Pediatrics (System-Integrated)

Adolescent substance use: screening (CRAFFT)

Clinical Overview and When to Suspect Adolescent Substance Use

— By 12th grade, ~60% have used alcohol, ~45% cannabis, ~25% have vaped nicotine in the past month (Monitoring the Future data trends)

— Substance use disorders (SUDs) initiated in adolescence carry a 4–7× higher lifetime SUD risk than adult-onset use

— Leading contributors to adolescent mortality (unintentional injury, suicide, homicide) all have substance use as a major modifiable risk factor

— AAP and USPSTF (alcohol/drug use in adolescents — Grade I, but AAP recommends universal annual screening) endorse screening at every well-child visit ages 11–21, plus acute care visits when relevant

— Also screen at: sports/camp physicals, mental health visits, ED visits for injury, school problems, new psychiatric symptoms, unexplained somatic complaints, GI symptoms with weight loss, syncope, MVCs

— Higher pre-test probability: declining grades, new peer group, depression/anxiety, ADHD, LGBTQ+ youth (minority stress), trauma/ACEs history, parental SUD, foster care, juvenile justice involvement

— Step 1: Three opening "Part A" frequency questions (past-12-month use of alcohol, cannabis, anything else)

— Step 2: If any "yes," proceed to the 6 CRAFFT questions (Part B)

Board pearl: The single most common Step 3 wrong-answer trap is ordering a urine drug screen as your first move. The correct first step in an asymptomatic adolescent is confidential, validated verbal screening (CRAFFT)—not toxicology, not parental interview, not "reassurance and return in a year."

Scope of the problem in US adolescents (ages 12–21):

Why Step 3 cares: Primary care pediatricians and family physicians own this screening. The exam tests whether you screen universally, use a validated tool (CRAFFT), respond proportionally, and navigate confidentiality correctly.

When to suspect / screen (the answer is: always):

Framework — screening is a 2-step process:

Presentation Patterns and Key History

— Asymptomatic well-adolescent visit ("routine 16-year-old physical") — tests whether you screen at all

— Adolescent with declining school performance, irritability, new friend group, sleeping all day

— ED visit after single-vehicle MVC, fight, or "found down" at a party

— Recurrent abdominal pain, headaches, fatigue without clear etiology

— New psychiatric symptoms: panic attacks (cannabis, stimulants), psychosis (cannabis, hallucinogens, stimulants), depression worsening on SSRI

— Home, Education/employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety

— Move from least sensitive (home, school) to most sensitive (drugs, sex, suicide)

— Normalize: "Many teens your age try alcohol or marijuana — have you?"

— Substance(s), age of first use, frequency, route, quantity, last use

— Context: alone vs. social, before school, to cope with mood

— Consequences: school, legal, fights, blackouts, sexual regret, MVCs

— Co-use: nicotine/vaping, prescription misuse (stimulants, benzos, opioids)

— Family history of SUD (strong genetic loading, ~50% heritability)

— Mental health: depression, anxiety, trauma, ADHD — 40–60% of SUD youth have co-occurring psychiatric illness

Step 3 management: Interview the adolescent alone for at least part of every visit starting at age 11. If the parent refuses to leave, that itself is a red flag and a documentation point. A vignette where the mother answers all questions for a 15-year-old should prompt you to ask the parent to step out, not to proceed with the joint interview.

Typical Step 3 vignette setups:

History technique — HEEADSSS framework opens the door:

Critical history elements once use is disclosed:

Confidentiality script (high-yield): "What we talk about is private. The exceptions are: someone is hurting you, you're going to hurt yourself or someone else, or you're in immediate danger." Document that this was stated.

Physical Exam Findings and Hemodynamic Assessment

— Tachycardia, hypertension: stimulants (cocaine, methamphetamine, MDMA), acute cannabis, withdrawal from alcohol/benzos/opioids

— Bradycardia, hypotension, respiratory depression: opioids, benzodiazepines, GHB

— Hyperthermia: MDMA, cocaine, methamphetamine, serotonin syndrome

— Weight loss / failure to gain: stimulants, untreated SUD with neglected nutrition

— Conjunctival injection, dry mouth → cannabis

— Miosis → opioids; mydriasis → stimulants, hallucinogens, anticholinergics, withdrawal

— Perforated nasal septum, rhinorrhea, epistaxis → intranasal cocaine

— Dental erosion ("meth mouth"), bruxism → methamphetamine, MDMA

— Burned lips, soot → inhalants ("huffing")

— Track marks, abscesses, cellulitis → IV drug use

— "Dermatitis around mouth/nose" (rash from solvent contact) → inhalant abuse — high-yield in younger adolescents (12–14)

— Self-injury scars (co-occurring mental health)

— Tattoos in unusual places hiding track marks

Board pearl: The combination of an adolescent + dermatitis around the mouth/nose ("glue sniffer's rash") + altered mental status is classic for inhalant abuse, which is most common in early adolescence (12–14) and uniquely associated with "sudden sniffing death" from catecholamine-sensitized myocardium → fatal arrhythmia. Avoid epinephrine if resuscitating; use beta-blockers cautiously.

General principle: Most adolescents with early/moderate substance use have a normal exam. Absence of findings does NOT rule out use — screening must be verbal. But certain physical clues raise suspicion and direct further questioning.

Vital signs / general:

HEENT:

Skin:

Pulmonary: Wheezing, chronic cough → vaping/EVALI risk, cannabis smoking

Cardiac: Murmur in IVDU → endocarditis (tricuspid)

Neuro: Nystagmus (PCP, ketamine, alcohol), ataxia, slurred speech, altered mental status

Diagnostic Workup — The CRAFFT Tool (Initial Screen)

— A1: Drink any alcohol (more than a few sips)?

— A2: Use any marijuana (smoke, vape, edibles, dabs)?

— A3: Use anything else to get high (any illegal drug, prescription med, OTC med, inhalant)?

— (+N): Vape or use nicotine?

— All "0 days" on A1–A3 → Ask only the "C" — Car question (riding with an impaired driver). Stop. Praise abstinence.

— Any use reported → Ask all 6 CRAFFT questions

— Car: Ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol/drugs?

— Relax: Use to relax, feel better about yourself, or fit in?

— Alone: Use while by yourself, or alone?

— Forget: Forget things you did while using (blackouts)?

— Family/Friends: Family or friends tell you to cut down?

— Trouble: Gotten into trouble while using?

— 0–1: Lower risk → brief positive reinforcement, anticipatory guidance

— ≥2: Higher risk → indicates possible SUD; requires brief intervention and consideration of referral

— Score ≥2 has sensitivity ~80%, specificity ~80% for SUD in adolescents

Key distinction: CRAFFT is a screening tool, not a diagnostic tool. A score of ≥2 means "higher risk — investigate further with a clinical interview using DSM-5 SUD criteria." It does not diagnose substance use disorder by itself. The Step 3 wrong answer is "diagnose cannabis use disorder and start treatment based on CRAFFT score of 3."

CRAFFT 2.1+N is the AAP-endorsed adolescent screen (validated ages 12–21). The "+N" adds nicotine/vaping.

Part A — Opening frequency questions (past 12 months, number of days):

Branching logic:

Part B — The 6 CRAFFT questions (each "yes" = 1 point):

Scoring:

Diagnostic Workup — Advanced Studies and Drug Testing

— NOT a screening test in asymptomatic adolescents

— Indicated: acute altered mental status, unexplained psychosis/seizure, MVC trauma, treatment monitoring in established SUD care, court-ordered

— Must obtain adolescent's consent when clinically (non-emergent) indicated — AAP opposes involuntary drug testing of competent adolescents at parental request

— Standard immunoassay panel: amphetamines, cocaine, opioids, cannabinoids (THC-COOH), PCP, benzodiazepines

— Misses: synthetic cannabinoids ("K2/Spice"), synthetic cathinones ("bath salts"), fentanyl (unless specifically ordered), MDMA, LSD, ketamine, GHB, kratom

— Order fentanyl-specific testing separately given fentanyl-contamination epidemic

— Alcohol: 6–12 h (urine); EtG/EtS up to 80 h

— Cannabis: 3 days (occasional) up to 30 days (chronic heavy)

— Cocaine metabolites: 2–4 days

— Opioids (most): 1–3 days; methadone 3 d; buprenorphine requires specific assay

— Amphetamines: 2–3 days; methamphetamine 3–5 d

— Benzodiazepines: variable; alprazolam and clonazepam often missed by standard immunoassay

— CBC, CMP (LFTs in alcohol use), lipase

— Pregnancy test before any pharmacotherapy

— HIV, HBV, HCV, syphilis, GC/CT in IVDU or high-risk sexual behavior

— ECG (stimulants, methadone — QTc)

Board pearl: A parent demands you drug-test their competent 16-year-old without the teen's knowledge. Correct answer: decline. Explain confidentiality, offer to facilitate a family conversation, screen with CRAFFT during a confidential interview.

DSM-5 SUD criteria (2 of 11 in 12 months): impaired control (4), social impairment (3), risky use (2), pharmacologic (tolerance, withdrawal). Severity: 2–3 mild, 4–5 moderate, ≥6 severe.

Urine drug screening (UDS) — when and how:

Detection windows (high-yield):

Adjunct labs as clinically indicated:

Risk Stratification and the SBIRT Framework

— Positive reinforcement: "I'm impressed you've chosen not to use — that's the healthiest choice for your developing brain."

— Anticipatory guidance: peer pressure refusal skills, safe-ride contract (call parent, no questions, anytime)

— Rescreen annually

— Brief advice: clear, personalized recommendation to stop (or not start)

— Connect use to adolescent's own goals (sports, driving, college)

— Discuss developing brain (prefrontal cortex matures to ~25), addiction risk multiplier with early use

— Anticipatory guidance, rescreen at next visit

— Brief motivational interviewing intervention (5–15 min): OARS — Open questions, Affirmations, Reflective listening, Summaries; readiness ruler (0–10)

— Assess DSM-5 SUD criteria

— Refer for further assessment/treatment — outpatient adolescent SUD program, behavioral health

— Address co-occurring depression/anxiety/ADHD/trauma simultaneously

— Daily use, IV use, opioid use, withdrawal symptoms, suicidality, overdose history, failed outpatient treatment, pregnancy

— Refer to higher level of care: intensive outpatient (IOP), partial hospitalization, residential, or inpatient detox

Step 3 management: A 17-year-old with CRAFFT score 4 (cannabis daily, alone, forgetting, friends told him to cut down) — the next step is brief motivational interviewing in the office plus referral to an adolescent SUD treatment program, not "order UDS confirmatory testing" and not "admit for detox" (cannabis withdrawal does not require admission). Engage parents with the adolescent's permission unless safety overrides confidentiality.

SBIRT = Screening, Brief Intervention, and Referral to Treatment — the AAP/SAMHSA framework that maps directly onto CRAFFT scoring. This is the Step 3 management algorithm for adolescent substance use.

CRAFFT 0, no use reported (Car = 0):

CRAFFT 0–1 with any use (low risk):

CRAFFT ≥2 (higher risk — possible SUD):

CRAFFT ≥2 with red flags → escalate urgently:

Pharmacotherapy — Brief Intervention and Medication-Assisted Treatment

— Motivational Enhancement Therapy (MET)

— Cognitive Behavioral Therapy (CBT)

— Family-based: Multidimensional Family Therapy (MDFT), Family Behavior Therapy, Brief Strategic Family Therapy

— Contingency management (high evidence for stimulant and cannabis use disorders)

— 12-step facilitation (adjunct; not standalone)

— Opioid use disorder (OUD): Buprenorphine (or buprenorphine/naloxone) is FDA-approved ≥16 years and is first-line. AAP policy: do NOT withhold MAT from adolescents who meet OUD criteria — undertreatment is the rule and is harmful. Naltrexone (extended-release IM) is an option ≥18. Methadone requires age ≥18 (with 2 failed treatments) per federal rules, with exceptions.

— Alcohol use disorder: Naltrexone has the best adolescent evidence (off-label <18). Acamprosate and disulfiram are options. Treat acute withdrawal with benzodiazepines (rare in adolescents; if present, severe alcohol use disorder).

— Nicotine/vaping: Counseling + nicotine replacement therapy (NRT) can be offered; varenicline approved ≥16; bupropion off-label. AAP supports NRT for adolescents who can't quit with behavioral approaches alone.

— Cannabis, stimulant, hallucinogen use disorders: No FDA-approved pharmacotherapy — behavioral therapy is the answer.

Board pearl: A 17-year-old with severe OUD after counterfeit-pill (fentanyl) overdose — the correct answer is initiate buprenorphine (often via low-dose induction or standard induction once in mild–moderate withdrawal, COWS ≥8), prescribe naloxone, refer to adolescent OUD program. "Refer to abstinence-only residential program" is the wrong answer.

First-line "treatment" in primary care is behavioral, not pharmacologic for most adolescents — but Step 3 expects you to know when and which medications are indicated.

Behavioral first-line therapies (evidence-based for adolescents):

Pharmacotherapy by substance — adolescent specifics:

Always co-prescribe naloxone to any adolescent using opioids (or whose household member uses opioids) — and to families given the fentanyl-contamination risk in counterfeit pills.

Brief Intervention Technique — Motivational Interviewing in the Office

— Ask — screen with CRAFFT

— Advise — clear personalized recommendation

— Assess — readiness to change (0–10 ruler)

— Assist — collaborative plan, MI techniques

— Arrange — follow-up, referral

— Precontemplation ("I don't have a problem"): raise awareness, share concern, leave door open. Do NOT argue.

— Contemplation ("Maybe I should cut back"): decisional balance — pros/cons of using vs. cutting back

— Preparation: SMART goal setting, identify triggers, build skills

— Action: concrete plan, frequency of follow-up, contingency planning

— Maintenance: relapse prevention, identify high-risk situations

— Relapse: normalize, re-engage, NOT a treatment failure

— Open questions ("What role does cannabis play in your life right now?")

— Affirmations ("It took courage to be honest with me about this")

— Reflective listening ("So school is getting harder AND the cannabis helps you sleep")

— Summaries — link statements, transition to plan

CCS pearl: In a simulated case of a 16-year-old with vaping daily and CRAFFT of 3, your CCS orders should include: "Counseling, motivational interviewing"; "Counseling, smoking/vaping cessation"; "Nicotine replacement therapy" if appropriate; "Follow-up appointment, 2 weeks"; "Referral, adolescent behavioral health" — not "urine drug screen" or "chest CT."

The 5 A's structure (adapted for adolescent SUD):

Stages of change (Prochaska/DiClemente) — match intervention to stage:

OARS micro-skills (used throughout):

Avoid the "righting reflex" — lecturing, scare tactics, and confrontation increase resistance and reduce behavior change. This is heavily tested.

Readiness ruler example: "On a scale of 0 to 10, how ready are you to cut back on vaping?" → "You said 4 — why not lower, like a 2?" elicits change talk from the patient.

Documentation: Document CRAFFT score (not the answers verbatim, to protect confidentiality of the chart parents may access), brief intervention provided, plan, follow-up.

Special Populations — Younger Adolescents and Developmental Considerations

— Early adolescence (11–14): Concrete thinking, peer influence dominant. Inhalants peak here (cheap, accessible — glue, aerosols, nitrous, "whippets"). Screen for inhalants explicitly — they are missed on UDS.

— Middle adolescence (15–17): Identity formation, risk-taking peaks. Highest rates of alcohol initiation, cannabis, prescription misuse, first sexual experiences under influence.

— Late adolescence (18–21): Transition to adulthood, college binge drinking, increased autonomy. Confidentiality rules change at 18 (now an adult — parents have no right to information without patient consent, even with shared insurance).

— Chronic alcohol use → transaminitis, fatty liver (rising in adolescents with obesity + alcohol)

— Inhalants (toluene) → distal renal tubular acidosis, hepatotoxicity

— Acetaminophen co-ingestion (opioid combo products) → hepatotoxicity

— Anabolic steroids → cholestasis, hepatic adenomas

— Adjust pharmacotherapy: naltrexone contraindicated in acute hepatitis/liver failure; buprenorphine generally safe in hepatic impairment but monitor LFTs

Board pearl: A 13-year-old with new perioral dermatitis, declining grades, and a "musty" smell on clothes — think inhalants (toluene/spray paint). Order basic metabolic panel looking for non-anion-gap metabolic acidosis (type 1 RTA, hypokalemia) and counsel; UDS will be negative, which doesn't rule it out.

CRAFFT validation extends down to age 12. For children <12 with suspected use (rare but occurs, especially inhalants and prescription misuse), use the BSTAD (Brief Screener for Tobacco, Alcohol, and Drugs) or S2BI — both NIDA-endorsed for ages 12–17, with BSTAD more sensitive in younger adolescents.

Developmental considerations:

Renal/hepatic impairment in adolescent SUD:

Disability and cognitive impairment: Adolescents with intellectual disability, autism, or ADHD are over-screened with assumptions of non-use — screen all. Use simplified language; involve family appropriately.

Special Populations — Pregnancy, LGBTQ+, Justice-Involved, and Other Subgroups

— Universal substance use screening at the first prenatal visit (ACOG) — use the 4 P's or CRAFFT-equivalent prenatal tool; verbal screen, not biological

— Tobacco, alcohol, cannabis — all should be stopped; counsel on fetal alcohol spectrum disorders (no safe alcohol amount), neonatal abstinence syndrome (opioids), low birth weight (cannabis, tobacco)

— Opioid use disorder in pregnancy: continue/initiate buprenorphine or methadone — do NOT attempt medically supervised withdrawal/detox (higher relapse, worse outcomes). Naltrexone is not first-line in pregnancy.

— Mandatory reporting laws vary by state — know that prenatal substance use is reported as child welfare concern at birth in many states (CAPTA — Plan of Safe Care required for substance-exposed newborns)

— 2–4× higher rates of substance use due to minority stress, family rejection, victimization

— Screen with affirming language; ask about chosen name/pronouns

— "Chemsex"/party drugs (MDMA, GHB, methamphetamine, poppers) — screen specifically in older adolescents

— Highest-risk populations; rates of SUD 3–5× general adolescent population

— Continuity of care often disrupted — arrange warm handoffs, not just referrals

— Federal 42 CFR Part 2 protects SUD treatment records even more stringently than HIPAA

— Anabolic steroids, stimulants (ADHD med diversion), supplements

— Ask about supplement use; counsel on contamination, cardiac risk

— Pre-participation physical is a screening opportunity

Step 3 management: Pregnant 17-year-old with OUD presenting in withdrawal — admit, initiate buprenorphine induction, OB and addiction medicine consult, hepatitis/HIV screening, ultrasound for dating, plan for naloxone and continued MAT throughout pregnancy and postpartum (relapse risk peaks postpartum). Do not detox.

Pregnant adolescents:

LGBTQ+ youth:

Justice-involved / foster care / unhoused youth:

Athletes:

Complications and Adverse Outcomes of Adolescent Substance Use

— Overdose (opioids — fentanyl-laced counterfeit pills are now the leading cause of adolescent overdose death in the US)

— Alcohol poisoning, aspiration, hypothermia

— Stimulant-induced MI, stroke, arrhythmia, hyperthermia, rhabdomyolysis

— Cannabis: hyperemesis syndrome (cyclic vomiting, relieved by hot showers), acute psychosis especially with high-THC concentrates ("dabs")

— EVALI (e-cigarette/vaping-associated lung injury) — bilateral infiltrates, hypoxia, especially with vitamin E acetate in THC vapes

— Inhalant "sudden sniffing death" — catecholamine-sensitized arrhythmia

— MVCs (leading cause of adolescent death; ~25% involve alcohol; cannabis also impairs driving)

— Drowning, falls, violence, sexual assault

— Cannabis use in adolescence → 2× risk of psychotic disorder, dose-dependent; risk highest with daily high-potency use before age 16

— Worsening depression, anxiety, suicidality

— Stimulants → psychosis, paranoia

— Adolescent brain (prefrontal cortex, hippocampus) is uniquely vulnerable

— Cognitive decrements with chronic cannabis (executive function, memory, IQ — Dunedin cohort)

— Early use → earlier and faster progression to SUD

Board pearl: Adolescent with cyclic vomiting, hot-shower-seeking behavior, normal labs/imaging, and daily cannabis use → cannabinoid hyperemesis syndrome. Treatment: cessation of cannabis (definitive); topical capsaicin to abdomen and haloperidol or droperidol for acute episodes (better than ondansetron, which often fails).

Acute medical complications:

Injury/trauma:

Mental health:

Long-term neurodevelopmental:

Infectious: HIV, HCV, HBV, endocarditis (IV use); STIs from disinhibited sexual behavior

Social: School failure/dropout, juvenile justice involvement, family conflict, sexual exploitation

When to Escalate Care — Higher Level of Treatment

— Level 0.5: Early intervention (SBIRT in primary care)

— Level 1: Outpatient (<9 hrs/week)

— Level 2.1: Intensive outpatient (IOP) — 6–19 hrs/week, school-compatible

— Level 2.5: Partial hospitalization (PHP) — 20+ hrs/week

— Level 3: Residential (3.1 low-intensity, 3.5 medium, 3.7 medically monitored)

— Level 4: Medically managed inpatient (acute detox, medical instability)

— Acute overdose, suspected fentanyl exposure → ED, naloxone, observation

— Severe withdrawal (alcohol, benzodiazepines, opioids in pregnancy) — admit for medically supervised withdrawal

— Suicidality, homicidality, acute psychosis → psychiatric admission

— Medical complications (endocarditis, EVALI, DKA from alcohol/stimulants, rhabdomyolysis)

— Pregnancy with active SUD requiring stabilization

— Severe SUD with failed outpatient treatment

— Unsafe home environment incompatible with recovery

— Co-occurring severe mental illness requiring structured setting

— Repeated overdoses

— CRAFFT ≥2 + DSM-5 SUD criteria met → adolescent addiction medicine or behavioral health referral

— Opioid use disorder → buprenorphine-waivered provider (X-waiver eliminated 2023; any DEA-registered prescriber can now prescribe buprenorphine, but adolescent expertise matters)

— Co-occurring disorders → integrated dual-diagnosis program preferred over sequential

CCS pearl: A 16-year-old brought to ED unresponsive, pinpoint pupils, RR 6. CCS sequence: Naloxone IV/IM/IN, oxygen, bag-mask ventilation, IV access, continuous monitoring, ECG, fingerstick glucose, fentanyl-specific UDS, observe for re-sedation (fentanyl t½ may exceed naloxone — repeat dosing often needed), social work, addiction consult, initiate buprenorphine before discharge, prescribe take-home naloxone for the family, arrange follow-up within 72 h. Do not discharge without MAT linkage.

ASAM (American Society of Addiction Medicine) adolescent levels of care:

Indications for inpatient/ED escalation (emergent):

Indications for residential treatment:

Consultation/referral threshold:

Key Differentials — Other Substance-Use-Related Conditions

— Substance use (any) vs. substance use disorder (DSM-5): Use ≠ disorder. SUD requires ≥2 of 11 criteria over 12 months with functional impairment.

— Intoxication vs. withdrawal: Often opposite phenomenology

— Cannabis use disorder vs. cannabinoid hyperemesis syndrome vs. cannabis-induced psychotic disorder

— Prescription stimulant misuse (diversion for academic performance) vs. ADHD treatment — ask about source, dose escalation, route (crushing/snorting)

— Designer drugs:

— Polysubstance use is the rule, not the exception in adolescents — always ask "anything else?" three times

Key distinction: A 15-year-old with severe agitation, hyperthermia, hypertension, and UDS positive only for cannabinoids — consider synthetic cannabinoid (K2/Spice) intoxication; the immunoassay typically does NOT detect synthetics. Send comprehensive GC-MS if available. Manage with benzodiazepines for agitation, cooling, IV fluids; avoid antipsychotics for hyperthermia (lower seizure threshold).

Within the substance-use category, distinguish:

Opioid intoxication: miosis, sedation, hypoventilation

Opioid withdrawal: mydriasis, yawning, lacrimation, rhinorrhea, piloerection, diarrhea, not life-threatening (except in pregnancy and neonates)

Alcohol/benzo withdrawal: tachycardia, tremor, seizures, DTs — life-threatening

Stimulant withdrawal: hypersomnia, hyperphagia, dysphoria — not medically dangerous but suicidality risk

Synthetic cannabinoids (K2, Spice): unpredictable psychosis, AKI, seizures — UDS negative

Synthetic cathinones (bath salts): severe agitation, hyperthermia, rhabdo

Kratom: opioid-like; can cause dependence and withdrawal

Key Differentials — Non-Substance Causes of the Same Presentation

— Depression, anxiety, bipolar disorder (especially new-onset mania in mid-adolescence)

— ADHD (often unmasked or worsened in high school)

— Learning disability decompensating with academic demand

— Sleep disorders — delayed sleep phase, sleep apnea

— Thyroid disease — hyper or hypo

— Iron deficiency — fatigue, cognitive symptoms

— Mononucleosis, chronic infection

— Bullying, family conflict, sexual abuse, trauma/PTSD

— Eating disorders

— Early psychosis prodrome (schizophrenia, schizophreniform)

— Hypoglycemia (T1DM, insulinoma — rare)

— DKA, hyperammonemia (urea cycle, valproate), uremia

— CNS infection (meningitis, encephalitis — HSV)

— Seizure/postictal

— Traumatic brain injury (consider non-accidental trauma in younger adolescents)

— Acute psychosis (primary psychiatric)

— Serotonin syndrome, NMS, anticholinergic toxidrome (from prescribed meds)

— Hyperthyroidism, pheochromocytoma (rare)

— Serotonin syndrome (SSRI + linezolid, MAOI, tramadol)

— Anticholinergic poisoning (diphenhydramine recreational use — TikTok "Benadryl challenge" — should be on your radar)

— Sympathomimetic toxidrome (stimulants)

Board pearl: A 16-year-old with declining grades, irritability, weight loss, palpitations, and tremor — looks like stimulant use, but UDS negative and TSH suppressed with elevated free T4 → Graves disease. Always check thyroid in vignettes with autonomic and behavioral overlap.

Declining school performance + behavioral change — broader differential:

Altered mental status in an adolescent — non-substance causes:

Tachycardia + hypertension + agitation:

The trap: Anchoring on substance use when the diagnosis is primary psychiatric or medical. AND anchoring on "depression" when comorbid SUD is driving the symptoms. Always screen for both.

Secondary Prevention, Discharge Planning, and Long-Term Plan

— Establish a medical home with same-clinician continuity

— Co-occurring mental health treatment must be addressed concurrently (integrated care)

— Treat ADHD appropriately — untreated ADHD increases SUD risk; non-stimulants (atomoxetine, guanfacine) or long-acting stimulant formulations (lisdexamfetamine prodrug, OROS-methylphenidate) reduce diversion potential

— Naloxone for any adolescent or family with opioid use or opioid exposure risk (including homes with prescribed opioids)

— Buprenorphine continuation with adolescent OUD program

— NRT for nicotine/vaping cessation

— Multivitamin/thiamine if chronic alcohol use

— Contraception counseling — sexually active adolescents on teratogenic meds, or to reduce unintended pregnancy risk while in recovery

— Never use alone — fentanyl test strips, Never Use Alone hotline

— Don't mix substances, especially opioids + benzos/alcohol

— Naloxone training for friends and family

— Safe-ride contracts

— Lock medications at home (parent counseling)

— Annual well visit with confidential screening

— Brain development through ~25; substances are uniquely harmful in adolescence

— Driving + substances messaging

— Vaccine catch-up (HPV, meningococcal, Tdap, COVID, flu)

Step 3 management: Discharging a 17-year-old after an opioid overdose — minimum bundle: (1) naloxone Rx + training, (2) buprenorphine initiated and continued, (3) follow-up within 72 hours, (4) warm handoff to adolescent SUD program, (5) screen and treat HIV/HCV, (6) mental health referral, (7) involve family with patient consent, (8) safety planning if suicidality. "Discharge with referral to NA meeting and follow-up in 1 month" is the wrong answer.

For the adolescent who has used or has an SUD:

Discharge medications / take-home items:

Anticipatory guidance / harm reduction (Step 3 expects you to know this):

Universal anticipatory guidance for all adolescents:

Follow-Up, Monitoring, and Counseling Cadence

— Annual well-child visit with confidential CRAFFT, ages 11–21

— Acute visits when indicated (MVC, mental health, school problems)

— Brief advice now, rescreen in 3–6 months rather than waiting a full year

— Document score and intervention

— Follow-up in 2–4 weeks after brief intervention

— Monthly visits during active behavior change

— Engage parents with adolescent consent

— Weekly to biweekly initial visits during induction/stabilization

— Monthly once stable

— Buprenorphine OUD: clinical visits weekly initially, urine drug testing as a clinical tool (not punitive), monitor LFTs, pregnancy testing in females, mental health co-management

— Re-engage promptly after any relapse — relapse is part of the chronic-disease model, not a treatment failure

— Naltrexone (alcohol): LFTs at baseline, 3, 6, 12 months

— Buprenorphine: LFTs baseline and PRN, UDS for fentanyl/other, pregnancy testing

— Varenicline (nicotine ≥16): mood/behavior (rare neuropsychiatric effects)

— Disulfiram: LFTs, counsel on alcohol-containing products (mouthwash, OTC)

— Days abstinent, frequency of use, CRAFFT rescore, school attendance/grades, mental health symptom scales (PHQ-9-A, GAD-7), employment, legal status, family functioning

— Reinforce change, identify triggers and relapse warning signs, update safety plan, naloxone refill status, vaccination updates, sexual health, driving

Board pearl: After initiating buprenorphine for adolescent OUD, the next visit should be within 3–7 days, not 4 weeks. Early frequent contact dramatically improves retention, which is the single strongest predictor of long-term recovery and survival.

Universal screening cadence (no use or low risk):

Low-risk use (CRAFFT 0–1, some use):

Moderate/higher risk (CRAFFT ≥2, no SUD yet):

SUD in active treatment:

Monitoring parameters by treatment:

Outcome measures to track:

Counseling content per visit:

Ethical, Legal, and Patient Safety Considerations

— Most states grant minors the right to consent to and confidentiality of substance use treatment (varies — know your state, but Step 3 tests the principle)

— 42 CFR Part 2 provides federal protection for SUD treatment records — even stricter than HIPAA. Records cannot be released without specific patient consent, even to parents in most cases, and including for billing/insurance disclosures

— Discuss confidentiality and its limits at the start of every adolescent visit, with the parent present, then ask the parent to step out

— Imminent risk to self (suicidality)

— Imminent risk to others (homicidality, drunk driving plan with intent)

— Abuse/neglect (mandatory reporting)

— Court order

— Suspected child abuse or neglect — including a parent with severe SUD endangering the child, or substance-exposed newborns under CAPTA

— Adolescent driving while intoxicated in some states requires DMV reporting; counsel and document, but generally clinician-patient privilege protects most disclosures unless imminent danger

— Do not perform involuntary drug testing on a competent adolescent at parental request — violates autonomy and damages therapeutic alliance

— Exceptions: medical emergency, court-ordered, part of agreed treatment plan

— Random "home drug testing kits" are discouraged; AAP policy statement opposes them

— Explanation of benefits (EOB) sent to parent policyholder can inadvertently disclose SUD treatment — use confidential billing pathways, sliding-scale clinics, Title X, or Medicaid where available

— Adolescent-to-adult transition (~age 18–21) is a high-risk relapse window — formalize transition with a transition plan, not just a handoff

— Discharge from ED after overdose without MAT linkage has been called a "missed opportunity" with measurable mortality consequence — always initiate buprenorphine in the ED for OUD

Step 3 management: Mother demands you tell her what her 16-year-old disclosed about cannabis use. Correct response: decline to share specifics, explain confidentiality framework, offer to facilitate a joint conversation with the adolescent's permission, and reassure the parent you would disclose only if her child were in imminent danger.

Confidentiality — the cornerstone of adolescent SUD care:

Limits of confidentiality (must be disclosed up front):

Mandatory reporting:

Drug testing ethics:

Insurance/billing safety:

Transitions of care:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: If the answer choices include "lecture the adolescent about consequences," "involuntary drug test," "tell the parent everything," or "discharge with NA pamphlet" — none of these are correct. The answer is almost always confidential CRAFFT screen + brief motivational intervention + appropriate referral.

CRAFFT cutoff: ≥2 = positive (higher risk of SUD; needs further assessment)

CRAFFT validated ages: 12–21

AAP recommendation: universal annual screening 11–21 at every well visit

+N version adds nicotine/vaping (current standard)

Part A first (3 frequency questions) → branches to either the Car question only (if no use) or all 6 CRAFFT questions (if any use)

The 6 letters: Car, Relax, Alone, Forget, Family/Friends, Trouble

SBIRT = Screening, Brief Intervention, Referral to Treatment — the framework that operationalizes CRAFFT

Adolescent brain matures to ~age 25 — prefrontal cortex last; substance exposure during this window confers disproportionate addiction risk

Earlier age of first use → higher lifetime SUD risk (alcohol use before 15 = 4× SUD risk)

Fentanyl now contaminates most counterfeit pills ("Percs," "Xans," "M30s") — adolescent overdose deaths from fentanyl rose 6-fold 2018–2022; leading cause is counterfeit pills, not heroin

Buprenorphine FDA-approved ≥16 years for OUD; do not withhold MAT from adolescents

Cannabis adolescent use: linked to 2× psychosis risk, dose- and potency-dependent; CHS treated with cessation + topical capsaicin + haloperidol

Inhalants: peak ages 12–14; UDS negative; "sudden sniffing death"; perioral dermatitis

EVALI: vitamin E acetate (THC vapes); bilateral infiltrates, hypoxia

42 CFR Part 2 > HIPAA for SUD records

MET, CBT, family therapy, contingency management = evidence-based behavioral treatments for adolescent SUD

No FDA-approved meds for cannabis, stimulant, or hallucinogen use disorders

Pregnant adolescent with OUD: buprenorphine or methadone — do NOT detox

Board Question Stem Patterns

"A 15-year-old comes for a routine physical with her mother. After taking initial history together, what is the most appropriate next step?"

→ Ask the mother to step out and conduct a confidential interview, including substance use screening with the CRAFFT tool. Distractors: "Order UDS"; "Counsel on abstinence in front of mother"; "Continue history with mother present."

"A 16-year-old endorses smoking cannabis daily, using alone, has had blackouts, and friends have told him to cut down. CRAFFT score is 4. Most appropriate next step?"

→ Brief motivational interview and refer to an adolescent substance use treatment program. Distractors: "Order confirmatory UDS"; "Admit for detox"; "Reassure that cannabis is non-addictive"; "Disclose to parents without consent."

"Mother demands you drug-test her 17-year-old because she 'found a vape in his room.' The adolescent refuses. Most appropriate response?"

→ Decline involuntary testing, conduct confidential CRAFFT screen, facilitate family conversation.

"A 17-year-old is brought to ED after being found unresponsive with pinpoint pupils. After stabilization with naloxone, what should be done before discharge?"

→ Initiate buprenorphine, prescribe take-home naloxone, refer to OUD program, screen for HIV/HCV, follow-up within 72 hours.

"A 14-year-old with perioral dermatitis, hypokalemia, non–anion-gap metabolic acidosis, and a negative urine drug screen…"

→ Inhalant abuse (toluene). Counsel; UDS does not detect inhalants.

"A 16-year-old G1 at 12 weeks with active heroin use and withdrawal symptoms…"

→ Initiate buprenorphine (or methadone); do NOT attempt detox; arrange OB and addiction medicine co-management.

"A 17-year-old with cyclic vomiting, relieved by hot showers, daily cannabis use, normal workup…"

→ Cannabinoid hyperemesis syndrome — cessation of cannabis is definitive; topical capsaicin and haloperidol for acute episodes.

Key distinction: When a vignette emphasizes the method of screening, the answer is CRAFFT (confidential, verbal). When it emphasizes the management response to a positive screen, the answer is brief motivational intervention + appropriate referral, not biological testing or punitive measures.

Stem 1 — The well-visit screen:

Stem 2 — The high CRAFFT score:

Stem 3 — The parental drug test demand:

Stem 4 — The opioid overdose ED case:

Stem 5 — The "missed" diagnosis on UDS:

Stem 6 — Pregnant adolescent with OUD:

Stem 7 — The cannabis hyperemesis case:

One-Line Recap

Universal annual confidential screening of adolescents (ages 11–21) with the CRAFFT 2.1+N tool, followed by a stage-matched motivational brief intervention and appropriate referral (SBIRT), is the standard of care — protecting confidentiality, avoiding involuntary drug testing, and initiating evidence-based pharmacotherapy (like buprenorphine for OUD ≥16) when indicated.

Board pearl: The single most-tested principle across every Step 3 adolescent substance-use vignette is this — screen everyone confidentially with CRAFFT, respond proportionally with SBIRT, never substitute a urine drug test for a conversation, and never break confidentiality except for safety. Master that, and you will get every question right.

CRAFFT essentials: 6 questions (Car, Relax, Alone, Forget, Family/Friends, Trouble); score ≥2 = positive → further assessment for SUD; validated 12–21; preceded by 3 Part A frequency questions + nicotine.

SBIRT cadence: Negative screen → reinforce + annual rescreen. Use without disorder → brief advice + 3–6 month follow-up. CRAFFT ≥2 → motivational intervention + referral. Severe/overdose/pregnancy → escalate to MAT (buprenorphine), inpatient if indicated, integrated mental health.

Confidentiality and ethics: Interview adolescents alone; disclose limits up front (self-harm, harm to others, abuse); decline parent-requested involuntary drug testing; respect 42 CFR Part 2; engage parents with adolescent consent; mandatory reporting only for abuse/imminent danger.

Don't miss: Inhalants in 12–14-year-olds (UDS negative, perioral dermatitis, RTA); fentanyl-contaminated counterfeit pills (leading cause of adolescent OD death — prescribe naloxone widely); cannabinoid hyperemesis (cessation curative); cannabis-induced psychosis (2× risk, dose-dependent); pregnant adolescent with OUD (buprenorphine, not detox); co-occurring depression/anxiety/ADHD (treat concurrently — untreated comorbidity drives relapse).