoses for substance use disorders. Ages 12-17, youth-reported or clinician-administered online tool with scoring; National Institute of Health.

Medication Guides

Pharmacological Treatment of Youth Substance Use Disorders (PDF Document 507 KB)
Article with 2 helpful tables - Randomized Controlled Trials of Pharmacotherapy for Adolescent Substance Use Disorders and Summary Table of Medications for Adolescent Substance Use Disorders. Squeglia L, Fadus M, McClure E, and Tomko R J Child Adolesc Psychopharmacol. 2019 Sep 1; 29(7): 559–572.

Toolkits

SBIRT: Screening, Brief Intervention, and Referral to Treatment (SAMHSA)
Describes this evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs; Substance Abuse and Mental Health Services Administration.

Other

Prescription Drug Monitoring Programs (NASCSA)
Electronic databases which collect, maintain, and disseminate controlled substance prescription information specific to each jurisdiction's laws and regulations; National Association of State Controlled Substances Authorities.

Substance Abuse Treatment Facility Locator (SAMHSA)
A tool for people seeking (by ZIP Code) treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems; Substance Abuse and Mental Health Service Administration.

Patient Education & Instructions

Warning Signs for Suicide (American Foundation for Suicide Prevention)
Information about suicide signs related to speech, behavior and mood.

Helping Your Teen Cope with Traumatic Stress and Substance Abuse (NCTSN) (PDF Document 377 KB)
A 15-page guide for parents and caregivers who believe their teenagers might be experiencing problems as a result of traumatic stress and substance abuse; National Child Traumatic Stress Network.

Recognizing Drug Use in Adolescents (NCTSN) (PDF Document 1.0 MB)
Summarizes the signs of intoxication, use, and abuse commonly reported by substance users; National Child Traumatic Stress Network.

Using Drugs to Deal with Stress and Trauma (NCTSN) (PDF Document 215 KB)
An 11-page booklet for teens about the connections and risks of using drugs to deal with stress and trauma; National Child Traumatic Stress Network.

Patient Education (NIDA)
Booklets, fact sheets, and posters for patient education; National Institute on Drug Abuse.

Patient Education about Substance Use (SBIRT)
Free, printable patient education tools that describe the effects of alcohol, marijuana, and other substances and provides options for decreasing substance use; University of Missouri-Kansas City | School of Nursing and Health Studies.

Resources for Patients & Families

Information on the Web

Family Resources (AACAP)
Family education for disorders that include anxiety, autism, depression, conduct disorder, oppositional defiant disorder, and more, Includes facts, videos, and a psychiatrist finder tool; American Academy of Child & Adolescent Psychiatry.

Drug Guide for Parents (Partnership for Drug-Free Kids)
A comprehensive, up-to-date source of drug information for parents that include warning signs of adolescent drug use.

NIDA for Teens (NIDA)
Videos, games, blogs, and facts developed specifically for students and young adults; National Institute on Drug Abuse.

Understanding Drug Abuse and Addiction (DrugFacts)
A simple explanation of addiction and its effect on the brain; National Institute on Drug Abuse.

Drug Abuse and Addiction: Tools for Parents and Educators (NIDA)
Science-based information about the health effects and consequences of drug abuse. Lesson plans and school resources for teachers. Videos for parents about talking with kids about the impact of drug use; National Institute on Drug Abuse.

Prescription Drug Misuse (MedlinePlus)
Information for families that includes description, frequency, causes, inheritance, other names, and additional resources; from the National Library of Medicine.

National Alliance of Mental Illness (NAMI)
A national organization provides information and resources for families and professionals, including a helpline, local chapter resources, and advocacy, links to state chapters, information about conferences, and links to additional resources.

National & Local Support

Narcotics Anonymous
Literature, news, and meeting locator services from an organization that supports freedom from active addiction.

Alcoholics Anonymous (A.A.)
This is the national website for Alcoholics Anonymous. A meeting locator tool can help find local support groups.

Al-Anon/Alateen
Support for teens, parents, and caregivers to help cut back or stop drinking.

Studies/Registries

Clinical trials, substance abuse (National Institute on Drug Abuse)

Clinical trials, substance abuse (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in Nevada (NV)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: May 2017; last update/revision: August 2021
Current Authors and Reviewers:
Author: Travis Norseth, BS
Senior Author: Mary Steinmann, MD, FAAP, FAPA
Authoring history
2017: update: Mary Steinmann, MD, FAAP, FAPAA
2014: update: Susan Wiet, MDA
2011: update: Catherine Jolma, MDA
2011: update: Susan Wiet, MDA
2010: first version: Mark Pepper, MS, CPCIA
AAuthor; CAContributing Author; SASenior Author; RReviewer

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