Substance Use in Adolescents: Recognition and Management in the Emergency Department (Controlled Substances CME and Pharmacology CME)

Table of Contents

 

About This Issue

Substance use is becoming increasingly common in adolescents and is a common reason for emergency department use. The presentation will vary based on the substance, and it is important for clinicians to recognize common presenting signs, symptoms, and physical examination findings. This issue reviews commonly used substances in the adolescent population and provides a general framework for approaching, assessing, and managing these patients. In this issue, you will learn:

Recommendations for prehospital management, including administration of prehospital naloxone; important information to gather at the scene and from friends, family, or bystanders; and options for managing agitation

Common acute presentations of frequently used substances

Limitations of urine drug screens, including common cross-reacting substances and drugs of abuse that do not commonly appear on basic urine drug screens

General treatment recommendations

The pathophysiology, presentation, and management of commonly used substances

Recommendations for disposition, including education and administration of take-home naloxone

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
       1. Urine Drug Screens
    2. Imaging Studies
11. Treatment
    1. General Treatment Principles
    2. Pathophysiology, Presentation, and Management, by Substance
       1. Marijuana
          • Management of Cannabinoid Hyperemesis Syndrome
       2. Alcohol
          • Managing Alcohol Intoxication
          • Managing Alcohol Withdrawal
       3. Stimulant Medications
          • Methamphetamines
          • 3,4-Methylenedioxymethamphetamine
          • Cocaine
       4. Opioids
          • Opioid Reversal
          • Opioid Withdrawal
12. Special Populations
13. Controversies and Cutting Edge
    1. Take-Home Naloxone
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Evaluation and Management of Substance Use in Adolescents
18. 5 Things That Will Change Your Practice
19. Clinical Pathway for Management of Suspected Drug Intoxication in Adolescents
20. Tables and Appendix
21. References

Abstract

Adolescent substance use continues to be a prevalent problem and is a cause of morbidity, mortality, and high rates of resource utilization. The variability in presentations of drug intoxication can make accurate identification of the ingested substance, and thus efficient treatment, challenging. This issue provides a review of typical presenting signs, symptoms, and physical examination findings of commonly used drugs. Evidence-based recommendations are offered for a general approach to managing adolescent patients who present with drug intoxication, with specific guidance, when indicated.

Case Presentations

A 16-year-old girl presents with generalized abdominal pain and intractable vomiting…

• The patient has been having 5 to 6 episodes of nonbloody, nonbilious emesis for 2 days and is unable to keep down liquids or solids. The girl denies fever, chills, diarrhea, chest pain, or trouble breathing.
• The girl’s vital signs are: temperature, 37°C; heart rate, 120 beats/min; blood pressure, 135/83 mm Hg; and respiratory rate, 18 breaths/min.
• Upon further questioning privately, she admits daily marijuana use, but otherwise denies use of alcohol and other recreational drugs, as well as sexual activity.
• What are the first steps in diagnosis and treatment of this patient?

You hear EMS is inbound with a 17-year-old boy who was found unresponsive and apneic…

• EMS personnel tell you the boy still has a pulse. Naloxone was administered, with return of spontaneous respirations.
• When the boy arrives to the ED, he is somnolent. His vital signs are: temperature, 36.1°C; heart rate, 50 beats/min; blood pressure, 90/60 mm Hg; and respiratory rate, 6 breaths/min.
• What are the next steps for acute management of this patient?

Your next patient is a 13-year-old boy who was brought into the ED by his parents for agitation…

• The boy’s mom tearfully tells you that he has been more withdrawn the last few months. This evening, he returned from a friend’s home and was very agitated and aggressive. The parents are worried he took some type of drug.
• The boy’s vital signs are: temperature, 37.7°C; heart rate, 130 beats/min; blood pressure, 140/90 mm Hg; and respiratory rate, 22 breaths/min.
• What physical examination findings will help identify a possible ingested substance?

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Clinical Pathway for Management of Suspected Drug Intoxication in Adolescents

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Tables and Appendix

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Johnston LD, Miech RA, O’Malley PM, et al. Monitoring the future: national survey results on drug use 1975-2019: overview, key findings on adolescent drug use. Accessed October 1, 2023. (National survey)

4. * Ali B, Fisher DA, Miller TR, et al. Trends in drug poisoning deaths among adolescents and young adults in the United States, 2006–2015. J Stud Alcohol Drugs. 2019;80(2):201-210. (Retrospective chart review; 36,422 adolescents) DOI: 10.15288/jsad.2019.80.201

7. United States Centers for Disease Control and Prevention. SUDORS dashboard: fatal overdose data. Accessed September 1, 2023. (National database)

8. Substance Abuse and Mental Health Services Administration. Preliminary findings from drug-related emergency department visits, 2021; Drug Abuse Warning Network (HHS Publication No. PEP22-07-03-001). 2022. (National database)

9. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health. 2020: Accessed September 1, 2023. (National database)

14. Tran K, Mierzwinski-Urban M. Ketamine for pharmacological management of aggression and agitation in pre-hospital settings: a review of comparative clinical effectiveness, safety and guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. 2019: Accessed September 1, 2023. (Review)

17. Substance Abuse and Mental Health Services Administration. Clinical drug testing in primary care. 2012: Accessed September 1, 2023. (National database)

26. National Institute on Drug Abuse. Cannabis potency data. 2022: Accessed September 1, 2023. (National database)

38. Rome Foundation. Rome IV criteria. 2016: Accessed September 1, 2023. (Webpage)

39. * Sorensen CJ, Desanto K, Borgelt L, et al. Cannabinoid hyperemesis syndrome: diagnosis, pathophysiology, and treatment—a systematic review. J Med Toxicol. 2017;13(1):71-87. (Systematic review; 183 articles) DOI: 10.1007/s13181-016-0595-z

42. * Castro-Rodríguez C, Lorente-Romero J, Rivas-García A, et al. Acute alcohol intoxication in pediatric emergencies. Pediatr Emerg Care. 2022;38(9):e1523-e1528. (Cross-sectional study; 126 patients) DOI: 10.1097/pec.0000000000002808

50. National Center for Drug Abuse Statistics. Drug use among youth: facts & statistics. 2022. Accessed September 1, 2023. (National database)

51. Farzam K FR, Saadabadi A. Stimulants. StatPearls. 2023. Accessed September 1, 2023. (Review)

52. * Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345-364. (Systematic review; 120 studies, 2358 patients) DOI: /10.3109/15563650.2016.1142090

53. * Connors NJ, Alsakha A, Larocque A, et al. Antipsychotics for the treatment of sympathomimetic toxicity: a systematic review. Am J Emerg Med. 2019;37(10):1880-1890. (Systematic review; 73 articles) DOI: 10.1016/j.ajem.2019.01.001

82. * Abdelal R, Banerjee AR, Carlberg-Racich S, et al. The need for multiple naloxone administrations for opioid overdose reversals: a review of the literature. Subst Abus. 2022;43(1):774-784. (Systematic literature review; 24 articles) DOI: 10.1080/08897077.2021.2010252

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Keywords: substance use, drug use, overdose, drug overdose, intoxication, urine drug screens, ketamine, synthetic cannabinoids, synthetic opioids, buprenorphine, fentanyl, 3,4-methylenedioxymethamphetamine, MDMA, ecstasy, molly, benzodiazepines, marijuana, cannabinoid hyperemesis syndrome, alcohol intoxication, alcohol withdrawal, stimulant medications. methamphetamines, cocaine, opioid reversal, opioid withdrawal, naloxone, take-home naloxone