Behavioral Signs of Substance Use and Abuse
A combination of the following signs should alert you to the possibility that
a patient is using illicit substances and to the importance of exploring that
possibility through an interview and/or laboratory testing:
- Sudden decline in school achievement. Since alcohol and other types of
drug intoxication interfere with learning, it is not surprising that rapidly
deteriorating school performance frequently results. Poor functioning in
school that contrasts sharply with earlier adequate functioning, especially
in the absence of a school change or other obvious explanation, should
- Cigarette smoking.
- Marked shift in the childís peer reference group, especially association
with known or suspected drug users.
- Serious erosion of parental trust in the child.
- Support by the child for the idea of legalizing marijuana.
- Marked personality changes. Although childhood and especially
adolescence are often marked by mood swings and some instability, evidence
of social withdrawal, a new guardedness in communication with other family
members, inexplicable depression or other evidence of psychological
disruption such as changes in sleeping patterns, are all possible indicators
of drug involvement.
- Withdrawal from extracurricular activities that were previously
important to the child, such as athletics, religious or youth programs,
- Cutting classes, tardiness or truancy from school.
- Deterioration in appearance and personal hygiene.
- Increased secretiveness unexplained phone calls, heightened hostility to
inquiry, sudden onset of hypersensitivity.
- Going out every night. Youth who are intensely involved with weekday
social activity consisting primarily of "hanging around" (as opposed to
scheduled youth activities or activities on weekends) may be drug involved.
- Unexplained disappearance of family funds, or family and personal
possessions (this may be related to a need for money to purchase drugs.)
- Aggressive behavior such as recurrent fighting, violent hostility, or
other evidence of social alienation.
- Heavy use of over-the-counter preparations to reduce eye reddening
(e.g., injected conjuctiva produced by acute marijuana intoxication), nasal
irritation (resulting from "snorting" cocaine), or tell-tale bad breath
(produced by alcohol or cigarettes).
Physical Symptoms of Alcohol and Other Drug Use
Behavioral manifestations, not physical appearance, are the red flags of
alcohol and other drug use. Generally, physical symptoms or sequelae of
substance abuse will not be obvious. For example, smoking marijuana or crack
cocaine may not usually cause coughing, wheezing, or other obvious irritation of
the upper respiratory system. While a reddening of the eyes of occurs, eye
irritation can have a variety of other causes, so this symptom is hardly
pathognomonic. Even acute intoxication with marijuana may not be apparent. Many
experienced marijuana users are able to hide the outward signs of the drugís
intoxicating effects, thereby disguising their use and fooling even the most
Although some clinicians have noted a quality of listlessness, unhealthy
pallor and complaints of tiredness in their young, drug-using patients, these
symptoms may not always be apparent even in advanced stages of use. While weight
loss and other evidence of malnutrition may occur following continued use of
cocaine or other stimulant drugs, these signs are unlikely to result from
recently initiated or occasional use.
Evidence of I.V. Drug Use
Given the risks of such secondary infections as hepatitis and AIDS, and of
anaphylactic reaction to the injected material, any evidence or admission of
I.V. drug use should be regarded as indicating a need for assessment by an
experienced drug treatment professional.
Since alcohol and other drugs are
not used in vacuum, your knowledge of the individual, how they
are getting along with their families, their teachers, and their peers is
Be on the lookout for behavioral signals. Behavioral changes or
problems that have developed since a childís last visit are often evident after
even brief interviews with the patient and parent. Usually, children who are
involved with alcohol and other drugs send out behavioral signals and frequently
such changes or problems will emerge during the routine questioning you
undertake as part of your examination.
Using Opportunities to Discuss Substance Abuse
The amount of time you can spend with any patient is very limited, but
even that required for a routine physical examination can be used to explore
possible substance use and encourage a drug-free lifestyle. The routine
chest examination provides an excellent opportunity to ask about cigarette
smoking and marijuana use. Since the youngster may believe that you can detect
use of these substances by your chest auscultation, he or she will usually
respond openly to direct, but nonjudgmental inquiry. Routinely asking about
alcohol use in the childís school and among his or her peers readily leads to
questions about personal use. This questioning is likely to be non-threatening
to your patient in the context of your concern for his or her overall health and
Reactions to Your Questions
An important clue to more serious involvement with substance abuse is marked
defensiveness about the essence of alcohol or other drug use or any kind of
emotional response to your routine questions. If this reaction occurs, it
provides a further basis for inquiry, indicating the patient that the topic
seems to be a sensitive one and making the patient aware that you wonder why.
Why are they Using Drugs?
The drug use may be the patientís way of self-medicating anxiety or dealing
with problems in living or a lack of self-esteem. But even though drugs may
temporarily alleviate some of these feelings, substance abuse is destructive to
emotional maturation and other aspects of growth and development. Thus,
objective confirmation can sometimes be a relief to all concerned, making it
easier for both the youngster and the parent(s) to acknowledge that a problem
requiring their attention exists.
How to Respond to Isolated or Minimal Use
If use has, in fact, been relatively isolated, the child may find evidence in
your concern reassuring of adult love, especially if the use is not
moralistically condemned, but treated as a potential health hazard. Avoiding a
moralistic stance without in any way condoning use is important.
- The Alcohol Argument - Young people are sometimes very indignant
that adult use of alcohol or tobacco is socially acceptable, but their drug
use is not. Emphasizing that abuse of all drugs, including alcohol and
tobacco, is a serious medical and social problem and that your concern is
with the health and development hazards, regardless of the drugís legal
status or social acceptability, may help to defuse the argument.
- The intoxication Issue - Making the point that intoxication with
any substance is undesirable at any age and especially while undergoing
marked developmental changes and acquiring the necessary skills for adult
life, may also be useful. Since using marijuana is a form of intoxication
more analogous to getting drunk, the argument that the adolescentís "joint"
is like the adultís before dinner cocktail loses much of its force.
- The Health and Developmental Implications of Use - Frank
acknowledgement of the seriousness of adult alcohol, tobacco, and other drug
use can make it clear that you are not advocating a double standard. You
should make clear to your patient that your concern is with the health and
developmental implications of use. Moreover, just as there is good reason to
be particularly concerned about diet and other health habits during
pregnancy, there are equally good reasons for concern about behavior that
can potentially interfere with healthy childhood or adolescent development.
RESOURCES FOR HEALTH PROFESSIONALS
The American Society of Addiction Medicine (ASAM)
ASAM is an association of 3,000 physicians dedicated to improving the treatment
of alcoholism and other addictions by educating physicians, medical students,
and the general public, and promotion addiction research and prevention.
4601 North Park Avenue #101, Arcade Level
Chevy Chase, MD 20815
National Association of Alcoholism and Drug Abuse Counselors (NAADAC)
With 17,000 members, NAADAC is the largest national organization of alcoholism
and drug abuse professionals across the country who treat addicted individuals
1911 N. Fort Myer Dr. Suite 900
Arlington, VA 22209
(703) 741-7686 or (800) 548-0497
The International Nurses Society on Addictions (IntNSA)
IntNSA is a professional specialty organization for nurses that is committed to
the prevention, intervention, and treatment of addictive disorders, including
alcohol and other drug dependency, nicotine dependency, eating disorders, dual
and multiple diagnosis, and process addictions such as gambling.
1500 Sunday Drive, Suite 102
Raleigh, NC 27607
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